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Conscious sedation is increasingly recognised as an integral element for the control of pain and anxiety, and this is considered both a right for the patient and a duty placed on the dentist.
Intravenous sedation is one modality under the umbrella of conscious sedation. Conscious sedation is “a technique in which the use of a drug or drugs produces a state of depression of the 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”.
Modern dentistry has evolved to be more intricate and elaborate and our treatment times are often longer with more complex treatment plans, especially in the older age groups. In turn, the expectation of the public has increased and patients look for a more comfortable dental journey alongside a pain-free one.
The demand for sedation in primary care has risen substantially and dentists are offering intravenous sedation to more patients in dental practice. Peripatetic sedationists have been in demand and they have allowed for IV sedation to be more accessible to patients.
This article highlights the essential factors to consider when instructing a visiting sedationist for your patients.
The provision of sedation is underpinned by the requirement for high standards of education and training for the entire clinical team.
It is essential to ensure that your visiting sedationist is thoroughly following appropriate guidelines and consistently applying them throughout the entire sedation process to ensure patient safety and adherence to best practices.
It is recommended that a formal agreement be established between the dental practice and the sedation provider. This agreement should specify that the visiting sedationist will adhere to the sedation standards and ensure that their sedation practices comply with guidelines.
A variety of conscious sedation techniques are available, and the choice of method should be tailored to the specific needs of each patient. The selection must be based on clinical appropriateness rather than the convenience of the operator or sedationist, or pressure from third parties. The patient's safety, comfort, and individual circumstances are paramount when determining the most suitable sedation technique.
Standard sedation typically refers to the use of a single benzodiazepine drug, commonly midazolam, to achieve the desired level of sedation. This approach is favoured because single-drug benzodiazepine regimens are generally easier to titrate, offer a wide margin of safety, and benefit from the availability of a reversal agent if needed. This method of titrated intravenous midazolam is used to manage the sedation of most patients due to its simplicity and effectiveness.
Other sedation techniques often refer to multi-drug sedation (which involves the use of two or more different types of sedative) or the use of anaesthetic drugs to achieve the desired level of sedation. Commonly, this may include the use of drugs such as propofol or fentanyl in combination with midazolam.
The most straightforward technique, which is likely to be effective based on a thorough patient assessment and clinical needs, is generally the best initial choice. The use of multiple sedation drugs should only be considered if simpler options have proven ineffective or if the sedationist can justify their use based on the results of the assessment visit or the patient's prior experiences with sedation.
In addition to routine checks like indemnity and immunisation, keep detailed records of the sedationist’s qualifications and training, especially for IV sedation. This includes registration with the relevant bodies and any relevant postgraduate training. Ensure the sedationist has evidence of qualifications specific to the technique they use. Retaining these records ensures that all credentials are easily accessible and that the sedationist's expertise is properly verified and current.
Practitioners must provide a certificate of age-appropriate life support, and this must be in date according to guidelines. Any records of continuous professional development by the sedationist must be recorded and kept by the host practice.
Understand the sedation options for different age groups in primary dental care and ensure your sedationist adheres to them.
You should request evidence that all equipment is maintained and functioning as per the manufacturer's schedule. The provider should provide the practice with a compliance certificate for the calibration and testing of all medical devices which must be in date.
In primary dental care, thorough documentation is essential for safe and effective sedation. Key records include written patient consent for both sedation and the dental procedure, outlining the risks, benefits, and alternatives. Sedation assessments should also document a detailed review of the patient's medical history, including allergies, pre-existing conditions, and current medications, to ensure suitability and address any risks.
The sedation protocol and plan must be carefully documented. This includes specifying the justification for sedation, the type of sedation technique used, the sedative drugs administered, their dosages, and the method of administration. Pre-sedation information must be given to the patient or guardian, and this should also be recorded.
During sedation, document vital signs (heart rate, blood pressure, oxygen saturation, consciousness) and any sedation adjustments. After treatment, record details of the procedure, duration, and any complications. Include recovery and discharge information, post-op instructions, and signs of complications. Also, thoroughly document any incidents, including their management and corrective actions. These records are crucial for ensuring quality and improving future sedation practices.
All sedation-related records must be entered into the patient's notes by the sedationist at the time of the procedure, ensuring that these records are made contemporaneously. From a dentolegal perspective, contemporaneous records are considered more reliable because they are less prone to errors and are less likely to be influenced by hindsight bias. Documenting information immediately after treatment ensures that the details accurately reflect the events as they occurred, thereby strengthening the credibility of the records in legal or regulatory reviews.
In conclusion, following guidelines and thorough documentation are key to safe sedation in dental care. Ensure visiting sedationists comply with these standards and keep detailed records of consent, assessments, and monitoring. Verify qualifications and maintain accurate equipment records to manage risks effectively.
By following these practices, dental practices can deliver sedation care that is patient-centred, safe, effective and aligned with current standards.
