Capnography monitoring during conscious sedation is not currently required for dentistry in Britain and Ireland. Other countries have introduced guidelines and standards requiring capnography monitoring for procedural sedation. This review highlights the variability of procedural sedation including the setting, the position on the sedation continuum, and the routine use of supplemental oxygen. Specific research is required for conscious sedation in a dental setting to support standards and guidelines with regard to capnography monitoring

Brady, Paul

Giovannitti Jr., Joseph A.

Hayes, Martina

O'Halloran, Ken D.

Cork Open Research Archive

Title What's new in ... capnography monitoring for dental conscious sedation:a clinical reviewAuthor(s) Brady, Paul; Hayes, Martina; O'Halloran, Ken D.; Giovannitti Jr., JosephA.Publication date 2017-01Original citation Brady P., Hayes M., O'Halloran K. and Giovannitti J. (2017) 'What'snew in ... Capnography Monitoring for Dental Conscious Sedation: AClinical Review'.  SAAD Digest, 33, pp. 3-6.Type of publication Article (peer-reviewed)Link to publisher'sversionhttps://www.saad.org.uk/index.php/digest-newslettersAccess to the full text of the published version may require asubscription.Rights © 2017 Society for the Advancement of Anaesthesia in DentistryEmbargo information Access to this article is restricted until 9 months after publication by therequest of the publisherEmbargo lift date 2017-09-01Item downloadedfromhttp://hdl.handle.net/10468/3871Downloaded on 2018-08-23T18:34:50Z3SAAD DIGEST | VOL.33 | JANUARY 2017REFEREED PAPERAbstractCapnography monitoring during conscious sedation is notcurrently required for dentistry in Britain and Ireland. Othercountries have introduced guidelines and standards requiringcapnography monitoring for procedural sedation. This reviewhighlights the variability of procedural sedation including thesetting, the position on the sedation continuum, and the routineuse of supplemental oxygen. Specific research is required forconscious sedation in a dental setting to support standards andguidelines with regard to capnography monitoring.The Academy of Medical Royal Colleges and their Facultiesemphasise that each specialty must produce its own guidance forthe use of sedative techniques.1 Clinical practice guidelines for themonitoring and safe practice of sedation vary by specialty andinstitution. Standards are generally set from the best availableevidence based research. There is a growing body of literature thatrecognises the potential additional value of capnography (ETCO2)monitoring during procedural sedation in different settings and fordifferent sedation techniques.2-5 In these studies, capnographyreduced the incidence of hypoxaemia during procedural sedation.A meta-analysis published by Waugh et al. (2010) concluded thatend-tidal carbon dioxide monitoring is an important addition indetecting respiratory depression during procedural sedation.6 Amore recent systematic review by Conway et al. (2016) concludedthat patients monitored with capnography in addition to standardmonitoring had a reduced risk of hypoxaemia compared to thosewith only standard monitoring.7 However, it has to be noted thatboth the Waugh and Conway reviews contained substantialstatistical heterogenicity which is likely to affect the quality of theevidence.As research evidence for capnography monitoring from themedical settings studied became available, new standards forcapnography monitoring were introduced in several countries(Table 1).What’s new in... Capnography Monitoring for DentalConscious Sedation: A Clinical ReviewPaul J Brady BDS MFDS FFDRCSI(OS) MSc Con SedCork University Dental School and Hospital, IrelandMartina Hayes BDS MFDSCork University Dental School and Hospital, IrelandChristine E McCreary MD FDS(OM) FFDRCSICork University Dental School and Hospital, IrelandKen D O' Halloran BSc PhD Department of Physiology, University College Cork, Ireland Joseph A. Giovannitti Jr. DMD Department of Dental Anesthesiology, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, USA Correspondence to:Dr. Paul Brady, e-mail: paul.brady@ucc.ieTable 1: Sedation Guidelines and StandardsAmerican Society Royal College of Surgeons and Canadian Anesthesiologists Australian Dental of Anesthesiologists Royal College of Anaesthetists Society AssociationLevel of statement Standards Standards Guidelines GuidelinesYear written/updated 2015 2015 2012 2014Assessment of depth of sedation Required Required Required RequiredPulse oximetry Required Required Required RequiredCapnography Moderate and deep sedation Not required for conscious sedation Required for conscious Required for conscious required unless precluded or in ASA I & II sedation sedationinvalidated by the nature of May be recommended ASA III & IVthe patient, procedure, or and with supplemental oxygenequipment4 SAAD DIGEST | VOL.33 | JANUARY 2017REFEREED PAPERThe American Society of Anesthesiologists amended its standardsfor basic monitoring, in October 2010, to include the capnographicassessment of ventilation during moderate or deep sedation.8Following suit, in 2012 the Canadian Anesthesiologists Societypublished “Guidelines to the Practice of Anesthesia – RevisedEdition 2012” which included an important amendment in thesection regarding required monitors – CO2 monitoring(capnography) during conscious sedation.9 The Australian DentalAssociation in its policy statement in 2010, regarding conscioussedation stated: “All patients undergoing sedation must be monitoredcontinuously with pulse oximetry, blood pressure and ETCO2”.10 Thismay have been prompted by a widely publicised death of a patientunder dental intravenous sedation in New South Wales, Australia,in 2002 while being treated by a dentist with appropriate trainingin intravenous conscious sedation, (Graduate Diploma in ClinicalDentistry; Conscious Sedation and Pain Control, University ofSydney) which brought into question the safety of Intravenoussedation. The cause of death was irreversible cerebral hypoxiafollowing a cardiac arrest, which was precipitated by numerousperiods of ever-deepening hypoxaemia.11Despite growing pressure for capnography to be used universallyin the U.K., it is not currently required for conscious sedation indentistry. The U.K. issued new guidance on Standards for conscioussedation in the provision of dental care which were published inApril 2015 by the dental faculties of the Royal Colleges of Surgeonsand the Royal College of Anaesthetists.12 The report stated thefollowing with regard to capnography: “its routine use for ASA gradeI and II dental patients lacks high level scientific validation and cannotbe recommended.”Dental sedation in the U.K. and Ireland lies in the mild to moderaterange of the sedation continuum (conscious sedation), in contrastto the U.S.A. and Canada where deep sedation is possible in adental setting. According to the Standing Dental AdvisoryCommittee: “Any technique resulting in the loss of consciousness isdefined as general anaesthesia and in the UK “deep sedation” isconsidered within this category. The practice of general anaesthesiaunder the guise of Conscious Sedation is totally unacceptable andmust be strongly deprecated in view of the risk of jeopardising patientsafety”.13Previous capnography studies are difficult to summarise, due tovariations in sedation techniques, settings and varying patientpopulations.  When we set out to conduct this review, it was withthe intention of performing a meta-analysis looking atcapnography monitoring specifically for conscious sedation.However, we found that the diversity of the study settings andvariability of the sedation techniques of published research studieswere not easily comparable and therefore not suitable for meta-analysis.  We present here three studies which demonstrate thevariability and difference of the procedural sedations from that ofconscious dental sedation.Beitz et al (2012): The primary goal of this randomised, controlledstudy was to determine whether intervention based on additionalcapnography monitoring reduces the incidence of arterial oxygendesaturation during sedation for colonoscopy.  A total of 760patients were enrolled at three German endoscopic centres.Patients received 2L/min of supplemental oxygen. The intention-to-treat analysis revealed a significant reduction in the incidence ofoxygen desaturation in the capnography arm in comparison withthe conventional arm (38.9% vs. 53.2%). The study conclusion wasthat additional capnography monitoring reduces the incidence ofoxygen desaturation and hypoxemia during propofol sedation forcolonoscopy.2Deitch et al (2010): This randomised, controlled trial took place inan emergency room setting. A total of 132 patients took part in thestudy. Hypoxia was defined as an SpO2 < 93% for 15 sec.  Theincidence of oxygen desaturation in the capnography arm incomparison with the conventional arm was 25% vs. 42%. Allpatients received supplemental oxygen (3L/min). The studyconclusion was that the addition of capnography to standardmonitoring in this setting reduced the incidence of hypoxia andprovided advanced warning for all hypoxic events.3Qadeer et al (2009): This randomised trial sought to determinewhether intervention, based on microstream capnography woulddecrease hypoxemia during endoscopy. A total of 247 patientstook part in the study. They showed a significantly reduced rate ofhypoxia (46% vs 69%), defined as an oximetry reading < 90% for 15sec. Significant risk factors for hypoxemia in multivariate analysiswere higher age, female gender and blinded arm of capnography.The level of sedation in this study was not quantified and therewas a relatively large cohort of ASA 3 patients in the study withcomorbidities. 147 patients received supplemental oxygen duringthe procedure. The study conclusion was that capnographymonitoring of respiratory activity improves patient safety duringprocedural sedation for elective endoscopy.5Conscious Sedation in a dental setting differs significantly fromother procedural sedation settings with respect to the following;Different patient populationsIn the standard dental sedation technique, ASA 1 & 2 adult patientsup to 65 years of age receive sedation. The reviewed studiescontain many elderly patients. Elderly patients are known to bemore sensitive to sedative drugs and more likely to havesignificant co – morbidities (ASA3).Supplemental oxygenFor the standard dental sedation technique most patients breatheroom air. Supplemental oxygen is not routinely administeredunless indicated to correct hypoxia. In the reviewed studies mostof the patients received supplemental oxygen during theprocedure (2–3 L/min). Supplemental oxygen is likely to haveresulted in a decreased sensitivity of the pulse oximeter as asurrogate monitor of hypoxia due to respiratory depression. Thereare only a few studies where supplemental oxygen is notadministered and patients are administered sedatives breathingroom air. Van Loon et al (2014) in a relatively large clinical trial with427 patients enrolled for gynaecological procedures, concludedthat they were unable to confirm an additive role for capnographyin preventing hypoxaemia during elective propofol sedation inhealthy women in whom supplemental oxygen is not routinelyadministered.14 This is in agreement with the study by Sivilotti et al(2010) with 63 patients enrolled in an emergency room setting.15Therefore, in studies where patients were breathing room airduring their sedations and not routinely receiving supplementaloxygen, the addition of capnography did not decrease the rate ofoxygen desaturation.Depth of sedationThe publication from the Academy of Medical Royal Colleges, Safe5SAAD DIGEST | VOL.33 | JANUARY 2017REFEREED PAPERSedation Practice for Healthcare Procedures, gives the definitions of sedation and describes clearly the continuum from minimalsedation through to general anaesthesia, which is accompanied byincreased depression of the physiological systems.1 This increasesthe likelihood of adverse eventsFor the standard dental sedation technique, conscious or moderatesedation is the target state on the sedation continuum. However, itis recognised that sedated patients have the potential to progressto deeper levels of sedation and it has been suggested that theability to recognise early warning signs may provide a criticalopportunity to intervene and prevent sedation-related morbidityand mortality.16 There remains, a relative paucity of research in theconscious sedation (minimum to moderate) end of the sedationspectrum. The few studies that exist in dentistry are of a lowevidence base and there are no reported randomized controlledstudies in this setting.17-19 The reliability of extrapolating findingsfrom other sedation settings and applying them to dental sedationis unknown. DrugsA titrated intravenous dose of midazolam is usually the first choiceintravenous sedation technique for dentistry. A range of othersedative drugs were used in the reviewed studies e.g. propofol andketamine. Drugs used in combination have the potential to actsynergistically to produce significant respiratory depression. Whencombined with other drugs and in particular opioids, thepossibility of respiratory depression is increased.AnalgesiaLocal anaesthetic is given in dentistry to provide analgesia duringsedation. In the reviewed studies, analgesia was often achievedwith the use of intravenous agents such as opioids.20Desaturation (SpO2)For the standard dental sedation technique an SpO2< 95% isregarded as the threshold for early desaturation. This is areasonable threshold in this setting where sedation isadministered by a non-anaesthetist outside of the operating roomsetting. In some more medically supported environments thesignificance of this threshold is likely to be of less importance.Studies from other settings used varying thresholds fordesaturation as the study outcome measure. For example, Deitch etal. (2010) used a threshold < 93% and Qadeer et al. (2009) <90%.3-5The guidelines and recommendations that have been maderequiring capnography for procedural sedation in North Americaare perhaps understandable as dental sedation in those countriesmay be practised by any dentist meeting appropriate training andpermit requirements.  Thus, sedation levels may encompass theentire anaesthesia continuum using a variety of drug classes.  Sinceit is possible that patients may slip to a level of sedation beyondthe desired intent, capnography serves as an early warning systemfor ventilatory compromise and aids in the early “rescue” of anobtunded patient.  Additonally, sedation and anaesthesia is oftenpractised by dentist anesthesiologists and oral and maxillofacialsurgeons. The scope of practice of these clinicians is much broaderthan that of a dentist practising conscious sedation in the U.K. andIreland. They often provide deep sedation and general anaesthesiain non-hospital settings e.g dentist’s office. Therefore, it is likelythat many patients will receive sedations in North America in thedeep sedation end of the sedation continuum. In the dentalconscious sedation setting as practised in the U.K and Ireland,"""! ! ! !!0 " " " " " " " " " " " " " " " "" " " " " " " " " " " " " " "" " " " " " " " " " " " " " " " " "" " " " " " " " " " " "" " " " " " " " " " " " " " " "" " " " " " " " " " " " " " " " " " "" " " " " " " " " " " " "" " " " " " " " " " " """"E";<;)$;:*"<9;)$H:98%>"*8>:"8M"L<*$i8&$L"<>"%>%$&&+";?:"M<)>;"7?8<7:"<9;)$H:98%>">:*$;<89";:7?9<S%:"M8)"* " " " " " " " " " " " " " " " " "" " " " " " " " " " " " " ": : + 9 +* % F < >F %[9 FFigure 1: Sedation Continuum 6 SAAD DIGEST | VOL.33 | JANUARY 2017REFEREED PAPERadditional monitoring which may be of limited clinical benefitcould potentially hinder attention to other important monitoringparameters.In conclusion, a one size fits all approach to requiring capnographyfor procedural sedation is perhaps erroneous. There is emergingevidence in the literature that for patients receiving conscioussedation on room air, capnography is of little additional benefit inpreventing hypoxaemia. Factors which make dental sedation aspractised in the U.K. and Ireland significantly different to that ofother procedural sedations include the position on the sedationcontinuum and the fact that patients do not routinely receivesupplemental oxygen.The benefits of capnography must be quantified in the targetpopulation, before its routine incorporation into practice. There is aneed for dentistry specific research into capnography monitoringduring conscious sedation.References:1. Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures inAdults. Academy of  Medical Royal Colleges.  Nov 2001.2. Beitz A, Riphaus A, Meining A,  et al. Capnographic Monitoring Reduces theIncidence of Arterial Oxygen Desaturation and Hypoxemia During PropofolSedation for Colonoscopy: A Randomized, Controlled Study (ColoCap Study). Am JGastroenterology. 2012; 107:1205-12. 3. Deitch K, Miner J, Chudnofsky CR, et al. Does End Tidal CO2 monitoring duringemergency department procedural sedation and analgesia with propofoldecrease the incidence of hypoxic events? A Randomized, Controlled Trial. AnnEmerg Med. 2010; 55:258-64. 4. Lightdale JR, Goldmann DA, Feldman HA,et al. Microstream capnographyimproves patient monitoring during moderate sedation: a randomized, controlledtrial. Pediatrics. 2006;117.5. Qadeer MA, Vargo JJ, Dumot JA, et al. Capnographic monitoring of respiratoryactivity improves safety of sedation for endoscopic cholangiopancreatographyand ultrasonography. Gastroenterology.2009; 136:1568-76.6. Waugh JB, Epps CA, Khodneva YA. Capnography enhances surveillance ofrespiratory events during procedural sedation: a meta-analysis. J Clin anesthesia.2011.7. Conway A, Douglas C, Sutherland JR. A systematic review of capnography forsedation. Anaesthesia 2016; 71:450-4.8. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring.Approved by the ASA House of Delegates on October 21, 1986, and last amendedon October 20, 2010 and affirmed on October 28, 2015.9. Merchant R, Chartrand D, Dain S,  et al. Guidelines to the Practice of AnesthesiaRev Ed 2012. Can J Anesthesia 2012; 59: 63-102.10. Australian Dental Association. Policy Statement 6.17 - Conscious Sedation inDentistry, April 2014.11. Viljoen A, Byth K, Coombs M, et al. Analysis of Oxygen Saturations RecordedDuring Dental Intravenous Sedations: A Retrospective Quality Assurance of 3500Cases. Anesthesia Progress 2011; 58:113-120.12. The Dental Faculties of the Royal College of Surgeons and the Royal College ofAnaesthetists, Standards for Conscious Sedation in the Provision of Dental Care,2015.13. Department of Health Standing Dental Advisory Committee. Conscious Sedationin the Provision of dental Care. Report of an Expert Working Group onSedationfor dentistry. London: Standing Dental Advisory Committee, 2003.14. van Loon K, van Rheineck Leyssius AT, et al. Capnography during deep sedationwith propofol by nonanesthesiologists: a randomized controlled trial. Anesthesia& Analgesia 2014; 119: 49-55.15. Sivilotti ML, Messenger DW, van Vlymen J, et al. A comparative evaluation ofcapnometry versus pulse oximetry during procedural sedation and analgesia onroom air. Can J Emerg Med 2010; 12: 397-404.16. Gerstenberger PD. Capnography and patient safety for endoscopy. ClinGastroenterol Hepatol 2010; 8: 423-5.17. Brady P, Wilson K, Meeke R, et al. Capnometry monitoring during intravenoussedation with midazolam for oral surgery. Oral Surg 2015;9: 94-101.18. Kaneko Y. Clinical perspectives on capnography during sedation and generalanesthesia in dentistry. Anesthesia progress 1995; 42: 126.19. Prstojevich SJ, Sabol SR, Goldwasser MS, et al. Utility of capnography in predictingvenous carbon dioxide partial pressure in sedated patients during outpatient oralsurgery. J Oral Max Surg 1992; 50: 37-9.20. Milgrom P, Beirne OR, Fiset L, et al. The safety and efficacy of outpatientmidazolam intravenous sedation for oral surgery with and without fentanyl.Anesthesia progress. 1993; 40: 57.Online CPD from the SAAD WebsiteLog-on to the membership area and follow the link‘Online CPD’Answer the multiple-choice questions relatingto the refereed papers section of this issueof the SAAD DigestCPD certificate provided as a download

What's new in ... capnography monitoring for dental conscious sedation: a clinical review

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What's new in ... capnography monitoring for dental conscious sedation: a clinical review

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