Review of Conscious Sedation Techniques in the Department of Oral and
Maxillo-Facial Surgery GRH
Introduction:
This report has been created to provide evidence to the department that national
standards for conscious sedation are being met. It covers conscious sedation
techniques provided within the department but not the use of sedation for patients on
scheduled theatre lists. The review was carried out on 28th April 2010 by Dr E Anne
Thornberry, Consultant Anaesthetist.
The standards used are those defined within the DH report Conscious Sedation in the
Provision of Dental Care 2003. A checklist based on the Standardised Evaluation of
Conscious Sedation Practice for Dentistry in the UK Toolkit (Practice Inspection
Checklist 1) was used as a template for the review.
General
Facilities
Sedation
practice
Findings
The department only provides intravenous
sedation and this is restricted to one agent midazolam
Sedation is only provided by Mr Thomas
Lees or members of the Oral and MaxilloFacial Dept with full medical registration
and appropriate training.
Inclusion criteria are defined
Children under the age of 16 are excluded
ASA 1 patients and occasional ASA 2
patients with stable conditions are included
The waiting areas and recovery are separate
There is good access for emergency service
The surgery is of good size with adequate
room around the patient for resuscitation
The dental chair can be tilted head down
The practice has an operational policy
which is in the final stages of development.
An inclusion protocol is laminated and
widely available within the clinical areas so
that suitability for sedation can be assessed
at the primary clinic appointment
Intravenous sedation is titrated to a
recognised sedation endpoint
Recognised discharge criteria are defined in
the operational policy
Dr E Anne Thornberry FRCA
Comments
Levels of training
are defined within
the department
operational policy
This was reviewed
and is in line with
the standards
mentioned above
A sedation score is
recorded for each
patient and this is
used as auditable
data
There may be some
value in creating a
laminated version of
the discharge criteria
(similar to the
inclusion protocol)
and displaying it in
the recovery area to
provide consistency
if temporary
recovery staff are
required to work in
the department.
The patients are seen by the surgeon
involved before discharge
All patients are provided with emergency
contact information which is also provided
to their escorts
All patients have an escort
Documentation Written information about preoperative
preparation and post-operative expectations
are given to the patient in the first clinic
appointment when a decision is made for
sedation
A pre-operative check list is completed by
nursing staff immediately prior to the
procedure
Specific post-operative instructions are
given to the patient after the procedure and
explained to the escorting adult.
A 2 sided proforma is used to record
medical and dental history, dental treatment
required, pre-operative and intra-operative
vital signs, site of IV cannulation, drug
therapy given and dental treatment
completed
Consent is obtained and recorded using the
generic Trust consent form
The patients are monitored throughout using
Details of IV
an NIBP and pulse oximeter
sedation
techniques
The equipment is regularly serviced and the
service is up to date
Supplementary oxygen is given during the
procedure via nasal cannulae and piped
oxygen
There is a backup supply of O2 in a cylinder
Piped suction is available with a backup
It may be worth
electrical suction
considering a
portable/battery
suction pump in case
of a need to
evacuate a patient
A full Trust resuscitation trolley complete
Dr E Anne Thornberry FRCA
Drugs
Support staff
with self-inflating bag, AED and emergency
drugs is present in recovery and easily
accessible from the surgery. Drugs are in
date and regularly checked by staff and the
Trust pharmacist.
The only sedative used is midazolam 1
mg/ml
Flumazenil is available
Appropriate labels are available
Some nurses have completed the National
Reported verbally –
Course for Sedation for Dental Nurses
evidence not
inspected
All staff complete mandatory BLS training
Reported verbally –
annually
evidence not
inspected
The patients are recovered by one of two
nurses who are trained theatre nurses with
recovery competences
A review of the individual practice of Mr Thomas Lees was carried out at his
request to support his appraisal
Thomas Lees
Name
Qualifications BDS MFDS
Intravenous sedation
Conscious
sedation
techniques
used
2-3/week therefore approximately 100 - 150 Log book seen
Number of
sedation cases
carried out per
annum
1 day theory update at the Eastman 2009
Verbal report –
Training
SAAD course
evidence not
specific to
ALS – 4 year cycle
inspected
conscious
BLS annually
sedation/CPD
Up to date with personal reading of current
guidelines and standards
Does not provide sedation for children
Children
under 16
Treats ASA 1 and occasional stable ASA 2
ASA grades
patients e.g. stable asthmatics.
Keeps a logbook of cases including details
Problems of
Clinical
of sedation scoring; assessment of operating acquiring patient
Governance
conditions; quality of recovery of patients
feedback discussed.
Evidence of auditing records and presenting Suggest prospective
to department.
requests for
feedback would be
simpler than
retrospective.
Dr E Anne Thornberry FRCA
Conclusions:
The department has developed a robust operational policy, which complies with all
the mandatory and recommended national standards for intravenous conscious
sedation in dentistry. My brief inspection of current practice provided evidence that
processes are in place to ensure that all these standards can be met and that these
processes are being followed satisfactorily. The only minor exception is that portable
suction is not available for use in the rare event of having to evacuate a patient, whilst
still sedated.
Dr E Anne Thornberry FRCA