Estabrooks - EventPilot

AAPD
th
65 Annual Session
San Diego, CA
May 25,2012
1:30-4:30 PM
Risks of Dental
Sedation/Anesthesia
Could This Happen To Me?
Lewis Estabrooks DMD,MS
May 25,2012
1:30 – 4:30PM
Disclosure
• Retired Oral Surgeon
• Chairman of the Board of :
– OMSNIC Risk Retention Group
– Fortress Insurance Company
• Data is from These Dental Professional
Liability Companies
• Any opinion I may express are my own and do
not reflect the companies
RISKY
When The Wheels Come Off
Airway- Airway- Airway
"Airway management for children is the primary
thing, and breathing problems can lead to
cardiac arrest”
OXYGEN
Is your best friend
Could This Happen To Me?
• 6 y/o child
• 30 Kg. 48 in. (BMI 20.1)
• The office has sedated several times in the
past for dental work
• Required several restorations with sedation
• PMH negative
• NPO
AAP/ASA Recommendations for Duration of NPO
Before Elective Procedures
Solid and Nonclear
Liquids*
Age
Clear Liquids
< 6 mo
4-6 h†
2h
6-36 mo
6h
2h
> 36 mo
6-8 h‡
2h
*Infant formula, breast milk, nonhuman milk.
Could This Happen To Me?
• Induced with N2O2/O2 (70-30)
• IV started in L forearm with angiocath & D5W
• Versed 1mg titrated (Initial dose 0.025 to 0.05
mg/kg; total dose up to 0.4 mg/kg may be
needed to reach the desired endpoint but
usually does not exceed 10 mg)
• Robinul 0.1mg (0.004 mg/kg intravenously)
• Ketamine 30mg (1.5 mg/kg intravenously)
Could This Happen To Me?
•
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Discharged criteria met
Instructed to rest the rest of the day
Went to sleep at home
2 hours later Never woke-up
EMTs transported to ER
Unable to resuscitate
Could This Happen To Me?
What happened?
Could This Happen To Me?
• Body temperature was 107
Robinul Injection (glycopyrrolate)
Uses
• preoperative antimuscarinic to:
– reduce salivary, tracheobronchial, and pharyngeal
secretions;
– reduce the volume and free acidity of gastric
secretions;
– block cardiac vagal inhibitory reflexes during
induction of anesthesia and intubation
• Glycopyrrolate protects against the peripheral
muscarinic effects (e.g., bradycardia and
excessive secretions)
Robinul Injection (glycopyrrolate)
Warning
in the presence of fever, high environmental
temperature and/or during physical exercise,
heat prostration can occur with use of
anticholinergic agents including glycopyrrolate
(due to decreased sweating), particularly in
children and the elderly.
Robinul (Glycopyrrolate)
• Glycopyrrolate reduces the body's ability to
cool off by sweating.
• In very high temperatures, glycopyrrolate can
cause fever and heat stroke
Why Are We Here?
• Review closed case examples
• It is laudable to review errors especially when
they are someone else's
• Learn from others misadventures
• Improve safety in our anesthesia
administration
Why Are We Here?
• Give some statistics
– Best way to know the truth
– Best way to preserve our ability to provide
sedation/anesthesia
– Best way to identify areas for improvement
Increased Sedation
• Sedation is becoming more common in
pediatric dental procedures because so many
children are coming into dentist offices at
younger ages with caries, and they sometimes
need extensive work
• Indru Punwani, D.D.S., M.S.D., a spokesperson
for the AAPD
Not Here
• To teach an Anesthesia/sedation techniques
• Turf battles
Could this happen to me?
Question?
Who administers the sedation/anesthesia?
1. Nurse anesthetist under my supervision
2. MD Anesthesiologist
3. Myself/team
Question?
How many have state anesthesia permits?
RISK
Avoid the Swine Flu
Fame & Recognition
• News Papers
• TV broadcasts
• Social Media
Media Headlines
• Christ walks on water
• Jesus can’t swim
Headlines
• Are pediatric sedation deaths on the rise?
• By Donna Domino, Features Editor
May 18, 2010 -- In the past 15 months, four
pediatric patients have died in the U.S. after
undergoing sedation prior to dental treatment -a tragic reminder of the need to ensure proper
sedation training and emergency preparedness
Headlines
• Chicago dentists settle out of court in sedation
death
• By Kathy Kincade, Editor in Chief
August 14, 2008 -- Two Chicago dentists who
had their licenses suspended July 31 because
a patient died while under sedation in their
office must now pay the patient's family $3.9
million.
Headlines
• Woman sues sedation training firm over
husband's death
• By Kathy Kincade, Editor in Chief
March 26, 2010 -- A Missouri woman whose
husband died in 2007 following conscious
sedation for a dental procedure is now suing
the company that provided the dentist's
sedation training.
Comments
• “Nicole Cunha, a family friend and executive
director of the Raven Maria Blanco
Foundation - a non-profit group dedicated to
protecting pediatric dental patients - told ABC:
'Something should have been done at the first
sign of the emergency happening. If they
hadn't waited so long, Jenny would still be
here.‘”
Common Issues in Emergencies
• Delay in calling 911
• Delays in responding to treatment of the
emergency
• No emergency protocols in place
• Lack of proficient staff training for emergency
situations
• Little or no documentation of event
Catastrophic Errors
Expectations
Public and media perception is that someone
should not die from going to the dentist
• State attorney prosecute for criminal actions
Dentist The Menace
Children Killed Undergoing Procedures at the
Dentist
• http://dentistthemenace.com/deathbytheden
tist.htm
Unrecognized Errors
Developing pulmonary issues
• 1/9/08 saw allergist c/o cough and “rattling”
in lungs
• 3/16/08 ENT visit c/o sinus problem
• CT of sinuses & Chest X-ray
• 3/25/08 Chest X-ray
• Foreign body
• Post-obstructive atelectasis
Developing pulmonary issues
• 3/31/08 Bronchoscopy
• Implant driver
• Culture showed E. Coli
• Erythema of right middle and lower lobe
• Treated with Levaquin
Implant Driver Retrieved by Bronchoscopy
Adaptor
Weakness of case
• Can a lost driver go unnoticed?
• No documentation
Claim
• Negligence causing aspiration of implant
driver
• Allegation of deliberate failure to disclose act
to pt
• $500,000 demand
• Threat of pleading intentional tort (punitive
damages)
Pretreatment issues
• Conscious sedation
– Versed 5 mg
– Fentanyl 50 mics
During treatment issues
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Throat screen
Rubber dam
Confirmation of equipment
Was there any coughing?
Post treatment issues
• Was the instrument count correct?
• Where did the missing instrument go?
– Suctioned-up
– Swallowed
– Aspirated
• Duty to find
– Strain suction
– ER referral for x-rays
Litigation
No poet ever interpreted nature as freely
as a lawyer interprets truth
Stupidity
And
This is Why You Buy
Malpractice
Insurance
Question?
Do you use IV sedation?
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8 year old female, great general health
Has 5yo and 11yo male siblings
3rd grade, straight A student
Mother is teacher in patient’s school
8/17/2006
• Referred by her general dentist due to delayed
eruption of #10, impacted H and retained G
• OMS plans IV anesthesia for removal of G
and H
Do Not scratch
out entries
??
SOAP format
Consultation
Note with good
documentation
for problem,
diagnosis, and
planned
treatment
This is actually a
case with “Good
Records”
8/24/2006
• Patient for procedure, NPO with Mom
• IV access
• Midazolam, Fentanyl, Ketamine, Anzamet – all
reasonable doses
• Anesthesia record shows 250ml IV fluids
• Surgery was uneventful
Reasonable dosages of drugs
and good VS through surgery
8/24/2006
• Patient awakened from anesthesia tearful and
complaining of headache
• IV was maintained and additional Fentanyl
was given
• Patient complained of nausea – wheelchair to
bathroom for vomiting
• IV Phenergan given
• Mom taking patient to bathroom again for
nausea and patient has seizure
8/24/2006
Patient returned to OR, SaO2 63%
Patient clenching teeth, constant seizure
OMS ventilates with ambu-bag, SaO2 95%
911 called, Internist assist with resuscitation
IV running out, asks for another bag, asst
hangs another 500ml bag of IV fluids
• EMS arrives, transfers patient to local ER, OMS
ventilates with ambu-bag
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What are some causes for seizures?
8/24/2006
• Admitted to ER, unresponsive in continuous
active seizures
• Patient is intubated, ER unable to stop
seizures
• Patient is transferred to University Hospital
• Patient is placed in a medically induced coma
to stop seizures - 8 days
Result
• 8 year old female
– Significant brain disorder
– Cognitive disorders
– Anteriograde amnesia
– Seizure disorder
– Personality changes
– Behaviorial disorders
– Etc.
Pediatric Neurologist Expert
What happened?
Is there negligence?
What Is Negligence?
• It can be generally defined as conduct that is
culpable because it falls short of what a
reasonable person would do to protect
another individual from foreseeable risks of
harm. In the words of Lord Blackburn,
What happened?
Multiple office systems failures?
The ‘Swiss cheese’ model of
organizational accidents
Hazards
Some holes due
to active failures
Losses
Other holes due to
latent conditions
Successive layers of defences
Modified from James Reason, 1991.
What happened?
• 6/27/06 – Nurse telephone ordered 2 boxes of
500ml D5W IV solution
• 6/28/06 – Nurse telephone ordered 2 vials of
D50W
• 6/29/06 – office received 2 boxes of 5 D50W
and 2 individual 500ml D50W
• 6/29/06 – Nurse received order and noted 2
boxes IV fluids and 2 x 500ml D50W
What Happened?
• Assistant - opened the boxes and stored IV
fluids
• Note:
– 500ml D50W comes in silver packaging
– 500ml D5W comes in clear packaging
– Once open the only difference is the D50W bag is
slightly larger than the D5W bag
What Happened?
• Day of the procedure, the assistant opened a
silver package and hung the IV fluids in the OR
for the procedure
• OMS came in and started the IV infusion
• When the internist asked for another bag of
fluids, the assistant opened another silver
packaged bag
Hospital ER
• Initial blood glucose in ER was 2178 mg,
thought to be a lab error
• 2nd blood glucose was 2497 mg
• 3rd was 1886 mg
• ER physician noticed D50W hanging with 150
ml remaining
• CT showed subarachnoid or cerebellar
intraparenchymal hemorrhage
36 + 2 = 38 500ml bags of D50W were delivered,
10 remained + 2 this patient = 12, 26 bags were
evidently used before this patient was treated
Problems
• OMS did not notice IV bag was D50W
• Staff who received order and unpacked the
order failed to recognize the IV solution was
D50W not D5W
• Surgical assistant failed to notice D50W when
hanging the bag to set-up for the case
Indemnity
• OMSNIC paid policy limits on both the OMS
liability policy and the corporate policy due to
employee liability
• $2.0 million dollar indemnity payment
The Unexpected
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16 y/o patient with seizure disorder
On Dilantin
VS WNL 110 lbs. 5 ft. 3 in
Monitors applied
IV versed titrated 3mg
2% Lidocaine 1/100,000 epinephrine-3
carpules
The Unexpected
• IV sedation with supplemental nasal Oxygen
– Multiple restorations
– Crowns & Bridge preparation
– Removal of hyperplastic gingivae
• The assistant covered the patient’s eyes with a
towel
During the procedure the surgeon used
electrocautery
• Flash fire occurred
• Tissues were “sun burned” in the midfacial
and nasal regions
• The doctor completed the procedure after the
fire
Postoperative Care
• The doctor prescribed topical cream
• 3 days later pt went to a walk-in clinic and was
referred to a plastic surgeon
• Diagnosis: 2nd Degree burns
• Rx: Silver Sulfadiazine
8 days postoperative
Permanent Damage
What Can We Learn
• Do not use oxygen with electrocautery or laser
• Do not use any instrument that can create a
spark with a flammable liquid
• Throat screens are also flammable with
electrocautery or lasers
• Burns are always worse than they initially
appear
• Lungs are often damaged
Consequences
Could this Happen to Me?
4 y/o
Wt. 30 kg.
PMH healthy
Parents and doctor felt required sedation for
“accurate and humane” completion of dental
procedures
• Script liquid versed
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Could this Happen to Me?
• Versed Syrup 2mg/ml
• Disp: 30ml
• Sig: 1 tsp. po. on awakening, 1 tsp. po. on
leaving for office, 1 tsp. po. when arrives at
office.
Could this Happen to Me?
• Mom stated the child would be unmanageable
in the morning
• ½ hour drive to office
• Instructions reviewed and stated that he
would decide if he needed the office
medication dose
Could this Happen to Me?
• The appointment is for 8:00 am
• Mom gets up late and is in a rush to dress the
child and to leave.
• On leaving the house she gives the entire 30
ml of syrup.
• The child is placed in the back seat in a car
seat with a winter coat on.
Could this Happen to Me?
• When she arrives the child is asleep
• Has to wait for the office personnel to open
the office
• Sits in the waiting room
• When she removes his coat she is concerned
because he does not appear to be breathing
• Notifies the receptionist--
Could this Happen to Me?
• The doctor is late to arrive
• Office staff go to get another doctor in the
building
• Resuscitation equipment was not readily
available
• 911 called
Could this Happen to Me?
• Child pronounced at the ER
• Mom had thought she was to give all the
syrup
• Doctor had given enough for several visits so
he would not have to write another script
• Doctor did not like to have to wait for the
effects of the versed
Could this Happen to Me?
• Midazolam HCI syrup is indicated for use as a
single dose (0.25 to 1 mg/kg with a maximum
dose of 20 mg) for preprocedural sedation and
anxiolysis in pediatric patients.
• Midazolam HCI syrup must only be
administered to patients if they will be
monitored by direct visual observation by a
health care professional.
Could this Happen to Me?
• Litigation ensued
• Settlement
Could this Happen to Me?
• Do not give sedation medications until the
patient is in your office.
• In a designated area
• Under continuous supervision by staff person
Anesthesia
Morbidity & Mortality
OMSNIC
2000-2011
Minimal Sedation
Minimal depression of patient’s level
of consciousness, that retains the
patient’s ability to independently and
continuously maintain an airway and
respond normally to tactile
stimulation and verbal commands
Moderate Sedation
• A drug-induced depression of consciousness
during which patients respond purposefully to
verbal commands, either alone or with light
tactile stimulation. No interventions are
required to maintain a patent airway, and
spontaneous ventilation is adequate.
Deep Sedation / GA
Sufficient depression of patient’s level
of consciousness, anxiety, pain and
recall . . . May result in partial or
complete loss of protective reflexes
and/or ability to maintain an
independent airway.
Anesthesia Reported Claims
2000-2011
Deaths= 124
Other = 189
TOTAL = 313
OMSNIC Policyholders
Number of OMS years
2000 - 2011
= 49,581
2011
Average Number of Anesthetics
Administered Per OMS/yr = 671
2000-2011 average = 669
Total Number of Office Anesthetics
2000- 2011
General anesthetics = 71%
Sedation anesthetics = 29%
Total Number = 33,191,562
Notes: Anesthesia Death/Brain
Damage Claims & Incidents
Includes only cases reported to OMSNIC
Includes events in recovery and
immediately after emergence
Not all deaths are a direct result of
anesthesia — may be related to stress
from the procedure
OMSNIC Anesthesia
2000-2011
Death & Brain Damage Cases
Office -----------91
Hospital --------33
TOTAL = 124
Total In-Office Death/Brain
Damage
Cases Reported to OMSNIC
2000 - 2011
91
Frequency of Office Anesthetic
Deaths 2000-2011
• 91 office deaths
• 49,581 insured years
Incidence of In-Office
Anesthesia Death & Brain
Damage Cases
91 cases
33,191,562 procedures
=
1
364,742
What is the likely hood of an OMFS
experiencing an Office Anesthetic Death?
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30 year of practice
669 anesthetics / year
Total 20,070 anesthetics in a career
Frequency is 1/364,742 cases
• Thus 1/18 OMFS will experience an office
anesthetic death during their career
Frequency of Office Anesthetic
Deaths 2000-2011
1 in every 545 OMS will
experience an office anesthetic
death per year
Additional
Anesthesia Claims 2000-2011
• Inadequate anesthesia--19
• Phlebitis----------------------17
• Nerve Injuries---------------11
– Needle stick (9)
– Positioning (2)
• Recovery room falls-------10
• Inappropriate anesthesia--6
Additional
Anesthesia Claims 2000-2011
(Required transfer to ER)
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Respiratory distress---18
Seizures-------------------13
Excitation-------------------9
Chest pain-SOB-----------9
Aspiration------------------7
Allergic reaction----------6
Tachycardia----------------6
Additional
Anesthesia Claims 2000-2011
(Required transfer to ER)
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Slow emergence-----------------6
Nausea & Vomiting-------------4
Myocardial Infarction----------3
Stroke----------------------------- 3
Pulmonary emboli------------ 2
Hypertension–----------------- 2
Additional
Anesthesia Claims 2000-2011
• (Required transfer to ER)
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Hypotension---------------------1
Laryngospasm ------------------1
Congestive Heart Failure-----1
Swelling from Ace Inhibitor-1
Methadone withdrawal------1
Additional
Anesthesia Claims 2000-2011
• Deaths after taking post op pain meds
at home---------------7
• Billing disputes--------------6
• Stormy induction, restraint
(Physical abuse)--------4
• Ocular Injuries---------------4
• Traumatic intubation-------2
• Non Licensed administer--2
Additional
Anesthesia Claims 2000-2011
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Molestation --------------2
Burn from ventilator--1
Broken needle-----------1
Reuse of I.V.---------------1
• aborted Induction-- realized his
notes were different---1
Squeezed
Economics
– Debt
Patient request
Pain Control
Could This Happen To Me?
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A 3 y/o child
Multiple non-restorable teeth
Negative history
Dentists uses “papoose board and wrap”
Local anesthesia
LOC- Convulsions-respiratory-cardiac arrest
Could This Happen To Me?
• Intra vascular injection?
– Aspirating syringe
• Allergic reaction?
• Dosing problem?
Could This Happen To Me?
• Administers 6 carpules of 2% Lidocaine with
1/100,000 epinephrine
• 2 carpules of 0.25% Bupivicaine
Could This Happen To Me?
• Lidocaine 216 mg
– No weight recorded (15kg)
– Max dose 4.5mg/kg = 67.5
• Bupivicaine 0.9 mg
– Max dose 2mg/kg= 30
– not approved for children <12
– Cardiac arrhythmias
Local Anesthesia
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Main stay for pain control
Various agents with different dosing levels
Know the signs of toxicity
Be able to resuscitate
Could This Happen To Me?
Early warning signs of central nervous system
toxicity
• restlessness, anxiety, tinnitus, dizziness,
blurred vision, tremors, depression or
drowsiness
• Progression to LOC and convulsions
Treatment
• Airway management
• Transport
• Control convulsions/seizures
Safety Improvements
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Improved local anesthetics
Aspirating syringes
Resuscitative equipment
Improved training/education
Fortress Anesthesia
• Death cases - 10
–5 pediatric
–5 adult
Fortress Local Anesthesia
• Paresthesia -7
–Septocaine – 4
–Other- 3
• Broken needle-5
• Seizures -5
Fortress Local Anesthesia
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Allergic reaction – 4
Wrong drug – 4
Panic attack – 4
Inadequate anesthesia – 3
Needle sticks - 2
Fortress Local Anesthesia
• Deaths – 2
– Related to overdoses
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Chest pain/SOB -1
Head ach to ER - 1
Fall – 1
MVA – 1
Consent-1
License issue -1
Fortress Sedation/Anesthesia
• Death cases – 8 (Out patient settings)
–Anesthesiologist -1
–Nurse anesthetist - 2
Fortress Sedation/Anesthesia
• Data is inaccurate and to
small to draw conclusions
Fortress Sedation/Anesthesia
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Transported to ER – 6
Permit issues – 3
Over dosage – 2
Inappropriately administered – 2
Aspiration – 2
Adverse reaction – 2
Unnecessary treatment – 2
Fortress Sedation/Anesthesia
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Inadequate treatment – 2
Fall – 2
Stroke – 2
Allergic reaction – 1
Cardiac arrest – 1
Seizure – 1
Pulmonary edema - 1
Most commonly used sedation agents
in pediatric dentistry
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Nitrous oxide
Chloral hydrate
Diazepam (Valium)
Midazolam (Versed)
Hydroxyzine (Vistaril)
Meperidine (Demerol)
Airway
• "Airway management for children is the
primary thing, and breathing problems can
lead to cardiac arrest”
Safety Improvements
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Color coding of gas cylinders and lines
Unique connectors
Fail safe anesthesia machines
Annual calibrations
Safety Improvements
• Monitoring devices
– SaO2, CO2, BP, HR, EKG, TS
• Monitors with printers, recorders, memory
• Improved education to understand monitors
Question?
Do your monitors have memory?
1. Yes
2. No
3. Do not know
Safety Improvements
Pre-op Evaluation
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•
Stairs
PMH, PH, FH, SH, PE, VS
ASA Status
Mallampati classification
Mets evaluation
Safety Improvements
Drug
• Local
• Inhalation
• Oral sedatives
– Chloral Hydrate, DPT, Triazolam, Valium, Versed
• IM
• IV
• Reversal agents
Safety Improvements
“Regulatory”
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Professional guidelines
State anesthesia permits
Accreditation requirements
Continuing education experiences
– Office evaluations
– SIM man
– PALS, BLS, ACLS
• Staff anesthesia training
Guidelines
• Parameters of care
• ASA Classification
• Evidence-based
medicine
• Dangerous when they
become iron clad rules
• Etiquette-based
medicine
Could This Happen To Me?
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A 5 y/o 20 KG
Oral versed sedation (Midazolam)
Given in office 20mg (0.25 to 1 mg/kg)
Waited 30 minutes
N2O2/O2 50-50
Pulse oximeter monitoring
Could This Happen To Me?
• 2% Lidocaine 1/100,00 epi-1 carpule
• 1 hour of restorative treatment
• Carried to a recovery area and placed on a bed
with mom
• 1 hour later assistant went to discharge
Could This Happen To Me?
• Mom was reading
• Child appeared asleep
• Non-responsive
It Ain’t Over ‘Til It’s Over
Yogi Berra
• Midazolam HCI syrup should only be used in
hospital or ambulatory care settings, including
physicians' and dentists' offices, that can
provide for continuous monitoring of
respiratory and cardiac function
• . Immediate availability of resuscitative drugs
and age- and size-appropriate equipment for
bag/valve/mask ventilation and intubation,
and personnel trained in their use and skilled
in airway management should be assured
• Midazolam HCI syrup must be given only to
patients if they will be monitored by direct
visual observation by a health care
professional
Reversal Agents
• FLUMAZENIL (Romazicon) is a
benzodiazepine receptor antagonist
– Usually IV –onset of reversal is usually evident
within 1 to 2 minutes. Eighty percent response will
be reached within 3 minutes, with the peak effect
occurring at 6 to 10 minutes. The duration and
degree of reversal are related to the plasma
concentration of the sedating benzodiazepine as
well as the dose of flumazenil given
Romazicon (Flumazenil) Dosage
0.1mg/ml
• Initial dose: 0.01 mg/kg IV over 15 seconds.
Repeat doses: 0.01 mg/kg given over 15
seconds; may repeat 0.01 mg/kg after 45
seconds, then every minute to a maximum
total cumulative dose of 0.05 mg/kg
Reversal Agents
• FLUMAZENIL (Romazicon)
– half-life of 4 to 11 minutes and a terminal half-life
of 40 to 80 minutes.
– 0.01 mg/kg flumazenil up to a maximum total
dose of 1.0 mg at a rate not exceeding 0.2
mg/min.
Flumazenil
• adverse effects including
seizures, adverse cardiac
effects, and death
Reversal Agents
• Naloxone is an opioid antagonist (Narcan)
indicated for the complete or partial reversal of
opioid depression, including respiratory
depression
– Usually IV acts within 1 minute up to 45
minutes
– Dosage: initial dose in children is 0.01 mg/kg
body weight given I.V. If this dose does not
result in the desired degree of clinical
improvement, a subsequent dose of 0.01
mg/kg body weight may be administered.
Reversal Agents
• Concerns: False sense of safety
– Resedation can occur- Monitor for 2 hours
– Circulation time
– Withdrawal symptoms
– Seizures
Most Common Error
Failure to properly
resuscitate in a timely
manor
Could this happen to me?
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New graduate returns to his home town
Hires a national dental supply company
Builds and opens a very plush new office
All new and current state of the art equipment
Uses a nurse anesthetist
Promotes his practice in the community
Could this happen to me?
• Second week in the office
• 12 y/o friend of his family is scheduled to have
extensive dental restorations
• History is negative
• VS all WNL
• Consents reviewed and signed
• Monitors attached-WNL
Could this happen to me?
• The doctor did a time out
• Directed the nurse anesthetist to start
Could this happen to me?
• Nurse anesthetist
– Pre-oxygenates with 50/50 nitrous/oxygen
– Starts an angiocath in the L ACF
– Continuous flow 1/2N saline
– Titrates Versed 3 mg
– Titrates 50 mics. Fentanyl
– Titrates 50 mg of Ketamine
– Titrates 50 mg Propofol
Could this happen to me?
• Doctor places a bite block
• Gives block and infiltrations with 4 carpules of
2% Lidocaine 1/100,000 epi.
• Places a throat screen with a tie attached
• On the third tooth preparation the patient
starts to cough
Could this happen to me?
• Anesthetist considers this an upper air way
irritant
• Start 100% O2
• Remove throat screen
• Suction air way
• PPO2 with a face mask
• SaO2 declines to 90
Could this happen to me?
• What is happening?
• How do you diagnose?
• How do you treat?
Could this happen to me?
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SAO2 continues to decline
He is able to ventilate
EKG develops a bradycardia and PVCs
Intubates
Call 911
EMTs take over and transport
Could this happen to me?
• Regains consciousness
• Permanent brain damage
• Litigation follows
Could this happen to me?
• Assistant diagnosed the problem
• N2O2-O2 lines were crossed
• Multimillion dollar settlement
Could this happen to me?
•
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High profile media coverage
Patient base dried up
Lack of support in the dental community
Filed bankruptcy
Dental board sanctioned
Moved to a new community
Could this Happen to Me?
• Lytic Cocktail/Demerol, Phenergan, and
Thorazine (DPT) for the Sedation of Children
• 2:1:1 mixtures Dosing varies by a factor of 10
• 0.1 ml/kg-1 ml/kg
• Slow onset 30 minutes
• Not reliable
• Prolong recovery
Could this Happen to Me?
• Doctor had the pharmacy mix:
– 50cc 50mg/cc meperidine (Demerol)
– 25cc 12.5 mg/cc promethazine (Phenergan)
– 25cc 12.5 mg/cc chlorpromazine (Thorazine)
• This was for his office use
• Dispensed to patients at their appointment
Could this Happen to Me?
4 y/o
Wt. 15kg.
1.5ml of DPT
Procedure completed
In the recovery area with the mom the
patient failed to awake
• 911 activated
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Could this Happen to Me?
• Patient expired
• Autopsy (Death by respiratory depression)
• Toxicology (Toxic levels of Methadone)
What Happened?
•
•
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Toxicology an error?
Wrong drug administered?
Sample from office contaminated?
Pharmacy mixing error?
Allegations of Mishap
* Inadequate preoperative evaluation;
* Lack of knowledge concerning the
pharmacology of drugs employed;
* Inadequate monitoring during the procedure;
and
* Lack of training in the management of
emergencies
Could this Happen to Me?
•
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Chloral hydrate 2 gms. PO
5 y/o
20 kg. (100 mg/kg)
Paradoxical agitation
Additional 1 gm. PO
Could this Happen to Me?
•
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nausea and vomiting
headache
prolonged drowsiness
disorientation, confusion
respiratory depression
Respiratory arrest
Staff Training
Have them competent
enough to resuscitate you
Prejudgment
Top 10 causes of Mortality in office
anesthesia
1. Loss of adequate oxygenation
A. First symptom
• Declining SaO2
• Difficulty breathing
• SOB
– MI
• Agitation
• Vomit
– Laryngospasm
– aspiration
• Apnea on induction
Top 10 causes of Mortality in office
anesthesia
1. Loss of adequate oxygenation (cont.)
• Change in blood color
• Wheezing –
– Asthma
– Acute allergic reaction
• Laryngospasm
• Brochospasm
• Pulmonary emboli
Top 10 causes of Mortality in office
anesthesia
1. Loss of adequate oxygenation (cont.)
• Aspiration
– Throat pack
– Tooth particles
– Instruments
Top 10 causes of Mortality in office
anesthesia
1. Loss of adequate oxygenation (cont.)
B. Anatomic challenge
• Obese-Thick neck,
• History of sleep apnea
• Trismus–
–
–
–
Infection
TMJ
Rheumatoid arthritis
Trauma
• Retrognathia
• Laryngeal and tongue carcinoma
Top 10 causes of Mortality in office
anesthesia
• 2. Delay in recognition of event
A. Inadequate monitoring
• SaO2, CO2, Auscultation, EKG, pulse
• Blame equipment connections
• Turn off alarms
Top 10 causes of Mortality in office
anesthesia
3. Delay in instituting proper resuscitation
A. Thinking it will get better
B. Wrong diagnosis
C. Equipment malfunction
Top 10 causes of Mortality in office
anesthesia
4. Failure to appropriately resuscitate
A. Unable to reestablish an airway
•
•
•
•
Unable to intubate
No LMA
Failed surgical airway
After intubation no confirmation
– By auscultation
– With CO2
Top 10 causes of Mortality in office
anesthesia
4. Failure to appropriately resuscitate (cont.)
B. Wrong diagnosis
• Able to ventilate but wastes time trying to intubate
with dropping SaO2
• No EKG
• Never checks pulse
C. Wrong drugs & or dosages
D. Failure to follow accepted algorithm
Top 10 causes of Mortality in office
anesthesia
5. Failure to respond –or wake up
A. Stroke
B. Delayed response
• Overdose
• Unknown reason
Top 10 causes of Mortality in office
anesthesia
6. Inadequate pre-op history
A. Patient does not give correct history
B. Doctor does not explore history response
C. Patient taking undisclosed recreational drugs
Top 10 causes of Mortality in office
anesthesia
• 7. Judgment on location for procedure
A. No documentation
•
•
•
•
Updated history
ASA
Mallampati
Medical risk
Top 10 causes of Mortality in office
anesthesia
8. Judgment on drug selection
A. Pre-op
B. Post -op
9. Judgment on level of anesthesia
A. Sedation vs. Anesthesia
B. Local Anesthesia
Top 10 causes of Mortality in office
anesthesia
10. Inadequate assistance
A. Not enough trained people to handle the
resuscitation
•
•
•
•
No one records
IV gets displaced and no one to restart
Chaos
Cannot find emergency equipment
Top 10 causes of Mortality in office
anesthesia
10. Inadequate Assistance (cont.)
B. EMTs take over
• Change IV then unable to restart
• Change monitors and lose all data
• Waste time trying to intubate when one is able to
ventilate
• Delay in transport
• Recline an unconscious breathing patient and lose
airway
• Tube becomes displaced during transport
Prejudgment