The year 2020 is not one the world will soon forget. For the dental industry, it’s been especially challenging to get moving again. Can you count the new protocols and procedures you implemented as you tiptoed into reopening? PPE sourcing, pre-procedure testing, planned distancing; the list continues.
If you’ve managed to obtain a steady PPE supply, you could feasibly get your sedation side of practice back up and running. The good news is most sedation protocols should remain basically the same. But there are a few unique considerations to be made so sedation is safe.
For example, you might want to take a closer look at your patient selection and consider an adjustment to your oxygen flow rate. Having a working knowledge of what needs to be sterilized on your nitrous unit also definitely deserves a second glance.
Patient selection is a key component of risk management for any procedure involving sedation. To minimize risk during a procedure, choosing patients who are healthy and psychologically stable is strongly recommended when administering inhalation sedation with nitrous oxide, single-dose minimal sedation, or moderate sedation.1
More and more people have been exposed to and/or have recovered from COVID-19. Because unknown respiratory and cardiovascular complications could present in a recovered patient, assessment of current physical status may be wise, according to the ASDA Interim Guidance for Dentist Anesthesiologists Practicing in the Office-Based Setting During the COVID-19 Pandemic.2 Additionally, you should be prepared to manage unexpected emergencies that could arise when choosing to sedate a COVID-19 recovered patient.
Supplemental Oxygen Flow Rate
Planning and implementation of recommended interventions to reduce the risk of the transmitting a viral disease is paramount for all procedures in the office. However, a unique challenge may be encountered in risk management for a sedation case: providing high-flow oxygen supplementation through a nasal cannula or face mask.3
The dispersion distance of exhaled air is a function of the flow rate, according to the referenced article by Fawley and Abdelmalak, “Procedural Sedation in the COVID-19 Era.” The Cleveland Clinic Journal of Medicine article further states that dispersion can reach up to a meter at flow rates of 5 L/min. Therefore, adjusting your sedation regimen to minimize the need for supplemental oxygen and reducing the rate of flow when it’s necessary to use oxygen, can be another risk mitigation strategy to add to your toolbox.
Nitrous System Sterilization
Sterilization processes for nitrous units have long been in place to minimize the spread of viral infection during nitrous administration. However, some practice routines haven’t included those processes. With management of risk at the forefront, it’s time to revisit them.
The components of your nitrous system and methods for sterilizing them will vary slightly between brands and makes and models; but there are specific instructions in respective user manuals. Understanding the methods that should be used for your particular unit is a must.
Porter Instrument’s infection control guidance explains that due to the one-way non-rebreathing valve that’s part of modern-day nitrous systems, there’s no threat of cross contamination with the flowmeter and the breathing bag.4 The bag tee combined with scavenging flow prevents the patient’s exhalation from traveling upstream toward the breathing bag. If cross contamination of your flowmeter is a concern, covering your unit with a plastic barrier is a good idea.
In regard to the rubber goods, the ADA Return to Work Interim Guidance Toolkit mentions using disposable nasal hoods.5 But don’t be led to believe you can’t use autoclavable hoods. Use of hoods that can be sterilized is not prohibited, according to Porter’s guidance document. There are a couple of things at play. First, when using disposable nitrous hoods, don’t send them home with patients to bring back at following appointments. Second, reusable hoods—as well as the tubing—should be sterilized after each patient.
In general, the coaxial hose, hood/hose connectors, outer masks and inner liner should be sterilized between patients. A resource page that links to guidance documents and user manuals of major nitrous system brands is available at https://sedationresource.com/covid-19-resources/.
The heightened alert of the medical and dental communities regarding infection control standards lends itself to changes that can only contribute to a safer environment for patients and healthcare providers. The extended attention needed to sterilize the nitrous components should not deter from offering services needed to provide excellent care. On the bright side, you’ll save a bit by cutting down your oxygen flow rate; and everyone will benefit from being more selective.
1 Jackson DL, Johnson BS. Conscious sedation for dentistry: risk management and patient selection. Dent Clin North Am. 2002;46(4):767‐780. doi:10.1016/s0011-8532(02)00034-4
2 Interim Guidance for Dentist Anesthesiologists Practicing in the Office-Based Setting During the COVID-19 Pandemic, Last Updated May 5, 2020; https://asda.org/wp-content/uploads/2020/05/1_Guidance-ASDA-5.7.20_0.pdf
3 Procedural sedation in the COVID-19 era; Nicholas Fawley, Basem Abdelmalak; Cleveland Clinic Journal of Medicine Jun 2020, DOI: 10.3949/ccjm.87a.ccc043
4 Guidance For Infection Control and Sterilization of Porter and Matrx Nitrous Oxide and Oxygen System Components, Updated April 28, 2020
5 ADA Return to Work Interim Guidance Toolkit Updated June 9, 2020; https://success.ada.org/~/media/CPS/Files/Open%20Files/ADA_Return_to_Work_Toolkit.pdf