Transcript Morbidity and mortality in dentistry sedation

MORBIDITY AND MORTALITY IN
DENTISTRYSEDATION
Mario Dauri
Cattedra 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)
WHATABOUTFROMINTERNATIONAL
LITERATURE?
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
 1 in every 200
disproportionate
number of sedationrelated adverse events
(32 / 95) involving
sedation/anesthesia
for dental procedures
(most in a nonhospitalbased venue)
Coté, 2000
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
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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)
Guidelines
•Scottish Intercollegiate Guidelines Network (SIGN)
•American Academy of Pediatrics- American Academy of Pediatric Dentistry(
AAP–AAPD)
•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
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.
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 .
Pediatr Dent. 2008-2009;30(7 Suppl):160-2.
Conclusions I
 There is a great variability of mortality rate depending by
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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
collegialworkingrelationshipwithournonanesthesiacolleagues.
… I believethatallsedationservicesshouldbeunder the direct
supervision of the DepartmentofAnesthesiology so
astoassurethatournonanesthesiatrainedcolleagues
can develop and retain the skillsneededtosafely
sedate healthychildrenwhileleaving the complex
casestous. The variouspapers in thisissueof
PediatricAnesthesiaallseemtobegiving a similar
message, we just needto figure out howto do thisas
friendsratherthanfoes.
Coté CJ, PediatricAnesthesia, 2008
Coté CJ, PediatricAnesthesia, 2008
GRAZIE PER L’ATTENZIONE