Cuidados Posoperatorio Cirugia

RESOURCES: SEDATION RECORD
Procedural Sedation Record

Patient Selection Criteria Date: ________________________
Patient: ____________________________________ Birth Sex M F DOB ____/____/______ Weight: ________kg Height: ________cm
Physician name/phone number: ______________________________________________________ BMI: __________ BMI% for age: ________
Indication for sedation: Fearful/anxious patient for whom basic behavior guidance techniques have not been successful
Patient unable to cooperate due to lack of psychological or emotional maturity and/or mental, physical, or medical disability
To protect patient’s developing psyche
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 ________________________________ Limited neck mobility
Current medications (including OTC, herbal) ________________________________ Micro/retrognathia
Relevant diseases (including COVID) ________________________________ Limited oral opening
Previous sedation/general anesthetics ________________________________ Macroglossia
Physical/neurologic impairment ________________________________ Brodsky grading scale: 1 2 3 4
Snoring, obstructive sleep apnea, mouth breathing ________________________________ Mallampati classification: I I I III IV
Relevant birth, family, or social history ________________________________
For female: Post-menarchal ________________________________
ASA classification: I I I I I I* IV* E If any * is medical consultation indicated? NO YES Date requested: ______________
Comments: __________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Is this patient a candidate for in-office sedation? YES NO Doctor’s signature: ______________________________ Date: ___________________
Plan Name/relation to patient Initials Date By

Informed consent for sedation obtained from ___________________________________ ________ _____________ ______________________
for protective stabilization obtained from ___________________________________ ________ _____________ ______________________
for dental procedures obtained from ___________________________________ ________ _____________ ______________________
Preoperative instructions reviewed with ___________________________________ ________ _____________ ______________________
Postoperative 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 VItal Signs (if unable to obtain, ckeck )
Change in medical hx/ROS Clear liquids ____hrs Upper airway clear Pulse: _____/min
Change in medications Milk, other liquids, Lungs clear SpO2: _____%
Recent respiratory illness/COVID &/or foods ____hrs Tonsillar obstruction (___%) BP: _____/ _____ mmHg
Pregnancy test indicated Medications ____hrs Weight: _____kg Height: _____cm Resp: _____/min
Date: _______ Test: ________ Results: _________ BMI: _____ BMI % for age: ______ Temp: _____oF
Presedation cooperation level: Unable/unwilling to cooperate Rarely follows requests Cooperates with prompting Cooperates freely
Behavioral interaction: Definitively shy and withdrawn Somewhat shy Approachable
Guardian was provided an opportunity to ask questions, appeared to understand, and reaffirmed consent for sedation? YES NO
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Safety Checklist Monitors tested & functioning as intended Emergency kit, suction, & high-flow oxygen
No contraindication to procedural sedation Two adults present or extended time for discharge accepted
Drug Dosage Calculations

Sedatives
Agent ________________________________ Route ________ ________mg/kg X _______kg = ________mg 8_________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

Cuidados Posoperatorio Cirugia

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Cuidados Posoperatorio Cirugia

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RESOURCES: SEDATION RECORD

Procedural Sedation Record

Plan Name/relation to patient Initials Date By

Assessment on Day of Sedation Date: ___________________

Drug Dosage Calculations

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