In 2002 the American Society of Anesthesiologists. the organization for medical specialists in anesthesia, in response to an increase in the use in medicine of sedation by physicians, many of whom had little background or training in anesthesiology, published “Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists."
In the introduction it is stated: "These Guidelines are designed to be applicable to procedures performed in a variety of settings (eg., hospitals, freestanding clinics, physician, dental. and other offices} by practitioners who are not specialists in anesthesiology. Because minimal sedation (anxiolysis) entails minimal risk, the Guidelines specifically exclude it.
Examples of minimal sedation include peripheral nerve blocks, local or topical anesthesia. and either less than
50% nitrous oxide (N2O) in oxygen with no other sedative or analgesic medications by any route; or a single oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of insomnia , anxiety, or pain.
Another extremely important concept included in these guideline: is the principle uf the need io be able to "‘rescue" a patient from unintended entry into a more profound level of CNS depression than intended:
"Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to producea given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation / Analgesa (Conscious Sedation) should be able to rescue patients who enter a state ol Deep Sedation / Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue patients who enter a state of general anesthesia".
Rather than maintain a set of clinical standards slightly at variance with those of the anesthesiologists, and recognizing the expertise of the American Society of Anesthesiologists in this area. the House of Delegates of the ADA reviewed the ADA guidelines from 2002 and ib October 2007 passed a revised document and a new document providing guidelines for the teaching of sedation and anesthesia to dental students.
The following definitions of levels of sedation are excerpted from the two new ADA guidelines:
Minimal sedation (this definition was previously associated with anxiolysis)—"a minimally depressed level of consciousness that retains the patient's ability to independently and continuously maintain an airway and respond appropriately to physical stimulation or verbal command and that is produced by a pharmacological or non-pharmacological method or a combination thereof. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are uhaffected.
Note: "In accord with this particular definition, the drug(s) and / or techniques used should carry at margin of safety wide enough never to render unintended loss of consciousness. Further, patients whose only response is reflex withdrawal from repeated painful stimuli would not be considered to be in a state of minimal sedation."
"When the intent is minimal sedation for adults, the appropriate initial dose of a single enteral drug is no more than the rnaximurn recommended dose (MRD) of a drug that can be prescribed for unmonitored home use."
Moderate sedation (this definition was previously associated with conscious sedation)—"a drug-induced depression of consciousness during which patients respond
required to maintain a parent airway. and spontaneous ventilation is adequate Cardiovascular function is usually maintained.
Note: ln accord with this particular definition, the drug(s) and / or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Repeated closibg of an agent before the effects of previous closing can be fully appreciated may result in a greater alteration of the state of consciousness than is the intent of dentist. Further, patients whose only response is reflec withdrawal from repeated painful stimuliwould not be considered to be in a state od moderate sedation.
Deep sedation : a drug-induced depression of consciousness during which patients cannot easily be aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a parent airway, abd spontaneous ventilation may be inadequate, Cardiovascular function is usually maintained.
General anesthesia : a drug-induced loss of cobsciousness during which patients are not arousable,even by painful stimulation. The ability to independenely maintain ventilatory function is often impaired. Patients often require assistance an maintaining a patients airway and possitive pressure ventilation may be required because of depressed spontaneous verntilation or drug-induced depression of neuromuscular function. Cardiovascular function may be inpaired."
Read the table compares the different levels of CNS depression described in the American Society of Anesthesiologist guidelines.
THE CONCEPT OF "RESCUE”
Recognizing that serious instances of morbidity and mortality have occurred associated with the administration of sedation by nonanesthesiologists, the guidelines from American Society of Anesthesiologists included and stressed in the important concept of "rescue";
" Because sedation and general anesthesia are a continuum, it is not always possible to predict how an individual will respond. Hence. practitioners intending to produce a given level of sedation should be able to diagnose and manage the physiologic consequences (rescue) for patients whose level of sedation becomes deeper than initially intended.
For all levels of sedation, the practioner must have the trainning, skills, drugs and equipment in identify and manage such an occurrence until either assistance arrives (emergency medical service) or the pateints return to the intended level of sedation without airway or cardiovascular comlications.
The principle governing a health care provider's responsibility to the victim during a medical ernergency is quite similar to the definition of "rescue" previously presented.
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