Patient Safety Tip
of the Week
November 28, 2017
More on Dental
Sedation/Anesthesia Safety
Lee and colleagues recently asked why we aren’t doing more
to avoid tragedies related to dental sedation/anesthesia (Lee
2017). They described a case where a young patient with dental caries was
sedated with Versed and nitrous oxide for dental work because he had behavioral
issues. More Versed was required during the procedure and after the procedure
was done the dentist left the child in recovery with a dental assistant. But
when he returned with the boy's mother, the child was cyanotic. Rescue efforts failed and the boy was dead upon arrival at the hospital.
Lee and colleagues call for more data and more research on the reasons for
pediatric sedation deaths during dental procedures.
Actually, a considerable amount of data collection and
analysis has been done recently, as noted in our March 28, 2017 Patient Safety Tip of the Week “More
Issues with Dental Sedation/Anesthesia”, which we’ll reiterate later.
But very timely is an article from the California Dental Association
(CDA
2017) in which Dr. Steven Yun, a board-certified M.D. anesthesiologist who
specializes in dental office anesthesia, is interviewed about safe dental
sedation in the office.
Dr. Yun notes 2 important trends in improving dental
sedation safety: “There is now an emphasis on the team model, meaning that as
an anesthesiologist I must recruit and activate each member of the treatment
team to take an active role in patient safety. Dentists, dental assistants and
the front-office staff must be recognized as important and valuable members of
the care team when it comes to anesthesia patient safety.” He describes how he introduces himself to
each member of the team and talks about their role(s), in a manner that
promotes a culture in which team members feel empowered to speak up. He also
reviews basic emergency procedures with the office, checks backup emergency
equipment and completes a pre-anesthesia checklist before every procedure.
The second important trend is the use of checklists. Dr. Yun
uses a Safety
Checklist for Office-Based Procedural Sedation/Anesthesia downloaded
from the American Dental Society of
Anesthesiology. That checklist is similar to the Safe
Surgery Checklist we’ve so often discussed and is customizable.
Another important
point is that he provides his patients and their parents access to a variety of
information about safety on his website and emphasizes the need to do this well
in advance.
And then he provides
several very practical recommendations:
- Don’t take shortcuts.
- When a patient develops distress, call 911 first!
- Follow sedation/anesthesia guidelines promulgated by specialty
societies.
- Practice, practice, practice…for emergencies.
- Be prepared for failures of things like equipment, including
emergency equipment.
The point about
calling 911 first is very important. Dr. Yun emphasizes that one of the most
common mistakes is waiting too long to seek emergency assistance. That
was one of the root causes identified by the Texas Blue Ribbon Panel that we
discussed in our March 28, 2017 Patient Safety Tip of the Week “More
Issues with Dental Sedation/Anesthesia”.
We’ve also
emphasized over and over that the only way to be prepared for rare emergencies,
whether they are events related to dental sedation or hospital events like
surgical fires, is to practice for them. Every member of the team needs
to understand their role in such events. We also like the way he stresses that everyone,
including front office staff, are critical to successfully handling sedation
emergencies.
Periodic inspection
(with a log) of all emergency equipment should be done regularly.
Of course, Dr. Yun
is an anesthesiologist. We doubt that most dental practices are using an
anesthesiologist. Much more often the dentist, who is also doing the dental
work, is the one certified in dental sedation/anesthesia. That dual role is
obviously problematic, regardless of how well we think we can multi-task.
Proper procedures
and guidelines for pediatric sedation (Coté 2016)
were discussed in our August 2016 What's
New in the Patient Safety World column “Guideline
Update for Pediatric Sedation”.
Our March 28, 2017 Patient
Safety Tip of the Week “More
Issues with Dental Sedation/Anesthesia” discussed the Texas blue ribbon panel (Texas
SBDE 2017) recommendations that were made after analyzing multiple Texas
cases with adverse events and reviewing the scientific literature, the above
mentioned guidelines, and regulations in place in other states.
The panel’s review of incidents that had occurred in Texas
included some of the following root causes and contributing factors:
- Emergency drugs were
available but given in the wrong dose
- Emergency ventilation
equipment was available but used ineffectively
- Emergency ventilation
equipment was not available
- Supplemental oxygen was
available but not administered when indicated
- The provider was slow to
activate the emergency medical system (EMS)
The latter factor (long delays in calling 911 or otherwise
activating the EMS) was the most common contributing factor identified, though
it was not universal. The panel identified several root causes for such delays,
including fear that such might lead to a regulatory investigation, considering
the need for EMS as a personal failure, and lack of practice in crisis management.
One other factor suspected, but which was difficult to
prove, was that in some cases the sedation provider may have left the dental
operatory for a period of time, leaving the patient
unobserved. Current rules in Texas require continuous presence of the sedation
provider until the patient has reached a defined level of recovery.
The panel found that at least 2 major failures had occurred
in all 6 major events and that no sedation related event would likely have
occurred if all rules currently in place had been closely followed and failures
avoided.
The Texas blue ribbon panel made several recommendations,
including the following:
- Dentists should have in
place written emergency protocols and be required to document that these
protocols are practiced with office staff using drills or similar
exercises.
- At least one support
staff member assisting with a sedation procedure must receive training in
recognition and management of sedation/anesthesia related emergencies.
- Age-specific sedation
training (for moderate/deep/general anesthesia) must be documented for
those dentists providing services to children under the age of 8 and also for other “high risk” patients (eg. BMI ≥ 30, ASA class 3 or 4, age 75 or
older).
- Basic ventilation
equipment must be onsite at all sites, including offices where portable
providers practice.
- Capnography and a
precordial stethoscope are mandated for procedures using
moderate/deep/general anesthesia.
Other suggestions included encouraging or mandating a
preoperative sedation checklist, clarifying what should be included in the
preoperative evaluation, and what constitutes an acceptable sedation/anesthesia
record.
They also had multiple administrative recommendations and
suggestions that you can read in our prior column.
Texas already had a rule/regulation that at least one member
of the assistant staff be present during nitrous oxide/oxygen inhalation
sedation. The dental provider may delegate monitoring of nitrous oxide/oxygen
inhalation sedation (once pharmacologic and vital sign stability has been
established) to an assistant who is certified by the State Board of Dental
Examiners (SBDE) to do so. Assisting staff must also be certified in BLS (Basic
Life Support).
The updated 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” (Coté 2016)
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. We were glad to see the Texas blue ribbon
panel recommendation for use of capnography.
The updated AAP/AAPD 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 also discusses selection of drugs and the
importance of knowledge about the duration of action of the drugs used. It also
discusses the needs for the emergency cart/kit and backup emergency services
access and availability. There is also a good section on discharge issues,
including what should be monitored by families after discharge.
One important item we could not find in either Texas’
current regulations or the recommendations made by the panel is a statement
about patient restraints or immobilization devices. You’ll recall that several
of the events we described in our March
15, 2016 Patient Safety Tip of the Week “Dental
Patient Safety” involved use
of a pediatric restraint called a “papoose” that may have contributed to the
adverse outcomes. The updated AAP/AAPD guideline has a good discussion about
the use of immobilization devices, such as the “papoose” boards. 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.
We do like the Safety
Checklist for Office-Based Procedural Sedation/Anesthesia downloaded
from the American Dental Society of
Anesthesiology. It has sections for room setup, pre-procedure issues, postop
recovery, and record keeping. But we also wonder how often dental practices do
pre-procedure huddles (briefings) and post-procedure debriefings. Those offer
the opportunity to both plan for contingencies and analyze things that might
have been done better.
We certainly concur with Lee and colleagues that deaths and
other adverse events related to dental sedation/anesthesia should be avoidable.
There are already some excellent guidelines and recommendations available. The
question is how often dental practices comply with those guidelines and
recommendations.
Sedation/anesthesia probably allows dental and oral surgery
procedures needed by many young children. But it is not something that dental
practices or parents of young children should approach cavalierly. Guidelines
like those outlined today need to be adhered to closely and a high level of
vigilance incorporated into such dental practices.
Some of our previous columns on dental patient safety
issues:
March 15, 2016 “Dental
Patient Safety”
August 2016 “Guideline
Update for Pediatric Sedation”
March 28, 2017 “More
Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation
for Pediatric MRI Rising”
References:
Lee H, Milgrom P, Huebner CE, et al. Ethics Rounds: Death After
Pediatric Dental Anesthesia: An Avoidable Tragedy? Pediatrics 2017, e20172370
CDA (California Dental Association). Dental anesthesia
safety: Say something if you see something. CDA News/Events 11/09/2017
ADSA (American
Dental Society of Anesthesiology). Safety Checklist for Office-Based Procedural
Sedation/Anesthesia.
https://irp-cdn.multiscreensite.com/f37fe5b3/files/uploaded/ADSAChecklistFINAL%20copy.pdf
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
State Board of Dental Examiners (Texas). Report to the Texas
Sunset Advisory Commission by the Blue Ribbon Panel on
Dental Anesthesia/Sedation Safety. January 4, 2017
https://lintvkxan.files.wordpress.com/2017/01/anesthesia-recommendations-final-report.pdf
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