ADVANCED SEDATION TECHNIQUES A NEW APPROACH AT THE TOOTHBEARY DENTAL PRACTICE

1. ADVANCED SEDATION TECHNIQUES A NEW APPROACH AT THE TOOTHBEARY DENTAL PRACTICE

2. British Society of Paediatric Dentistry and their Policy Document on Management of Caries in the Primary Dentition (Int J of paed dentistry 2001; 11:153-157) • Current provision of sedation and GA services in paediatric dentistry is fairly poor in its access and availability. • Need for such services is indisputable. • Due to the severe burden on the NHS hospital sector and the high costs involved with General Anaesthesia in an in-hospital setting: • Use of sedation as standard or advanced sedation techniques have become an ever more important option in provision of dental treatment to children. • This trend is also seen at international level.

3. CURRENT UK GUIDELINES IN SEDATION FOR CHILDREN. • To ensure safe and appropriate sedation practice, it is important to consider current UK guidelines. • However one can not ignore what is going on at international level in the fast growing field of paediatric sedation.

4. UK SEDATION GUIDELINES • NICE guidelines for sedation in children and young people (December 2010) • The Scottish National Guidelines on “Conscious Sedation In Dentistry”. Conscious Sedation in Dentistry Dental Clinical Guidance. • Conscious Sedation In The Provision Of Dental Care. Report Of An Expert Group On Sedation For Dentistry. Standing Dental Advisory Committee (SDAC) 2003, and theStanding Dental Advisory Committee guidelines 2007.

5. INTERNATIONAL SEDATION GUIDELINES • American Society of Anaesthesiologists Task Force on Sedation and Analgesia by Non-Anaesthesiologists. Practice Guidelines for Sedation and Analgesia. • Guidelines from the South African Society of Anaesthetists (SASA) on Procedural Sedation and Analgesia in Children. (These guidelines are children specific and cover all areas important in paediatric sedation.)

6. GUIDELINES IN SEDATION:MAIN FOCUS • Pre-sedation assessment, communication and patient information and consent. • Patient selection: A crucial aspect in paediatric sedation outside of the operating room. By implication all children do not qualify for sedation outside the hospital. • Fasting • Personnel and training. (The team concept.)

7. GUIDELINES IN SEDATION:MAIN FOCUS • Monitoring • Documentation • Equipment necessary in emergency situations • Drugs and sedation techniques • Recovery and discharge criteria

8. APPROACH TO ADVANCED SEDATION AT TOOTHBEARY • Dedicated Advanced Sedation Days (Currently 3/month) • First choice of sedation for all patients: LA/RA • Only the small minority of patients who can not be treated through simple sedation techniques are given the option of intravenous or combination oral sedation.

9. REPRESENTATION OF ALL CHILDREN TREATED UNDER IV OR ORAL SEDATION

10. REASONS FOR CONSIDERING ADVANCED SEDATION • Extensive and complicated dental treatment. • Age of the child. • Severe anxiety and behavioural difficulties, especially those who have had previous traumatic experiences. • Unable to cope with treatment under behavioural management techniques or RA.

11. PATIENT AND PARENTS • These patients are fully evaluated by the sedation practitioner and the dental team. • Parents are fully informed of the treatment options and sedation plan prior to the sedation day. Effective communication with the parents remains important. • Parents are also provided with written information regarding treatment of the child and sedation, including pre-and post-sedation instructions. • Parents are encouraged to ask questions if they are uncertain about anything.

12. PATIENT EVALUATION • Any potential medical problems or contra-indications for sedation are: • Identified from the medical history questionnaire or in communication with the parents. • Communicated to the sedation practitioner before the sedation appointment in order to consider the way forward. • As clearly stated in all sedation guidelines, only children considered to be ASA 1 or 2are eligible for sedation. • All important medical information and full day list is sent to the sedation practitioner the day before the sedation day.

13. START OF THE SEDATION DAY • Team meeting to discuss the day list and any potential problems. (“Group huddle”) • On arrival, the child is encouraged to use the play area to relax and familiarize. • Simultaneously, all administrative details are double checked with the parents and informed consent is signed.

14. PRE-SEDATION PATIENT ASSESSMENT • One of the recovery nurses will: • Meet the child and establish rapport • Review medical history. • History of recent colds or respiratory symptoms. • Last food and liquid intake. • Weight and temperature measurements. • Local anesthetic applied to areas for cannulation. (Even for combined oral sedation in case of emergency.)

15. PRE-SEDATION PATIENT ASSESSMENT • All information is then communicated to the sedation practitioner. • Sedation Practitioner will: • Meet and discuss the sedation plan with the parents. • Evaluate the patient’s airway (Priority!), and a brief examination of the heart and lungs.

16. PRE-SEDATION PATIENT ASSESSMENT • Special care is taken to look for signs of Upper Respiratory Tract Infection. (URTI) • Particularly difficult problem in sedation with children. • This is an important point as children often suffer from allergic rhinitis which may be misdiagnosed as a URTI. • Communication of all the information gathered is essential and careful documentation is made of all findings.

17. THE SEDATION TEAM • The team concept in sedation practice is acknowledged world - wide. • The Dentist: ILS trained, sedation training in Germany and USA, 10 years of experience with sedation involvement and GA for children. • 3 Dental nurses: ILS trained, all attend SAAD courses.

18. THE SEDATION TEAM • Sedation Practitioner: Postgraduate training in Sedation and Pain Control for standard and advanced sedation techniques,7 years experience as a full- time sedationist for children andadults, and regularly updates knowledge and skills by attending refresher courses and sedation symposia. • Recovery nurses (at least 2): Registered Medical Nurses, EPLS trained, both with years of experience in paediatric anaesthetic recovery and nursing.

19. THE SEDATION TEAM-CONTINIOUS PROFFESSIONAL DEVELOPMENT • At Toothbeary, the sedation team must meet the requirements for safe sedation practice as set out in all sedation guidelines e.g. qualifications and updating knowledge and skills. • Regular in-house training sessions focusing on emergency scenarios, as well as discussions on sedation related topics. (All documented.)

20. THE SEDATION TEAM-CONTINIOUS PROFFESSIONAL DEVELOPMENT • Annual clinic appraisal by Prof James Roelofse, Visiting Professor from University College London, who is also an Executive Member of the Paediatric Committee of the World Society of Intravenous Anaesthesia. • During the clinic appraisal, the sedation practitioner also undergoes supervised clinical training as stipulated by all sedation guidelines e.g. the NICE guidelines.

21. SEDATION EQUIPMENT AND MONITORING • All necessary dental equipment, including good suctioning units! • Oxygen (and N2O if needed) • Clinical monitoring: At least two qualified people take part in the monitoring of the child. • Electronic monitoring: • Pulse Oximeter(SaO2) • NIBP • ECG • Capnograph

22. SEDATION EQUIPMENT AND MONITORING • Fully equipped Resuscitation trolley: • For Any emergency: A, B, C… • Emergency drugs • Spare oxygen cylinder. • AED (With paediatric converter) • Infusion pump

23. SEDATION TECHNIQUE • In the UK, Conscious Sedation is the only appropriate level of sedation allowed. (Out of hospital) • Conscious sedation: Patient has to remain conscious and be able to respond purposefully to verbal commands. • In anxious and/or very young children, this can be: • Extremely difficult or challenging!

24. SEDATION TECHNIQUE • However, at Toothbeary it has been shown to be both possible and safe to treat children with complex dental needs, using advanced combination drug sedation. • This has also been proven by various publications on procedural sedation in children.

25. SEDATION TECHNIQUE • Mainly two sedation techniques are used at Toothbeary on the dedicated sedation days: • (A new route of sedation, namely nasal sedation has recently been introduced and will be discussed in more detail later.) • Everything discussed in terms of drugs and doses have been published in evidence based studies.

26. COMBINED ORAL SEDATION • Oral sedation in children is a controversial issue but there are advantages. There is however a proviso for using oral sedation and that is that the drug must never be administered at home. • Drugs used: Midazolam and Ketamine. • Indications for Oral sedation: • Small children/young age: Under 3 yrs old. (No cannulation needed!) • Small/ short procedures • Parental choice

27. INTRAVENOUS (IV) SEDATION • Indications for IV Sedation: • Children older than 3 years. • Difficult/ extensive dental treatment required. • Behavioural problems/ Severe anxiety.

28. INTRAVENOUS (IV) SEDATION • A combination of drugs: • Midazolam (low dose, usually 0.5mg -1mg in total) • Ketofol (Ketamine 5mg/ Propofol 9mg per ml mixture) for induction and intermittentboluses as needed. The dose used is 0.25 mg/kg of ketamine…..this dose will giveabout 0.5mg/kg Propofol as a bolus. • Propofol continuous infusion (6-10mg/kg/h), and titrated to effect. If using TCI (Target Controlled Infusion), then the dose of Propofol is 1 – 2 ųg/ml, again titrated to effect. It mustbe remembered that children need higher doses for effective sedation but recovery then also may take longer. • Total dosage of Ketamine usually does not exceed 1mg/kg per hour.

29. SEDATION TECHNIQUES • By using a combination of drugs, rather than just a single drug, less of each drug is used as when a drug is given alone. This approach also leads to a lower incidence of side effects. • During treatment under sedation, the value of clinical monitoring is crucial. Never leave the child alone. Special attention to monitoring of the airway and breathing is crucial. • As can be expected with conscious sedation, patient movement is sometimes possible. This is sometimes more troublesome for the dentist and the implications should be discussed with the dentist. • Treatment sessions usually last from 30 minutes to 90 minutes, with the average around 45min.

30. AIRWAY MANAGEMENT • Airway management in dental patients especially, can be a problem for various reasons: • The airway is shared with the dentist, and dental equipment. • Water from the drill may flood the pharynx with possible laryngospasm. It isprobably wise to check the amount of water from the drill, before sedation starts. • Secretions……..children often have allergic rhinitis which may cause excessive secretions. • Depression of the lower jaw by the dentist may cause airway obstruction.

31. AIRWAY MANAGEMENT • Upper Respiratory Tract infections can complicate airway management significantly in children. The sedation practitioner must be alert to this possibility.

32. AIRWAY MANAGEMENT • To deal with all these potential hazards associated with the airway and paediatric dental sedation, use: • Moderate extension of the head by putting a pillow/cushion under the shoulders may help in preventing airway obstruction. • Good suction (sometimes up to 3 different suction tubes) • Small yellow sponges to absorb water and blood in the mouth • A rubber dam.

33. AIRWAY MANAGEMENT • It is very important though to remember that these patients are done under conscious sedation and that any manipulation of the mouth or airway, the use of dental equipment or aids, like the rubber dam, still has to be done in a careful and gentle way, so as not to disturb the patient’s level of consciousness.

34. POST-SEDATION RECOVERY • As soon as the treatment is completed, the patient will be transferred to one of the recovery rooms, where the patient will be placed in: • The recovery position and monitored • Continuous Sa02 monitoring with recovery nurse at the patient’s side. • Parents are then invited to join the patient in recovery.

35. POST-SEDATION RECOVERY • The recovery phase has the potential of being the weak link in the whole sedation procedure. (As has been pointed out in a recent article by Dr Michael Sury (Consultant Paediatric Anaesthetist, GOSH, Continuing Education in Anaesthesia, Critical Care and Pain (2012) 12 (3): 152-156.) • The child is usually not stimulated in the recovery room and may slip into deeper levels of sedation. • The trained and highly experienced medically trained nurses in the recovery area are aware of this possibility. • Usually following the treatment, the patient will sleep undisturbed for around 20 to 30 minutes before they will wake spontaneously. The recovery nurse never leaves the patient unattended.

36. POST-SEDATION RECOVERY • Intravenous cannulas are normally left in place until the patient has recovered to the point where the need for any reversal drugs or other emergency medication is unlikely. • Most patients will remain in recovery for around 30 minutes to 1 hour, by which time they will be: • Fully conscious (and cannula removed) • Normal pulse rate and SaO2 • No nausea/ vomiting/ pain/ bleeding

37. POST-SEDATION COMMUNICATION • Parents are fully informed of the postoperative care and any special instructions. • Parents are also given after hours contact numbers, including a mobile number, and what to do in case of a medical emergency. • Parents will be contacted the next morning to complete a post sedation review over the phone. • The dentist will reassess them 10-14 days after the sedation (to get feedback about sickness, nightmares, behavioural changes ) and to reassess the dental status (check extraction wounds, crown margins, dental hygiene). • This approach contributes to a positive experience (successful visit, she/he will remember for months afterwards) for the child. • All these findings are recorded in the patient’s sedation notes.

38. SAFETY AND EFFICACY • Over the last 12 months, the Toothbeary team has successfully sedated and treated around 150 patients, with no serious adverse events, nor any escalation in care. • Furthermore, they have been very successful in their treatment plans as demonstrated by the following graphs:

39. PROBLEMS DURING ADVANCED SEDATION

40. PROCEDURES UNDER ADVANCED SEDATION

41. ADAVANCED SEDATION PATIENTS

42. THOUGHTS ON THE SEDATION PRACTICES AT TOOTHBEARY • Avery specialized sedation service. • Emphasis on the importance of using specialized and trained staff. • Continuous professional development: Aim to attend as many sedation symposia as possible. • Toothbeary works closely with specialists in this field of paediatric sedation, like Prof James Roelofse, who helps to improve and evolve their service. This forms part of the quality control, an also their vision for the future.

43. FOR THE FUTURE… • Nasal Midazolam & Ketamine: • Many studies have been done on drug delivery via the nasal route. • A recent study by Roelofse et al compared the use of a combination of Sufentanil/Midazolam vs. Ketamine/Midazolam administered intra-nasally for its analgesic efficacy and safety in sedation for preschool children undergoing multiple extractions. • The outcome was that there seem to be no difference in analgesic, sedative and safety effects from either combination, and that both provided adequate post-extraction pain relief.

44. FOR THE FUTURE… • Studies like these have encouraged a closer look at this form of sedation, and also because of obvious and proven/published advantages: • Ease of administration. (No needles/ bitter tasting medication) • Good absorption and bioavailability. • Rapid onset of sedation (10-20 minutes). • Parental acceptance. • Acceptable rates of side effects. (Extremely low at sub-anesthetic doses) • No demonstrable prolonged recovery.

45. FOR THE FUTURE… • Important to note: Intra-nasal administration of these drugs can still potentially induce deeper levels of sedation, and should therefor only be used by persons trained and experienced in delivery of advanced sedation techniques.

46. FOR THE FUTURE… • Since the start of August 2012: • Started using a combination of Midazolam 0.3mg/kg and Ketamine 5mg/kg. • Using the MAD device for nasal delivery. • Very promising results. • This has now replaced combination oral sedation as a choice of sedation at Toothbeary, as it has already shown to be far more effective and acceptable to both parents and patients.

47. FOR THE FUTURE… • Bispectral Index (BIS) Monitor: • Another potential objective monitoring tool of the level of consciousness during sedation. • Some recent studies have shown a good correlation between the BIS level during sedation and already validated and established sedation scoring systems like the Modified Wilson Scale.

48. CONCLUSION The Toothbeary Dental Practice enjoys: • Providing parents and patients with choice. • Be accessible to a wider section of the population than is mostly available in the private medical sector. • Deliver a safe and effective medical service. • Strive to keep up with the best international practices in dentistry and advanced sedation.