Why is multi-drug pediatric oral conscious sedation prohibited in some parts of North America?
Children present the highest risk and lowest error tolerance in patient safety during sedation procedures.
As an oral conscious sedation provider in a dental clinic, the clinician is both the dentist and anesthetist. At all times, you are monitoring the vitals of your patient/ adjusting their head position/ stimulating them to breathe better and performing dentistry. It is mandatory for all members on your dental team to be trained in Basic Life Support but additionally, those involved in caring for sedated patients should have additional training in advanced life support/pediatric advanced life support.
The best way to prepare for an emergency is to prevent it. This is the main goal of a thorough pre-sedation assessment, which is repeated the day of sedation to make sure patient is safe to proceed.
Team drills simulating medical emergencies is a must. This is important even if a dental office is not sedating patients. As a pediatric dentist, we still need to refresh our memory for managing emergencies in adult patients as we may see a parent collapse in our dental office, instead of our child patient.
Coming back to the topic at hand - why is multi-drug pediatric oral conscious sedation (OCS) not allowed in many states in the US and provinces in Canada?
We have all seen those eye grabbing headlines when a dental patient dies in the dental office during a procedure. Well, the safety of margin is narrower in the very young patients and unfortunately, due to many reasons, pediatric deaths have occurred during oral conscious sedation. It is for this reason that many states/provinces have prohibited pediatric dental offices from using oral conscious sedation.
Let’s explore some studies that have taken a closer look at what occurred during these unfortunate incidents -
A study by Chicka et al, 2012 titled, “Adverse Events During Pediatric Dental Anesthesia and Sedation: A Review of Closed Malpractice Claims” -
They looked at 17 claims dealing with adverse anesthesia events of which 13 involved sedation, 3 involved local anesthesia alone, and 1 involved general anesthesia.
💉57% of the claims were LA overdose during sedation procedures.
🚸82% of the claims involved adverse events in children under 6 years of age.
👶🏼Average age of patient in adverse events with major outcome severity was 3.6 years.
🩺Of the 13 claims involving sedation, only 1 claim involved the use of physiologic monitoring.
Another study by Lee et al., 2013 titled “Trends in death associated with pediatric dental sedation and general anesthesia” found the following deficient practice patterns -
💊Medication Error: inappropriate doses of a sedative, a local anesthetic, or a paralytic agent.
🩺Inadequate Monitoring: reports of an untrained staff member who did not recognize respiratory failure in the post anesthesia setting and absence of vital sign monitoring, equipment, or documentation.
💉Inadequate resuscitation: ranged from failure to recognize cardiac arrest to inadequate or no resuscitation efforts.
❌Global practice issues: general statements such as ‘grossly negligent or incompetent care’ and ‘unprofessional conduct’.
🔎Inadequate preoperative preparation: inadequate discussion of anesthetic risks and a lack of medical evaluations.
So if you are able to provide OCS to your pediatric patients, the following recommendations can help minimize adverse events -
✅ Thorough pre-sedation assessment as discussed in my previous post.
✅ Weighing children prior to dental tx - weight-based dosages of both LA and sedative agents.
✅ Proper monitoring consistent with AAPD sedation guideline.
✅ Dentist and staff must be prepared to diagnose and treat emergencies.