Procedural Sedation Policy

Subject:                    Procedural Sedation Policy
Effective Date:       January 1994
Revision Dates:    August  2002, October 2016

Purpose

The Procedural Sedation Policy of the School of Dentistry is intended to support the safe and effective management of fear or anxiety associated with dental therapy.  The goal of this policy is to provide the benefit of mild or moderate sedation to the dental patient with minimal risk of complications.

General Policy

The use of medications and techniques to relieve pain and anxiety is an established and integral part of dental practice.  The dental students and graduate students of the School of Dentistry not only administer local anesthesia but also use various inhalation, enteral, and parenteral agents to alleviate the fear and anxiety associated with dental treatment.  Washington State Law establishes standards for the safe administration of sedative agents that the School of Dentistry policy meets or exceeds.  Washington State Law defines Minimal sedation as a “drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Minimal sedation is limited to oral or intramuscular medications, or both.”  Moderate Sedation “means a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

The School of Dentistry’s Procedural Sedation Policy should be considered to be the minimum standard within the school and its affiliated clinics.  Clinicians must use appropriate physiological monitors or emergency equipment and medications to prevent or manage sedation-related complications and emergencies.

Implementation

I. Nitrous Oxide/Oxygen Sedation Alone or with One Oral Agent

A. Authorization

  1. The student must have he didactic courses of instruction in nitrous oxide/oxygen sedation before administering nitrous oxide. A faculty member who has completed a course containing a minimum of 14 hours of either predoctoral dental school or postgraduate education must supervise administration of nitrous oxide sedation by the student.  Both the student and the supervising faculty must have current certification  in Basic Life Support.
  2. The student and supervising faculty member must review the current medical status and anxiety of the patient before making any decisions about whether nitrous oxide/oxygen sedation is indicated. If the patient or their guardian provides o receiving nitrous oxide/oxygen sedation, the supervising faculty member must hat the student may obtain the equipment necessary to administer the nitrous oxide/oxygen sedation.

B. Administration of nitrous oxide

  1. Before each administration of nitrous oxide/oxygen sedation, the analgesia machine is to be inspected. This inspection should minimally include checking the hoses and reservoir bag for leaks, making sure the gas cylinders contain enough gas to complete the proposed dental treatment, that all connections on the machine are tight and not leaking, and that the appropriate scavenging device is properly attached and in working order.
  2. The patient must be continuously observed while nitrous oxide/oxygen sedation is administered. The patient’s blood pressure, heart rate and respiratory rate must be taken immediately before administering nitrous oxide/oxygen sedation and just before dismissing the patient at the end of the procedure when he/she has recovered from the sedation. For young children, it may not be possible to get an accurate blood pressure and then the clinician should document the reason for not obtaining it. If there are any adverse reactions, the vital signs (blood pressure, heart rate, and respiratory rate) must be measured and recorded as indicated.
  3. Following the completion of nitrous oxide/oxygen sedation, the patient must breathe 100% oxygen for at least 5 minutes. The patient should be allowed to recover an additional 5 minutes following the administration of 100% oxygen.  The patient can be released when he/she feels fully recovered and the post-sedation vital signs are within the patient’s normal range.
  4. The Dean of Clinical Affairs or the Department Chairperson responsible for a clinic must identify and maintain a secure area(s) for the storage of equipment used for administering nitrous oxide/oxygen sedation (e.g., analgesia machine, compressed gas cylinders). Restricted access to this area is intended to prevent misuse of the equipment and accidents. The analgesia machine and associated equipment must be routinely inspected by the Office of Environmental Health and Safety for malfunctions and leaks.
  5. After discharging the patient, the nitrous/oxide equipment must be returned to a secure area with restricted access. The analgesia machine hoses must be disinfected using standard methods established by the School of Dentistry after each patient use, and the disposable nosepieces discarded. If using reusable nosepieces (Proter), the inner piece should be processed through sterilization and the outer piece should be thoroughly wiped down with disinfectant.
  6. The dental chart must contain a note documenting the duration of the sedation and concentration of the nitrous oxide that was used. In addition the patient’s vital signs before the administration of nitrous oxide/oxygen sedation and before discharge must be recorded in the chart.  Any adverse reaction to the nitrous oxide must also be documented in the patient’s chart, including a description of the reaction, the actions taken to treat the reaction, and the outcome of the reaction and its treatment.
  7. If the faculty member supervising sedation approves the concomitant use of a single enteral sedative with nitrous oxide/oxygen sedation, the patient must be given a prescription for the enteral medication and obtain it from a pharmacy. The medication should be administered by the clinician prior to the patient’s appointment. This is true for both adults and children. A patient who is administered an enteral sedative in preparation for dental treatment must be accompanied to and from the dental school clinic by a responsible adult. The patient must also be informed that he/she should not operate hazardous equipment or motorized vehicles (e.g., automobile), nor make important decisions for the 24 hour period that follows their taking the enteral sedative.  The sedative and the dose prescribed needs to be recorded in the chart, as well as the time the patient takes the sedative and the duration and concentration of nitrous oxide.  The name of the patient’s escort needs to also be recorded in the chart.  Similar to the chart notations required for nitrous oxide/oxygen sedation described in #6, pre- and post-sedation vital signs need to be measured and recorded in the chart when single enteral sedatives are taken alone or with nitrous oxide and oxygen. Unwanted side effects and/or reactions need to also be documented in the patient’s chart as well as how they were managed and their resolution.

II. Moderate sedation with multiple oral or parenteral agents

A. Authorization

  1. The student must have successfully completed the didactic courses of instruction in nitrous oxide/oxygen sedation and before administering this type of sedation. The administration of such sedation may occur only under the supervision of a faculty member who has been issued a valid  permit for Moderate Sedation with Parenteral or Multiple Oral Agents and/or General Anesthesia/Deep Sedation by the State of Washington.
  2. The supervising faculty member must have a valid license to practice dentistry in the State of Washington and a permit from the federal Drug Enforcement Administration (DEA). The Department Chairs must submit a list of the faculty who are qualified to sedate patients to the Dean and Associate Dean of Clinical Affairs.
  3. The student, staff, and supervising faculty member must be certified in Basic Life Support and Advanced Life Support or Pediatric Advanced Life Support.

B. Administration of sedation with multiple enteral or parenteral agents.

  1. The student and supervising faculty member must review the patient’s current medical status and anxiety to determine if sedation with multiple enteral or parenteral agents is appropriate. The student and faculty should confirm the NPO status of the patient prior to administering medications. Following evaluation of the patient, written consent for sedation must be obtained and a signed copy placed in the patient’s chart.  After consent and permission of the supervising faculty member are obtained, the student may obtain the appropriate sedative medications. The student administering the medication must be continuously assisted by at least one individual experienced in physiological monitoring of sedated patients.  The physiological monitoring includes continual measuring of heart rate, respiratory rate, blood pressure, and hemoglobin saturation.  The hemoglobin saturation is to be monitored with a oximeter during sedation.  Continuous monitoring of the heart’s electrical activity with an electrocardiograph is recommended but not required.  Heart rate, respiratory rate, blood pressure, and hemoglobin saturation must be measured and recorded immediately before and after the procedure, as well as at appropriate (5 or 10 minute) intervals throughout the procedure.  Vital signs and level of consciousness must be measured and recorded prior to patient dismissal.
  2. A patient who is administered sedation with multiple enteral or parenteral agents for dental treatment must be accompanied to and from the dental school clinic by a responsible adult. The patient must also be informed that he/she should not operate hazardous equipment or motorized vehicles (e.g., automobile), nor make important decisions for the 24 hour period that follows their taking the enteral sedative.  The name of the patient’s escort needs to be recorded in the chart.  Pre- and post-sedation vital signs need to be measured and recorded in the chart when single enteral sedatives are taken alone or with nitrous oxide and oxygen. Unwanted side effects and/or reactions need to also be documented in the patient’s chart as well as how they were managed and their resolution.
  3. Patients will be given a prescription to obtain oral medications from a pharmacy. Parenteral medications must be kept in a secure area within the School of Dentistry.  Clinic personnel will dispense these medications after receiving authorization from the supervising faculty member.
  4. The dosage and forms of medication dispensed must be noted and recorded in the patient’s chart. The level of consciousness and the name of the patient’s escort must be recorded prior to the dismissal of the patient.
  5. Procedures for storage and disposition of controlled substances must follow the guidelines established by the federal Drug Enforcement Administration. The Associate Dean of Clinical Affairs and/or the Chairs of the appropriate departments must identify the secure areas and personnel that will maintain and dispense the controlled substances.
  6. In addition to the suction capable of aspirating gastric contents from the mouth and pharynx, portable oxygen delivery system with face masks and a bag-valve-mask combination with appropriate connectors capable of delivering positive pressure, oxygen-enriched patient ventilation, oral and pharyngeal airway of appropriate size, a pulse oximeter, and sphygmomanometer and stethoscope, an emergency drug kit must be available for response to adverse effects. The kits may contain any emergency drugs that the supervising faculty require but must contain the following: sterile needles, syringes, tourniquet, narcotic antagonist, alpha and beta adrenergic stimulants, vasopressor, coronary vasodilator, antihistamine, parasympatholytic agent, intravenous fluids, tubing and infusion set, and antagonists for any sedatives that are used.  Any adverse reactions must be documented in the patients chart and must include a description of the reaction, actions taken to treat the reaction, and outcome of the treatment.

 

Dean of UW SOD:

Joel Berg, Dean of the UW School of Dentistry
October 24, 2016