RESOURCES: SEDATION RECORD

Sedation Record
Patient Selection Criteria Date: ________________________
Patient: ____________________________________ Birth Sex q M q F DOB ____/____/______ Weight: ________kg Height: ________cm
Physician name/phone number: ______________________________________________________ BMI: __________ BMI% for age: _________
Indication for sedation: q Fearful/anxious patient for whom basic behavior guidance techniques have not been successful
q Patient unable to cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability
q To protect patient’s developing psyche
q To reduce patient’s medical risk
Medical history/review of systems (ROS) NO YES* Describe positive findings: ___________ Airway Assessment NO YES*
Allergies &/or previous adverse drug reactions q q ________________________________ Limited neck mobility q q
Current medications (including OTC, herbal) q q ________________________________ Micro/retrognathia q q
Relevant diseases, physical/neurologic impairment q q ________________________________ Limited oral opening q q
Previous sedation/general anesthetics q q ________________________________ Macroglossia q q
Snoring, obstructive sleep apnea, mouth breathing q q ________________________________ Brodsky grading scale: q1 q 2 q 3 q 4
Relevant birth, family, or social history q q ________________________________ Mallampati classification: q I q I I q III q IV
For female: Post-menarchal q q ________________________________
ASA classification: q I q I I q I I I* q IV* q E If any * is medical consultation indicated? q NO q YES Date requested: ______________
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Is this patient a candidate for in-office sedation? q YES q NO Doctor’s signature: ______________________________ Date: ___________________

Plan Name/relation to patient Initials Date By

Informed consent for sedation obtained from ___________________________________ ________ _____________ ______________________
for protective stabilization obtained from ___________________________________ ________ _____________ ______________________
Pre-op instructions reviewed with ___________________________________ ________ _____________ ______________________
Post-op precautions reviewed with ___________________________________ ________ _____________ ______________________
Scheduled for: Date: _________________ Time: _____________________ with Dr.: ________________________

Assessment on Day of Sedation Date: ___________________

Accompanied by: ____________________________________ and ________________________ Relationships to patient: ________________________

Medical Hx & ROS update NO YES NPO status Airway assessment NO YES Safety checklist

Change in medical hx/ROS q q Clear liquids ____hrs Upper airway clear q q q Monitors tested & functioning as intended
Change in medications q q Milk, other liquids, Lungs clear q q q Emergency kit, suction, & high-flow oxygen
Recent respiratory illness q q &/or foods ____hrs Tonsillar obstruction (___%) q q q No contraindication to procedural sedation
Pregnancy test indicated q q Medications ____hrs Weight: _____kg Height: _____cm BMI: _____ q Two adults present or extended time for
Date: _______ Test: ________ Results: _________ discharge accepted

Vital signs (If unable to obtain, check q and document reason: ______________________________________________________ )
Blood pressure: _______/_______ mmHg Respiration: _______/min Pulse: ________/min Temperature: _______oF SpO2: _______%
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Presedation cooperation level: q Unable/unwilling to cooperate q Rarely follows requests q Cooperates with prompting q Cooperates freely
Behavioral interaction: q Definitively shy and withdrawn q Somewhat shy q Approachable
Guardian was provided an opportunity to ask questions, appeared to understand, and reaffirmed consent for sedation? q YES q NO

Drug Dosage Calculations

Sedatives
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg ÷ _________mg/mL = _________mL
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg ÷ _________mg/mL = _________mL
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg ÷ _________mg/mL = _________mL
Emergency reversal agents
For narcotic: NALOXONE IV, IM, or subQ Dose: 0.1 mg/kg X _____ kg = ______mg (maximum dose: 2 mg; may repeat to maintain reversal)
For benzodiazepine: FLUMAZENIL IV (preferred), IM Dose: 0.01 mg/kg X _____ kg = ______mg (maximum dose: 0.2 mg; may repeat up to 4 times)
Local anesthetics (maximum dosage is based on weight; to calculate maximum volume, divide maximum dosage by agent concentration)
2% Lidocaine 4.4 mg/kg X _______ kg = ________ mg ÷ 20 mg/mL = _____ mL
4% Articaine 7 mg/kg X _______ kg = ________ mg ÷ 40 mg/mL = _____ mL
3% Mepivacaine 4.4 mg/kg X _______ kg = ________ mg ÷ 30 mg/mL = _____ mL
0.5% Bupivacaine 1.3 mg/kg X _______ kg = ________ mg ÷ 5 mg/mL = _____ mL
606 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY
 RESOURCES: SEDATION RECORD

Intraoperative Management and Post-Operative Monitoring EMS telephone number: ________________________

Timeout: q Pt ID q Agreement on procedure q Tooth/surgical site _________________
Monitors: q Observation q Pulse oximeter q Precordial/pretracheal stethoscope q Blood pressure cuff q Capnograph q EKG q Thermometer
Protective stabilization/devices: q Papoose q Head positioner q Manual hold q Neck/shoulder roll q Mouth prop q Rubber dam q _______

TIME Baseline : : : : : : : : : : : : : : : :
Sedatives1

N2O/O2 (%)
Local 2 (mg)

SpO2
Pulse
Blood pressure
Respiration
CO2

Procedure3
Comments4
Sedation level †
Behavior §

1. Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
Agent ________________________________ Route _________ Dose _________ Time _________ Administered by ______________________
2. Local anesthetic agent ___________________________________________________
3. Record dental procedure start and completion times, transfer to recovery area, etc.
4. Enter letter on chart and corresponding comments (e.g., complications/side effects, airway intervention, reversal agent, analgesic) below:
A. __________________________________ B. __________________________________ C. ___________________________________
D. __________________________________ E. __________________________________ F. ___________________________________
† Sedation level § Behavior/responsiveness to treatment
None (typical response/cooperation for this patient) Excellent: quiet and cooperative
Minimal (anxiolysis) Good: mild objections &/or whimpering but treatment not interrupted
Moderate (purposeful response to verbal commands ± light tactile sensation) Fair: crying with minimal disruption to treatment
Deep (purposeful response after repeated verbal or painful stimulation Poor: struggling that interfered with operative procedures
General Anesthesia (not arousable) Prohibitive: active resistance and crying; treatment cannot be rendered
Overall effectiveness: q Ineffective q Effective q Very effective q Overly sedated
Additional comments/treatment accomplished: _________________________________________________________________________________________
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________

Discharge
Criteria for discharge Discharge vital signs
q Cardiovascular function is satisfactory and stable. q Protective reflexes are intact. Pulse: ______/ min
q Airway patency is satisfactory and stable. q Patient can talk (return to presedation level). SpO2: ______%
q Patient is easily arousable. q Patient can sit up unaided (return to presedation level). BP: ______/______ mmHg
q Responsiveness is at or very near presedation level q State of hydration is adequate. Resp: ______/ min
(especially if very young or special needs child incapable of the usually expected responses) Temp: ______oF

Discharge process
q Post-operative instructions reviewed with ________________________________________________ by ________________________________________
q Transportation q Airway protection/observation q Activity q Diet q Nausea/vomiting q Fever q Rx q Anesthetized tissues
q Dental treatment rendered q Pain q Bleeding q ______________________________ q Emergency contact
q Next appointment on: _______________________________________________________________ for _______________________________________

I have received and understand these discharge instructions. The patient is discharged into my care at _________ q AM q PM
Signature: ______________________________________ Relationship: ________________________ After hours number: _________________________

Operator Chairside Monitoring

Signature: _____________________________ Assistant: _______________________ Personnel Signature: __________________________

Post-op call
Date: ______________ Time: _________ By: _________ Spoke to: __________________________ Comments: _______________________________
______________________________________________________________________________________________________________________________