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Royal College of Dental Surgeons of Ontario (RCDSO) Standards of Practice

Standard of Practice for the used of sedation and general anesthesia in the dental operatory
  • Sedation and general anesthesia are produced along a continuum, ranging from the relief of anxiety with little or no associated drowsiness (i.e, minimal sedation), up to and including a state of unconsciousness (i.e, general anesthesia).  

 

  • It is not always possible to predict how an individual patient will respond and, at times, it can be difficult to precisely define the endpoint of one level of sedation and the starting point of a deeper level of sedation.  Therefore, the drugs and techniques used for sedation must carry a margin of safety large enough to render loss of consciousness unlikely. 

  • Practitioners intending to produce a given level of sedation must be able to diagnose and manage the physiological consequences for patients whose level of sedation becomes deeper than initially intended.  For all levels of sedation, the practitioner must have the training, skills, drugs, and equipment to identify and manage such an occurrence until either assistance arrives or the patient recovers to baseline.

  • In general, the administration of sedation or general anesthesia in out-of-hospital dental facilities is reserved for those patients deemed ASA 1 or ASA 2.  Patients who are ASA 3 and/or present with other medical concerns may not be acceptable for treatment by practitioners who are qualified to administer mild to moderate levels of sedation.  Such patients should be carefully assessed, and consideration should be given to referring them to a more qualified practitioner.

  • All dentists providing minimal and/or oral moderate sedation must, at a minimum, maintain current BLS certification with a hands-on component.

  • All dentists providing oral moderate sedation to patients who are under 3 years of age or 15kg must maintain current PALS or PEARS certification, which must also include a hands-on component.

  • All dentists providing parenteral moderate sedation, deep sedation, or general anesthesia must also maintain current ACLS.

  • These 6 basic drugs must be included in the emergency kit of every dental office:   

    •   Oxygen (an E-size cylinder is required)

    •   Epinephrine (at least 2 sources of the 1:1000 preparation)

    •   Nitroglycerin

    •   Diphenhydramine

    •   Salbutamol inhalation

    •   ASA

  • Minimal sedation is usually accomplished by either the administration of an oxygen/nitrous oxide combination or a single sedative drug.

  • Oxygen/nitrous oxide combinations is the only modality where a dentist may exercise discretion as to whether a patient may be discharged unaccompanied.

  • Oral administration of a single sedative drug, specifically a benzodiazepine, is a prudent approach to minimal sedation.

  • Moderate sedation is usually accomplished by the oral administration of a single sedative drug with or without the administration of an oxygen/nitrous oxide combination OR the parenteral administration (intravenous, intramuscular, subcutaneous, submucosal, or intranasal) of a single sedative drug.

  • Oral administration of a single sedative drug, specifically a benzodiazepine, is a prudent approach to moderate sedation.  Successful completion of additional training is required if more than one oral sedative drug is to be used.

  • For the administration of oral moderate sedation to patients under 12 years of age, the use of oral midazolam, diazepam or hydroxyzine may be considered by those dentists who have successfully completed additional training in their use.  For oral midazolam, the dose must not exceed .5mg/kg, with a maximum dose of 15mg for 1 appointment.

  • Parenteral administration of a single sedative drug, specifically a benzodiazepine, is a prudent approach to moderate sedation.  Other than the single parenteral sedative, no additional sedative agents are permitted to be used by any route of administration unless specific requirements are met by the operating dentist.

  • Parenteral moderate sedation for ambulatory dental patients must be administered through the combined efforts of the sedation team.  This team is composed of a minimum of 3 individuals, who must be in the operatory at all times during the administration of parenteral moderate sedation.  Generally, the sedation team will consist of a dentist, who is qualified and responsible for the dental procedure; a sedation assistant; and an operative assistant.

  • The sedation team must include at least one individual who has successfully completed a provider course in ACLS and maintains current BLS certification

Office Protocol and facilities

  • The facility must permit adequate access for emergency stretchers and have auxiliary powered backup ​​for suction, lighting, and monitors for use in the event of a power or system failure.

  • The process for ensuring that only suitable patients receive office-based sedation starts with careful patient selection.  An adequate medical history, including past and present illnesses, hospital admissions, current medications and dose, allergies, and a functional inquiry or review of medical systems, along with an appropriate physical examination must be completed for each patient and must form a permanent part of each patient's record.

  • The patient's ASA classification and risk assessment must then be determined to establish the appropriate facility and anesthetic technique used.

  • The patient must have complied with the minimum duration of fasting prior to appointments that is consistent wit ASA guidelines.

  • Consent must be obtained prior to the administration of any oral sedative, which should be documented.

  • Clinical observation must be supplemented by the following means of monitoring throughout the sedation administration, including into recovery (for oral moderate sedation): continuous pulse oximetry monitoring of oxyhemoglobin saturation, recorded at a minimum of 15-minute intervals; blood pressure and pulse must be taken and recorded pre-operatively and throughout the sedation period at appropriate intervals, not greater than every 15 minutes; continuous observation of respiration, with rate recorded at a minimum of 15-minute intervals.

  • A sedation record must be kept that includes the recording of vital signs as listed above.

  • The patient may be discharged once he/she shows signs of progressively increasing alertness and has met the following criteria: conscious and oriented; vital signs stable; ambulatory.

  • It is the dentist's responsibility to ensure that the dental office in which oral moderate sedation is being performed is equipped with the following:

    • portable apparatus for intermittent positive pressure resuscitation​

    • pulse oximetry with clearly audible, variable pitch tone

    • stethoscope and sphygmomanometers of appropriate sizes

    • full face mask of appropriate sizes and connectors

    • portable auxiliary systems for light, suction and oxygen

    • current emergency drugs in appropriate amounts (as stated above)

  • For parenteral moderate sedation, clinical observation must be supplemented by the following means of monitoring throughout the sedation administration: continuous pulse oximetry monitoring of oxyhemoglobin saturation, recorded at a minimum of 5-minute intervals; blood pressure and pulse must be taken and recorded pre-operatively and throughout the sedation period at appropriate intervals, not greater than every 5-minutes; continuous observation of respiration, with rate recorded at a minimum of 15-minute intervals.

  • Recovery accommodation and supervision is mandatory when parenteral sedation is administered.

  • The dental office in which parenteral moderate sedation is being performed should be equipped with all of the equipment required for oral moderate sedation plus: automated blood pressure monitor with programmable alarm settings and audio component; tonsil suction (Yonkauer) adaptable to the suction outlet; adequate selection of endotracheal tubes or laryngeal mask airways and appropriate connectors; laryngoscope with an adequate selection of blades, spare batteries and bulbs; Magill forceps; adequate selection of oral airways; apparatus for emergency tracheotomy or cricothyroid membrane puncture; defibrillator (either an AED or one with synchronous cardioversion capabilities; intravenous indwelling catheters and needles.

  • current drugs in appropriate amounts for management of emergencies during parenteral moderate sedation include everything required for oral moderate sedation plus: 4 sources of epinephrine 1:1000, parenteral vasopressin, parenteral atropine; parenteral corticosteroid; appropriate intravenous fluids.

  • all dentists administering deep sedation or general anesthesia must have authorization from the RCDSO to do so.  All physicians administering deep sedation or general anesthesia must have approval from the RCDSO to do so.

  • All dentists and physicians administering deep sedation or general anesthesia must maintain current ACLS certification.

  • All dentists and physicians administering deep sedation or general anesthesia for patients under 12 years of age must be able to satisfy the RCDSO that they have appropriate training and experience to possess the knowledge, skills and judgement necessary for the care of such patients.  In addition, current PALS certification is required.

  • All facilities where deep sedation and general anesthesia is being offered must have written policies and procedures, including check lists for the management of emergencies.  The facilities written policies and procedures must be reviewed with staff regularly, which must be documented.

  • General anesthesia or deep sedation for ambulatory dental procedures must be administered through the combined efforts of the anesthetic team.  This team is composed of a minimum of 3 individuals, who must be in the operatory at all times during the administration of deep sedation or general anesthesia.  The anesthetic team can consist of 2 formats: a dentist, who is qualified and responsible for the anesthesia and dental procedure; an anesthetic assistant; an operative assistant.  In the other format, the anesthetic team includes, as a minimum: a dentist who is responsible for the dental procedure only; another dentist or a physician, who is qualified or responsible for the anesthesia only; and an operative assistant.

  •  In addition, the anesthetic team must include at least 2 individuals with current ACLS certification. 

  • General anesthesia and deep sedation must be, in addition to clinical observation, monitored at 5-minute intervals using the following measurements: continuous pulse oximetry monitoring; blood pressure and pulse; continuous observation of respiration; continuous electrocardiogram monitoring; continuous capnography monitoring; if non-intubated, a precordial stethoscope is also recommended; if intubate or using an laryngeal mask airway, than an oxygen analyzer is required; if a volatile inhalational anesthetic is being used, an anesthetic agent analyzer is required.

  • If triggering agents for malignant hyperthermia are being used, measurement of temperature and appropriate emergency drugs (i.e, dantrolene) should be readily available.

  • recovery period monitoring for patients that received deep sedation or a general anesthetic must use: a minimum ratio of recovery supervisors to patients is one to one; continuous pulse oximetry and capnography is required and should be monitored at 5-minute intervals; blood pressure and heart rate must also be monitored at 5-minute intervals.

  • recovery period monitoring for patients that received for moderate or minimal sedation must include: the minimum ratio of recovery supervisors to patients is one to two; Pulse oximetry, blood pressure and heart rate must be recorded at a minimum of 15-minute intervals.  

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