Hopefully you’ve been following along this year and know all about the changes that came to our profession’s rules and laws with the passage of the Sunset Bill. As expected, and rightfully so with the best of intentions to our patients, a large portion of the current changes deal with sedation requirements. Currently the TSBDE Advisory Committee on Dental Anesthesia is in its infancy, so more rule changes are very likely to follow in the coming years. This is just my personal speculation, but I think that the requirements are likely to get even more strict. With this in mind, let’s review a few requirements.
For Level 1 Minimal Sedation, monitoring requirements state that pulse oximetry should be used with a single drug sedative, and pulse oximetry must be used when a single drug sedative is combined with nitrous oxide. Ventilation must also be continually monitored by both chest excursions and respirations.
For Level 2 Moderate Sedation (enteral only) and Level 3 Moderate Sedation (parenteral), pulse oximetry is required, as well as continuous ventilation monitoring, either by auscultation of breath sounds, monitoring end-tidal CO2, or by verbal communication with the patient.
So all three sedation levels require the provider to continuously monitor the airway. Proper sedation levels allow for continued and adequate ventilation and a patent airway. Our patients wake up. But can you, the operating dentist concentrating on the 3rd molar extraction, or even your highly-trained assistant, REALLY continuously monitor ventilations and still concentrate on the task at hand? There’s a better way.
Growing in popularity are pretracheal and precordial stethoscopes. If you’re not familiar, traditionally these are constructed of an earpiece attached to tubing and a stethoscope bell, and placed near either the heart (precordial) or near the trachea (pretracheal). These stethoscopes reduce background noise and amplify breathing sounds directly to your ear, allowing the wearer to better monitor the patient’s respirations. Modern technology has given us an even more convenient version, allowing for a microphone to be placed in the desired area, with the amplified respiratory sounds sent to a wireless Bluetooth headset. This creates further reduction of background noise and increased mobility within the operatory.
Also growing in popularity, and becoming the standard of care for deeper levels of sedation, is end-tidal CO2 monitoring, more commonly referred to as capnography. Capnography is the measurement of CO2 concentrations in expired breaths via sensors placed in nasal canulae or nitrous oxide masks. Capnography provides a real time reading on the condition of your patient’s respiratory condition, and most capnography monitors have an easy to read display. In sedation emergencies, seconds matter, and pulse-oximeters can give normal readings 1-2 minutes after a patient has stopped breathing.
With the current rules, pulse-oximetry is required, so you are not allowed to replace your pulse-ox with a capnograph, but using both in combination with an amplified pretracheal stethoscope certainly would be providing your sedated patients the best options available. If it were your child or mother in the operatory, would you want the “standard of care,” or something just a little bit better?
By Jonathon R. Kimes, DDS