Opioid Safety, Respiratory Compromise

Standards for Dental Anesthesia Should Require Patient Monitoring An Update and Commentary on 5-Year Old Amber Athwal who Suffered Brain Damage Following Teeth Extraction

Five-year old Amber Athwal suffered brain damage after having dental surgery to extract some of her teeth. For our earlier post, which provides a summary of the lawsuit , “Capnography Monitoring of Five-Year Old Amber Athwal May Have Prevented Her Brain Damage,” please click here.

Dr. William Mather Tribunal Hearing

CBC News reports that Dr. William Mather, the dentist who performed the dental procedure which resulted in “permanent brain damage because of oxygen deprivation”, faces five counts of unprofessional conduct, and has pleaded guilty to three of the charges. Dr. Mather recently retired from dental practice.

Dr. Mather’s colleague, Dr. Darren Fee recently testified at the tribunal hearing investigating the Amber case:

During his testimony, Fee told the hearing he was urgently summoned to help that day by Mather’s dental assistant.

He rushed from his own office just down the hall.

“I said, ‘Let’s put the child on the ground,’ and asked on my way out the door to make sure 911 was called,” Fee, a dentist and dental anaesthesiologist, told the hearing Wednesday.

He told the tribunal that CPR could only be properly administered if the patient was on a hard surface. That’s why he told them to move Amber to the floor.

Fee ran into the back hallway shared by both offices to get his nurse and a crash cart. When they returned, Amber was on the ground.

No one was performing CPR, but Fee said Mather was holding an oxygen mask over the child’s face. Fee said he quickly discovered the oxygen wasn’t turned on.

The hearing has been told Amber was in post-surgical recovery when she went into cardiac arrest.

Fee said it’s standard practice for a vital-signs monitor to be attached to a patient in recovery.

“There were no monitors attached to her,” Fee testified. “The monitor was turned off and the monitor extensions were rolled up next to the monitor.”  

Canadian Dentists and Dental Sedation

Although we could not find a position statement on sedation on the Canadian Dental Association website, in the Journal of the Canadian Dental Association, there is this statement on sedation safety during dental anesthesia:

“Although dental board regulations for the provision of in-office enteral conscious (oral) sedation vary widely with respect to training and pharmacologic strategies, they agree on the use of drugs that are inherently safe, the use of pulse oximetry and the availability of emergency equipment, including pharmacologic antagonists.

Patient safety is of greatest concern and is best addressed by appropriate selection of patients, adequate training of personnel and appropriate monitoring of patients [emphasis added].”

Moreover, better training and education of dentists in anesthesia would seem to be needed. In a 2007 13-item survey of dentists’ views about approaches to pain and anxiety management that was distributed in Atlantic Canada, “respondents indicated that about 50% had training in conscious-sedation techniques and 20% had learned to administer intravenous (IV) sedation.”

Monitoring of Dental Sedation

Although the case occurred in Canada, as the majority of PPAHS’s readers are in the US, we think that the guidelines of the American Dental Association (ADA) are instructive.

In 2007, the ADA established guidelines for the use of sedation and general anesthesia by dentists in 2007.  In putting forth theses guidelines, the ADA states:

“The American Dental Association is committed to the safe and effective use of these modalities by appropriately educated and trained dentists. The purpose of these guidelines is to assist dentists in the delivery of safe and effective sedation and anesthesia.”

These guidelines then provide that monitoring of the patient must include oxygenation, ventilation, and circulation:

A dentist, or at the dentist’s direction, an appropriately trained individual, must remain in the operatory during active dental treatment to monitor the patient continuously until the patient meets the criteria for discharge to the recovery area. The appropriately trained individual must be familiar with monitoring techniques and equipment. Monitoring must include:

  • Oxygenation:
    • Color of mucosa, skin or blood must be evaluated continually.
    • Oxygen saturation by pulse oximetry may be clinically useful and should be considered.
  • Ventilation:
    • The dentist and/or appropriately trained individual must observe chest excursions continually.
    • The dentist and/or appropriately trained individual must verify respirations continually.
  • Circulation:
    • Blood pressure and heart rate should be evaluated pre-operatively, post-operatively and intra-operatively as necessary (unless the patient is unable to tolerate such monitoring).

Patient Monitoring Provides Early Detection of Respiratory Compromise

It cannot be predicted how patients who receive sedation will react.  As Richard Kenney, MSM, RRT, NPS, ACCS, RCP (Director, Respiratory Care Services, White Memorial Medical Center, Los Angeles) stated in this interview on the Health & Safety Podcasts:

We know that patients react differently to medications. Some react lightly and some have some pretty severe reactions to it. Opioids at certain dosages can lead to respiratory depression, as we know. If too depressed, the risk of respiratory failure could occur and jeopardize the patient’s health. If it goes unnoticed by those monitoring that patient, for example, the patient may appear to be OK at a simple glance, but when the respiratory rate drops, we’re now faced with a compromised patient. So, it’s important that we pay particular attention to those patients receiving opioids.

As our position statement on patients receiving opioids provides, all patients receiving opioids should be continuously monitored with pulse oximetry for oxygenation and with capnography for adequacy of ventilation.

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