9/6/18
Christina D. Diaz MD, FASA, FAAP Dental Sedations/ Anesthetics: z What the Anesthesiologist Should Know When Advising Your Patients
z Learning Objectives
After completing the activity, the provider can:
1. Review some sentinel cases of dental sedation with catastrophic outcomes. 2. Understand the various sedation practices of the dental community, with a specific consideration regarding the pediatric patient.
3. Describe the pediatric physiology that puts children at increased risk during sedation/anesthesia.
4. Be able to describe Wisconsin laws and accreditation requirements regarding dental sedations.
5. Discuss the recommendations of the American Academy of Pediatrics, the American Society of Anesthesiologists, and the Society for Pediatric Anesthesia with regard to monitoring, recovery, and sedation practices when providing in office and procedural sedation.
z
Culture & Special Caleb’s Story Society Populations
Dental Risks and Anesthesia Contents Sedation Complications Standard
Consensus Patient Statement Advocacy
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z
Caleb’s Story
z Caleb’s Story: Playing with Fire
• 6 ½ y.o. Boy in CA
• Scheduled for Supernumerary tooth extraction b/w incisors
• Oral Surgeon Anesthetic w/ 2 dental assistants
• IV – fentanyl, midazolam, Propofol, & ketamine
• Concurrent Dental Procedure
• Noted apnea when pulse ox. – 69%
• Failed intubation (knocked out teeth)
• Failed cricothyrotomy
• No CPR/ No oxygen 20 min
Pediatric 141:4, April 2018
z Another Child’s Death
§ 4 y.o. Boy - significant ECC (Early Childhood Caries)
§ Behavioral problems
§ Pediatric Dentist, license – Mod. Sedation
§ Dental Assistant - PALS certified
§ Midazolam X2, Nitrous Oxide
§ Recovery – Cyanotic, Apnea, no pulse ox
§ CPR, 911, Dead on Arrival to hospital
Pediatrics 140:6, Dec. 2017
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z
Culture & Society
z Society & Culture
§ ECC (Early Childhood Caries) - most common chronic childhood disease – Surgeon General
§ 100,000 to 250,000 pediatric dental sedation or general anesthetics in the USA / year
§ Presumed same safety profile - medical community
Pediatrics 140:6, Dec 2017
z Society & Culture
§ Parents don’t associate preventive dental care with health
§ ECC disproportionately greater - low socioeconomic & special health care needs
§ Parents don’t want their children to feel discomfort and
increasingly request sedation and general anesthesia (Pediatric Dent. 2002. 24(4):289-94.)
Pediatrics 140:6, Dec 2017
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z
Special Populations
z Pediatrics – Special Population
§ Challenging Airway
§ Increased airway obstruction
§ Smaller airway
§ Respiratory arrest
§ Increased HR & oxygen requirements
§ Quick to desaturate
§ Weight based dosages
z Pediatrics – Special Population
§ Younger Children - more likely to need sedation
§ Behavioral/ Developmental Challenges
§ Longer procedures/ increased work
§ Ped. Pts – sedation for anxiety, pain, immobility
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z Pediatrics – Special Population
“Of all patients receiving deep sedation/anesthesia for diagnostic and therapeutic procedures, the pediatric population is the subgroup at the highest risk level and with the lowest tolerance for error.” – Cravero, et. Al.
Pediatric Anesthesiology 108:3, March 2009
z Special Population - Pediatrics
§ Ped Sedation Research Consortium – even with skilled & motivated personnel – apnea, desaturations, laryngospasm & obstruction.
§ Children younger than 6 (esp. < 6 month) at greatest risk on
adverse event. (Anesth Analg 2009;108 (3):795-804.)
§ Dev. Delay Pt – 3 fold increase risk of desaturation (Cote Pediatr Dent 2016;38(4)E13-39)
z Special Population - Pediatrics
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z Incidence & Nature of Adverse Events During Pediatric Sedation/Anesthesia with Propofol Outside the Operating Room
§ 49,836 Propofol anesthetics, 37 different sites, any service
§ No deaths
§ CPR X2
§ Aspiration X4
§ O2 < 90 for > 30s – 154/10,000
§ Central Apnea/ Airway obstruction 575/ 10,000
§ Stridor 50/10,000 & laryngospasm 96/10,000
Pediatric Anesthesiology 108:3, March 2009
z Slippery Slope
§ Terms “sedation” or “procedural sedation & analgesia” used when the patient would meet Joint Commission and Anesthesiologist’s definition of ”Anesthesia”.
§ “Children can easily slip from one level to a deeper level, and one would have to constantly be stimulating children to test their responsiveness to truly define their state.”
§ Concept of RESCUE essential to peds sedation! (Cote Pediatr Dent 2016;38(4)E13-39)
Pediatric Anesthesiology 108:3, March 2009
z
Dental Sedation
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z Dental Anesthesia History
§ Dec. 11, 1844 –
Extraction under N2O (First Anesthetic)
§ 1846 – Ether used successfully for Extraction
§ 1940’s Lidocaine presented & used
J. Clinc. Diag. Research 11:6 (June 2017) Photo by Maurizio Procaccini et al / CC BY 2.0
z Dentistry & Sedation
§ General Anesthesia
§ Dentist, Dental Anesthetist, Anesthesiologist
§ Inhalational Anesthesia (N2O Up to 75%)
§ IV anesthetics/ IM/ SQ (Parenteral) Photo by 2009 § Oral Sedation (Enteral) - 05 / Public domain
z Dental Specialties
§ Oral Surgeons (Oral Maxillary Facial Surgeons)
§ Pediatric Dentists
§ General Dentists
§ Subspecialties
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z Education & Licensing in WI
Class 1 Permit – Oral conscious sedation
Class 2 Permit – Enteral & parenteral Class 3 Permit – “Deep sedation, general anesthesia, conscious sedation−parenteral, and conscious sedation−enteral."
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
Photo by Billy Hathorn / CC BY-SA 3.0
z Sedation Requirements in WI
§ ““Operative supervision” means the dentist is in the operatory performing procedures with the aid of qualified staff.”
§ ““Qualified staff” means a person is certified in the administration of basic life support in compliance with the standards set forth by the American Heart Association, the American Red Cross, or other organization approved by the board, and has training in how to monitor vital signs, and how to use a pulse oximeter, blood pressure cuff, and a precordial or a pretracheal stethoscope. If the dentist is administering deep sedation and general anesthesia a person shall also be trained in how to use an EKG. “
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Depth of Sedation & General Anesthesia
JADA 146(9), Sept 2015
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z Nitrous Oxide in WI
§ Dentist or Dental Hygienist
§ At least 25% oxygen
§ BLS certified
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Anxiolysis in WI
§ BLS certified by AHA
§ Administered before or during procedure
§ Pt eyes open, appropriately responsive
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Conscious Sedation Enteral in WI
§ First must obtain Class 1 Permit
§ Board Approved training course – 18 hrs. didactics - physical assessment, conscious sedation enteral, & emergency management
§ OR graduate level training
§ 20 cases observed or participated
§ BLS & Approved Airway Course or ACLS
§ PALS (for 14 or under)
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
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z Conscious Sedation – Parenteral in WI
§ Must obtain a Class 2 Permit
§ Approved Course w/ 60 hrs. didactic – IV sedation, emergency management, physical assessment
§ 20 cases parenteral routes (managed)
§ OR Graduate level training
§ OR utilization of conscious sedation 5 years prior to 2007
§ ACLS or PALS
§ Qualified Staff present – for parenteral route
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Deep Sedation and General Anesthesia in WI
§ Requires a Class 3 Permit
§ Completion of Board approved post-doctoral training in deep sedation & GA
§ OR Completion of ACGME Anesthesiology
§ OR Completion of at least 1 year Anesthesiology Advanced training ADA standards
§ OR practiced 5 years GA as a licensed dentist before 2007
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Deep Sedation and General Anesthesia In WI
§ ACLS or PALS
§ Must have qualified staff present throughout procedure
§ Nothing is to stop the dentist from using an Anesthesiologist, Dental Anesthetist, or CRNA – must remain on premises until returned to consciousness
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
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z Office Requirements in WI
§ Oxygen, capability of positive pressure ventilation
§ Suction & backup
§ Chair able to withstand CPR or backboard
§ Pulse ox, BP cuff, precordial stethoscope + EKG (deep & GA)
§ Emergency Equipment, medications, defibrillator, pocket mask
§ Recovery Area (can be same as operating room) w/ approp. equipment
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Standards of Care in WI
§ Before Sedation – Medical Hx, Allergies, Meds
§ Q 5 min BP, HR, SpO2
§ Conscious Sedation – enteral & parenteral
§ Deep Sedation
§ General
§ Monitor continuously oxygen, ventilation, & circulation
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Standards of Care in WI
§ Medications – time, dosage, & route
§ Maintain records of anesthesia
§ Continually observed by dentist or qualified staff
§ No permit holder will have more than 1 sedated patient
§ Exception – Recovery
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
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z Standards of Care in WI
§ Deep Sedation & GA require “operative supervision”
§ Qualified staff to monitor continuously in recovery room
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Standards of Care in WI
§ “Any dentist whose patient lapses into conscious sedation− enteral from anxiolysis shall meet the requirements” of a class 2 permit
§ “Unless a dentist holds a class 3 permit, he or she shall not administer any drug that has a narrow margin for maintaining consciousness including, but not limited to, ultra−short acting barbiturates, propofol, ketamine, or any other similarly acting drugs.”
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
z Reporting of adverse occurrences related to anesthesia administration in WI
§ Within 30 days to the Board
§ Mortality, temporary or permanent physical or mental injury requiring hospitalization, or a result of anesthesia.
https://docs.legis.wisconsin.gov/code/admin_code/de/11.pdf
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z
Risks and Complications
z Associated Risks
§ Sedation and Anesthesia in non-hospital environment (dental or physician office) – Increased incidence of “failure to rescue” from
adverse events. (Cote Pediatr Dent 2016;38(4)E13-39)
§ Multiple medications leads to trouble
z How safe is deep sedation or general anesthesia while providing dental care? JD Bennett DMD, KJ Kramer DDS, RC Bosack DDS
§ OMSNIC insures 80% OMFS § Conclusion:
§ 2000-2013 – 39,392,008 1. Establish patient safety office based anesthetics database for anes. M&M
§ 113 cases-death or brain 2. Maintaining current injury knowledge, preparation, teamwork. § 1 event every 6.4 weeks
§ Infer all dentists – exceeds 1/month
JADA 146 (9), Sept. 2015
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z Trends in Death Associated with Pediatric Dental Sedation and General Anesthesia HH Lee, P Milgrom, H Starks, W Burke
§ US Media report – death § Results: associated with dental 1. Most deaths 2-5 y (n=21/44) procedures 2. In office setting (n=21/44) § Categorized depth of anes 3. Gen./pediatric dentist § Examined location (n=25/44) § Identified person providing 1. 17/25 linked with sedation sedation/anesthesia
Paediatric Anaesthesia, Aug 2013
z No Centralized Database for Dental Anesthesia/Sedation Complications
§ Caleb’s Law Part 1- (2016) – mandated Dental Board of California to collect specified epidemiologic info on adverse events
§ Mandated dental board -study on sedation safety
§ Specified contents of “disclosure form” for parents concerning anesthesia risks
z No Centralized Database for Dental Anesthesia/Sedation Complications
§ Caleb’s Law Part 2
§ Codify the previous requirements
§ Separate Anesthesia provider for young children – Deep Sedation & General Anesthesia
Ø Dental Lobby Challenging Ø Cite Increased Cost
Ø Disingenuous – 2 invoices
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z
Anesthesia Standard
z Risks and complications
Photo by Ian Furst / CC BY-SA 3.0
z Anesthesiologist Safety Profile
§ Wake Up Safe (Sponsored -Society for Pediatric Anesthesia)
§ 32 Pediatric Anesthesia Departments
§ No Anesthesia related deaths or neurologic injury in 2 million healthy children!
Pediatric 141:4, April 2018
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z Pediatric Sedation Research Consortium
§ 2017
§ Collaborative, multi-institutional, multi-disciplinary
§ 48 institutions
§ NO deaths or significant complication in over 500,000 reported cases to date
Pediatric 141:4, April 2018
z
Consensus Statement
z 2016 American Academy of Pediatrics & American Academy of Pediatric Dentistry
§ Unify guidelines
§ Emphasize difference between pediatric and adult pts
§ Critical - Practitioners need to recognize deeper levels of sedation and have skillset and personnel to rescue the child
Pediatric 141:4, April 2018
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z
Patient Advocacy
z Dental Ethics Advocacy
§ ADA - Chronic disease management, surveillance, and arrest
§ Focus more on prevention (challenge for low socioeconomic)
PEDIATRICS Volume 140, number 6, December 2017
z Dental Ethics Arguments
§ Treat diseased teeth with 38% silver diamine fluoride
§ Painted on decay, quick, painless, safe
§ Turns decay areas dark, repeat Q 6 month
§ Glass ionomer cement and preformed crowns
§ Antibacterial, prevent new lesions
§ Argument – “unethical and wasteful” to not treat early and with advanced disease require GA
PEDIATRICS Volume 140, number 6, December 2017
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z Preventable Death of a Child Should Never Occur
§ American Academy of Pediatrics, American Academy of Emergency Physicians, American Academy of Anesthesiologists and American Dental Association – set standards of physiologic monitoring
§ Barely half comply outside OR (Arch Pediatr Adolesc Med. 2012;166(11):990–998)
z Can’t Find a Solution if We Don’t Acknowledge the Problem
§ Need to track the Morbidity and Mortality of Dental Sedation
§ Only then can we really work to improve patient safety
§ Systematic Review – Systems Errors
z Anesthesiologist’s Patient Advocacy
§ Take the opportunity to advocate for your patient
§ Encourage them to ask questions about monitoring, personnel present, emergency resources
§ Limit scope of practice when appropriate
§ Advocate locally & nationally for a dedicated anesthesia/ sedation provider and against the single provider model.
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z References
1. Cote CJ, Karl HW, Et. al. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. 2000 Oct;106(4):633-44.
2. Mortazavi H, Baharvand M, Et al. Death Rate of Dental Anaesthesia. J Clin Diagn Res. 2017 Jun;11(6):ZE07-ZE09.
3. Lee H, Milgrom P, Et al. Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy?. Pediatrics. 2017 Dec;140(6).
4. Agarwal R, Kaplan A, Et al. Concerns Regarding the Single Operator Model of Sedation in Young Children. Pediatrics. 2018 April; 141(4).
5. Cravero JP, Beach ML, Et al. The Incidence and Nature of Adverse Events During Pedaitric Sedation/Anesthesia With Propofol for Procedure Outside the Operating Room: A report from the Pediatric Research Consortium. Pediatric Anesthesiology. 2009 March; 108(3).
6. Lee HL, Milgrom P, Et al. Trends in Death Associated with Pedaitrci Dental Sedation and General Anesthesia. Paediatr Anaesth. 2013 Aug; 23(8): 741-746.
7. Cote CJ, Wilson S. Guidelines for Monitoring and Management of Pedaitric Patients Before, During and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. American Academy of Pediatric Dentistry, American Academy of Pediatrics. Pediatr Dent 2016; 38(4):E13-E39.
z References
1. Bennett JD, Kramer KJ, Et al. How safe is deep sedation or general anesthesia while providing dental care? JADA 2015 Sept:146(9); 705-708.
2. Langhan ML, Mallory M, Et al. Pediatric Sedation Research Consortium. Physiologic monitoring practices during pediatric procedural sedation: a report from the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med. 2012;166(11):990–998 .
3. Saxen MA, Urman RD, Et al. Comparison of Anesthesia for Dental/Oral Surgery by Office-based Dentist Anesthesiologists versus Operating Room-based Physician Anesthesiologists. Anesth Prog. 2018; 65: 212-220.
4. Guidelines for the Use of Sedation and General Anesthesia by Dentists. Adopted by the ADA House of Delegates, October 2016.
5. code/dhttps://docs.legis.wisconsin.gov/code/admin_e/11.pdf
6. Jastak JT, Peskin RM. Major morbidity or Mortality from Office Anesthestic Procedures: A Closed-Claim Analysis 13 cases. Anesth Prog 1991 38:39-44.
7. Chicka MG, Dembo JB, Et al. Adverse Events during Pediatric Dental Anesthesia and Sedation: A Review of Closed Malpractice Insurance Claims. Pediatr Dent 2012; 34(3): 231-238.
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