Intravenous conscious sedation in children for outpatient dentistry

Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service

Regular and robust audit of conscious sedation practice is key to the delivery of safe and effective patient care in all clinical settings. Analysis of outcomes will help to highlight any necessary modifications to procedures and techniques. The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) states that conscious sedation procedures must be the subject of robust and regular audit in which every member within the team takes part.¹ This completed audit cycle highlighted the efficacy of intravenous (IV) midazolam in anxious patients undergoing oral surgical procedures and the suitability for its use in the primary care setting. No patient safety concerns or complications were recorded in this audit and midazolam was administered within the recommended dose range. By the conclusion of two audit cycles, all clinicians providing intravenous sedation within the service were aware of the missing elements in sedation record-keeping and were able to complete accurate contemporaneous records before, during and after conscious sedation, ensuring the continuous delivery of high-quality, safe, and patient-centred care.

The self-perceived role of sedation-trained dental nurses within a Community Dental Service: a qualitative study

Background Dental nurses trained in assisting with relative analgesia with nitrous oxide (RA) play an important role in patient care. Provision of RA is a service provided in the Community Dental Service based in Doncaster, Barnsley and Rotherham.Aim To explore how sedation-trained dental nurses perceive their role within a Community Dental Service, and to explore what motivates them and how they feel changes could enhance the provision of care.Methods Twelve nurses who had experience of assisting with RA for at least one year in three community clinics in a South Yorkshire-based Community Dental Service were recruited and undertook a semi-structured interview. All interviews were transcribed verbatim and subsequent thematic analysis of the manuscripts was undertaken.Results Five major themes were identified: 1) motivation; 2) role; 3) training and continuing professional development; 4) pressures on the service; and 5) service enhancements.Conclusion Within this qualitative study, the dental nurses perceived that they had a crucial role in patient and parent behavioural management and keeping the patient safe during treatment. Helping patients to accept planned dental treatment gave them significant job satisfaction. Overall, this study has shown that they feel that they have a crucial role in assisting with RA treatment.

An audit of the use of intravenous ketamine for paediatric dental conscious sedation

AIM

An audit of the use of intravenous ketamine for the provision of conscious sedation in paediatric dentistry was carried out over a three-year period. AUDIT DESIGN: In the audit, 3,751 children were treated and an evaluation was carried out for safety and effectiveness of the drug and procedure, the quality of sedation and clinical procedures provided. In addition, the occurrence of any adverse effects and parental satisfaction were noted along with recovery. All children were ASA I and II, with an average age of 7.5 years. Children were referred because of management problems and were assessed to be at the high anxious level of four and five on the Venham scale. A weight related 0.25 mg/kg was initially administered with additional increments of 0.25 mg/kg given if required. The average total dose provided was 0.41 mg/kg.

RESULTS

The majority of children (76%) accepted all treatment with no problems, with 19% experiencing a small amount of resistance. Although a range of dental treatment was provided, it was mostly exodontias of carious primary dentition. A 27% response was provided assessing satisfaction which was very favourable. No adverse reactions occurred although the most common postoperative experience was nausea.

CONCLUSION

This audit demonstrated the safety and effectiveness of using intravenous ketamine for paediatric conscious sedation and implications for training and appropriate service delivery were discussed.

Complications Associated with Intravenous Midazolam Sedation in Anxious Dental Patients

Aim

This prospective study was designed to establish the nature, frequency and sequelae of complications arising in patients receiving dental treatment under intravenous midazolam sedation.

Methods

All patients attending the Sedation Department at Newcastle Dental Hospital for intravenous sedation over a six-month period were audited. A standardised data-collection pro forma was designed in order to collect data relating to the patient, the sedation episode, the dental treatment and any complications arising. The published standard used in this study states that the incidence of complications should be no more than 8%.

Results

Four hundred and one patients were included. The mean dose of midazolam administered was 7.6 mg with a mean titration rate of 0.9 mg/min. Complications were reported in 12 patients (3%), 11 of which were minor and one moderate. All complications were managed successfully within the department with no lasting sequelae. Treatment was completed in 382 (95.7%) patients, with failure to complete treatment in 17 (4.3%) patients due to disinhibition (1), poor cooperation (10), and the sedation wearing off (6).

Conclusion

The standard was met because complications arising were infrequent (3%) and predominantly minor in nature. Complications were managed conservatively and effectively, with all patients being discharged home the same day with no lasting sequelae. The study demonstrates that intravenous midazolam provides a safe sedation technique, suitable for adult dental patients in primary care, when administered by trained personnel on carefully selected patients and in accordance with nationally agreed protocols and guidelines.

Paediatric conscious sedation: views and experience of specialists in paediatric dentistry

OBJECTIVES

The objectives were three-fold: to investigate the level of conscious sedation training received prior to and during specialist training in paediatric dentistry; to establish the use of conscious sedation during and following specialisation; and to determine the attitudes of specialists in paediatric dentistry to conscious sedation.

SUBJECTS AND METHODS

A self-administered postal questionnaire was sent to all specialists in paediatric dentistry registered with the General Dental Council in January 2008. Non-responders were contacted again after a four-week period.

RESULTS

A response rate of 60% was achieved. Of the 122 respondents, 67 (55%) had received sedation training as an undergraduate; 89 (75%) had been trained during specialisation. All respondents performed dental treatment under sedation as a trainee and the majority used nitrous oxide inhalation sedation (NOIS). Over 90% of respondents felt that NOIS should be available to all children, both in appropriate primary care settings and in hospitals. One hundred and twenty-one (99%) respondents thought that all trainees in paediatric dentistry should have sedation training.

CONCLUSIONS

The most popular form of sedation amongst specialists in paediatric dentistry was NOIS. However, some of the respondents felt that children should have access to other forms of sedation in both the primary care and hospital settings. Additional research on other forms of sedation is required to evaluate their effectiveness and safety.

Anesthesia outside the operating room in the office-based setting

PURPOSE OF REVIEW

The majority of anesthesia services provided outside the operating room or ambulatory surgery center is in the office-based setting. This review will focus on three areas that are critical to office-based anesthesia: safety, quality of care and patient satisfaction.

RECENT FINDINGS

Data obtained from the State of Florida office-based surgery adverse event data repository indicate that, even with The American Society of Anesthesiology I patients, there remains opportunity to improve outcomes. Careful patient selection remains critical, especially the patient with a history of sleep apnea. While general anesthesia remains the gold standard, expanded use of local anesthesia, regional blocks and variation on sedation techniques offer alternatives that may reduce risks but still maintain a high quality of care. While there is limited office-based anesthesia satisfaction data, limiting postoperative nausea and vomiting remains a major patient satisfier of which an occurrence rate of zero may be possible.

SUMMARY

There is rapid growth for the need of safe and high quality office-based anesthesia. To meet these needs, a special set of skills is required, which may require expanded exposure and experience during training. An office-based anesthesia central data repository is needed for benchmarking and identifying areas for improvement. Finally, with advances in surgical technology, there is a need for focused research in office-based anesthetic techniques and modalities and patient satisfaction.