Remembering the classics: Sedation Guidelines Historical Perspectives Part 2
Charles J. Cote MD
The AAP sedation guideline continued to evolve. The data from my outcome studies,1 2 capnography studies,3 along with two deaths in children that occurred in cars after children were sedated at home prior to dental procedures, resulted in further changes to the AAP guideline in 2006; this revision was accomplished again with the input and support of the American Academy of Pediatric Dentistry (AAPD) who rejoined the process as copartners:4 The guideline now prohibited administration of sedatives without medical supervision (no home prescriptions), the use of capnographjy was “encouraged”, assessing use a neutraceuticals was suggested, patient simulation was encouraged as was the development of skill with supraglottic devices.
The 2006 guideline was again revised in 2016 after the AAPD requested that the AAP develop a position statement on the use of capnography. Instead we revised the sedation guideline to now incorporate such monitoring.5 Capnography was now required for deep sedation and “strongly recommended” for moderate sedation. This revision was interestingly requested by the ASA who revised their sedation document in 2018 and it also included the requirement of capnography for sedated patients.6 Shortly after the AAP document was published, a five-year-old boy, Caleb, was scheduled for removal of the supernumerary tooth in a dental office in California. An IV was started and he received several sedating medications (personal communications with his parents and review of office records) which led to airway obstruction. The oral surgeon was unable to perform bag mask ventilation, did not use any supraglottic devices such as an oral airway or nasal trumpet, did not administer any reversal agents, and was unable to intubate resulting in severe neurologic injury and death. The initial events that caused the AAP to develop a sedation guideline, i.e., deaths in the dental office continue after all of these years…history repeated itself! This terrible event resulted in his aunt, who was a physician, to work with several California legislators to craft Caleb’s Law. This would have required the sedation of children to be performed with practitioners having anesthesiology skills separate from the operating dentist. Unfortunately the oral surgery lobby defeated this law and instead codified their own single-provider model whereby the oral surgeon simultaneously directs the sedation/anesthesia while performing the dental procedure (and bills the family for both). There is no requirement for another skilled practitioner to be present. Obviously this is a very dangerous practice that would never be allowed on the medical side of healthcare and so as a response to this we convinced AAP leadership with the input of AAPD to revised the sedation guideline with very specific language in 2019.7 The reason that we revised this guideline was because healthy children continue to suffer adverse outcomes in dental settings. The oral surgery community claims they in fact are following the guidelines of the AAP; we wanted to make it clear that the single-provider model did not align with the AAP document and that such practice was dangerous. The previous guidelines had always required an independent observer whose only responsibility was to monitor the patient but the oral surgeons continue to use Dental Anesthesia Assistants certified by the American Academy of Oral and Maxilofacial Surgeons (https://www.aaoms.org/continuing-education/certification-program-daance). It is beyond my understanding how such a person with no educational requirements, who takes a 36 hour internet course, could possibly have any true understanding of “basic sciences, evaluation and preparation of patients with systemic disease, anesthetic drugs and techniques, anesthesia equipment and monitoring, and office anesthesia emergencies”. How could such a person be of any help with a true life threatening emergency since by most state laws these individuals cannot draw up or administer medications and they certainly do not know how to perform bag/mask ventilation.? The 2019 document was designed to further clarify the responsibilities of this independent observer and the training that was required specifically for dental procedures:
“During deep sedation and/or general anesthesia of a pediatric patient in a dental facility, there must be at least 2 individuals present with the patient throughout the procedure. These 2 individuals must have appropriate training and up-to-date certification in patient rescue, as delineated below, including drug administration and PALS or Advanced Pediatric Life Support (APLS). One of these 2 must be an independent observer who is independent of performing or assisting with
the dental procedure. This individual’s sole responsibility is to administer drugs and constantly observe the patient’s vital signs, depth of sedation, airway patency, and adequacy of ventilation. The independent observer must, at a minimum, be trained in PALS (or APLS) and capable of managing any airway, ventilatory, or cardiovascular emergency event resulting from the deep sedation and/or general anesthesia. The independent observer must be trained and skilled to establish intravenous access and draw up and administer rescue medications. The independent observer must have the training and skills to rescue a nonbreathing child; a child with airway obstruction; or a child with hypotension, anaphylaxis, or cardiorespiratory arrest, including the ability to open the airway, suction secretions, provide CPAP, insert supraglottic devices (oral airway, nasal trumpet, or laryngeal mask airway), and perform successful bag-valve-mask ventilation, tracheal intubation, and cardiopulmonary resuscitation. The independent observer in the dental facility, as permitted by state regulation, must be 1 of the following: a physician anesthesiologist, a certified registered nurse anesthetist, a second oral surgeon, or a dentist anesthesiologist.”
Thus, the most recent guideline clearly addresses the issue of the need for an anesthesia practitioner when children will be deeply sedated for a dental procedure. It requires the operating dentist to be the second pair of skilled hands and that dentists must be up to date in pediatric advanced life support (PALS) training.
So, this is been a long journey for me having been involved with sedation guidelines for over 36 years; I will tie this all together with a story dating back to when I was 16 years old and why life experiences can change you in ways that are not immediately predictable.
I had developed an abscessed tooth and needed a root canal procedure. My uncle, who was a dentist, had arranged for one of his oral surgeon friends to take care of me. I had eggs, bacon, toast, and milk, for breakfast and drove 35 miles from Rockland Massachusetts to Fall River Massachusetts. I arrived at the dental facility, and they never asked a single question about how I got there, how I would get home, or anything about my health or NPO status. They wrapped a gray cuff around my upper arm which squeezed hard and then I felt pain in my antecubital fossa and was out (most likely a methohexital infusion). I had never had my blood pressure taken before and that is why I did not know what the gray cuff was for (it also was a tourniquet). I woke up in a room with no lights on, vomiting, rolled over, and fell on the floor. When they heard the noise, someone came in, turned on the lights, and said “Oh you can go now” and they sent me out front door! Certainly, I was very lucky that I did not obstruct my airway or vomit and aspirate since no one was watching me. I then went to a corner diner and had my 1st cup of black coffee because on TV at that time cowboys were always given black coffee when they were drunk and I felt drunk even though I had never had any alcohol at that point. I then left the diner and vomited and walked around for about two hours until I felt almost back to normal. I drove to my aunt’s house nearby and stayed there is an additional four hours and then drove home. Certainly, if I had gotten into my car I could have driven into a tree or had a head-on crash and killed somebody or killed myself. Perhaps looking back this is the reason I became so interested in sedation safety and in particular sedation associated with pediatric dental procedures!
1. Cote CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. Oct 2000;106(4):633-44.
2. Cote CJ, Notterman DA, Karl HW, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: a critical incident analysis of contributing factors. Pediatrics. Apr 2000;105(4 Pt 1):805-14.
3. Cote CJ, Rolf N, Liu LM, et al. A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology. Jun 1991;74(6):980-7.
4. American Academy of P, American Academy of Pediatric D, Cote CJ, Wilson S, Work Group on S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. Dec 2006;118(6):2587-602.
5. Cote CJ, Wilson S, American Academy Of P, American Academy Of Pediatric D. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. Jul 2016;138(1)
6. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. Mar 2018;128(3):437-479.
7. Cote CJ, Wilson S, American Academy Of P, American Academy Of Pediatric D. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. Jun 2019;143(6)