MORBIDITY AND MORTALITY IN DENTISTRYSEDATION

Mario DauriCattedra di Anestesiologia e Rianimazione

Università di Roma Tor Vergata

In Virginia, on May 11th, 6 yearoldJacobiHildied under anesthesiafordental work.

In California, 5 yearold Jenna Bautistadied under sedationwhen a cottonrollfell down herwindpipe.

In 2008 in Riverside CA, 7 yearold Jacqueline Martinezswallowed a toothwhile under anesthesia and died.

In Cedar Key, Fl., 5 yearold Dylan Stewart died last month.

In Tampa in February 2009, 9 yearoldCory Moore, Jr. died.

Background

Anesthesia-related morbidity and mortality is

a serious risk to oral and maxillofacial surgery patients receiving outpatient anaesthetic procedures; especially, the pediatric population represents the highest risk, lowest error tolerance subgroup.

(Coté CJ 2000)

Background Currently, different

forms of sedation, for example, oral, intravenous (i.v.), inhalation, intranasal and combinations of treatments are used for pediatric dental patients worldwide.

Background

But it is not possible with the available evidence to reach a definitive conclusion on the most effective method for conscious sedation of pediatric dental patients.

(Matharu LM, 2006. Cochraine review)

WHATABOUTFROMINTERNATIONALLITERATURE?

Ourreviewfromliterature

Mortality

29 death or neurological injury / 32 overall complications related to dentistry sedations

(Coté 2000)

45% of 1778 active members of the American Academy of PediatricDentistry reported cases of morbidity and/or mortality related to children sedations for odontoiatric procedure in a 15 year follow up survey

(Houpt 2002)

No death ( Cravero

2006) (Cravero 2009) (Malviya 1997)

Mortality

morbidity and mortality increases in the extremes of age and with worsening ASA classification.

there is a significantly higher incidence of deaths for procedures performed in offices than in ambulatory surgery centers.

Complications The most common

complications are respiratory events (desaturation, apnea, laryngospasm, secretion requiring suction, vomiting) ; their incidence increase with the increasing of sedation level.

- Cravero, 2006 - Coté, 2000- Milton Houpt., 2002- Malviya , 1997- Dionne,2006- Cravero,2009

Providers of deep sedation/anesthesia must also demonstrate proficiency in airway obstruction and respiratory depression management, or have immediate and completely reliable access to such assistance

The ASA recommends that only professionals trained in the delivery of general anesthesia should deliver deep sedation/anesthesia.

Complications

There is a disproportionate number of sedation-related adverse events (32 / 95) involving sedation/anesthesia for dental procedures (most in a nonhospital-based venue)

Coté, 2000

1 in every 200 sedations required airway and ventilation interventions ranging from bag-mask ventilation to oral airway placement to emergency intubation

Cravero, 2006

Wichfactorsleadstocomplications?

effects of sedating medications on respiration

inadequate resuscitation by health care providers

medication errors inadequate monitoring inadequate medical evaluation before

sedation

Monitoring

Pulse oximetrymonitoring is mandatory for all sedation leveland the use of capnography is encouraged by the last guidelines for the first time in nonoperating room venues.

(Hosey, 2002) (Scottish Intercollegiate

Guidelines Network, 2004) (Coté, 2006)

•Scottish Intercollegiate Guidelines Network (SIGN)•American Academy of Pediatrics- American Academy of Pediatric Dentistry( AAP–AAPD)

Guidelines

•proper preparation:SOAPME (Suction, Oxygen source, proper functioning Airway equipment, appropriate Pharmaceuticals, Monitors, and special Equipment)

•proper evaluation

•appropriate skills to rescue the patient

•proper recovery

lead to safe and successful sedation of children

Differences: Europe

Dentists can treattheirpatientsonlywithconscioussedation

GDC definition : A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.”

Differences: USA

Isadmittedthe use of anesthesia personnel to administer deep sedation/ general anesthesia in the pediatric dental population

The anesthesia care provider must be a licensed dental and/or medical practitioner with appropriate state certification for deep sedation/general anesthesia; he must have completed a 1- or 2-year dental anesthesia residency or its equivalent.

Differences: USA

Despite this, a critical incident analysis of pediatric (medical and dental) sedation in

USA suggested that permanent neurological injury or death occurred most frequently in

non-hospital- based facilities

For this reason untoward and unexpected outcomes must be reviewed to monitor the

quality of services provided. This will decrease risk , allow for open and frank discussions, and improve the quality of care for the pediatric dental patient .

 

American Academy on Pediatric Dentistry Clinical Affairs Committee-Sedation and General Anesthesia Subcommittee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on use of anesthesia personnel in the administration of office-based sedation/generral anesthesia to the pediatric dental patient.

Pediatr Dent. 2008-2009;30(7 Suppl):160-2.

Conclusions I

There is a great variability of mortality rate depending by drug administred , physicians experience in emergency management , sedation’s level, age and ASA classification of the patient.

Permanent neurological injury or death occur most frequently in non-hospital- based facilities for dental sedations.

Respiratory events represent the most common complications , causing often morbidity .

In every case it’s possible (most of the times) airways protective reflex have to remain intact.

In conclusion the end result and the take home message is: proper preparation, proper evaluation, appropriate skills to rescue the patient, and proper recovery to reach the goal of safe and successful pediatric sedations.

Conclusions II

…My personal opinion isthatanesthesiologistsmust take the leadhere in training, education, and

establishing a collegialworkingrelationshipwithournonanesthesiacoll

eagues.… I believethatallsedationservicesshouldbeunder

the directsupervision of the

DepartmentofAnesthesiology soastoassurethatournonanesthesiatrainedcolleagues

can develop and retain the skillsneededtosafelysedate healthychildrenwhileleaving the complex

casestous. The variouspapers in thisissueofPediatricAnesthesiaallseemtobegiving a similar

message, we just needto figure out howto do thisasfriendsratherthanfoes.

Coté CJ, PediatricAnesthesia, 2008

Nowchildren can sleepsafely!

Coté CJ, PediatricAnesthesia, 2008

GRAZIE PER L’ATTENZIONE