What's new in governance for conscious sedation in dental practice.

T technique of intravenous sedation with a benzodiazepine is a well documented and successful method for reducing fear and anxiety in many patients who regard dental treatment as challenging and potentially painful. One of the most important factors to achieving a well sedated patient is ensuring the dose of the drug given is titrated to the individual patient. Five years ago, a Rapid Response Report issued by the National Patient Safety Agency changed the concentration of midazolam within a 5ml ampoule from 10mg/5ml to 5mg/5ml. A retrospective audit of 300 patients undergoing oral surgery treatment under intravenous midazolam sedation at Birmingham Dental Hospital was carried out over a 6-month period to assess whether this difference in midazolam concentration had any influence on the average dose of midazolam given to these patients. Study group: the midazolam doses given by five clinicians were audited both before and after the concentration change. Results: the mean midazolam dose that was administered by three clinicians decreased following the change in concentration. In addition, the number of patients given greater than 5mg midazolam following the change decreased with all five clinicians. Conclusions – the change in midazolam concentration from 10mg/5ml to 5mg/5ml ampoules has resulted in the overall average dose of midazolam given by five clinicians at Birmingham Dental Hospital to decrease. Background Conscious sedation is defined as ‘a technique in which the use of a drug or drugs produces a state of depression of the CNS enabling treatment to be carried out, but during which verbal contact is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely.’ Thus, the patient retains reflexes, can independently maintain their own airway and is able to understand and respond to verbal commands throughout treatment. Since being published, this definition has gained widespread acceptance amongst numerous specialist sedation groups including SAAD (Society for the Advancement of Anaesthesia in Dentistry), DSTG (Dental Sedation Teachers’ Group,) SDAC (Standing Dental Advisory Committee), NDAC and the Scottish Dental Clinical Effectiveness Programme as well as regulatory bodies such as the GDC and the DOH. In addition, these guidelines apply to all methods of sedation currently used in the UK, including nitrous oxide inhalation sedation, intravenous benzodiazepine sedation and oral/transmucosal benzodiazepine sedation. The 2007 guidelines by the Standing Committee on Sedation for Dentistry explore the use of drug combinations and sedation for children under twelve. REFEREED PAPER SAAD DIGEST | VOL.29 | JANUARY 2013 40 A RETROSPECTIVE AUDIT TO EVALUATE THE EFFECT OF THE CHANGE IN MIDAZOLAM CONCENTRATION FROM 10MG/5ML TO 5MG/5ML AMPOULES ON MIDAZOLAM DOSES GIVEN TO SEDATION PATIENTS FOLLOWING THE RAPID RESPONSE REPORT (RRR) Shazia Kaka BDS MJDF(RCS) Pan Taneja BDS MFDS(RCS) Birmingham Dental Hospital, St Chad’s Queensway, Birmingham B4 6NN The report also ensures the definition is respected. The Standard Dental Advisory Committee states that ‘The standard, recommended technique for intravenous sedation is the use of a titrated dose of a single benzodiazepine. The use of fixed or more rigid doses is unacceptable as success is directly related to titration according to the individual patient’s needs.’ Thus, the dose of midazolam required for conscious sedation will vary between individuals due to factors such as age, gender, anxiety, social habits, procedure being performed and medical conditions. Prior to December 2008, midazolam was routinely supplied as ampoules of 10mg/5ml (2mg/ml), usually drawn up into a 5ml syringe. Following the Rapid Response Report published by the National Patient Safety Agency in December 2008, these ‘high strength’ ampoules were replaced with a lower concentration of 5mg/5ml in virtually all treatment areas. The report’s reasoning behind this was that in medicine and surgery, between November 2004 and 2008, the National Reporting and Learning service had received 498 patient safety incidents, three of which had resulted in death because the dose of midazolam prescribed or administered to the patient was inappropriate. Specifically, most of these incidents were the result of shortcomings in medical sedation training, techniques and practices: quantities/concentrations not being checked prior to administration, bolus injections being given rather than titrated doses as well as the drug being given mistakenly due to unlabelled syringes. This suggests that it is not the higher concentration formulation of midazolam that is the problem, rather the medical training associated with its use. Only two of the reported incidents were related to dentistry and these were of prolonged recovery, rather than respiratory depression requiring the use of flumazenil. Dental practice therefore did not have a problem with the higher strength formulation of midazolam as ‘when it is administered by slow titration and in accordance with current guidelines, the risk of oversedation is extremely low’. The SAAD response to the RRR Report goes on to state that ‘many adult dental patients require more than 5mg midazolam in order to produce effective conscious sedation’ and ‘using the lower concentration means that, for most patients, practitioners will have to draw up two 5mg in 5ml ampoules (making 10mg in 10ml) in a 10ml syringe in preparation for administering sedation’. Thus, if the sedationist routinely draws up only one ampoule of the newer, lower formulation at the beginning of a dental procedure, it may have a tendency to promote undersedation.