Thursday, February 8, 2018

Complications associated with anesthesia administration for dental treatment in a special needs clinic


Department of Pediatric Dentistry
Lutheran Medical Center
          
Resident’s Name: Michael Hatton
Date: 2.8.17
Article Title: Complications associated with anesthesia administration for dental treatment in a special needs clinic
Author(s): Boynes SG, Moore PA, Lewis CL, Zovko J, Close JM
Journal: Spec Care Dentist
Date: 2010
Major Topic: Special Healthcare Needs
Type of Article: Prospective study
Main Purpose: Assess perioperative complications related to anesthesia for patients with special needs receiving dental care
Key Points: Anesthesia administration during dental treatment for patients with special needs is safe and effective.

The overall complication rate was 23.8%; of which 95.8% were mild, 4.2% were moderate and no severe complications. The most common complications encountered were airway obstruction (11.4%) and nausea/vomiting (9.4%).



Factors influencing anesthetic complications were:
·        ASA classification
·        Anesthetic technique
·        Mallampati airway classification
·        Type of dental procedure

Anesthetic type included in this assessment:
·        Nitrous oxide (1% of cases)
·        Oral sedation/anxiolysis (minimal sedation) (1% of cases)
·        IV sedation (moderate to deep sedation) (90.6% of cases)
·        General endotracheal anesthesia (7.4% of cases)

Classification of complications:
Mild complications – resolved during course of standard anesthetic care or not requiring pharmacologic intervention (overall 11.4% n=23)
·        Nasal pharyngeal airway 56.5%
·        Manual manipulation (chin-lift) 43.5%
Moderate complications – resolve in an immediate manner with pharmacologic intervention
Severe complications – resulted in extensive pharmacological treatment, initiation of emergency medical management, hospitalization, ER visit, and/or death

Discussion:
Overall, types and rates of complications similar to general population, contrary to the initial hypothesis that complications rate would be higher.

Adverse Sedation Events in Pediatrics: A critical Incident Analysis of Contributing Factors








Department of Pediatric Dentistry
NYU Langone Health

Resident’s Name: Albert Yamoah, DDS                                                                                      Date: 02/08/2018
Article Title: Adverse Sedation Events in Pediatrics: A critical Incident Analysis of Contributing Factors
Author(s): Cote, MD, et al.
Journal: Pediatrics
Date: April 2000
Major Topic: Adverse sedation events in Pediatrics
Type of Article: Critical incident analysis
Main Purpose: Identify areas of improvement for pediatric sedation
Key Points
-        Adverse events that occurred in the a non-hospital based venue were most likely to result in sever neurologic injury or death (these also happen to be older and healthier patients)
-        Inadequate monitoring (mostly failure to use a pulse oximetry) was rated as major factor contributing to poor outcomes in all venues
-        Other issues: errors in managing complications (failure to rescue), inadequate pre-procedure medical evaluations, medication errors, inadequate recovery procedure and lack of an independent observer
-        Pulse oximetry should be mandatory for all sedation, size-appropriate equipment and medications for resuscitation should be immediately available in a designated crash cart, all health care providers should have advanced airway management and resuscitation skills, practitioners should consider the risks and benefits for sedating children beyond the safety net of a hospital or hospital like environments, realizing the possible absence of skilled back-up personal
-        Adverse outcomes despite the benefit of an early warning regarding oxygenation likely reflect lack of skill in assessment and in the use of appropriate interventions, ie, a failure to rescue the patient.

Methods:
-        A database was formed from adverse events that were in the FDA’s adverse drug event reporting system, from the US Pharmacopeia, and from survey of pediatric specialists.  
-        Reports were reviewed and had to have consensus from three pediatric subspecialties (anesthesiology, critical care and emergency medicine).  
-        Data collected included the year of the incident, age, weight, gender, type of procedure, venue in which the sedation drug were administered, venue were the adverse sedation event took place (hospital vs. non-hospital based), the medical specialty of the individual directing drug administration, the monitoring which was reported as being used, and the underlying medical conditions.  

Results:
-        118 adverse events were reviewed, after exclusion criteria 95 remained.  
-        51 cases resulted in death
-        9 permanent neurologic injury
-        21 has a prolonged hospitalization without injury
-        14 there was no harm. 

Conclusion
-        Adverse events that occurred in the a non-hospital –based venue were most likely to result in sever neurologic injury or death (these also happen to be older and healthier patients)
-        Inadequate monitoring (mostly failure to use a pulse oximetry) was rated as major factor contributing to poor outcomes in all venues
-        Other issues: errors in managing complications (failure to rescue), inadequate pre-procedure medical  evaluations, medication errors, inadequate recovery procedure and lack of an independent observer
-        Uniform specialty-independent guidelines for monitoring children during sedation are essential, the same level of care should apply to hospital-based and nonhospital-based facilities
-        Pulse oximetry should be mandatory for all sedation, size-appropriate equipment and medications for resuscitation should be immediately available in a designated crash cart, all health care providers should have advanced airway management and resuscitation skills, practitioners should consider the risks and benefits for sedating children beyond the safety net of a hospital or hospital like environments, realizing the possible absence of skilled back-up personal
Assessment of Article:  
Level of Evidence/Comments: Level III