By Dr. Carol Wilson
Dental sedation services rely on the attention and training of each member of the office team. By working together, team members can jointly ensure the safety of patients, particularly registered dental hygienists and assistants. From time to time (and as required by state dental regulation), experienced sedation dentistry team members need to refresh their knowledge of monitoring responsibilities and patient safety to reduce the likelihood of mistakes.
Perhaps most important, don't sedate any patient without high-quality monitoring equipment, such as the EDAN X10 hospital-grade monitor. It's imperative for team members to know how to use this equipment and how to set all the alarms (training for this is a DOCS membership benefit). Cardiac and pulmonary functions must be monitored and recorded every five minutes, or more often depending on state dental regulations. These functions include: blood pressure, pulse rate, heart rhythm, pulse oximetry (SpO2), and now end-tidal CO2 (capnography). In this article, we'll review this and other important factors to remember when monitoring sedation patients.
Establish Healthy Pre-Sedation Baselines
Before every sedation procedure, there should be a “sedation workup” appointment in which an extensive list of information is acquired.
The purpose of the pre-sedation workup appointment is to verbally ask patients about their health history, medication history, and social habits to uncover “Red Flag” conditions before they become a problem during sedation. How many times have you seen a patient check a medical condition such as high blood pressure, but list no medications to help control it? Conversely, how many times have you seen a patient deny any medical conditions, but list at least four medications that control medical conditions? In the first scenario, the patient does not receive regular medical care and is more than likely, non-compliant with regular physician visits. In the second scenario, the patient believes he/she no longer has the condition because medicines control the condition. Both are worth further discussions with the patient.
Red flags are warning signs that will alert you to conditions that may be potential management issues during sedation. Team members are crucial in helping to identify potential issues before they occur. Sedation paperwork is normally completed by clinical team members (assistants or hygienists), though the dentist is responsible for its accuracy. Front office team members assist in sending medical consultation or clearance letters to the physicians and to monitor for their return before scheduling patients for their appointments. Upon transfer to each department, the expectations the patient must meet to have a safe sedation appointment are reiterated in front of the patient and, at times, the caregiver as well.
Red Flag Conditions
- Advanced age: Patients over 65 require special attention. Americans are living longer and therefore are more prone to hypertension (due to a loss of elasticity of the heart muscle and blood vessels), high cholesterol, diabetes, and heart disease. Elderly patients have decreased plasma proteins to bind to medications, so sedation drugs should be given at half the normal dose.
- Date of last medical exam: There are guidelines based on age and health of the patient as to when the patient should have seen a physician for medical evaluation.
- Hypertension: Increased blood pressure affects every one in three adults in the United States.
- Diabetes: It is estimated that one in 12 Americans is diabetic. Type 1 diabetics are insulin deficient and require insulin injections. Type 2 diabetics have tissues that are insulin resistant. A baseline blood glucose reading should be obtained for diabetics at the sedation workup visit. The patient should be asked about their most recent hemoglobin A1C value. Hemoglobin A1C is an average blood sugar level over a 90-day (three month) period.
- Angina: When the heart muscle demands more oxygen than can be supplied to it, chest pain occurs. Angina is reversible ischemia. These patients are at higher risk for myocardial infarction (irreversible ischemia). It can be argued that sedation for these patients with stable angina is safer than treatment without sedation as sedation helps lower blood pressure, increases vasodilation, and therefore reduces cardiac workload.
- Myocardial Infarction/Coronary Stents: After having a heart attack, a stent placed, or undergoing other cardiac surgery, a patient should not have dental work for 6 months following the event. Emergency dental treatment should be referred to a specialist, usually an oral surgeon.
- HIV/Hepatitis: Although patients are not required to inform you if they are HIV positive, a list of their medications could clue you into some type of hepatic infection. Drugs that treat HIV often end in -ease.
- Pregnancy: Any woman in childbearing years should be asked if she is pregnant, trying to get pregnant, or could be pregnant at every appointment in the sedation process. The only time a sedative is indicated in pregnancy for dental treatment is if the emergency is life-threatening, such as an infection that is closing off the airway. However, that would not be treated in a general dentist’s office.
- Respiratory Diseases: Asthma and COPD (chronic bronchitis and emphysema) are the most common respiratory conditions. Well-controlled asthmatics can be sedated, in fact nitrous oxide could help prevent bronchospasm. Patients with COPD cannot.
- Sleep Apnea/BMI: Patients with OSA, larger neck circumferences, BMI over 30, and Mallampati scores of III to IV require special consideration.
- Cirrhosis: Cirrhosis is a hardening of the liver due to the formation of scar tissue replacing normally functioning liver tissue. The importance to sedation dentists is that a patient with cirrhosis will have decreased ability to biotransform or break down sedation drugs in the liver.
- Polypharmacy: Not only are patients living longer, but they’re also taking more prescription medications. The increased number of medications a patient takes increases the possibility of drug-drug interactions. Be sure to check drug interactions with an online resource such as Lexicomp prior to sedating a patient.
The office should invest in a high-quality monitoring device when practicing sedation. A device that can record vital signs every five minutes is paramount in providing safe sedations and may be required by your dental regulation. One such device is the Edan X. It is a hospital-grade monitor with the ability to physically print and digitally record heart rate, three lead heart rhythm, end-tidal CO2, and pulse oximetry.
Monitoring Heart Rate Throughout
It’s common for patients nervous about dental care (often a large portion of sedation patients) to experience elevated pulse rates at their appointment. As simple as it sounds, monitoring a patient’s heart rate is elemental in administering and monitoring sedative drugs.
Blood Pressure Changes During Sedation
Patients complaining of feeling dizzy, lightheaded, or blacking out may be suffering from low blood pressure. This can result in low blood flow to bodily organs and is common when a person is anxious or gets up out of the chair too quickly. Having a baseline blood pressure will aid in knowing if the patient’s blood pressure is normal for them.
Blood Oxygenation Levels
Blood oxygenation levels are the most important part of patient safety regarding the risk for negative patient impact during conscious sedation. Rarely is there a cardiac event in sedation. Most emergencies begin because the patient is not breathing. The loss of oxygen creates a cardiac emergency. Although most pulse oximeters typically have built-in alarms to alert teams to abnormally low blood oxygen levels, precautions must be taken to limit poor oxygenation to begin with, such as conducting a thorough physical exam to make sure the patient has cardiovascular levels within normal limits. Lower than normal oxygenation often indicates respiratory diseases or habits like smoking. Since conscious sedation patients are not intubated, this aspect is crucial in every procedure.
Monitoring End-Tidal CO2
End-tidal CO2 monitoring (ET CO2) is the ability to measure a patient’s exhaled carbon dioxide, which reflects the metabolic process of ventilation. Whereas oxygenation reflects the relative amount of oxygen that the blood is carrying, ventilation measures the result of oxygenation of tissues (cellular metabolism), which produces carbon dioxide as a byproduct. The waveform that is produced on the monitor is called capnography.
Another advantage of measuring ET CO2 versus SpO2, is that ET CO2 is a more real-time measurement.
It takes cardiologists years to learn all the heart rhythms. You should know what a normal heart rhythm looks like so you can better recognize what doesn’t.
A Note About Blood Glucose Levels
Patients with a medical history of hypoglycemia or diabetes require an extra level of attention during all dental procedures, regardless of whether sedation is used or not. Be sure to watch the individual for signs of low blood sugar, such as sweating, heart palpitations, shakiness, headache, or feeling nauseous. Since any of these symptoms can also result from anxiety, be sure to conduct a thorough health history.
Annual Review for the Sedation Dentistry Team
From pre-treatment screening to in-chair monitoring and patient dismissal, team training and confidence in managing sedation cases is crucial to the success of patient care practices. All teams who work with sedation patients, particularly those who do so less frequently or haven’t had a refresher in best practices in over a year or more, must have a comprehensive review of their responsibilities and protocols to ensure industry safety standards, as well as dental regulations, are met. Likewise, frequent refreshers boost the confidence of the team and reassure practice management and doctors that patients are looked after properly.
The most efficient dental sedation teams are those who've trained every person in the office. Monitoring sedation patients is a team effort. Understanding that the most important steps in keeping patients safe are: maintaining consciousness and appropriate response to verbal commands throughout the appointment; detecting “red flags” before they become problematic; and using high-quality monitoring machines is vital to maintaining a safe and well-trained sedation team.
Author: Dr. Carol Wilson is a 2006 University of Kentucky College of Dentistry graduate with distinction. She is a DOCS faculty member and clinical instructor for the DOCS IV sedation program.