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  • East Central Regional Hospital DENTAL DEPARTMENT MODERATE SEDATION/ANALGESIA (INTRAVENOUS CONSCIOUS SEDATION) Table of ContentsI. Introduction 1II. Purpose 1III. References 1IV. Definitions 1V. Facilities and Equipment 2VI. Pre-Sedation Assessment and Moderate Sedation Procedure Record 3VII. Monitoring 3VIII. Documentation 3IX. Criteria for Dismissal of Clients 5X. Care In The Living Area Following Moderate Sedation 5XI. Professional Training 6XII. Selection of Sedatives 7XIII. Summary 8 MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - i)
  • East Central Regional Hospital DENTAL DEPARTMENT MODERATE SEDATION/ANALGESIA (INTRAVENOUS CONSCIOUS SEDATION)I.INTRODUCTION: It is the philosophy and the goal of the dental program of East Central Regional Hospital to provide the highest quality of dental service to all clients treated in the clinic (both on campus and community-based clients) consistent with the limitations presented by each client. Approximately one-half of these clients with MR/DD present maladaptive behaviors within the dental environment. Dental treatment for these clients must be individualized to allow quality dentistry to be accomplished in the least restrictive environment possible. This necessitates the use of some special treatment modalities, including medical restraints, and at times sedative medications. When the choice of sedatives includes the intravenous route of administration, special procedures should be carried out.II.PURPOSE: The purpose of this document is to provide the necessary detail for the use of Intravenous Conscious Sedation at East Central Regional HospitalIII.REFERENCES: JCAHO CAMBHC Standards Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists Anesthesiology, 1996; 84:459-71 Guidelines for Dental Programs in Facilities for the Mentally Retarded/Mentally Ill - Southern Association of Institutional DentistsIV.DEFINITIONS: A.Minimal sedation (anxiolysis) A drug-induced state during which individuals served respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected; B.Moderate sedation/analgesia ("conscious sedation") A drug-induced depression of consciousness during which individuals served respond purposefully (reflex withdrawal from a painful stimulus is not considered a purposeful response) to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - ii)
  • C.Deep sedation/analgesia A drug-induced depression of consciousness during which individuals served cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Individuals served may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained; and D.Anesthesia Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which individuals served are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Individuals served often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Minimal and moderate sedation are the only sedation modalities approved for use in the ECRH Dental Department. Deep Sedation and general anesthesia are not utilized in the Dental Clinic at ECRH.V.FACILITIES AND EQUIPMENT It is the responsibility of ECRH to provide a safe environment in which to manage clients who require moderate sedation for dental services. It is the responsibility of all dental practitioners who use moderate sedation medications to be thoroughly aware of the facilities, personnel, and equipment needed in order to manage any reasonably foreseeable emergency experienced by the client. It is the responsibility of each dental staff member to respond to any emergency in the Dental Clinic by: (1) maintaining an adequate airway, (2) administering oxygen, if necessary, (3) providing cardiac and/or pulmonary resuscitation, if necessary, and (4) activating emergency backup services, if necessary. The dental clinic has designated operatory # 6 as the IV conscious sedation area. This area has more room about the dental chair and unit to allow greater freedom of movement for the practitioners involved. A positive pressure oxygen delivery system is available. Additionally, extra oxygen tanks are maintained in the storage room across the hall from operatory # 6. A monitor is provided that is capable of cyclical monitoring of blood pressure and continuous monitoring of oxygen saturation and pulse rate. The monitor is capable of printing a record for each conscious sedation session. New, sterile intravenous paraphernalia is provided for each procedure. The Dental Department emergency drug kit is maintained through the Pharmacy Department and is brought into the IV conscious sedation area before beginning an IV procedure. Attending dentists are responsible for evaluating equipment and supplies before beginning an IV procedure. MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - iii)
  • VI.PRE-SEDATION ASSESSMENTS - Moderate Sedation Procedure Record When a consumer is identified by the dentist for a procedure with IV Conscious Sedation, the dentist will initiate ECRH Form #CLN-030 (Moderate Sedation Procedure Record). When the dentist has completed section one of the form, he/she will notify the consumer’s physician and forward the record to the physician to complete section 2. When the physician clears the consumer for the procedure, the dental clinic is notified and the appointment is scheduled. Immediately prior to starting the IV, the dentist must conduct an immediate reassessment for every client undergoing IV Conscious Sedation. The immediate reassessment includes the consumer’s baseline vital signs and pre-sedation Aldrete score, a review of the consumer’s medical information and sedation history, documentation that preoperative orders have been carried out, and documentation of the appropriate time-out procedure. The information from the immediate reassessment is documented in the top part of section 3 of the Moderate Sedation Procedure Record.VII.MONITORING All dentists, assistants, and hygienists are trained in monitoring and resuscitative procedures. Continuous monitoring of a sedated patients consciousness and responsiveness shall be accomplished by every dental staff member involved in the treatment. All intravenous sedation procedures are scheduled with two attending dentists, both of whom are responsible for continuously monitoring the client. However, many adolescent and adult mentally retarded clients present with combative, aggressive, and totally uncooperative behavior which renders manual or mechanized recording of vital signs both impossible and meaningless. Thus, the practitioner should utilize other signs of the degree of the patients consciousness or responsiveness. The patients color, (i.e., nail beds, mucosa, etc.) and degree of head and neck muscle tone (i.e., amount of resistance to retraction of cheek and lips or stabilization of head) should be visually monitored on a continuous basis by the staff members involved in the treatment. A monitor is provided that is capable of cyclical monitoring of blood pressure and continuous monitoring of oxygen saturation and pulse rate. The monitor is capable of printing a record for each conscious sedation session. The monitor is attached to the client before initiating treatment to allow for a baseline reading of oxygen saturation, pulse rate and blood pressure. During the IV procedure, the monitor remains in position and is set to continually monitor oxygen saturation and pulse rate and periodically monitor blood pressure (the cycle is normally set for 5-minute intervals). A printout is made of the trending of the statistics monitored. The printout becomes part of the treatment record, and is attached in section 3 of the Moderate Sedation Procedure Record along with other pertinent intraoperative information. Restraining devices should be checked to prevent chest constriction. The patients head position should be checked frequently to insure a patent airway. At no time shall a sedated or restrained client be left unobserved by a trained person.VIII.DOCUMENTATION MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - iv)
  • Consent – The ECRH Policy on Consent Process governs the consent for dental treatment (see C-47 Policy - Consent Process ). Special consent is obtained when Moderate Sedation is involved (see ECRH Dental Consent Form). Medical History – The medical history and physical examination information on ECRH clients should be current and readily available in the medical record which accompanies the client to the Dental Clinic. The medical history information on ECRH outpatients should also be current. Although accurate medical history information for community- based clients is often difficult to obtain, it is the responsibility of the dental practitioner to obtain the highest quality information possible. Moderate Sedation Procedure Record - While using intravenous conscious sedative medication, all pertinent information should be clearly entered into the Moderate Sedation Procedure Record. The attending dentist must complete Section 3 of the Moderate Sedation Procedure Record in its entirety to provide appropriate intra- procedure documentation. For the purpose of this procedure, the following standard terms to document sedation effectiveness will be used: EFFECT AMPLIFIEDNOTATION EXPLANATION Client is compliant with requests and responds in purposeful manner with minimal physical resistance. Note: reflex withdrawal from a painful stimulus is not considered a purposeful response. Client is sleepy and remains quiet and still throughout theExcellent procedure. Clients at this level are considered to have reached the level of MODERATE SEDATION and require careful monitoring as described in section VII above. Client is compliant with requests and responds in his/her usual manner. Although medical protective safety devices are generally needed at this level of sedation in order to maintain a safe environment, physical intervention by dental assistants is usually limited to stabilizing the head (including mouth prop use) and verbal Good prompting. Clients at this level are considered to have reached the level of MINIMAL SEDATION and should be continually monitored visually and mechanically with a pulse oximeter. Client is only moderately compliant with verbal instructions and unsafe behavior continues with only sporadic cooperation. Client responds in his/her usual manner to verbal prompting. Medical protective safety devices are necessary to prevent injury. Scheduled treatment is completed with some difficulty. Fair Clients at this level are considered to have reached the initial stages of MINIMAL SEDATION and require continuous visual monitoring supplemented by mechanical monitoring with a pulse oximeter when possible - mechanical monitoring may be of limited value due to client movement. Client is non-compliant with verbal instructions and unsafe behavior continues with rare or no cooperation. Client responds in his/her usual manner to verbal prompting. Medical protective safety devices are necessary to prevent injury. Scheduled treatment is completed with difficulty or modification in scheduled treatment is Poor necessary (e.g. abbreviated treatment). Clients at this level are considered to have reached only the very initial stages of MINIMAL SEDATION and require continuous visual monitoring. Mechanical monitoring with a pulse oximeter is usually impractical or impossible due to continuous, excessive movement.MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - v)
  • Client is non-compliant and scheduled treatment must be significantly altered or rescheduled. Clients at this level are considered to have not reached even the very initial None stages of MINIMAL SEDATION. Visual monitoring is sufficient to prevent client injury. Pulse oximetry is recorded when possible as a baseline for future reference. Table 1 No pre-doctoral trainee shall enter/record entries. An ECRH staff dentist must countersign post-doctoral trainee entries.IX.CRITERIA FOR DISMISSAL OF CLIENTS WHO HAVE RECEIVED MODERATE SEDATION (IV CONSCIOUS SEDATION MEDICATION) Once an individual has returned to his/her pre-sedation Aldrete score (or at least to a score of 9 for those with a pre-sedation Aldrete score of 10) he/she will continue to be monitored in the recovery area by a qualified practitioner for at least 30 minutes. If no problems are identified during this period, the client may be discharged to the unit. If a reversal agent has been used, increased monitoring is necessary. In this case monitoring in the dental clinic will extend at least one hour after the administration of the reversal agent. Since cognitive function and coordination may be impaired, a staff member should assist any client who has received any sedative medication until the effects are no longer noticeable. Such assistance would include aiding with ambulation, particularly in the transition form sitting or lying to standing and walking. Clients who are judged mildly ataxic may return to the living area under the observation of living area staff.X.CARE IN THE LIVING AREA FOLLOWING MODERATE SEDATION/ANALGESIA (IV CONSCIOUS SEDATION) Post sedation monitoring continues after discharge from the dental clinic. A qualified, competent practitioner must monitor vital signs and level of consciousness on the unit until the patient returns to his/her baseline. This monitoring is to be done every 30 minutes as a routine. Of course, if any problems are noted, the monitoring can be done more often. The nurse will document the post-operative monitoring in section 4 of the Moderate Sedation Procedure Record. Clients who have received moderate sedation/analgesia (IV conscious sedation) for a dental appointment may require special care in the living area. If the client is at his or her usual baseline, it is appropriate to return to usual activities, including work, training, or off-campus visits. However, if the client is lethargic, increased living area care will be necessary. Foremost will be the necessity for the client to rest quietly under the observation of living area personnel during the time that the sedation is affecting the clients ability to function independently. The degree to which a person appears sedated greatly depends on the amount of external stimulation received by that person. While in the environment of the Dental Clinic, background stimulation or treatment will often result in the client remaining alert throughout the appointment. After returning to their home living area, the medication may appear to become more effective. Many clients will sleep a good part of the day. This is normal and expected. Living area personnel should be instructed to allow the client, if he or she is so inclined, to nap in MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - vi)
  • the living area while being checked periodically. Since cognitive function and coordination may be impaired, a staff member should assist any client who has received any sedative medication until the effects are no longer noticeable. Such assistance would include aiding with ambulation, particularly in the transition from sitting or lying to standing and walking. This monitoring in the living area is a continuation of the intraoperative monitoring accomplished in the dental clinic and is to be accomplished according to the following standard set of orders: 1) Activity: a) Head to be elevated at least 30 degrees at all times, and limit activity to seated activities, ambulation with assistance, and bed rest ad lib, for the next 6 hours or until the client has returned to baseline. b) Wake client every hour until client remains awake and responsive. a) Notify physician if client is not awake and responsive within 2 hours of return to Living Area. 2) Vital Signs - Take vital signs now - If at any time blood pressure is less than 90/60, or pulse rate is less than 60 or respiratory rate is less than 12, immediately repeat vital signs and notify physician and dental clinic. 3) Diet - Give 6 ounces of gingerale or equivalent prior to offering solid foods AND: a) If client is able to handle this with no problem, resume routine diet, OR b) If client has difficulty swallowing and is at high risk for aspiration, keep NPO with head elevated at least 30 degrees for the next 2 hours THEN: i) If client is alert at 2 hours post returning to Living Area, again attempt to give 6 ounces of liquids AND: (1) If client is able to handle this with no problem, resume routine diet, OR (2) If client has difficulty swallowing, notify physician. 4) Routine medications - If client is sleepy or lethargic, consult unit physician before administering routine behavior or anticonvulsant medications. 5) Notify Dental Clinic for: a) Evidence of pain related to dental treatment b) Excessive intra-oral bleeding 6) Notify Physician at once for: a) Vomiting b) Labored respiration or cyanosis c) Aspiration d) Not arousable to verbal or tactile stimulationXI. PROFESSIONAL TRAINING It is the responsibility of ECRH to employ staff dentists with the competencies needed to provide the highest quality of dental care including, when necessary, the use of intravenous conscious sedation procedures. ECRH is also responsible for monitoring these skills and augmenting these competencies, when necessary, with additional professional training. Any training required of, or provided to, staff dentists and auxiliaries will be guided by the "Guidelines for Teaching the Comprehensive Control of Pain and Anxiety in Dentistry" promulgated by the American Dental Association Council on Dental Education, November 1985, as well as advice and council from the faculty of the School of Dentistry of the Medical College of Georgia. All IV conscious sedation medications will be administered by a MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - vii)
  • dentist with a current "Conscious Sedation Permit" issued by the Georgia Board of Dentistry inclusive of IV sedation. Post-doctoral dentist trainees may participate in IV conscious sedation procedures, under the direct supervision of a staff dentist with a valid permit. In addition to training expected of and/or provided ECRH staff dentists, staff dental hygienists and dental assistants are provided the training needed in order to assist the dentist in monitoring the effects of dental sedation procedures. In addition, every dentist must be currently certified in Advanced Cardiac Life Support (ACLS). Update training is provided for all ECRH dental staff on an annual basis.MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - viii)
  • XII. SELECTION OF SEDATIVES FOR INTRAVENOUS CONSCIOUS SEDATION IN THEDENTAL DEPARTMENT The choice of sedative medications and routes of administration is the responsibility of the individual dental practitioner based upon his/her training and experience. In sedating ECRH clients, the attending dentist, unit physician, pharmacist, team leader, and others involved in direct care are encouraged to work closely in order to better understand and evaluate the effects of any medications the client is receiving, and the effectiveness or undesirable side effects of any past sedation regimens for that particular client. With ECRH outpatients this information is more difficult to obtain, but clear efforts should be made by the attending dentist to ascertain the effects and problems of past sedation practices. Valium® (diazepam) (tranquilizer) *Typical dose range: 10-20 mg (.2 to .3 mg/kg) 1) Advantages a) Very safe drug. b) Easy to handle. c) Can be titrated to obtain desired level of sedation. d) Reversal agent (RomaziconR) available 2) Disadvantages a) May cause phlebitis if not flushed with saline solution. b) May cause local irritation. c) Cannot use small veins such as those on dorsum of hand or wrist. Demerol® (meperidine) (analgesic) *Typical dose range: 25-50 mg (.25 to 1 mg/kg) 1) Advantages a) Raises the pain threshold. b) Many dental practitioners have long experience with this drug combination. 2) Disadvantages a) Demerol® has significant respiration depressant qualities, although this effect is readily reversible by administration of a narcotic antagonist (Narcan®). b) May produce a transient tachycardia in some patients. Versed® (midazolam) (tranquilizer) *Typical dose range 2-8 mg (.03 to .1 mg/kg) MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - ix)
  • 1) Advantages a) Shorter half life than Valium®. b) Dilutes with saline solution. c) May use small veins. d) Less chance of phlebitis than Valium®. e) Can be titrated on each appointment to obtain desired level of sedation. f) Reversal agent (Romazicon®) available 2) Disadvantages a) Cost. b) Practitioner experience with this drug is less than with Valium®. NOTE: CAUTION: Typical dose ranges and dose/kg relate to healthy adolescent and adult mentally retarded clients and are provided as a general reference only. The prescribing dentist obviously must consider many factors prior to selecting drug doses for an individual patient. In any case, the use of sedative medications in the dental clinic is restricted to maintaining clients in a state of conscious sedation. Under no circumstances is any client to be sedated to the point of deep sedation or general anesthesia.XIII. SUMMARY The use of intravenous conscious sedation for some ECRH dental clients is a necessary and routine treatment modality and in no way should be confused with use of psychotropic medications employed on a regular basis to address general behavioral problems. It is the responsibility of ECRH to provide a safe environment for dental intravenous conscious sedation use. It is the responsibility of the dental practitioner to be aware of the most current information regarding the efficacy and safety of drug regimens utilized in this program. Dental practitioners should also be aware of other current practices and guidelines found in the dental literature, and to exercise cautious clinical judgment in employing dental conscious sedation practices. MODERATE SEDATION/ANALGESIA (Intravenous Conscious Sedation) (Page - x)