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What’s New in the Patient Safety World

September 2019

New Guidelines for Pediatric Dental Sedation

 

 

We’ve published multiple columns on the risks of sedation for dental procedures (see list below). The AAP (American Academy of Pediatrics) and the AAPD (American Academy of Pediatric Dentistry) recently updated their joint “Guideline for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures” (Cote 2019). This is a comprehensive guideline that notes how pediatric procedural sedation differs from that in adults and focuses on multiple facets of procedural sedation in pediatric patients:

-        no administration of sedating medication without the safety net of medical/dental supervision

-        careful pre-sedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications

-        appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure

-        a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction

-        a clear understanding of the medication’s pharmacokinetic and pharmacodynamic effects and drug interactions

-        appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access

-        appropriate medications and reversal agents

-        sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient

-        appropriate physiologic monitoring during and after the procedure

-        a properly equipped and staffed recovery area

-        recovery to the pre-sedation level of consciousness before discharge from medical/dental supervision

-        appropriate discharge instructions

 

The principles really apply to pediatric procedural sedation in a variety of settings and venues, but the purpose of this updated report was to unify the guidelines for sedation used by medical and dental practitioners and to add clarifications regarding monitoring modalities, particularly regarding continuous expired carbon dioxide measurement, and other refinements.

 

A group of 6 healthcare organizations has recently endorsed those new guidelines for pediatric dental sedation. The 6 include the American Academy of Pediatrics, the American Academy of Pediatric Dentistry (AAPD), the American Society of Anesthesiologists (ASA), the Society for Pediatric Anesthesia, the American Society of Dentist Anesthesiologists, and the Society for Pediatric Sedation.

 

Perhaps the most important item in the guideline is a requirement that such procedures be done in the presence of two qualified individuals. That means that the dentist or oral surgeon performing the dental or oral surgery procedure cannot be the individual administering and monitoring the sedation. This ensures that individuals are attending to one primary task and not involved in two different tasks simultaneously.

 

The guideline also clarifies that deep sedation or general anesthesia must be administered by a qualified anesthesia provider (a physician anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist or second oral surgeon). Because children commonly pass from an intended sedation level to an unintended deeper level of sedation, practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure. The ability to rescue means that practitioners must be able to recognize the various levels of sedation and have the skills and age- and size-appropriate equipment necessary to provide appropriate cardiopulmonary support if needed.

 

The guideline includes discussion on monitoring and documentation before, during, and after the procedure. There is good discussion on capnography for continuous expired carbon dioxide measurement.

 

The guideline also emphasizes caution, as we have in multiple columns, regarding the use of devices such as “papooses” that might restrict chest movement or obstruct airways.

 

We are also pleased to see the guideline emphasizes the need, for nonhospital facilities, for a protocol for the immediate activation of the EMS system for life threatening complications. We’ve previously advised that drills and simulations include even front office staff so they can facilitate such emergency responses.

 

There is far more in the updated guideline than we can fit is a short column. We encourage you to read the guideline in its entirely.

 

 

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

November 28, 2017    “More on Dental Sedation/Anesthesia Safety

July 2019                    “Dental Prescribing Called Into Question

 

 

 

References:

 

 

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. Pediatrics 2019; 143(6): June 2019

https://pediatrics.aappublications.org/content/143/6/e20191000

 

 

 

 

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