Guidelines for Pharmacosedation Introduction



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Indian Health Service Oral Health Program Guide



1Guidelines for Pharmacosedation

Introduction

Pharmacosedation is a necessary adjunctive procedure for many dental procedures, most often for behavior management and/or surgical procedures. Specific training is required, and these guidelines are not meant to be a substitute for that training. Sedative techniques are subject to Joint Commission on Accreditation of Healthcare Organization (JCAHO) review and facilities may restrict techniques for a variety of considerations. These guidelines are based on guidelines developed by the American Dental Association (ADA) and the practitioner is urged to review the most recent revision.

The goals for the management of pharmacosedation in the ambulatory patient are:


  • Patient welfare

  • Control of patient behavior

  • Facilitate and augment the provision of quality care.

  • Production of positive psychological response to treatment

  • Return to pretreatment level of consciousness by time of discharge

Definition of Terms

For the purpose of this document the following definitions shall apply:



  • Nitrous Oxide-Oxygen Analgesia: The relative reduction of fear, anxiety, and pain response through the controlled delivery of nitrous oxide and oxygen through a dental inhalation sedation delivery system.

  • Anxiolysis (minimal sedation): A dissolution or reduction of anxiety through the use of the hypnotic dose of a sedative agent, i.e., light sedation

  • Definition (ADA): Anxiolysis–“the diminution or elimination of anxiety”

  • Definition (JACHO): Minimal Sedation–“A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.”

  • Definition (American Association of Pediatric Dentists [AAPD]): Mild sedation (Level 1)–“decreased anxiety”

  • Conscious Sedation: A controlled, pharmacologically-induced, minimally depressed level of consciousness that retains the patient's ability to maintain a patent airway independently and continuously, and respond appropriately to physical stimulus and verbal command.

  • Deep Sedation: A controlled, pharmacologically-induced state of depressed consciousness from which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes, including loss of the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal command.

  • General Anesthesia: A controlled state of unconsciousness accompanied by a loss of protective reflexes, including the ability to maintain an airway independently and respond purposefully to physical stimulation or verbal command.

  • Must or Shall: “Must” or “shall” indicate an imperative need and/or duty; essential or indispensable; mandatory.

  • Should: “Should” indicates the recommended manner of achieving the standard; highly desirable.

  • May or Could: “May” or “could” indicate freedom or liberty to follow a suggested or reasonable alternative.

  • American Society of Anesthesiology (ASA) Classification (Modified):

  • Class I. A normally healthy patient with no organic, psychological, biochemical or psychiatric disturbance or disease.

  • Class II. A patient with mild to moderate systemic disturbance or disease.

  • Class III. A patient with severe systemic disturbance or disease.

  • Class IV. A patient with severe and life-threatening systemic disease or disorder.

  • Class V. A moribund patient who is unlikely to survive without the planned procedure.

General Considerations

  • Applicability: These guidelines should be considered as minimum guidelines and may be superseded by more stringent local policies and procedures.

  • Privileging: Each dental program should use a Dental Privileges Request Form. Dentists requesting privileges for Pharmacologic Management must specify each technique for which privileges are requested. Full or limited privileges will be granted or denied on the basis of the requesting dentist's documented training and experience. Documentation of training and experience in the form of an appropriate training certificate or a letter specifying past experience from the requesting dentist's current or immediate past dental supervisor must accompany the Dental Privileges Request Form.

  • Local Anesthesia: All local anesthetic agents can become cardiac and central nervous system (CNS) depressants when administered in excessive doses. There is a potential interaction between local anesthetic and sedatives used in pediatric dentistry, which can result in, enhanced sedative effects and/or untoward events; therefore, particular attention should be paid to doses used in children. To avoid excessive doses, a maximum recommended dose in mg/kg or mg/lb should be calculated for each patient and recorded prior to administration for all sedatives and local anesthetics used (Table 1).

  • Candidates: A preoperative physical assessment should be completed the day of treatment by a qualified practitioner for all patients undergoing sedation at levels deeper than anxiolysis. A medical consult may be appropriate. Patients who are ASA Class I or II may be considered candidates for conscious sedation or deep sedation. Patients in ASA Class III or IV present special problems and require individual consideration and should be treated in a hospital setting. General anesthesia requires consultation with an anesthesiologist, unless the person administering the general anesthesia has been adequately trained and privileged to assess the patient.

  • Responsible Adult: The pediatric patient should be accompanied to and from the treatment facility by a parent, legal guardian, or other responsible adult who should be required to remain at the treatment facility for the entire treatment period. Adult patients should be accompanied by a responsible adult.

Additional Points

  • Pediatric Life Support (PALS) and/or Advanced Cardiac Life Support (ACLS) are strongly encouraged.

  • For IV sedation/deep sedation, providers must be able to start and maintain an IV line, provide positive pressure ventilation, and intubate a patient.

  • Providers should demonstrate current competence via provision of documentation that they have properly performed the procedure a minimum of 10 times during the past year or continuing education every two years at minimum.

  • Any patient given a sedating agent in the clinic should be appropriately monitored by an individual trained and competent in the monitoring of sedated patients. Because there have been reported instances of children receiving a sedating agent, returning to the waiting room to await the onset of sedation, and suffering respiratory depression due to the lack of adequate monitoring, administration of agents with patients returning to the waiting room for onset of sedation is not acceptable in the IHS. No medications for conscious sedation or deeper levels of sedation should be administered outside of the clinical setting.

  • Supplemental oxygen is recommended for all sedated patients (not including anxiolysis).

Table 1: Local Anesthetic Dosages

Generic per Name

Brand Name

Conc. (%)

Max. Rec. Dose (Mg/Kg)

Mg Carpule

Lidocaine

Xylocaine

2

4.4

36

Mepivacaine

Carbocaine

2

4.4

36

Mepivacaine

Carbocaine

3

4.4

54

Prilocaine

Citanest

4

6.0

72

Bupivacaine

Marcaine

0.5

2.0

9

Septocaine

Articaine

4

7.0

72


Facilities

  • Medical support: The dental supervisor and the clinical director may limit the use and type of dental sedation performed based upon the availability of medical support. Utilization of some sedation techniques, e.g., IV sedation techniques, may require the prior notification of a physician present in the facility to assure that adequate medical support is available.

  • Staffing: The staff required to safely conduct a sedation procedure will vary with the technique used.

  • Armamentarium: Basic emergency diagnostic and treatment equipment and an emergency drug kit must be readily available. This should include the following: sphygmomanometer, stethoscope, oxygen source capable of delivering bag and mask ventilation greater than 90% oxygen at 10 liters per minute flow for at least 60 minutes, adequate suction apparatus with tonsillar suction tip, oral and nasal airways of different sizes, and IV kits. The equipment and supplies should be appropriate for both pediatric and adult patients. If narcotic drugs are administered, Naloxone must be available in the emergency drug kit. If Midazolam is administered, flumazanil (reversal agent) must be available. Additionally, strong consideration should be given to having a crash cart with defibrillator available.

  • Nitrous Oxide: When nitrous oxide is used, the facility should be compliant with the guidelines in the Environmental Health and Safety section (Section VI) of this guide. A flowmeter capable of delivering 100% O2 must be used, and only flowmeters which require 20% minimum O2 flow rate are acceptable. Normal operation should be restricted to 50% or less N2O.

Emergency Services

Back-up emergency services should be identified. A protocol outlining necessary procedures for their immediate employment should be developed and operational for each facility. For nonhospital facilities, an emergency assist system should be established with the nearest hospital emergency facility and ready access to ambulance service must be assured.



Documentation Prior to Treatment

The practitioner must document each sedation procedure in the patient's record. Documentation should include the following:



  • Informed consent: Each patient, parent, or other responsible individual is required to be informed regarding benefits, risks, and alternatives to sedation and to give consent. The patient record should document that appropriate informed consent was obtained according to the procedures of the facility.

  • Instructions to parents or responsible individual: The practitioner should provide verbal and written instructions to the parents or responsible individual. Instructions should be explicit and include an explanation of pre- and post-sedation dietary precautions, potential or anticipated postoperative behavior, and limitation of activities.

  • Dietary precautions: The administration of sedative drugs should be preceded by an evaluation of the patient's food and fluid intake. Intake of food and liquids should be as follows: (a) no milk or solids after midnight prior to scheduled procedure; (b) clear liquids up to 4 hr. before procedure for children ages 6 months to 3 years; (c) clear liquids up to 6 hr. before procedure for children ages 3 to 6 years; and (d) clear liquids up to 8 hr. before procedure for children aged 7 years or greater. No restrictions are necessary for anxiolysis or nitrous oxide-oxygen sedation.

  • Preoperative health evaluation: Prior to the administration of sedatives, the practitioner should obtain and document information about the patient's current health status as detailed in the following sections concerning the various sedation modalities.

  • Patient immobilization: If patient immobilization will be required as part of the procedure, specific informed consent, including planned device and duration, should be obtained.

  • Prescriptions: When prescriptions are used for prescribing drugs, such as minor tranquilizers to be administered orally by a responsible adult preprocedurally outside the treatment facility, a copy or a note describing the content of the prescription should be documented in the patient's record, along with a description of the instructions given to the responsible individual.

General Requirements for the Monitoring and Documentation for Oral and Parenteral Conscious Sedation and Deep Sedation

The patient should be monitored from the time of drug delivery until discharge.



  • Vital Signs. The patient's record should contain documentation of intermittent quantitative monitoring and recording of oxygen saturation (pulse oximetry), heart and respiratory rates, and blood pressure, as recommended for specific sedation techniques. Responsiveness of the patient should be monitored at specific intervals before and during the procedure and until the patient is discharged.

  • Drugs. The patient's record should document the name, dose and route, site, and time of administration of all drugs administered. The maximum recommended dose per kilogram or pound should be calculated and the actual dose given shall be documented in appropriate units (e.g., fentanyl is administered in microgram doses, not milligrams). The concentrations, flow rate, and duration of administration of oxygen and nitrous oxide should be documented.

  • Patient Immobilization. Patient immobilization devices used and duration should be documented.

The condition of the patient and the time of discharge from the treatment facility should be documented in the record. Documentation should include that appropriate discharge criteria have been met. The record should also identify the responsible adult to whose care the patient was discharged (Table 2).

Table 2: Recommended Discharge Criteria


1.

Cardiovascular function is satisfactory and stable.

2.

Airway patency is uncompromised and satisfactory.

3.

Patient is easily arousable and protective reflexes are intact.

4.

State of hydration is adequate.

5.

Patient can talk, if applicable.

6.

Patient can sit unaided, if applicable.

7.

Patient can ambulate with minimal assistance, if applicable.

8.

For the very young child or disabled person who is incapable of the usually expected responses, the presedation level of responsiveness or the level as close as possible for that person has been achieved.

9.

Responsible individual is available.


Sedation Techniques, Specific Criteria

Anxiolysis

  • Training

    Documentation of training and pharmacology in the form of dental school transcripts or a letter attesting to training from the institution. Where anxiolysis was not taught, training should be at least 16 hours in duration and include supervised administration of anxiolytic sedation in no fewer than five cases.



  • Staffing

    No additional staff beyond those needed for the routine dental procedure are required



  • Armamentarium

    No additional armamentarium beyond the normal dental procedure set-up is required



  • Preoperative Evaluation

    Only a review of the dental/medical history form is required.



  • Monitoring

    No additional monitoring beyond visual and verbal monitoring is required



  • Documentation

    Documentation should include drug and dose used and its effectiveness.



Nitrous Oxide-Oxygen Sedation

Nitrous oxide is colorless with a faint, sweet smell. It is an effective analgesic/anxiolysis agent causing central nervous system (CNS) depression and euphoria, with little effect on the respiratory system. It causes minor depression in cardiac output while peripheral resistance is slightly increased, thereby maintaining blood pressure (advantage when treating patients with cerebrovascular system disorders).

Nitrous oxide is absorbed rapidly, allowing for both rapid onset and recovery (2–3 minutes). It causes minimal impairment of any reflexes, thus protecting the cough and gag reflexes. To be considered anxiolysis, no other anxiolytic, sedative or antihistamine drug may be used concomitantly.

Nitrous oxide has been cited extensively in the literature for more than 150 years as a safe and effective drug.



  • Training

    Documentation of nitrous oxide training and pharmacology in the form of dental school transcripts or a letter attesting to training from the institution. Where nitrous oxide was not taught, training should be at least 16 hours in duration and include supervised administration of nitrous oxide oxygen sedation in no fewer than five cases. Training in emergency procedures is required. Only providers with appropriate credentials and privileges should be allowed to administer nitrous oxide/oxygen.

    Dental assistants training must include basic life support. Individuals involved with nitrous oxide/oxygen should participate in documented periodic review of emergency protocols, drug cart and simulated exercises to assure proper emergency management response.


  • Staffing

    During administration of nitrous oxide/oxygen, two qualified people must be present to monitor the patient (may be dentist and chair side dental assistant).



  • Armamentarium

    Only fail safe machines that deliver a minimum of 30% oxygen at all times will be used in the dental clinic.

    Equipment must have an appropriate scavenging system.

    Equipment must be checked and calibrated regularly according to the practitioners state laws and regulations (this is to include scavenging system).



  • Preoperative Evaluation

    A review of the dental medical history form is required.

    Evaluation of airway patency and respiratory system


  • Potential contraindications include the following:

  • Upper respiratory infection, respiratory diseases, or asthma

  • Lobar emphysema

  • Possible bowel obstruction

  • Patients with severe emotional disturbances or drug-related dependencies

  • Chronic Obstructive Pulmonary Disease (COPD)

  • Patients with pulmonary fibrosis

  • Tuberculosis (TB)

  • Pregnancy, first trimester

Medical consultations as needed, including but not limited to:

  • Severe obstructive pulmonary disease

  • Congestive heart failure

  • Recent tympanic membrane grafts

  • Eye surgery

Methodology

  • Select appropriate size nasal hood.

  • 100% oxygen for 1 to 2 minutes.

  • Nitrous oxide will be titrated to achieve the appropriate effect based on individual patient response.

  • Concentration of nitrous oxide may be varied depending on the difficulty of the procedure, but should not exceed 50%.

  • Once procedure is completed patient should receive 100% oxygen for 3–5 minutes. (Avoids diffusion hypoxia).

  • Patient must return to pretreatment responsiveness prior to discharge.

Monitoring

Only visual and verbal monitoring of the patient for ventilation and level of consciousness throughout the procedure are required. The patients’ responsiveness (verbal), color, respiratory rate and rhythm should be observed.

The provider may utilize monitoring equipment (precordial stethoscope, pulse oximeter, blood pressure) as deemed necessary for the care of a particular patient. Pulse oximetry is recommended, but not required.

Patients must be observed by dental personnel until discharged (never should a patient be left alone).

Documentation


  • Informed consent for nitrous oxide

  • Indications for the use of nitrous oxide

  • The concentration of nitrous oxide used, flow rate, duration, effectiveness, and duration of oxygen flush

  • Patient’s condition on release

Oral Conscious Sedation

Training


  • At least 40 hours of formal training, along with a proctored period with a specific number of cases being monitored should be a minimum requirement for the administration of oral conscious sedation.

  • A written and/or practical exam should also be considered. Persons who have received formal training in a residency or specialty program may not require these guidelines, but a letter from the residency director detailing the scope of training and competency should be required. The provision of the proctored sedation procedures may take place following didactic instruction at the training facility or at the dentist's duty station, if supervision is available by a health professional adequately trained in the conscious sedation technique being taught. Senior clinicians who are currently practicing sedation techniques should demonstrate sufficient experience by providing documentation that they have properly performed the procedure a minimum of 10 times during the past year or that they have attended a refresher course in the past year.

  • Satisfactory completion of a graduate training program or residency in a recognized dental specialty or ADA-approved General Practice Residency which provides training and experience in the use of sedation, including airway management, risk assessment, physical evaluation, and medical emergency management. As stated above, letter from the residency director detailing the scope of training and competency should be required.

  • ACLS and/or PALS are encouraged.

  • The practitioner and all treatment facility personnel should participate in periodic reviews of the office's emergency protocol, including simulated exercises to assure proper equipment function and staff interaction.

Staffing

  • The dentist should have at least two properly trained dental personnel present for proper monitoring and support, one to assist in the dental procedure and one to monitor the patient. At least one must be certified in basic life support.

  • The practitioner responsible for the treatment of the patient and/or the administration of drugs for conscious sedation must be appropriately trained in the use of such drugs and techniques, must provide for appropriate monitoring, and must be capable of managing any reasonably foreseeable complications.

  • In addition to the operating practitioner, an individual trained to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures required should be present. Both individuals must have training in basic life support, should have specific assignments, and should have current knowledge of the emergency cart (kit) inventory.

Armamentarium

  • The operating facility used for the administration of conscious sedation should have available all facilities and equipment previously recommended. The minimum monitoring equipment for sedation shall be a pulse oximeter. A precordial/pretracheal stethoscope is highly desirable. ECG monitoring equipment should be considered but is not required.

Preoperative Evaluation

  • Health history

  • Review of systems

  • Vital signs, including heart rate, respiratory rate, and blood pressure

  • Risk assessment (ASA guidelines)

  • Evaluation of airway patency

  • Evaluation of the respiratory and cardiac systems is needed

Monitoring

  • Whenever drugs for conscious sedation are administered, the patient should be monitored continuously for responsiveness and airway patency. There should be continuous monitoring of oxygen saturation by pulse oximetry and of heart and respiratory rates. Respiratory rate alone may not be a reliable guide to oxygenation, especially when the rate is hard to determine and respirations are shallow. ECG monitoring is once again encouraged. A precordial/pretracheal stethoscope also may be used for obtaining additional information on heart and respiratory rates and for monitoring airway patency. Restraining devices should be checked periodically to prevent airway obstruction or chest restriction. The patient's head position should be checked frequently to ensure airway patency. A sedated patient must be constantly observed by a trained individual from the time the sedating agent is administered until discharge from the facility.

Documentation

  • Oxygen saturation and heart and respiratory rates should be recorded intermittently on a time-based record (e.g., every 5 minutes) throughout the procedure and until the patient is discharged.

  • After completion of the treatment procedures, vital signs should be recorded at specific intervals. Postoperative monitoring, of blood pressure, heart rate, pulse oximetry , and possibly ECG is prudent. The practitioner shall assess the patient's responsiveness and discharge the patient only when the appropriate discharge criteria have been met.

Parenteral Conscious Sedation

Training


  • The training requirements for parenteral conscious sedation are the same as for oral conscious sedation except that a minimum of 80 hours, rather than 40 are recommended. The potential for a conscious sedation technique to progress to the level of deep sedation, especially with the administration of intravenous drugs, necessitates this higher level of training.

Staffing

  • Staffing requirements are the same as for oral conscious sedation.

Armamentarium

  • Same as for oral conscious sedation, with the addition of IV armamentarium

Preoperative Evaluation

  • Health history

  • Review of systems

  • Vital signs, including heart rate, respiratory rate, and blood pressure

  • Risk assessment (ASA guidelines)

  • Evaluation of airway patency

  • Evaluation of the respiratory and cardiac systems is needed

Monitoring

  • Same as for oral conscious sedation. Due to the potential for a parenteral conscious sedation procedure to progress to deep sedation, the monitoring standards for deep sedation should be considered.

Documentation

  • Same as for oral conscious sedation.

Deep Sedation

Training


  • The training requirements for deep sedation are the same as for parenteral conscious sedation.

Staffing

  • The dentist must have at least two properly trained dental personnel present during any sedation procedure for proper monitoring and support. They should be certified in basic life support.

  • The techniques for deep sedation require the following individuals: 1) the treating practitioner who may direct the sedation; 2) a qualified individual to assist with observation and monitoring of the patient and who may administer drugs if appropriately licensed; and 3) other personnel to assist the operator as necessary. The operator and at least one other individual must be currently certified in basic life support.

Armamentarium

  • In addition to the facilities and equipment previously recommended for oral and parenteral conscious sedation, in the operating facility used for the administration of deep sedation, the capability for ECG monitoring, and the availability of a capnograph and a defibrillator are desirable.

Pre-op evaluation

  • Health history

  • Review of systems

  • Vital signs, including heart rate, respiratory rate, and blood pressure

  • Risk assessment (ASA guidelines)

  • Evaluation of airway patency

  • Evaluation of the respiratory and cardiac systems is needed

Intravenous Access

  • Patients receiving deep sedation should have an intravenous line in place prior to the start of the procedure if the patient is cooperative; otherwise, as soon as possible after the procedure has begun. The time to start an IV is before problems arise. It can be very difficult to start an IV on a crashing patient due to cardiovascular collapse and confusion in the operatory.

Monitoring

  • The sedated patient should be continuously monitored by an appropriately-trained individual. There should be continuous monitoring of oxygen saturation (by pulse oximetry), heart and respiratory rates, and blood pressure. A pulse oximeter, precordial/pretracheal stethoscope, and blood pressure cuff are minimum monitoring devices; ECG, capnography, and temperature monitoring are desirable, (the AAPD considers capnography to be a standard of care for deep sedation). The patient's head position should be checked frequently to ensure airway patency. A sedated patient must be constantly observed by an appropriately-trained individual.

  • After treatment has been completed, the patient must be observed in a suitably-equipped recovery facility. This facility must have functioning suction apparatus and suction catheters of appropriate size, as well as the capacity to delivery greater than 90% oxygen and provide positive pressure ventilation. An individual experienced in recovery care must be in attendance at all times in order to assess and record vital signs, observe the patient, and ensure airway patency. The patient must remain in the recovery facility until cardiovascular and respiratory stability are ensured and appropriate discharge criteria have been met.

Documentation

  • Oxygen saturation, heart and respiratory rates, carbon dioxide, and blood pressure should be recorded intermittently on a time-based record (e.g., every 5 minutes).

  • After completion of the treatment procedures, vital signs should be recorded at specific intervals. Postoperative monitoring, of blood pressure, heart rate, pulse oximetry , and possibly ECG is prudent. The practitioner shall assess the patient's responsiveness and discharge the patient only when the appropriate discharge criteria have been met.

General Anesthesia

Policies and procedures for the provision of general anesthesia are the prerogative of the Medical Staff Committee or Anesthesia Department of the facility. The dental practitioner should make himself/herself aware of all applicable provisions. General Anesthesia may be administered by a qualified person on appropriate patients without medical consultation, in an adequate facility, with provision for recovery, if local Policies and Procedures so permit.



Table 3: Summary Table of Characteristics, Armamentaria, And Monitoring Requirements For Various Levels Of Sedation

(from the AAPD’s “Guideline on the Elective Use of Minimal, Moderate, and Deep Sedation and General Anesthesia for Pediatric Dental Patients,” used with permission)



Template of Definitions and Characteristics for Levels of Sedation and General Anesthesia




Minimal Sedation

Moderate Sedation

Deep Sedation

General Anesthesia

Goal


Decrease or eliminate anxiety; facilitate coping skills

Decrease or eliminate anxiety; facilitate coping skills. Younger patients show age-appropriate behaviors, including crying; older patients demonstrate interactive state.

Eliminate anxiety; coping skills unaffected and overridden. Patient uneasily aroused but may respond to purposeful stimulation

Eliminate sensory and skeletal motor activity; autonomic activity depressed

Patient responsiveness

Subjectively, the patient may sense and/or express less anxiety about the clinical procedure compared to pre-sedation periods. Objectively, the patient may appear calm, less overtly responsive to clinical stimuli, and purposefully interactive with the clinician compared to pre-sedation periods

Subjectively, the patient may sense and/or express less anxiety about the clinical procedure compared to pre-sedation periods.

Objectively, the patient may appear less tense, cognizant of, but less overtly responsive to, clinical stimuli, and purposefully interactive with the clinician, compared to presedation periods. The patient, if behaviorally and cognitively cooperative should be able to independently move his/her head and/or mandible, as directed by the clinician and to assist in maintaining optimal airway patency



Subjectively, the patient may sense and/or express limited or no feelings of anxiety associated with the clinical procedure. Objectively, the patient may appear very relaxed, not cognizant of and minimally or nonresponsive to clinical stimuli. And noninteractive with the clinician at any time. The patient would not be able independently to move his/her head and/or mandible to maintain optimal airway patency consistent with the clinical situation. Under these circumstances, the patient requires continuous monitoring of the airway and continual assistance of the clinician (e.g. Head tilt, chin lift procedure)

Unconscious and unresponsive to surgical stimuli.

Physiologic changes

Patient remains stable and within age-appropriate and health status norms for parameters involving hemodynamic, ventilation, and oxygenation functions. No loss of protective reflexes.

Patient remains stable and within age-appropriate and health status norms for parameters involving hemodynamic, ventilation, and oxygenation functions. No loss of protective reflexes.

Patient remains stable and either minimally or moderately below the patient’s age and health status norms for hemodynamic, ventilation, and oxygenation functions. Accompanied by partial or complete loss of protective reflexes.

Partial or complete loss of protective reflexes, including the airway; does not respond purposefully to verbal command or physical stimulus.

Personnel needed

2

2

3

3

Monitoring Equipment

Clinical observation unless patient becomes moderately sedated, then appropriate monitoring needed.

BPC, PO, PC or capno

BPC, PO, PC, capno, ECG

BPC, PO, PC, capno, ECG, temp

Monitoring Information and frequency

Skin color, respiratory effort (continual)

HR, RR, BP, SaO2, (q 15 min)

HR, RR, BP, SaO2, ETCO2 (q 5 min)

HR, RR, BP, SaO2, ETCO2 temp (q 5 min)

BP=blood pressure; BPC= blood pressure cuff/sphygmomanometer; capno = capnography/end tidal carbon dioxide monitor; EC=electrical conductivity as demonstrated on ECG; ECG=electrocardiography; ETCO2 = end tidal carbon dioxide; temp=temperature; HR=heart rate; PO=pulse oximetry; PC=precordial/pretracheal stethoscope; RR=respiratory rate; SaO2= oxygen saturation


Additional Information

Additional information and guidelines for the use of pharmacosedation in the dental clinic can be found at the following sites:



ADA guidelines and statements:

  • The Use of Conscious Sedation, Deep Sedation and General Anesthesia in Dentistry: http://www.ada.org/prof/resources/positions/statements/useof.asp

  • ADA Statement On Dental Anesthesia: http://www.ada.org/prof/resources/positions/statements/anes.asp

  • Guidelines for the Use of Conscious Sedation, Deep Sedation and General Anesthesia for Dentists: http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf

AAPD guidelines:

  • Appropriate Use of Nitrous Oxide for Pediatric Dental Patients: http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf

  • Elective Use of Minimal, Moderate, and Deep Sedation and General Anesthesia for Pediatric Dental Patients: http://www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf

ATTACHMENT 1: Sample Privileges Request Form For Sedation/General Anesthesia

PRIVILEGE

LEVEL REQUESTED

LEVEL APPROVED




FULL

LIMITED

NONE

FULL

LIMITED

NONE

Nitrous Oxide/Oxygen Sedation



















Anxiolysis



















Oral Conscious Sedation



















Oral Deep Sedation



















Parenteral Conscious Sedation



















Parenteral Deep Sedation



















General Anesthesia




















ATTACHMENT 2: Indications for Sedation in the Dental Clinic

  1. The precooperative and the fearful, anxious, or uncooperative child whose disruptive behavior precludes the safe delivery of quality dental care and whose developing psyche should not be exposed to the potential emotional/psychological liabilities of treatment under duress.

  2. A patient who has had prior sensitization to, or exhibits an acute anxiety reaction to the professional environment and has resisted reasonable behavior modification techniques.

  3. A coexisting medical complication presenting either a relative or absolute contraindication to treatment outside a sedation modality (i.e., poorly controlled seizure disorder, severe cerebral palsy, etc.).

  4. Patients who are physically, mentally, or sensorily compromised and whose disabilities present management problems in a fully conscious state.

  5. Patients with severe orofacial trauma or requiring extensive oral surgical treatment.

  6. The patient with extensive treatment needs who lives in a remote area and has a verified transportation constraint.

ATTACHMENT 3: Instructions to Parents for Sedation of a Child

In order to provide the best dental and emotional care for your child, a technique involving one or more sedative drugs will be used.

In order to make this sedation as safe and effective as possible, we ask that you follow the following instructions.


  1. The child should have nothing to eat or drink for 4 to 6 hours before the appointment time. Also, the most recent meal should be light and easily digestible.

  2. It is important that you inform us of any recent changes in the child's medical history, medications, history of illnesses, hospitalizations, or reaction to any drugs.

  3. The child must be accompanied by a parent or guardian for all appointments.

  4. No tight clothing should be worn by your child. Short sleeved pajamas are a good choice.

  5. Attend to bowel and urinary needs before the appointment.

  6. If your child develops a common cold at any time before the scheduled appointment, please inform us immediately. We may have to postpone the appointment until the cold is over.

  7. Please be on time for the appointment. We are setting aside extra time for your child's treatment needs, and this time may be wasted if you show up too late to sedate your child or if you fail to show up.

  8. After the appointment, do not allow your child to bite his/her lip, tongue, or cheek before the numbness wears off.

  9. After the appointment, your child should be under adult supervision for 12 hours and not be allowed to travel unrestrained in a vehicle or to play near streets, stairways, or other areas where injury could occur.

  10. Encourage the child to drink clear room temperature drinks such as ginger ale or 7-up to help reduce occasional nausea or vomiting.

  11. If the child vomits, help him bend over and turn the head to the side to make sure that he does not inhale the vomit.

  12. Your child may remain sleepy for several hours after the appointment, and may be irritable as the medicine wears off.

  13. If anything unusual should occur, please call us at .

Chapter 5-M-

Delivery of Dental Services 2007




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