Oversedation and Failure to Resuscitate in Dentistry

In oversedation emergencies, it is critical to administer reversal agents and respiratory support promptly. The highlighted case study discusses risk management issues involving sedation and outlines strategies to help dental professionals keep patients safe and mitigate risk.

An adult patient presented for treatment to a dentist who held a state dental board permit for moderate sedation. The patient had a significant medical history, including Down’s syndrome, severe mental impairment, congenital heart disease, and pulmonary hypertension.

Because an oral benzodiazepine was taken one hour before the appointment, the patient was lethargic upon arrival. Prior to the procedure, additional parenteral sedation in the form of a narcotic, a benzodiazepine, and an antihistamine were administered to the patient.

The combination of the medications and their dosages caused an oversedated state. As a result, the patient suffered respiratory depression and subsequent cardiac arrest. Although EMS transported the patient to the hospital, complications from multidrug intoxication resulted in the patient’s death.

A malpractice claim was filed against the dentist.

Risk Management Discussion

This case raises several risk management issues as it illustrates how a relatively safe technique can quickly evolve into a life-threatening situation. Moderate sedation (also known as conscious sedation) refers to a level of depressed consciousness in which the patient can maintain the airway and respond appropriately to physical stimulation and verbal commands.

The patient was already lethargic from the oral premedication taken prior to the procedure. When an oral medication has a significant effect on a patient, further intravenous sedation should be titrated carefully. An appropriate amount of time should transpire after administering an IV medication to determine its full effect before administering additional medication. This is particularly important when multiple, synergistic medications, such as a narcotic and benzodiazepine combination, are used.

When a patient becomes oversedated, it is critical to administer appropriate reversal agents (such as naloxone or flumazenil) promptly and to provide immediate respiratory support. Because of the risk that oversedation may return, continue monitoring the patient after the administration of reversal medications. (It is possible that the duration of the reversal agent is shorter than the duration of the medication that caused oversedation.)

The patient in this case had Down’s syndrome. A common physical characteristic of individuals with Down’s syndrome is an enlarged tongue. Oversedation in a patient with an enlarged tongue can cause airway problems that may necessitate the use of immediate oral, nasal, or advanced airway management. To prevent critical cardiac complications, correct the compromised airway immediately.

While moderate sedation is common and safe for many patients who undergo necessary dental care, dentists should not become complacent about its use. Train all staff members periodically to ensure that everyone is aware of the location and proper use of emergency equipment. Nonclinical personnel should also be trained with guidelines to follow during an emergency, including who is responsible for contacting EMS, receiving EMS upon arrival, and communicating with any family members present.

Drills and simulations of emergency situations can be invaluable training for all dental staff members to help identify system weaknesses and improve the team’s response to an emergency.

The following strategies can help dental professionals keep patients safe and mitigate risk:

• Evaluate the health status of each patient before administering sedation. Include a review of all prescription, herbal, recreational, and over-the-counter medications.
• Assess the patient’s airway and your ability to handle possible complications. Document your airway examination and findings.
• Administer sedative medications incrementally while giving ample time between doses to assess the effect on the patient. Even intravenous medication may take several minutes to exhibit the full effect.
• Ensure that resuscitation medications and equipment are within date and in working order. Scheduling functional checks of your emergency equipment on a regular basis may help you discover problems that would otherwise go unnoticed.
• Conduct emergency drills and simulation training with staff for proper response to emergency situations. Ongoing and recurrent training in emergency procedures is essential.
• Review professional association recommendations and state regulatory requirements for necessary equipment and staff training. Place documentation of necessary training in each individual’s file.

For additional information, see our article “Moderate or Conscious Sedation in the Office Setting.” For guidance and assistance in addressing any patient safety or risk management concerns, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.