Conscious Sedation (Moderate Sedation) in the Office
As the first medical professional liability insurer to establish a patient safety department, The Doctors Company remains the leader in developing innovative tools that can help you reduce risk and keep your patients safe.
Perform and document a thorough pre-sedation evaluation and include an ASA score.
A pre-sedation exam is essential to patient safety. Assigning an ASA score (the ASA’s risk score) to each patient will ensure that those who need further workups (i.e., those with an ASA score of >2) will be cleared prior to sedation. Gaining appropriate written informed consent is part of the pre-sedation evaluation. In addition, ask pertinent patient history questions about prior problems with anesthetics, drug allergies, and smoking. For complete guidelines, visit the ASA Standards Guidelines and Statements page at http://asahq.org/publicationsAndServices/sgstoc.htm, and select “Distinguishing Monitored Anesthesia Care (‘MAC’) from Moderate Sedation/Analgesia (Conscious Sedation).”
Provide clear preprocedure instructions.
Provide the patient with clearly written preprocedure instructions, including the need for NPO status. Document in the dental record that all critical information, like NPO status, has been confirmed with the patient.
Follow patient safety guidelines.
The American Dental Association’s policy statement on the use of conscious sedation (moderate sedation), deep sedation, and general anesthesia in dentistry is available at: www.ada.org/sections/about/pdfs/anesthesia_guidelines.pdf. Become familiar with the following guidelines:
- Have emergency medications and equipment readily available.
- Have a designated, appropriately educated individual (other than the dentist performing the procedure) present to monitor the patient throughout the procedure.
- Check blood pressure and pulse every five minutes.
- Follow the titration guidelines for oral medications and other sedatives.
- Ensure appropriate postprocedure observation and monitoring.
- Maintain Basic Life Support certification for all dental care staff who supervise, administer, or monitor conscious sedation (moderate sedation).
- Ensure that an appropriately trained individual who can provide airway management (bag/mouth/mask ventilation with oxygen) is immediately available (within one to five minutes).
- Use pulse oximetry, including alarms, routinely.
- Monitor ventilatory function continually by observation, auscultation, or exhaled CO2 for patients whose ventilation cannot be directly observed.
Explore learning opportunities.
Keeping abreast of the latest research and drug modalities will help you maintain your competency and keep your patients safe from medication administration errors. Be aware of the pharmacology of the drugs being used, including the use and availability of reversal agents for commonly administered drugs.
Turn your alarms on—and keep them on!
Sedation disasters can still occur in spite of the sophisticated monitoring machines in use today. Most of these events should not occur, but do because the alarms had been silenced or they were silenced at the end of the prior case and not turned back on. (Some machines do not automatically reset the alarm.) Do not neglect the pulse oximeter and CO2 alarms. (The American Society of Anesthesiologists [ASA] guidelines require that alarms be audible to the members of the care team.)
By Susan Shepard, MSN, RN, Director, Patient Safety Education; and Ann S. Lofsky, MD (deceased), who was Anesthesia Consultant and Governor Emeritus.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.