What’s New in the Patient Safety World
August 2016
Guideline Update for Pediatric Sedation
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.
References:
Kronemyer B. Deaths of Children During Dental Procedures Raise Safety Concerns.
Anesthesiology News 2016; June 30, 2016
Pierrotti A. Defenders:
Investigating Dental Deaths. KVUE 2016; April 28, 2016
http://www.kvue.com/news/investigations/defenders/defenders-investigating-dental-deaths/158354392
Coté CJ, Wilson S, American
Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for
Monitoring and Management of Pediatric Patients Before, During, and After
Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016;
138(1): e2016121
http://pediatrics.aappublications.org/content/138/1/e20161212
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