RESOURCES: SEDATION RECORD
Procedural 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 (including COVID) q q ________________________________ Limited oral opening q q
Previous sedation/general anesthetics q q ________________________________ Macroglossia q q
Physical/neurologic impairment q q ________________________________ Brodsky grading scale: q1 q 2 q 3 q 4
Snoring, obstructive sleep apnea, mouth breathing q q ________________________________ Mallampati classification: q I q I I q III q IV
Relevant birth, family, or social history q q ________________________________
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 ___________________________________ ________ _____________ ______________________
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 q)
Change in medical hx/ROS q q Clear liquids ____hrs Upper airway clear q q Pulse: _____/min
Change in medications q q Milk, other liquids, Lungs clear q q SpO2: _____%
Recent respiratory illness/COVID q q &/or foods ____hrs Tonsillar obstruction q q (___%) BP: _____/ _____ mmHg
Pregnancy test indicated q q Medications ____hrs Weight: _____kg Height: _____cm Resp: _____/min
Date: _______ Test: ________ Results: _________ BMI: _____ BMI % for age: ______ Temp: _____oF
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
Comments: _____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
Safety Checklist q Monitors tested & functioning as intended q Emergency kit, suction, & high-flow oxygen
q No contraindication to procedural sedation q Two adults present or extended time for discharge accepted
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
6220.5% Bupivacaine 1.3 mg/kg
THE REFERENCE MANUALX OF_______
PEDIATRICkgDENTISTRY
= ________ mg ÷ 5 mg/mL = _____ mL
RESOURCES: SEDATION RECORD
Patient: __________________________________________________________ DOB _____/_____/________ Date: ___________________________
Intra- and Postoperative Management EMS telephone number: __________________________
Timeout: q Caregiver present for timeout q Pt ID q Agreement on procedure q Tooth/surgical site __________________________
Planned level of sedation: q Minimal q Moderate q Deep q GA
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 (e.g., Start, Completion, Recovery, Discharge)
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 Was all planned treatment completed? q Yes q No
Comments: ____________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
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 Postoperative 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/Dentist Chairside Monitoring
Signature: _____________________________ Assistant: _______________________ Personnel Signature: __________________________
Postoperative call
Date: ______________ Time: _________ By: _________ Spoke to: __________________________ Comments: _______________________________
______________________________________________________________________________________________________________________________
