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  • Writer's pictureLouie Romanos

Ummmm……Why isn’t my patient waking up?


The use of sedation is being seen more frequently in private clinics


Sedation and anesthesia in private clinics or non-hospital settings have been linked to higher patient-related safety events (Cote and Wilson, 2019). The age-old dilemma that medical practitioners face when using sedation continues to focus on how we can prevent over-sedating thereby maintaining higher procedural safety.



It is common for patients to move from different levels of sedation during pediatric dentistry


As a result, the American Academy of Pediatrics and the American Society of Anesthesiologists have developed practice guidelines for monitoring sedation depth in pediatric patients for both in-hospital and out-of-hospital practice (Malviya, Voepel-Lewis, Tait, Merkel, Naughton, 2002). Tools or scales for assessing sedation depth can alert practitioners to unsafe levels and prompt emergency interventions. The utility of any neurological monitoring strategy will be dependent on how easy it can be applied clinically and on whether it accurately identifies different sedation levels across a continuum (Malviya et al., 2002).



The University of Michigan Sedation Scale (UMSS)


· Great tool for non-anesthesia providers of sedation (Malviya et al., 2002)

· Reliable and valid

· Quick assessment

· Cost is minimal

· Should be assessed at regular intervals (q10min)

· Limitations include observer subjectivity and the disruptive effect of stimuli that needs to be given to assess sedation level (Haberland, Baker, Liu, 2011)






Bispectral Index Monitor (BIS)


· The use of electroencephalogram(EEG) to monitor the level of sedation

· EEG waveforms change with levels of alertness

· High-frequency, low-amplitude waves are associated with being awake

· Low-frequency, high-amplitude waves are associated with deep sedation

· The BIS monitor continuously analyzes EEG waveforms and then calculates a number between 0-100 that correlates with a specific level of sedation

· Cost: 13,500 (CAD) plus more for parts






Continuous monitoring and patient preparation are vital for successful outcomes


An alarming trend that continues to plague most research endeavors studying the use of sedation on kids is the reality of over-sedation (Malviya et al., 2002). There are many things that we can do as clinicians for managing patients that have moved into higher levels of sedation than intended.

1. Improved detection allows for quicker reversal and return to homeostasis. This highlights the importance of continuous monitoring and the consideration of UMSS, BIS, or some other sedation scale

2. Using drugs that have wide margins of safety so that unintended loss of consciousness is less likely

3. Training in emergency systems and this must include airway management (Cote and Wilson, 2019)




References


1. Malviya, T., Voepel-Lewis, A.R., Tait, S., Merkel, K., Naughton, R.(2002). Depth of sedation in children undergoing computed tomography: validity and reliability of the University of Michigan Sedation Scale (UMSS). British Journal of Anaesthesia,8(2), 241-245

2. Haberland, C.M., Baker, S., Liu, H. (2011). Bispectral Index Monitoring of Sedation Depth in Pediatric Dental Patients. Anesthesia Progress,58, 66-72

3. Cote, C.J., Wilson, S. (2019). Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics, 143(6):e20191000

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