Children are far more vulnerable to morbidity and mortality from sedation than adults, reports the University of Wisconsin School of Medicine and Public Health. Children also are at greater risk for adverse paradoxical reactions to medications.
A child’s airway isn’t simply a smaller version of an adult’s airway, and it presents additional significant compromises. Also, a child’s level of sedation may deepen within seconds. Fortunately, multiple professional organizations offer guidelines and standards for ensuring safety when using sedation and anesthesia with pediatric patients.
AAPD and AAP Guidelines
The American Academy of Pediatric Dentistry (AAPD) and American Academy of Pediatrics (AAP) adopted important guidelines in 2016 for the monitoring and management of pediatric dental patients before and after sedation services.
It’s important to understand that the categories of sedation levels (minimal sedation, moderate sedation, and deep sedation) can be deepened in children potentially within seconds. As such, monitoring for reversal must be ongoing.
Close active monitoring and recording of child sedation (moderate to deep sedation) patients must occur continuously, with personnel credentialed in proper training and skill sets. Additionally, both the treatment facility space and a recovery room must be suitably and independently equipped and staffed with appropriately certified personnel. As such, dental anesthesiology practitioners as well as their facilities and auxiliary staff must be properly trained and credentialed.
Historically, sedation and anesthesia provided in nonhospital environments such as dental offices have been associated with increased incidences of “failure to rescue” from adverse events because these locations may lack immediately available backup. Therefore, prudent pediatric dentists carry out child sedation services in a hospital operating room or surgical centers, where certified staffing, facility, and recovery rooms are all available, and emergency training is standard.
Guidelines of the AANA
The American Association of Nurse Anesthetists (AANA) has noted that conscious sedation is extremely safe when administered by qualified providers such as Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, dentists, oral surgeons, and other physicians. Specifically trained registered nurses (RNs) also may assist in its administration.
Providers who monitor the patient receiving conscious sedation, the AANA advises, should have no other responsibilities during the procedure and should remain with the patient at all times. In other words, the provider should not jump from treatment room to treatment room, answer telephone calls, or assist with other patients.
The Joint Commission Hospital Anesthesia Care Standards require providers who are permitted to be able to rescue patients at whatever level of sedation or anesthesia is achieved, since minimal to moderate sedation is a continuum and patient response can be unpredictable.
Also, patients may unpredictably advance to a deeper level of sedation than desired, so reversal and rescue abilities are required at all levels of sedation by personnel permitted to administer sedation, even at minimal levels, the AANA says.
Joint Position Paper
A joint white paper on sedation policy signed by the American Academy of Emergency Medicine (AAEM), the American College of Emergency Physicians (ACEP), the National Association of Children’s Hospitals and Related Institutions (NACHRI), and other organizations also provides guidelines.
“Procedural sedation requires the presence of two licensed professionals at the bedside. One licensed professional must be a RN whose competency in procedural sedation has been verified. This RN may administer the medication or monitor the patient and must not be involved in performing the procedure,” the paper says.
“Health care professionals monitoring the patient undergoing procedural sedation must not have other responsibilities that would compromise their ability to adequately monitor the patient before, during, and after the procedure,” the paper continues.
To reiterate, two healthcare staff certified and trained in sedation must be present during patient sedation delivery, according to the paper. Further, one must exclusively remain with that child, with exclusive duties, until post-recovery and dismissal.
More from the AAPD & AAP
The AAP and the AAPD further reinforce these critical points in their guidelines, noting that the use of moderate sedation should include a person in addition to the practitioner who is responsible for monitoring appropriate physiologic parameters and assisting in any supportive resuscitation measures if required. This individual also:
- May be responsible for assisting with interruptible patient-related tasks of short duration (though other medical community guidelines forbid interruptible tasks)
- Must be trained in and capable of providing basic pediatric life support
- Have specific assignments in the event of an emergency and current knowledge of the emergency cart inventory
Plus, “the practitioner and all ancillary personnel should participate in periodic reviews and practice drills of the facility’s emergency protocol to ensure proper function of the equipment and coordination of staff roles in such emergencies,” the guidelines say.
“There must be one person available whose only responsibility is to constantly observe the patient’s vital signs, airway patency, and adequacy of ventilation and to either administer drugs or direct their administration,” the guidelines continue.
“At least one individual must be present who is trained in, and capable of, providing advanced pediatric life support, and who is skilled in airway management and cardiopulmonary resuscitation; training in pediatric advanced life support is required,” they continue.
“An emergency cart or kit must be immediately accessible. This cart or kit must contain equipment to provide the necessary age- and size-appropriate drugs and equipment to resuscitate a nonbreathing and unconscious child,” they further state.
“It should be understood that the availability of EMS services does not replace the practitioner’s responsibility to provide initial rescue in managing life-threatening complications,” the guidelines conclude.
It’s simply inadequate to rely upon an emergency response team and upon the time it requires for the team to access the patient. The ability to initiate patient rescue must be immediate and on-site.
Seminal Paper from the ASA
The Journal of the American Society of Anesthesiologists (ASA) published a group white paper on moderate sedation guidelines in March of 2018. Contributors included the ADA, the American Association of Oral and Maxillofacial Surgeons, and the American Society of Dental Anesthesiologists.
The paper’s recommendations for recovery care include:
- After sedation/analgesia, observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression.
- Monitor oxygenation continuously until patients are no longer at risk for hypoxemia.
- Monitor ventilation and circulation at regular intervals such as every 5 to 15 minutes until patients are suitable for discharge.
- Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel.
The paper’s recommendations for sedative/analgesic medications intended for general anesthesia include:
- When moderate procedural sedation with sedative/analgesic medications intended for general anesthesia by any route is intended, provide care consistent with that required for general anesthesia.
- Ensure that practitioners administering sedative/analgesic medications intended for general anesthesia are able to reliably identify and rescue patients from unintended deep sedation or general anesthesia.
- For patients receiving intravenous sedative/analgesic medications intended for general anesthesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression.
- In patients who have received sedative/analgesic medications intended for general anesthesia by nonintravenous routes or whose intravenous line has become dislodged or blocked, determine the advisability of reestablishing intravenous access on a case-by-case basis.
- Administer intravenous sedative/analgesic medications intended for general anesthesia in small, incremental doses or by infusion, titrating to the desired endpoints. • Allow sufficient time to elapse between doses so the peak effect of each dose can be assessed before subsequent drug administration.
- When drugs intended for general anesthesia are administered by nonintravenous routes (eg, oral, rectal, intramuscular, transmucosal), allow sufficient time for absorption and peak effect of the previous dose to occur before supplementation is considered.
Seminal Paper in Pediatrics
In its seminal December 2017 article, “Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy?” Pediatrics noted that there exists no mandated reporting of morbidity and mortality for cases with adverse outcomes. Unfavorable outcomes predominate with low-income (usually Medicaid) populations. One author specifically stated, “Children should never, ever die during sedation for a dental procedure. Such deaths are eminently preventable. Yet, they continue to happen.”
Questions Remain
It’s important to appreciate that professional organizations are going to lengths to establish safer standards for pediatric sedation. Even a single death is one too many. Yet news reports are replete with seriously adverse outcomes for children treated with sedation for dental care.
What are the common factors influencing negative outcomes? What are state regulatory dental boards doing, or failing to do, to achieve favorable outcomes? The second part of this article will examine individual states and how failures to safeguard children’s dental sedation health occur.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.
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