Tuesday, October 30, 2018

David Craig at The Eastman 25th October 2018

On Monday I attended an Advanced Dental Sedation meeting at the Eastman mainly, it must be said, to hear what David Craig had to say on his view for dental conscious sedation for the next 5 years.

David as most will know, was a committee member for IACSD and a past president of both SAAD & the DSTG and has always been very supportive of my activities in relation to IHS training.
David was clear to point out that the points he was about to raise in his talk  were his personal views only.

As far as possible these are my verbatim contemporaneous notes. 
I have occasionally added a comment of my own in Italics.

His aim was to cover 4 areas:
·      Clinical techniques and service
·      Training
·      Research
·      Guidelines

He notes that  Guidelines were “Guidelines NOT “tramlines”!

Bearing in mind the audience were anaesthetists or sedationists involved in polypharmacy/advanced techniques, David re-stated the line that the
·      “vast majority of treatment under sedation could be achieved with single drug, Midazolam or Nitrous Oxide/Oxygen using IHS.

Midazolam included, IV, Oral and Intra-nasal. The latter two in particular for special needs whose management had been transformed this way.

Nevertheless there was a need for the small % not adequately covered by these methods to receive additional drugs such as Fenatnyl with an increase in the use of Propofol for those with dementia and ambulatory problems.  The use of these drugs have given rise to training availability.

David regretted what he saw as an arbitrary division or compartmentalization
(my term not his) into “Basic” and “Advanced” techniques.
Giving the impression that the former were ultra-safe whereas the latter were ultra dangerous. The truth is that there is a continuum.
The commissioning document (2017) pulls together various guidelines.

·      Sedation for under 12s could be/would be limited to Inhalation Sedation within 5 years.
·      Patient Assessments would/should include an airway assessment – including for sedation in medical disciplines, when this was often not done.
  • This needed to be a formal airway assessment regimen to ensure the possibility of using BVM (bag, valve,mask) in an emergency rather than intubation in the dental surgery. The latter not being normally relevant in general dental practice
He mentioned in passing the system used by Australian and NZ anaesthetists and I thought I heard him say “BONES” – in fact it looks like the mnemonic is M.O.A.N.S.   

This look to be a very comprehensive review: 63 pages on Airway assessment!  ANZCA.
My assumption from his comment is that advice on formal airway assessment is likley to be contained within this publication.

·      IACSD Standards are due for review. Since there is no new evidence nor any new problems, he saw no reason for any changes to be made.
·      There is the prospect of a new Intravenous drug on the horizon which he could not say more about other than its half life was very short, so suitable for quick interventions with a rapid recovery.

Capnography: Within 5 years in acute Trusts.
·      No help for ASA1 & 2 cases (those sedated with Midazolam in general practice).
·      In ASA3 cases, it could be very useful. Further research was needed but the warning of lowered respiratory function was very much faster compared to pulse oximetry – in fact a 240 secs faster response time.

Outcomes and Audit:

Keep it simple. The guidelines mention logs and Audit but he stressed the importance of recoding the outcomes. Was the sedation a success, was the planned treatment completed, were there difficulties or problems?

As far as audit was concerned he mentioned

·      The patient journey (no more added)
·      Did it meet their expectations?
·      Was the patient satisfied with the sedation?
·      Was the treatment able to be carried out?

Training (A topic close to my heart!)

The basic techniques were easy to train and to find trainers.
There were now 50 accredited courses and about the same number of independent (RCS STAC approved) supervisors now.

There were gaps for training in the use of Propofol and hands-on supervised clinical experience was very hard to find. So he felt the use of Propofol would not increase in the next 5 years.

“Mentors” as listed by SAAD and the DSTG had been done away with since some may not have been competent.

David raised the question of  the “Transitional Arrangements” (put in place by IACSD in 2015) and how long they would be in pace and that they might to be “tightened up” but then again unlikely as these were likely to be extended in the next 5 years. (I am unsure of what that might mean, since they were put in place to allow people already using sedation to continue without further training.
However by now, anyone returning to sedation I would think would need to be retrained or mentored again before restarting).

David said that “Thanks to Richard here. We were able to get things up and running with course accreditations” and …

·      We were unlikely to see a register of conscious sedationists
·      The eCPD requirements (over the next 5 years) were likely to remain the same.

Research Needed
·      Fasting:  Evidence needed but not for Nitrous Oxide or Midazolam
·      Capnography: needs to be studied in a dental setting to be appropriate.
·      Propofol:  Proven efficacy in dentistry but the algorithm in special care doesn’t work.
·      NEW Short-Acting BDZ: Work underway – he cannot say what – with a drug with very short alpha and beta half-lives, allowing rapid recovery and so NO ESCORTS!
·      Ketamine: Introduced to the UK by Prof. James Roelofse
·      Dexmedetomidine: No respiratory depression but longer recovery than Midaz?
·      Nitrous Oxide/Oxygen with Midazolam: (An idea he likes). Initiate sedation with Midazolam and finish off with N2O/O2.   

As an example, at the end of a treatment session with scaling/perio Tx in the last phase, which the patients often dislike. 
A standard technique in Canada. It avoids adding more Midazolam to the total dose whilst keeping the patient sufficiently sedated, allowing Midazolam to “wear off”.
·      CBT a very useful technique but not for acute cases.

He returned to guidelines etc.

He thought that NICE might look at under 19s but there was no new evidence/ nothing new and NICE were only supposed to make changes with evidence not expert opinion, though they do.

The Academy of Medical Royal Colleges 2013 guidelines would be reviewed
As well as IACSD. He hoped it would not be re-opened  again stating no new evidence, no new problems.
The Scottish SDCEP guidelnes had been accepted for all “New Starters”
Wales recently published their own guidelines.
Northern Ireland are still on the 2013 guidelines (news to me !)

All guidance was now aligned including that from the Royal College of Anaesthetists.

That's all Folks

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