Secretary’s correspondence

Manni Deol BDS, MJDF, PGCMedEd, PGDipConSed
SAAD Honorary Secretary and Clinical Advisor
manni.deol@saad.org.uk 

SAAD continues to receive many questions and queries relating to sedation. Please find below some of the questions received by the Secretary and Clinical Advisor’s office during the last year.

Q: Is it a requirement to have the oxygen cylinder in the surgery room where sedation on a patient is being carried out?
A. It is preferable and ideal that the oxygen cylinder is in the surgery where IVS is being carried out. You may require additional supplemental oxygen during IVS if the patient is not able to maintain their oxygen saturation levels, as well as during a medical emergency. Any delay in getting oxygen to the patient may unnecessarily put the patient at risk.

Q. What is the correct way to dispose of the waste midazolam that is left over in the syringe, if the full 5 mg ampoule is not given to the patient?
A. There are drug denaturing pots / kits available to dispose of unused midazolam.

Q. Is there is an upper age limit for who can be treated under intravenous sedation?
A. No, but it would very much depend on the assessment of an individual’s health. You should consider their ASA grade, assess their airway, as well as other co-morbidities, medication and the availability of an escort. For older patients, titrate Midazolam more slowly and in smaller increments ie give half the dose over double the time.

Q. I am planning on acquiring a BP / SpO2 monitor. What machine would you recommend?
A. There are many machines on the market and SAAD does not recommend any particular one. Personally I use a Dinamap machine which has BP and pulse oximeter in the one machine.

Q. Could you please advise me of any available guidance related to 'Statement of Purpose' required by CQC for practices introducing sedation services for patient care?
A. The Statement of Purpose is personalised to your sedation practice. It could include a brief statement of the type of sedation you provide, the environment in which you provide it, the target patients ie age range / anxious patients / complex surgical procedures / special care and the drugs used ie midazolam/ nitrous oxide and oxygen and the purpose of use.

Q. Please could you advise us how many cylinders of oxygen are needed for a practice that would only do occasional IV sedation? We currently have one 7.5 L one and one 3.75 L one. What's the recommended supply?
A. It would be advisable to have two oxygen cylinders: one for medical emergencies and one for sedation purposes. The sedation cylinder may be used as an adjunct during sedation if the patient's oxygen saturation is falling, is not maintained or for any emergency situation. This cylinder should be kept in the surgery where sedations are performed and be readily available.
Having two cylinders will always ensure there is at least one full cylinder on site at all times, make sure this is always the case.
Things to consider are the layout of the practice, where oxygen is kept and that all team members are made aware of this.

Q. Can you recommend a company who provide oxygen? We purchased our own cylinders a few years ago and have been using Tricodent to refill them but due to their recent issues we are looking for another supplier. I have looked at BOC but you have to rent their cylinders.
A. Unfortunately, I am not aware of any other company to fill existing oxygen cylinders. Personally, I use BOC and get the cylinders from them too.

Q. I have been providing the sedation services at my own practice for the last 15 years. I am planning to provide IV sedation services as a sedationist to other practices. Would you kindly help and guide me to find the site where I can get all the information about it. Also does the operator and the nurse have to have ILS training if I am the sedationist?
A. Regarding providing sedation services at other practices please consider the following:

• Create a checklist of things to check beforehand ie:
  • The practice's policies on sedation
  • Is the environment appropriate for sedation in line with IACSD guidelines?
  • Medical emergency drugs and equipment
  • How you will transport the sedation drugs (locked bag in car, keys always on your person) and log them?
  • Clinical records to be kept at the practice and by you
• Consider how you will do the pre-sedation assessment; this needs to be in person and before the day of sedation
• Consider how the consent for sedation will work
• As you will be just doing the sedation, the dentist and nurse do not need to be sedation trained but they should be ILS trained
• Make sure your sedation CPD and competency are up to date and in line with IACSD guidelines.: https://www.saad.org.uk/IACSD%202020.pdf

Q. I was wondering if you could tell me, do we need to inform CQC that we will be providing sedation at the practice? Our sedation dentist has been told previously that we must notify them but after researching this online I cannot find any evidence to suggest we do?
A. It is important that the CQC are aware that you provide sedation. If there's no clear guidance on how to inform them, from my own experience, they do ask you if you provide sedation before they book an on-site routine visit. It may be the case that you tell them at this point.

Q. We have been trying to source flumazenil over the last six weeks or so and we have found that all the dental suppliers and local pharmacies tell us it’s out of stock. Do you have any contacts who may have this drug in stock so we can purchase?
A. I order our flumazenil from Medical World 0121 580 6600. As far as I am aware there is no shortage. Please check with your suppliers again or feel free to use the details above.

Q. We have a CQC inspection in two weeks. It would be helpful if you could provide me with clinical and non-clinical audits related to IV sedation.
A. With regards to ideas for audits in relation to sedation, this should be customised to your practice and therefore there are not any ‘off the shelf’ ones, so to say. However, audits I have personally done in the past include using the Safe Sedation Practice Scheme Checklist as a template to audit my own practice. See pages 9 to 22 of the following document: https://saad.org.uk/images/Linked-Safe-Practice-Scheme-Website-L.pdf Another useful audit may be of patients’ compliance with pre-operative instructions. You could also audit the clinical records of sedation cases.

Q. I have a 30-year-old lady with 50% lung capacity due to underdeveloped lungs as a baby. She is classed as having severe asthma but says it is well controlled. She is very nervous and has two difficult extractions planned. I know IV sedation could be very unpredictable. I am wondering would RA sedation be suitable here?
A. Can you please clarify if you are in primary care, secondary care or tertiary care as this may have implications on the treatment of a patient with a complex medical history. I would assess this patient’s ASA level and then make a decision. If the patient is ASA 1 / 2, this is suitable for primary care, otherwise I would refer her to secondary or tertiary care. RA would be a safer option if you are concerned about the patient’s risk of respiratory depression.

Q. I am seeking clarification if the statement below means the responsible trained team member needs to be present with the escort and patient at all times in the recovery room, or whether it is acceptable for the patient in the recovery room to be in the presence of an escort at all times with the responsible trained member coming to monitor them periodically? During recovery, the patient must be supervised; a trained member of the dental team must be responsible for the patient and monitor the individual throughout this period.
A. I would advise that it is acceptable for the patient to be in the recovery room with the escort, and for the trained team member to regularly check on the patient and leave the room in between. It would be prudent to inform the escort exactly where the trained team member is during the time that the individual is out of the room in case of any emergency, and to treat each case individually ie if one patient seems more sedated than another when going into recovery this person will need closer monitoring by the trained individual than a patient who is virtually recovered. The sedationist can advise on this when they send the patient to recovery.

Q. What are the limitations / guidance in sedating a patient with epilepsy? Please note I only use midazolam (single drug) when sedating adult patients who fall into category ASA 1 and 2.
A. Thank you for your query regarding IV sedation with midazolam for an epileptic patient ASA grade 2. This is perfectly safe and a good option for these patients as stress and anxiety can be a trigger to exacerbate epilepsy. 

Q. We usually use a needle filter to draw up midazolam. The needle filter is currently on backorder and we cannot get any. My question is: can we draw up midazolam directly via a syringe? (with no needle filter, as cannulas usually have an air filter, and this may block any possible glass particles).
A. I would recommend using a syringe with any size needle that fits on it, for example I use BD Microlance 3 25G X 1”. It does not have to be a needle specifically for drawing up drugs but I would advise a needle is used rather than a syringe alone.

Questions answered by other Trustees

Q. Could you please signpost me to information on the management of patients with cerebral palsy with IV sedation?
A. IV sedation with midazolam is a good technique for patients with cerebral palsy and other movement disorders as it can reduce or eliminate unwanted movement, allowing dental treatment to be carried out safely. If the movement is severe, you will need to discuss manual support / clinical holding with the patient to cannulate. Inhalation sedation with nitrous oxide can also work well.
The only thing I would exercise caution with is the airway. Some, but not all, patients with cerebral palsy have involvement of the muscles used in swallowing. Obviously when doing procedures involving water in a sedated patient, in whom you have induced further muscle relaxation, aspiration / choking can pose a risk and be unpleasant for the patient. Therefore, good aspiration is vital and also using a 45-degree dental chair position. Similarly, the respiratory system can be compromised and baseline saturation at the assessment visit is essential. A good tip is to assess the viscosity of the saliva, clarity of speech (control of oral musculature) and the patient’s ability to drink water without coughing, at the assessment visit.
Having said that, a lot of patients have no problems with their airway and the cerebral palsy is mild. For these patients, midazolam IV sedation works well and enables patients to have ‘normal’ dentistry. There is a large spectrum of associated disability with this condition and the patient is likely to know their cerebral palsy well.
I hope this helps. Here is link to an article which might be useful: https://www.dental-update.co.uk/content/special-care-dentistry/sedation-for-patients-with-movement-disorders 

Q. I have just had a CQC inspection. One of the questions I was asked is if we take the height of our patients who undergo treatment under IVS. We only sedate adult patients and using midazolam alone. Please could you advise if it is mandatory to take the patient’s height?
A. The dosage of sedation drugs (IV or inhalation sedation) is not correlated in any way with a patient's height, weight, or BMI. This is why we have to titrate the drugs to the conscious sedation endpoint. The only time we might measure a patient's height is if there is some doubt that they have developed normally for their age. Abnormal development, not just height, might mean some sedation techniques might be unsuitable in a primary care setting.