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Patients Should Be Monitored for Adequacy of Ventilation with Capnography
Adaugat pe 16/05/2018 12:09:48 de lilyeven12
The updated AAPD guideline emphasizes the role of capnography in appropriate
physiologic monitoring: “A competent individual shall observe the patient
continuously. Monitoring shall include all parameters described for moderate
sedation. Vital signs, including heart rate, respiratory rate, blood pressure,
oxygen saturation, and expired carbon dioxide, must be documented at least every
5 minutes in a time-based record. Capnography should be used for almost all
deeply sedated children because of the increased risk of airway/ventilation
compromise. Capnography may not be feasible if the patient is agitated or
uncooperative during the initial phases of sedation or during certain
procedures, such as bronchoscopy or repair of facial lacerations, and this
circumstance should be documented. For uncooperative children, the capnography
monitor may be placed once the child becomes sedated. Note that if supplemental
oxygen is administered, the capnograph may underestimate the true expired carbon
dioxide value; of more importance than the numeric reading of exhaled carbon
dioxide is the assurance of continuous respiratory gas exchange (ie, continuous
waveform). Capnography is particularly useful for patients who are difficult to
observe (eg, during MRI or in a darkened room).” Do Not Delay in Calling 911 In
analyzing 78 cases of mishandled sedation or anesthesia, the Blue Ribbon Panel
on Dental Sedation/Anesthesia of the Texas State Board of Dental Examiners found
that, of the factors contributing to dental sedation incidents, the most common
was that “the provider was slow to activate EMS [emergency medical services].”
Sure, the practitioner may be embarrassed over having allowed an adverse event
to occur. However, any embarrassment is preferable to the death of the patient.
We cannot stress this point enough. Do not delay in calling 911. Practice,
Practice, Practice We must emphasize that every person in the dental practice,
including clerical and front office staff, has a responsibility in an emergency.
The only way to prepare all for such emergencies is to practice or perform
drills. Since many dental practices employ part-time employees, that means
drills must be performed on multiple occasions so all employees are familiar
with their roles in emergencies. In discussing factors that might have helped
avoid the death of Joan Rivers, Kenneth P. Rothfield, MD, MBA, chairman of the
Department of Anesthesiology at Saint Agnes Hospital in Baltimore and a member
of the board of advisors of the Physician-Patient Alliance for Health and
Safety, probably said it best when he told the Washington Post, “Unless you have
drilled for it, and trained for it, it can be hard to pull off.” Be Prepared
Being prepared is a key to managing adverse events and taking steps to avoid
patient deaths dental
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. We recommend two related tools to be prepared:
pre-procedure huddles (briefings) and post-procedure debriefings. These meetings
offer the opportunity to both plan for contingencies ahead of time and to
analyze things that might have been done better after a procedure. We also
encourage the use of checklists as a reminder of the key steps to be followed.
The American Dental Society of Anesthesiology provides a Safety Checklist for
Office-Based Procedural Sedation/Anesthesia (see the figure). This checklist has
broken down key considerations along the continuum of care: procedure room
setup, pre-operative encounter, post-operative recovery, and records tooth
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. Restraints Should Only Be Used With Extreme Caution
Dentists sometimes use a papoose board when treating pediatric patients. Papoose
boards restrain the patient from interfering with the dental procedure and may
have contributed to the adverse outcomes in several cases. The AAPD guideline
provides the following cautions to using papoose boards or other restraining
devices: “Immobilization devices, such as papoose boards, must be applied in
such a way as to avoid airway obstruction or chest restriction. The child’s head
position and respiratory excursions should be checked frequently to ensure
airway patency. If an immobilization device is used, a hand or foot should be
kept exposed, and the child should never be left unattended. If sedating
medications are administered in conjunction with an immobilization device,
monitoring must be used at a level consistent with the level of sedation
achieved.” Conclusion Although we cannot say for certain whether these seven
keys would have saved the lives of Caleb, Amber, and Sydney, we do know that the
application of a higher standard of care, in accordance with AAPD
recommendations, might indeed save the life of another patient.Using Floss Once A Day Helps Fight Decay? for more information.  

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