Last lecture of the day!! Oregon Board of Dentistry, Division 26: Anesthesia, begins on page 43 (last section of Day 1 handout).

Transcription

1 Last lecture of the day!! Oregon Board of Dentistry, Division 26: Anesthesia, begins on page 43 (last section of Day 1 handout).

2 Washington - N2O requires 14 hrs - Minimal Sedation hrs - Enteral Moderate Sedation Permit 28 hrs Oregon - N2O permit 14 hrs - Minimal Sedation Permit 16 hrs - Enteral Moderate Sedation Permit 24 pts & 10 pts California - no regs for minimal sedation - OCS Permit (minor) 25 hrs & 1 pt - OCS Permit (adult) 25 hrs & 1 pt

3 Regulations: Minimal Sedation Jason H. Goodchild, DMD December 2017

4 Caveats 1. The regulations about to be presented are accurate and current as of today. 2. This could change tomorrow. 3. It is up to every licensed professional to keep themselves updated on the regulations to which they are responsible. 4. This presentation serves as a supplement to your regulations, it does not replace them and is not as comprehensive as them. Take Home Messsage: Read Your Regs!

5 First, why do we have Regulations? To Protect the Public!

6 Laws vs. Regulations vs. Guidelines LAWS Generally passed by the State Legislature and define the laws and rules pertaining to the practice of dentistry. In the State of Oregon this is the Dental Practice Act (Revised 10/1/15) RULES & REGULATIONS These are rules and directives made and maintained by the State Dental Board. In the State of Oregon these are the Administrative Rules and cover the use of Anesthesia and Sedation GUIDELINES These are general rules and principles. They give advice and guidance and are made by professional organizations like the American Dental Association or other specialty organization (eg, AGD, ADSA, AAOMS, etc)

7 The most recent GUIDELINES from the ADA are from They are free to download at: n/membercenter/oral-healthtopics/anesthesiaand-sedation

8 Oregon Board of Dentistry Website Regulations

9 Oregon Board of Dentistry Website To open and review the Administrative Rules

10 Oregon Board of Dentistry Website Scroll down to Division 26 - Anesthesia Page 43

11 Classes of Permits Classes of Anesthesia Permit The Board shall issue the following classes of permits: (1) A Nitrous Oxide Permit authorizes a dental hygienist or a dentist to induce nitrous oxide sedation. (2) A Minimal Sedation Permit authorizes a dentist to induce minimal sedation and nitrous oxide sedation. (3) A Moderate Sedation Permit authorizes a dentist to induce moderate sedation, minimal sedation and nitrous oxide sedation. (4) A Deep Sedation Permit authorizes a dentist to induce deep sedation, moderate sedation, minimal sedation, and nitrous oxide sedation. The Board shall issue a Deep Sedation Permit to a licensee who holds a Class 3 Permit on or before July 1, (5) A General Anesthesia Permit authorizes a dentist to induce general anesthesia, deep sedation, moderate sedation, minimal sedation and nitrous oxide sedation.

12 Regulations: Minimal Sedation Some Definitions

13 Definitions "Anxiolysis" means the diminution or elimination of anxiety. Nitrous Oxide Sedation means an induced, controlled state of minimal sedation, produced solely by the inhalation of a combination of nitrous oxide and oxygen in which the patient retains the ability to independently and continuously maintain an airway and to respond purposefully to physical stimulation and to verbal command. Minimal Sedation means minimally depressed level of consciousness, produced by non-intravenous pharmacological methods, that retains the patient s ability to independently and continuously maintain an airway and respond normally to tactile stimulation and verbal command. When the intent is minimal sedation for adults, the appropriate initial dosing of a single nonintravenous pharmacological method is no more than the maximum recommended dose (MRD) of a drug that can be prescribed for unmonitored home use. Nitrous oxide/oxygen may be used in combination with a single nonintravenous pharmacological method in minimal sedation. Maximum recommended dose (MRD) means maximum Food and Drug Administration-recommended dose of a drug, as printed in Food and Drug Administration-Approved labeling for unmonitored dose.

14 Low Dose, Single Agents Single_Agents

15 Regulations: Minimal Sedation So Let s Look at Some Specific Parts of the Oregon Rules

16 But first a brief review of the Nitrous Oxide Sedation Rules A licensed dentist or hygienist who maintains a current BLS for Healthcare Providers or equivalent Has completed a 14-hr course and maintains a Class 1 permit in the State of Oregon Facilities, Equipment, and Drugs Required: Operating room, table, or chair large enough for emergencies (airway position and BLS) Lighting to evaluate skin and mucosal color, and a backup system Suction that permits aspiration of the oral and pharyngeal cavities, and a backup system An oxygen delivery system with full face masks, capable of positive pressure, and a backup A nitrous oxide delivery system with fail-safe mechanism Means to take blood pressure and pulse Before administering nitrous oxide sedation: Evaluate the patient Give pre-op instructions to the patient Certify the patient is a good candidate Obtain informed consent

17 But first a brief review of the Nitrous Oxide Sedation Rules If a patient chronically takes a medication which can have sedative side effects, including, but not limited to, a narcotic or benzodiazepine, the practitioner shall determine if the additive sedative effect of nitrous oxide would put the patient into a level of sedation deeper than nitrous oxide. If the practitioner determines it is possible that providing nitrous oxide to such a patient would result in minimal sedation, a minimal sedation permit would be required. The permit holder or anesthesia monitor shall record the patient's condition. The record must include documentation of all medications administered with dosages, time intervals and route of administration. Discharge Criteria: (must have a note in the chart that these criteria were met) Alert and oriented x 3 (person, place, and time) Can talk and respond coherently to verbal questioning Can sit up without assistance Can ambulate with minimal assistance Does not have nausea, vomiting, or dizziness

18 Who is an Anesthesia Monitor? "Anesthesia Monitor" means a person trained in monitoring patients under sedation and capable of assisting with procedures, problems and emergency incidents that may occur as a result of the sedation or secondary to an unexpected medical complication. Persons serving as anesthesia monitors in a dental office shall maintain current certification in Health Care Provider Basic Life Support (BLS)/Cardio Pulmonary Resuscitation (CPR) training, or its equivalent, shall be trained in monitoring patient vital signs, and be competent in the use of monitoring and emergency equipment appropriate for the level of sedation utilized. (The term "competent" as used in these rules means displaying special skill or knowledge derived from training and experience.)

19 I m not going to go through the entire regulations, they are printed in your handout, this is intended to highlight some specific passages

20 Minimal Sedation A licensed dentist who maintains a current BLS for Healthcare Providers or equivalent Has completed a 16-hr course that satisfies the ADA Guidelines and maintains a Class 2 permit in the State of Oregon Facilities, Equipment, and Drugs Required: SAME as for nitrous oxide sedation except, Emergency drugs including, but not limited to: pharmacologic antagonists appropriate to the drugs used (eg, flumazenil), vasopressors, corticosteroids, bronchodilators, antihistamines, antihypertensives and anticonvulsants. Before administering minimal sedation: Evaluate the patient Give written pre- and post-operative instructions to the patient Certify the patient is a good candidate Obtain informed consent

21 Minimal Sedation No permit holder shall have more than one person under minimal sedation at the same time. A patient under minimal sedation shall be visually monitored at all times, including recovery phase. The dentist or anesthesia monitor shall monitor and record the patient s condition. While the patient is being treated under minimal sedation, an anesthesia monitor shall be present in the room in addition to the treatment provider. The anesthesia monitor may be the dental assistant. After training, a dental assistant, when directed by a dentist, may administer oral sedative agents or anxiolysis agents calculated and dispensed by a dentist under the direct supervision of a dentist.

22 Minimal Sedation The patient shall be monitoring as follows: Direct visual assessment (continuous evaluation of mucosa, skin, blood) Continuous pulse oximetry to measure the patient s oxygenation Response to verbal stimuli Blood pressure, pulse, and respiration shall be monitored if they can be reasoably obtained Discharge Criteria (Must make a note in the patient s record) Vital signs stable Mental status appropriate (eg, oriented x 3) Can talk and respond coherently to verbal questioning Can sit up unaided Ambulation with minimal assistance No uncontrollable nausea or vomiting, minimal dizziness Patient must be released to a responsible third party

23 Minimal Sedation Permit Renewal: Minimal Sedation Permit holders must complete four (4) hours of continuing education in one or more of the following areas every two years: sedation, physical evaluation, medical emergencies, monitoring and the use of monitoring equipment, or pharmacology of drugs and agents used in sedation. Training taken to maintain current BLS for Healthcare Providers certificate, or its equivalent, may not be counted toward this requirement.

24 Things I ve learned after looking at many State Regulations on Minimal Oral Sedation

25 Things I ve Learned Read your Rules & Regulations, keep up to date Maintain BLS for you and your Team Get a focused Medical History Take baseline vitals (Pulse, BP, O 2 Sat%), and record at least three readings (pre-op, start of treatment, before discharge) Never leave sedation patients alone Pre-procedure dietary restrictions must be considered based on the sedative technique prescribed Pre-op & Post-op verbal and written instructions must be given to the patient, parent, escort, guardian, or care-giver Get a pulse oximeter! Use a time-oriented sedation record for documentation of monitoring parameters and drugs used Patient must satisfy discharge criteria for dismissal

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