Presentation on theme: "Mario Dauri Cattedra di Anestesiologia e Rianimazione Università di Roma Tor Vergata."— Presentation transcript:
Mario Dauri Cattedra di Anestesiologia e Rianimazione Università di Roma Tor Vergata
In Virginia, on May 11 th, 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)
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 SubcommitteeAmerican 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.American Academy on Pediatric Dentistry Council on Clinical Affairs 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 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
Nowchildren can sleepsafely! Coté CJ, PediatricAnesthesia, 2008