What if you can’t find a vein?

My experience of treating patients under sedation has been that once the venous access has been achieved, the session becomes easier from that point. The patient is relaxed, the team is relaxed and all is well. But finding that elusive vein can be very stressful!

At the initial consultation, the patient may be more relaxed and the vein obvious. But when then come for treatment for the first time, everything shuts down and the nice vein you noted previously has disappeared! What you really dont want is to be straggling around puncturing holes which will only increase the patients stress levels and reduce their confidence in your skills!

There are some great techniques that Ive come across over the years to help find decent access.

One of the simplest ways is to get venous pooling. Using a manual blood pressure cuff (still my favourite), hold the pressure between systolic and diastolic. The blood will pool and the veins will become engorged and therefore much more obvious.

If that fails, there are some great devices (gadgets) out there to help find the decent veins in the first place, even deep in the forearm. I love the VeinLite EMS, sold by Medisave. More details can be found at https://www.veinlite.com/.

This fantastic tool allows not only visualisation of the venous architecture, but when turned around, will hold the skin firm and anchor the vein down, so you cannulate through the access window in the device itself.

It costs around £160 but saves so much guesswork, feeling around for veins and failed access situations. I have used it several times on patients who have said “good luck finding a vein!”

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How do you treat the Needle Phobic Dental Patient? An introduction to Intranasal Sedation

My name is Dr Rob Endicott and I have been carrying out IV and RA sedation for over 10 years. I have been blessed over that time to have helped over 1000 patients achieve healthy mouths after years of neglect.

I have talked before about the “Guilt Spiral”, where nervous patients develop a dental problem and try to ignore it, knowing it needs to be sorted out. The problem worsens, develops into an infection and regular antibiotics seem to keep it at bay, but the patient still knows it needs to be sorted out. But this time, a lot of people are embarrassed and are are scared that the dentist will say or think “How can you let yourself get into this situation?”

So it is ignored again until the tooth breaks. The patient is left with stumps of teeth, recurring infections and pain and thinking, “not only am I going to be a bollocking from the dentist but it will be difficult and painful to get the tooth out.” So, the situation is ignored still further until a breaking point is reached, a cosmetic disaster, a life threatening swelling or inability to eat anymore.

This pattern is something we see an awful lot in Sedation / Phobia Dentistry. If only patients got to us sooner, trusting us not to tell them off and believing us when we say the treatment is going to be painless!

Its one of the reasons why Dentistry for nervous patients is so rewarding. We can see lives turned around, patients smiling again, routine maintenance dentistry easier to handle, depressions lifted, diets improved, personal care improved, relationships improved to the point of finding Mr or Mrs Right!

I often say to patients that getting them through the door, in the chair and talking about solutions to their dental problems is the hard bit. One they are passed that, the dentistry, especially with sedation, ends up being the easy bit.

But how do we cope with patients who have a fear of needles? IV sedation involves needles and so often we find that if patients dont want needles in their mouth (which we know we can do without hurting them) then possibly more uncomfortable injections in their skin can be an even worse fear.

We can try Relative Analgesia (or what Dr Richard Charon calls “Happy Air”). This is a great needle free way to relax patients and make their dentistry easier.

But so many of these severely phobic patients want to be “asleep” and be completely unaware of whats going on.

A few years ago, I started using Intranasal Sedation. Intranasal involves spraying a fine mist of concentrated Midazolam up the nostrils using an attachment on a 1 or 2ml syringe.

After about 10-15 minutes, the patient is experiencing similar effects to IV midazolam. You can then cannulate without the patient being aware, for top up and more importantly, for reversal.

There are many useful features of Intranasal uptake of Midazolam.

It has a slower absorption rate than IV so it is difficult to get a spike in the serum levels commonly associated with over-sedation. This makes the administration very safe.

It can provide the same depth or sedation and often topping up is not required. Because of the slower uptake curve of serum levels, and the subsequent slower half life, topping up with IV is a little unpredictable, as one dose is dropping off, another quicker one is being introduced. I often find there is no need to top up.

It is simple and cheap to provide. The Mucosal Atomisation Device that fist on the syringe is readily available, low cost and comfortable for patients. The Midazolam is made to special prescription by Guys and St Thomas’ Pharmacy and comes in a pack of 5 for around £60.

The half life, whilst slightly longer than IV, is still suitable for good safe recovery and fits in with the dental diary well. I often need to schedule just an additional fifteen minutes for recovery.

Patients are unaware and do not remember the cannulation!

Drawbacks

As with everything is life, IN sedation is not a magic bullet. There are some important things to know:

The recovery is not as clean as IV, the patient can feel “heavy headed” for longer than normal, but as most of my patients go home and then sleep for a few hours, that doesn’t seem to be a problem.

It is not an alternative for IV. It is important for safety reasons to be able to reverse it with Flumazenil so cannulation is always needed.

It is not an alternative where you can’t be certain of venous access. Where no vein is available and therefore access will be difficult to achieve once sedated, it should not be used. If there is difficulty finding a vein, then see my other post for some great tips.

It doesn’t taste that great. The vial does contain lidocaine topical anaesthetic which can reduce the unpleasantness, but even that tastes pretty foul. The taste and slight burning sensation can be reduced greatly by giving the patient either pure Orange Juice or Cherryade.

I have to admit though that these issues have never prevented me from using IN sedation with patients who are needle phobic. They seem like minor problems in comparison to the trauma of IV.

If you are interested as a practitioner on getting involved with IN, speak to your sedation mentor, SAAD, or email me at rob.

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For more information visit http://www.intranasal.net

http://en.m.wikipedia.org/wiki/Midazolam