Monitoring in Dental Anesthesia

Donald Wood, CRNA, CPHRM, Patient Safety Risk Manager II

Anesthetics are administered in a variety of locations ranging from the hospital operating room to the dental office. The administration of anesthesia needs to meet the same quality of care standards regardless of the setting where the service is being provided. To provide the highest level of care for your dental patients, you must provide timely anesthetic monitoring and utilize the appropriate monitoring equipment.

In a study of closed anesthesia claims conducted by The Doctors Company, the improper management of the patient under anesthesia was the third most common allegation noted. This includes inadequate monitoring of vital signs, delayed response to deteriorating vital signs, and inadequate response. This allegation was seen in 19 percent of all claims. Further review of those claims noted that inadequate patient monitoring was the fourth highest risk factor contributing to patient injury, calling attention to the need for implementation of an integrated monitoring package.

The ability to monitor the patient requires proficiency in the interpretation of the information presented. For example, problems with a patient’s oxygenation can be seen well before the patient becomes cyanotic. Misplacement of an endotracheal tube is immediately apparent through the ability to measure the end tidal carbon dioxide on a breath-by-breath basis. Furthermore, rather than just detecting either the presence or absence of carbon dioxide in the expired air, you can use the waveform of that tracing to understand valuable data on whether the patient’s condition has changed or whether there is a stuck valve in the anesthesia circuit.

For dental procedures utilizing moderate or deep sedation, the responsibility for monitoring and recording of the patient’s vital signs must be delegated to someone other than members of the team who are directly involved with the dental procedure. It is important to have an individual who has the training and experience to interpret the information presented and respond appropriately. This individual must be aware of the importance of the information presented on the monitors and the need to notify the dentist when the parameters exceed predetermined values.

As part of the integrated monitoring package, the setting of alarms becomes important. You should endeavor to set alarms consistent with the patient’s baseline status. When physiologic parameters deviate beyond those settings, an investigation is necessary to determine the reason for the alarm and the appropriate corrective action.

The America Dental Association adopted Guidelines for the Use of Sedation and General Anesthesia by Dentists in 2016 that address the use of monitors during general anesthesia by dentists. The guidelines address monitoring and documentation of several functional areas (level of consciousness, ventilation, oxygenation, circulation, and temperature). Additionally, the American Academy of Pediatric Dentistry, in conjunction with the American Academy of Pediatrics, has published guidelines for monitoring the pediatric patient during dental procedures.

Risk Management Strategies

  • Maintain monitors to ensure proper functioning. Periodic maintenance is often required along with inspection of all tubing to look for crimps, tears, and other physical defects that may interfere with proper operation of the monitor.
  • Correct application of the monitors to the patient is necessary for the monitors to function properly. This includes the possible removal of nail polish if the fingers are utilized for pulse oximetry and placement of EKG electrodes on skin without excessive body hair.
  • If you are assigned to monitor the patient, you must know that you are a key player in the procedure. Your responsibility includes effective communication with the dentist to advise him or her of developing trends in the monitored information.
  • Be sure to set alarms properly. It can be easy to be distracted and not notice an important change in parameters.
  • When an alarm does go off, investigate. If the pulse oximeter is indicating a low oxygen saturation, is this due to an obstructed airway, decrease in inspired oxygen, decrease in ventilation, hypo perfusion, or dislodgement of the sensor? Of those five possibilities, four of them are potentially life-threatening if not addressed in a timely manner.
  • Obtain and document an initial set of vital signs before administering any medication. This will give you a base line to work with as you care for the patient.
  • Criteria for discharge from the office after receiving anesthesia should include documentation that the blood pressure is within 20 percent of the preanesthetic level.
  • Items that come in contact with the patient or are exposed to body fluids should be cleaned on a regular basis. Single use, disposable patient items such as blood pressure cuffs may be a suitable alternative.

References

Cotè CJ, Wilson S, Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatric Dentistry. 2016; 38(4): E13-E39.


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 healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J11279 10/17

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