The general guidelines are as follows, see that you follow these guidelines otherwise your operation may have to be cancelled:

• No solid food for six (6) hours prior to the procedure
• All patients may drink clear liquids (like water, clear apple juice etc) until two (2) hours before the procedure. (No grape juice, as this could interfere with some of the sedative medication)
• Diabetic patients will get special instructions as far as food intake is concerned.
  You should receive pre-and post-operative instructions explaining what you can and can’t do. Always feel free to contact your sedationist if you have any questions in this regard.

As with any medication, the use of sedative anaesthetic agents can result in side-effects. However, the incidence of side-effects with sedation are rare and include unintended loss of consciousness, drowsiness, dizziness, shivering (4%), headaches (4%), and nausea & vomiting (0.7%) following the sedation.

You may choose:

• Not to have the treatment
• Have the treatment with local anaesthesia only
• Have the treatment under conscious sedation and local anaesthesia at the surgery
• Have general anaesthesia in a hospital.

Rarely you may experience:

• Discomfort or bruising at the site of injection.
• Vein irritation (phlebitis), which can last a week and can be painful. This rarely happens when an elbow vein is used.
• Allergic reaction to any of the drugs used. Allergic reactions to the sedative drugs are extremely rare.
• Nausea and vomiting, although very uncommon, may occur.

Conscious sedation is a very safe procedure. However, the very rare complications should be mentioned: depressed respiration (slowing or stopped breathing), brain damage, stroke, heart attack or even a fatal outcome. The information that you give us on the medical history form will assist us to decide whether you might be at risk to any known complications. Your sedationist is highly experienced in avoiding complications and is trained to deal with unexpected problems.

Yes, due to the sedative effects of the medication you will need a responsible adult to accompany you home, preferably by car or taxi.

The phrase conscious sedation was originally used by the American Dental Association; a technique used to make patients comfortable during the operation. Conscious sedation is probably the fastest growing area in anaesthesia care, and has become a very effective viable alternative to general anaesthesia for many surgical procedures e.g. dental procedures, plastic and reconstructive surgery, dermatology, endoscopies, bronchoscopies, and liver and renal biopsies. You will come in on the day of surgery and leave the same day usually within one hour after the operation. In addition, there is a significantly lower incidence of side effects with conscious sedation (incuding low incidence of nausea and vomiting, headaches, sore throats, muscle aches, and pain), and the costs for conscious sedation are much lower compared to general anaesthesia.

The aim of sedation is to make you comfortable, totally relaxed and safe during a procedure. Administration (through an injection into your veins) of the sedatives and analgesia (pain medication) results in you becoming drowsy and sleepy, pain free (usually with the addition of good local anaesthetic injections by your dentist/surgeon), and probably amnesic (forgetful) such that you will have very little recollection of the procedure.

Communication is possible if necessary during the operation because even though you are completely relaxed and unconcerned, you are not completely unconscious at any point in time. Your vital signs e.g. blood pressure, breathing, pulse rate, etc are monitored throughout the procedure to ensure your safety, and a sedationist will stay with you all the time.

Recovery after sedation is much faster than with general anaesthesia. The same applies for the side effect profile (unwanted effects from the medication) e.g. nausea and vomiting, headaches, muscle pains, sore throats, which is much less than with general anaesthesia – in fact very few patients experience any side effects at all. For these reasons, patient satisfaction is very high after conscious sedation – a recent survey of the experiences and satisfaction of patients who had sedation shows that 99.5% of patients would choose sedation again if they have a repeat procedure. Conscious sedation is achieved with intravenous agents/medicines injected into a vein (e.g. benzodiazepines/Valium-type drugs, opiates/morphine-type drugs and other sedative/anaesthetics like Ketamine) and/or inhalation agents/breathing in gasses (e.g. nitrous oxide/laughing gas).

There are three different levels of sedation that are defined and recognized internationally. The three sedation levels mostly referred to include:

• Minimal Sedation (or Anxiolysis): This is often referred to as changing the mood of the patient whereby the patient is calmed, responsive to verbal commands, and unconcerned about the procedure.
• Moderate Sedation or Conscious Sedation: This is where the patient is more deeply sedated, becomes drowsy and sleepy (and may even sleep intermittently), but stays responsive to verbal commands.
• Deep Sedation: At this level of sedation patients may become unconscious. This level is only possible in certain circumstances if the facilities are adequate and overseen by a trained and experienced team and sedation practitioner.

The main differences between conscious sedation and general anaesthesia is the level of consciousness, safety, side effects, and cost.

• Level of consciousness: with conscious sedation the patient is drowsy, comfortable, sleepy and relaxed, but remains conscious. Patients can be roused by verbal communication (spoken to) if necessary. With general anaesthesia the patient is completely unresponsive and cannot be roused by verbal communication or even pain.
• Safety: with conscious sedation the required dose of drug is low and the patient is still in control of major reflex functions such as breathing, coughing and swallowing. With general anaesthesia the higher doses of drugs renders the patient unconscious who then loses these reflexes which are then maintained artificially. Higher doses of drugs administered with general anaesthesia are associated with higher risk and side-effects.
• Side effects: due to the lower dose of sedative/anaesthetics the frequency of side effects is minimal when compared to general anaesthesia where the side effect profile is much more substantial.
• Cost: the fact that the recovery period of sedation is much quicker than with general anaesthetic, combined with the fact that sedation does not require hospital admission, means that the cost of sedation is far lower than that for general anaesthesia. General anaesthesia can only be done inside a hospital in an operating theatre.

A sedation provider service is a dedicated team of sedation practitioners, nurse practitioners and/or nurses who provide sedation. The team concept is an extremely important part of safe sedation practice. There are two types of sedation provider services:

• The operator sedation practitioner: here the surgeon administers both the sedation and also does the surgical procedure. Dedicated staff will be part of the team and help him/her to monitor the patient.
• The dedicated sedation practitioner: here a dedicated sedationist administers the sedation, while the surgeon does the surgery only. The sedation practitioner looks after the wellbeing of the patient from a conscious sedation perspective, which allows the surgeon to focus on the operative procedure.

All sedation practice is closely regulated to the highest professional and ethical standards. All sedation team members and practitioners must have appropriate training in the administration of conscious sedation including monitoring, management, and care of the patient while under sedation. It is also mandatory that sedation practitioners attend regular training updates in knowledge and skills.

As with any anaesthetic, the suitability of conscious sedation is determined by the patient’s health and need, as well as by the procedure being performed. In the first instance, indications for conscious sedation include:

• Procedures that do not need general anaesthetic such as:
  • Minor surgery such as cosmetics, urology, infertility, etc
  • Routine investigations such as biopsies or endoscopies
  • Routine interventions such as interventional cardiology or radiology
  • Dental procedures
  • Sedation is not suitable for procedures where general anaesthesia is required
• Very anxious patients – sedation calms the patient and overcomes their fear and anxiety
• Patients who have had a previous traumatic experience – sedation makes it possible to deal with post-traumatic stress of the patient relatingto medical or dental procedures
• Uncomfortable procedures – sedation relaxes, dissociates and helps comfort the patient
• More complex and prolonged procedures – sedation ensures the patient can remain still yet comfortable for long periods of time
• Procedures in adults and children with behavioural problems for procedures that may not be particularly painful, but require them to be very still
• From a medical perspective, adults who are healthy, or have controlled medical conditions eg hypertension, diabetes, asthma which are adequately controlled, can qualify for sedation. Patients with significant or uncontrolled medical conditions (eg severe heart disease, morbid obesity, etc) need to be assessed on a case by case basis as to their suitability for sedation. Some of these patients might need to be treated in hospital rather than a normal doctor’s surgery/dental clinic.
• For children, sedation can be an option on a case by case basis according to an assessment by an appropriately trained sedation practitioner.

Conscious sedation should thus always be evaluated with respect to other available options including local anaesthesia and/or regional anaesthesia, local anaesthesia with behavioural management techniques, general anaesthesia, and of course conscious sedation itself. Patients should always be involved in decision making after an explanation of the options available.

Even though you are not completely asleep, you will be drowsy, relaxed and pain free during the procedure. The sedative drugs combined with analgesics/pain medication and local anaesthesia ensures that you will have no pain. The drugs will also contribute towards a pain free period after the operation. Because you will still be able to communicate at some level, if you do experience any discomfort of any kind, you will be able to let your doctors know so that they can immediately attend to the problem.

The recovery time depends on the drugs used, the patient’s individual response to the drugs, and the time spent under sedation. The drugs and doses that are used for sedation have a rapid onset and offset. This means they start to work very quickly, but the effects disappear very quickly once it is no longer injected. After the administration of the sedative drugs is stopped (usually by stopping the infusion or drip), recovery is swift and, in most cases less than about 30 minutes. This is the time that you will need to remain at the clinic before being allowed to go home with your escort. The sedation practitioner will carefully monitor you to ensure that you are fit for discharge and ready to go home. Thereafter you may remain drowsy for a few hours, and will be given specific written and verbal instructions on what to do.

As with any medication, the use of sedative anaesthetic agents can result in side-effects. However, the incidence of side-effects with sedation are rare and include unintended loss of consciousness, drowsiness, dizziness, shivering (4%), headaches (4%), and nausea & vomiting (0.7%) following the sedation.

Elimination of the sedative agents from your body can take up to 24 hours. It is important during this time to rest and recover from the procedure. Therefore, however well you may feel, within that time you should NOT:
drive a vehicle (insurance will be void)

• Cook or use electrical implements
• Operate any machinery
• Sign important documents, cheques, etc
• Look after children
• Ride a bicycle, etc
• Make important decisions, etc
• Use alcohol, sleeping tablets, tobacco, abuse drugs
• Perform other complicated tasks or responsibilities

You will not be allowed to drive yourself home, and you will not be able to leave the clinic or facility if there is not a responsible adult that can drive you home and take care of the post-operative recovery period. You should remain in the company of a responsible adult after leaving the clinic, preferable for the remainder of that day.

You should contact your medical aid before the operation to get authorization and information. Medical insurance is increasingly interested in sedation services because of the many advantages including effectiveness, safety, cost savings, and convenience.

Sedation practitioners have all completed undergraduate medical studies and appropriate postgraduate training and qualification in anaesthetics and/or sedation. It is clear that conscious sedation can only be done by those trained AND experienced in how to evaluate and assess the patient, administer the sedative drugs, monitor the patient, and deal with any side-effects or situations that may arise. The South African guidelines on sedation, including all international guidelines require that conscious sedation practitioners must be appropriately trained and experienced. In addition, practitioners must undergo thorough post graduate training and appraisals to ensure fitness to practice. According to the American Society of Anaesthesiologists Task Force on Sedation and Analgesia, sedation can be provided by anaesthesiologists as well as non-anaesthesiologists who are appropriately qualified. There are thus three main groups of sedation providers:

• Professional sedation practitioners: this group are medically qualified practitioners with extensive postgraduate certification (Diploma, Masters qualification etc), training and experience in conscious sedation. They are usually full time in sedation practice in surgeries, clinics, hospitals, and often travel between facilities to administer sedation.
• Operator sedationist: these are practitioners from different sub-specialties e.g. dentists, radiologists, enterologists that in addition to performing the procedure also administer the sedation themselves.
• Anaesthetists: this group are usually qualified anaesthetists/consultants that also administer sedation inside hospitals. They do not normally practice sedation techniques full-time, and are a smaller group than those above.

Conscious sedation can be done in hospitals as well as outside a hospital or operating theatre setting, including in:

• Dental or medical surgeries or clinics.
• Approved facilities with necessary monitoring and emergency equipment and appropriately trained staff.

Conscious sedation should only be performed in an environment where the facilities, personnel, equipment and drugs required to administer, monitor, and manage any complication are immediately available to the same level of care as in the hospital environment.

Many patients are on herbal drugs for different reasons. It is very rare that they can interfere or cause serious complications with conscious sedation. However, it is important that the sedation practitioner knows if and which herbal medication you may be taking. The herbal drugs can influence sedation through interacting with the sedative drugs – some of the herbal drugs have a sedative effect and can potentiate the effect of the sedative drugs; or it can interfere in other ways such as increasing the chance of excessive bleeding. It is therefore important to let your sedationist know if you are taking herbal medications, and if possible consider stopping them a week or two before the procedure.

The different ways of having sedation relates to how the medicines or gasses are given to the patient.

You could have:

• Medicine to drink (oral sedation)
• Medicine given as an injection into one of your veins (Intravenous or I.V sedation)
• Medicine given as a nasal spray (nasal sedation)
• Medicine given rectally
• Medicine given as an injection into a muscle
• Gasses like laughing gas inhaled through a special mask.
• Or any combination of the above.

All the above-mentioned ways of giving or administering the sedative medication have their own benefits and potential difficulties and the most appropriate way will usually be quite clear. Your sedation practitioner might also only be able to provide certain ways of administering sedation. At Advanced Sedation, we normally only provide Intra-venous sedation as this is usually the most appropriate and best suited form of sedation for our patients.

You should feel free to discuss your own needs and questions in this regard with your sedationist.

Conscious sedation induces a state of deep relaxation. In over 90% of people the drugs used for conscious sedation produce either partial or full memory loss (amnesia) for the period of time when the drug is given until it wears off. As a result, time will appear to pass very quickly. Consequently, people who remember nothing at all, frequently report that they were “asleep” during the procedure.

The conscious sedation drugs are given to relax you whilst the local anaesthetic drugs will take the pain away. The local anaesthetic is usually administered after the sedation has taken effect. Therefor most patient will not even be aware or remember having the local anaesthetic injections at all.

Under sedation your tolerance to pain is much higher. Therefor the surgeon is able to use more local anaesthetic and has more options in the various techniques of administering local anaesthesia. Most patients with this kind of problem normally have no trouble when having their treatment under sedation.

Yes, the sedationist will be at your side all the time. In addition, your pulse, oxygen levels and blood pressure are constantly monitored and recorded to ensure your wellbeing.

The most commonly used drug for conscious sedation is Midazolam, which belongs to the same family of drugs as Valium. However, in order to make the injections in the mouth almost painless and also to produce a better quality of sedation, your sedationist may choose to add an opiate (morphine-type painkiller) and/or Propofol (and anaesthetic drug) or other drugs in controlled and titrated (small amounts at a time after checking for its effect) doses. Propofol allows for a much faster recovery but needs a dedicated trained sedationist to be present throughout the procedure.

In the unlikely event that you may feel sick after your treatment, it is safer for you not to eat anything for six hours before your appointment. However, you may drink water up to two hours before your appointment. Please continue to take your regular medication at the usual times with a little water. If you suffer from diabetes or have other dietary problems please discuss this with your sedationist before your appointment.

To comply with guidelines and for your own safety we must insist that you have a responsible adult to take you home after your appointment. In the event that you have no escort on the day of the sedation, your appointment may be cancelled and you will be charged in full. If you have no one to take you home we can arrange for a nurse to escort you home and stay with you. This will be at an additional cost and must be pre-arranged and pre-paid at least seven days prior to the appointment.

The length of your appointment will depend upon the procedure. There will be a recovery period of 20 – 30 minutes before you are discharged into the care of your escort. The sedative effect of the drugs will gradually wear off during the course of the day. Most patients are well enough to return to their normal activities within 24 hours depending on the nature of their work.

Conscious sedation (CS) is clearly useful for patients who have a fear or anxiety about having minor surgical or dental treatment. Sometimes, the dentist or surgeon may request the sedation in order to make the treatment more comfortable for you or to create the optimal working conditions. In dentistry CS is particularly useful for patients with a strong gag-reflex, small mouth opening or those individuals with a low tolerance to pain. It is also well suited for patients who fear the administration of local anaesthetic injections.

It is imperative that you advise the sedation practitioner of all the medication you are taking so that this can be factored into your assessment and administration of the sedation. You should continue to take your medications as usual, unless advised otherwise by the sedationist.

• Antihypertensive (high blood pressure) medications: continue taking these as usual.
• Asthma medications: continue taking these as usual and bring your inhalers with you.
• Diabetes medications: it is important that the sedation practitioner gives you guidance here since it may be that you should have a meal, and not take oral anti-diabetic drugs the morning of the operation. You are encouraged to monitor your blood glucose levels before the sedation, and bring these with you to the surgery.
• Antidepressants: an increasing number of patients are nowadays on antidepressants not only for the treatment of depression, but also to treat pain. It is of utmost importance that you inform the sedation practitioner of any antidepressants you may be taking, since certain classes of antidepressants can interact with the sedative agents, and it may be required that you stop these for a few days prior to the procedure.

Whatever medication you may be taking it is advisable to bring it to the surgery on the day of the operation to show to the sedation practitioner.

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