This article was first published in Patient Safety Solutions in August 2016. As part of our efforts to bring in expert viewpoints from across the #patientsafety community, we have reposted this with permission.
By Bradley T. Truax, MD
Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” noted numerous cases of death related to sedation in dental practices. The majority of those cases occurred in pediatric patients.
A recent article in Anesthesiology News (Kronemyer 2016) noted that a KVUE TV “Defenders” investigation (Pierrotti 2016) identified at least 85 patients in Texas who died shortly following dental procedures from 2010 to 2015. The Kronemyer article also notes that the American Dental Association (ADA) guidelines on sedation do not specifically address pediatric dental issues and that statewide regulations regarding dental sedation and anesthesia vary widely. That article notes that the ADA defers to the American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures”. Fortunately, the latter guideline has just been updated (Coté 2016).
The updated guideline, which applies to not just dental procedures but to sedation for all procedures, notes that children under the age of 6 years (and especially those under the age of 6 months) are particularly likely to suffer adverse events during sedation. It emphasizes that there is a very narrow margin in children between the intended level of sedation and much deeper sedation or anesthesia. Therefore, the practitioner must be trained not only in moderate sedation but must have the skills to rescue patients from such deeper levels. That would include the need for maintenance of the skills needed to rescue a child with apnea, laryngospasm, and/or airway obstruction, include the ability to open the airway, suction secretions, provide continuous positive airway pressure (CPAP), perform successful bag-valve-mask ventilation, insert an oral airway, a nasopharyngeal airway, or a laryngeal mask airway (LMA), and, rarely, perform tracheal intubation. The guidelines note these skills are likely best maintained with frequent simulation and team training for the management of rare events. The guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation.
The updated guideline emphasizes the role of capnography in appropriate physiologic monitoring and continuous observation by personnel not directly involved with the procedure to facilitate accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions. You’ll recall from our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” that many of the fatalities following sedation for dental procedures had the dentist or oral surgeon both doing the procedure and monitoring the patient.
Patient safety considerations for procedural sedation begin in advance of the procedure. There should be a careful preprocedure review of the patient’s underlying medical conditions and consideration of how the sedation process might affect or be affected by such conditions. The guideline specifically mentions that children with developmental
disabilities have been shown to have a threefold increased incidence of desaturation compared with children without developmental disabilities.
The SOAPME mnemonic is used to help teams remember all the equipment and supplies needed for conduct of safe sedation:
- S: Suction
- O: Oxygen; an adequate reserve supply
- A: Airway; size-appropriate equipment to manage a nonbreathing child
- P: Pharmacy; drugs needed to support life and appropriate reversal agents
- M: Monitors; size-appropriate oximeter probes/monitors appropriate for procedure
- E: Equipment; a defibrillator with appropriately sized pads
Without going into details about specific drugs, the guideline notes the importance of selecting the lowest dose of drug with the highest therapeutic index for the procedure. That choice should also depend on whether the procedure is expected to be a painful or non-painful procedure. Knowledge about the duration of action of the drugs is important in informing how long a patient needs to be monitored after the procedure. That is especially important when combinations of drugs are being used (eg. a sedating agent and an analgesic or anxiolytic agent).
The guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation. One critical point that should be of particular concern for dental practices, is that use of moderate or deeper sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures. While that individual might also be responsible for assisting with interruptible patient-related tasks of short duration, such as holding an instrument or troubleshooting equipment, the primary role of that individual is monitoring the patient. For deep sedation the sole role of the support individual is to monitor the patient. In either case that individual should be trained in and capable of providing advanced airway skills (eg, PALS) and shall have specific assignments in the event of an emergency and current knowledge of the emergency cart/kit inventory.
Monitoring is critical and should include the level of patient’s ability to communicate (where assessable), heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values (via capnography) should be recorded, at minimum, every 10 minutes in a time-based record. The guideline stresses use of capnography but acknowledges that it may not be able to be used in some procedures around the face, including many dental procedures.
The guideline discusses the needs for the emergency cart/kit and backup emergency services access and availability.
The guideline has a good discussion about the use of immobilization devices, such as the “papoose” boards we mentioned in our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety”. Such must be applied in such a way as to avoid airway obstruction or chest restriction and the child’s head position and respiratory excursions should be checked frequently to ensure airway patency. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended.
The guideline discusses what should be documented before, during, and after a procedure in which sedation is used and notes the importance of careful attention to calculating doses of drugs or infusions based on patient weight.
The guideline has a good discussion about discharge of the pediatric patient following a procedure in which sedation is used. It specifically highlights the dangers when a child is transported in a car seat where there is a need to carefully observe the child’s head position to avoid airway obstruction. Transportation in a car safety seat poses a particular risk for infants who have received medications known to have a long half-life. When there is only one adult to both drive and observe the child, there should be a longer period of observation in the facility where the procedure occurred. Discharge instructions should include details about what to look for, activity levels, dietary restrictions, and include a 24-hour phone number to call if necessary.
And while we have been emphasizing the application of the guideline to dental procedures, remember it applies to all diagnostic and therapeutic procedures. It has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites.
This guideline was extremely well researched, with almost 500 references including the most up-to-date studies and reports. The authors have produced very valuable recommendations that should improve the safety of children undergoing sedation for procedures in a variety of settings. You’ll find this very useful.
Dr. Truax is board-certified in both Neurology and Internal Medicine. He is a clinician and educator with 20+ years of experience in medical administration. He has been involved in patient safety for over 25 years.
For more information, please visit his website.