@Sublimazing did you give the 2mg of Midazolam? How? And over what time period? Any other pre-op meds given?
@osteotomy01 As a general rule if you are driving a Ferrari or Porsche and your ultimate destination is"Deep Sedation/GA town (from my limited experience with Ferraris) you go fast and hard. Driving down the freeway and noticing the sign for "Moderate Sedation Town" is not nearly the same as planning a trip to "Moderate Sedation Town" and touring the all the sites, etc.
@DaleDoback
Certainly, most of the descriptions you guys have given do not jive with any of the standard protocols taught or employed by IV Moderate sedation providers. For example:
1. PO Midazolam (almost any PO med for that matter except with peds but that us a whole other ball of wax) is never given when the desired end-point is moderate sedation. Why? Because you have to guess the dose. This is not titratable and hence less predictable. The only time we give PO meds is for very anxious patients following a stress-reduction protocol written about by Dental Anesthesiologists. This is actually quite often for me but it ends up being an anxiolytic dose of triazolam.
@DaleDoback how long did it take you to give 1mg of Midazolam? Why did you give the fentanyl? Why 50 micrograms? How long did it take you to give the narcotic?
We use all of the same monitors and have all of the same rescue equipment as you. Although most states do not require intubation armamentarium for moderate sedation providers.
All, please consider this statement by Joel Weaver:
"We must realize that no additional amount of required hours of training or continuing education or stricter dental board rules will totally eliminate human errors or their dire consequences. Poor outcomes do not necessarily mean that the guidelines and rules are faulty or that they must be immediately changed."
Also consider that deaths in the dental office do not go unreported in he media. And if it is not a child, it is someone from an oral surgeons office. If you think that deep sedation/GA with an unsecured airway is somehow safer than moderate sedation, regardless of your training, you are fooling yourself. It is the deep level of sedation and GA that put your ability to provide anesthesia at risk because "a conscious patient never dies." Topic for another day: why are healthy patients dying from dental appointments secondary to GA complications when they can be treated under local anesthesia, LA and minimal sedation, or LA and Moderate sedation? Obviously everyone take a much more cautious low and slow approach to geriatric patients but why so much GA for dental procedures where profound local anesthetic is easily achievable?
I still cannot understand how you can claim that a patient with moderate sedation can get a laryngospasm or ever need to be intubated. We are all using the same definition right?
"moderate sedation — a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained."3
"Note: In accord with this particular definition, the drugs and/or techniques used should carry a margin of safety wide enough to render unintended loss of consciousness unlikely. Repeated dosing of an agent before the effects of previous dosing can be fully appreciated may result in a greater alteration of the state of consciousness than is the intent of the dentist. Further, a patient whose only response is reflex withdrawal from a painful stimulus is not considered to be in a state of moderate sedation."
You ever try to tube someone like that? Again, why would you ever need to tube someone in moderate sedation? Only if the provider has gone waaaaaay beyond their scope and the patient is deep, deep, deep.
At our speeds with the Fusion we are always going low and slow. You may slam 3 mg Midazolam in 5 seconds followed by some GA meds. For me that same dose of Versed takes 3 minutes. You may immediately reach for a narcotic. I only reach for a narcotic if versed Valium combos haven't quite got me there. Yes. 1mg/minute Versed up to 5 mg, the 5mg/minute Valium up to 10 mg. that is 7 minutes and no local yet. You may have 1 and 32 out by then. But if my patient isn't moderately sedated yet, I am going back to versed 1mg/min up to 5 more and if still not there I am back to Valium same rate stopping at affect or at 10 mg more. If just about there (hopefully because this is approaching failure of moderate sedation) I can titrate up to 100 mics fentanyl at a rate of 20mics/minute. Yes 5 minutes to give 100 Fentanyl. If still not sedated that is a failure and we can talk the patient through treatment or set it up for GA. Keep in mind that is 19+ minutes of titration time in a failed case. Most of my cases are titrated in 5-10 mins.
Now don't get scared by the max doses because those are rare but much more common than a patient going too deep. I have done well over 500 cases. I have given reversal agents twice. I have had to pinch a few traps, do some head tilt-chin lifts, or jab the needle lingual to 8 and 9 a few times to those that over responded a bit but BIG scares, not really. I have never had to bag anyone. Throwing an airway in is only at review courses because I prevent that. Look how slow we dose. It is so safe. BZD's also carry the wide safety margin. Yes, I have had patients who only had 1mg Versed and they were snoring so I sure as he'll didn't add in a narcotic to further suppress their breathing. An ounce of prevention is a pound of cure.
I think we have beaten this horse to death. We will never be the anesthesia experts you all are. But we value anesthesia and our right to provide the small portions that are light and moderate sedation. And we are just as concerned about patient safety as you.
Holy crap that is a novel!
I appreciate response to my questions but I have no more cards to lay on this table. So, I look forward to your answers.