Standard of Practice: Minimal and Moderate Sedation Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice ©Copyright 2020 Alberta Dental Association & College ©Copyright 2020 Alberta Dental Association & College All rights reserved. No part of this publication may be reproduced without the prior permission of the publisher. Introduction This document of the Alberta Dental Association and College (ADA&C), the Standard of Practice: Minimal and Moderate Sedation Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice, is the standard of practice for administration of sedation and applies to all regulated members administering sedation. Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice replaces the former Standard of Practice: Dental Facilities Accreditation and is the standard of practice for administration of sedation with respect to dental surgical services in Alberta in accordance with Section 4 of the Dental Surgical Facility Accreditation Regulation. Contravention of the Minimal and Moderate Sedation Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice Standards may constitute unprofessional conduct under the Health Professions Act. The Health Professions Act requires that a Non-Hospital Surgical Facility (NHSF) or Dental Surgical Facility (DSF) must be accredited before a regulated member (dentist) provides Dental Surgical Services. The Health Professions Act, the Health Facilities Act, the Dentists Profession Regulation and the Bylaws of the ADA&C establish the overall regulatory framework and authority regarding Dental Surgical Facilities. Under this authority, the Dental Facility Accreditation Committee (DFAC) was established to uphold and enforce the Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice Standards. The Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice Standards and the College of Physicians and Surgeons of Alberta, Non-Hospital Surgical Facility Standards and Guidelines address accreditation requirements under the Health Professions Act, Schedule 7, Profession of Dentists, section 12(1). The Health Facilities Act establishes the overall regulatory framework for surgical facilities that applies to both dentists and physicians. This Act defines “insured surgical services” and also states that in order to operate a Dental Surgical Facility at which insured surgical services are provided, the Dental Surgical Facility must be accredited; have an agreement with a Regional Health Authority; and be designated by the Minister. Restricted activities that can be performed by regulated members are outlined in the Dentists Profession Regulation. With respect to anaesthetics, section 12(k) of the Dentists Profession Regulation authorizes all regulated members to prescribe or administer nitrous oxide for the purpose of anaesthesia or sedation. Section 13 of the Dentists Profession Regulation requires that, only regulated members who successfully complete an educational program in the administration of general and neurolept anaesthesia approved by the Council and have been authorized by the Council may perform the following restricted activities related to the administration of anaesthesia, other than nitrous oxide, in the practice of dentistry. Alberta Dental Association and College (ADA&C) regulated members (General Practitioner [Dentist], Endodontist, Oral and Maxillofacial Surgeon, Orthodontist and Dentofacial Orthopedist, Pediatric Dentist, Periodontist, Prosthodontist, Oral Medicine and Pathology, Oral and Maxillofacial Radiologist and Public Health Dentists) must register annually for sedation. Authorized Dentists by the Alberta Dental Association and College (ADA&C) must hold a current Alberta Dental Association and College (ADA&C) permit for Moderate Sedation, Deep Sedation/General Anaesthesia. Defined terms are used throughout the Minimal and Moderate Sedation Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice Standards. Reference should be made to Appendix A (Definitions) in the Minimal Sedation and Moderate Sedation and Appendix D (Definitions) in the Deep Sedation and General Anaesthesia for reference to these defined terms. Defined terms used throughout the Standard of Practice: Minimal and Moderate Sedation Deep Sedation and General Anaesthesia in Non-Hospital Dental Practice are defined terms whether the term is capitalized or not and whether the term is used in the singular or plural form. American Society of Anesthesiologists Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia* Minimal Sedation Moderate Sedation/ Analgesia Deep Sedation/ Analgesia General Anesthesia Anxiolysis (“Conscious Sedation”) Responsiveness Normal response to Purposeful** response to Purposeful** response Unarousable even with verbal stimulation verbal or tactile stimulation following repeated or painful stimulus painful stimulation Airway Unaffected No intervention required Intervention may be Intervention often required required Spontaneous Unaffected Adequate May be inadequate Frequently inadequate Ventilation Cardiovascular Unaffected Usually maintained Usually maintained May be impaired Function Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully** to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. * Monitored Anesthesia Care (“MAC”) does not describe the continuum of depth of sedation, rather it describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure.” ** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully** following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained. General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug- induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue*** patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”) should be able to rescue*** patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue*** patients who enter a state of General Anesthesia. ** Reflex withdrawal from a painful stimulus is NOT considered a purposeful response. *** Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner corrects adverse physiologic consequences of the deeper-than- intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation. https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia- and-levels-of-sedationanalgesia Minimal Sedation and Moderate Sedation Table of Contents Minimal Sedation and Moderate Sedation ................................................................ 10 1.0 Nitrous Oxide Sedation for patients 12 years of age and older ..................................... 11 Pre-Operative .......................................................................................................... 11 1.1 Regulated Member Training ............................................................................ 11 1.2 Patient Selection ............................................................................................. 11 Intra-Operative ........................................................................................................ 11 1.3 Staffing .......................................................................................................... 11 1.4 Monitoring ..................................................................................................... 11 Post-Operative ......................................................................................................... 11 1.5 Recovery .......................................................................................................