chapter 28 Practical Considerations
Many dentists wish to delegate the duties of venipuncture and drug administration to auxiliary personnel (i.e., the dental assistant, registered dental assistant, dental hygienist, or registered nurse). Although the Dental Practice Act in each state must be consulted for specific regulations, it is the law in most states that only the dentist (DDS, DMD or equivalent, or MD) or a certified registered nurse anesthetist (CRNA) may perform venipuncture and administer IV drugs. In some states, registered nurses (RNs) may perform venipuncture. As mentioned in Chapter 24, an auxiliary may perform virtually all of the duties relating to the IV moderate sedation procedure except for venipuncture and drug administration.
The response of patients to drugs exhibits great variation, as evidenced by the normal distribution curve. The fact that titration is possible for essentially all intravenously administered drugs (lorazepam is a notable exception) permits us to determine exactly where on this curve each patient lies. Some patients are hyporesponders, in whom the clinically observed effect of a drug at its maximum recommended dose will be suboptimal or may be nonexistent. The most reasonable approach to take when the maximum recommended dose of a drug has failed to produce clinically adequate sedation is to cease further administration of the drug and attempt the planned dental treatment. As mentioned earlier, I have been pleasantly surprised on numerous occasions with the ease with which treatment proceeds on an apparently nonsedated patient. If sedation is truly inadequate to permit the planned procedure to continue, the patient should be allowed to recover (despite the apparent lack of symptoms), discharged, and rescheduled at a later date for a different drug technique. For patients in whom midazolam has failed to produce adequate sedation, diazepam has frequently been successful at subsequent visits and vice versa.
Doses of drugs beyond those recommended should not be administered unless the dentist has completed training in anesthesiology. In many cases, persons with this training will not administer additional drugs because the administration of other drugs can only prolong and complicate recovery in the ambulatory outpatient setting.
The drug doses and techniques recommended in this section have withstood the test of time. When used as recommended, the success rate of IV moderate sedation approaches, but will never attain, 100%. The occasional failure will occur and must be accepted by the dentist. Inability to accept failure requires the dentist to inject larger and larger doses of more and more drugs, a situation potentially fraught with problems.
On occasion, usually once in a dentist’s career, a patient’s escort (ride home) will disappear or never show up. If the IV moderate sedation procedure has yet to begin, I strongly urge that the procedure be canceled unless another suitable escort can be arranged before the start of the procedure. It is tempting and natural for the dentist to want go ahead with the IV procedure because of the time that has been allotted for it in the day’s schedule. The dentist must resist such temptation.
Patients receiving midazolam or diazepam usually appear clinically recovered 1 hour after drug administration. Absent an escort, the patient may opine that he or she is recovered enough to be allowed to leave the office unescorted. This must never be permitted to happen. Explain to the patient that although he or she feels recovered, this is not the case. The feeling is similar to that which occurs when one has had some alcohol and feels normal but is unable to function at normal capacity.
Alternative escorts that may occur to the patient or the dentist include taking a taxicab, a bus, or train; walking home; or being accompanied by a member of the office staff. None of these alternatives is acceptable. The only person who should be permitted to escort the patient home is a relative or close friend of the patient, a person who can remain with the patient until he or she has recovered. I have come to describe the acceptable escort as “a responsible adult, a person who has a vested interest in the health and safety of the patient.” This definition precludes use of a taxi, bus, or other form of public transportation in which the escort is a stranger to the patient. The dangers involved in the alternatives are unacceptable. It is good practice for a member of the office staff to contact the patient the day before the scheduled IV procedure to review preoperative instructions, reemphasizing the need for an escort.