Pediatric anesthesia

You may have read about the recent tragic deaths of two healthy children – Marvelena Rady, age 3, and Caleb Sears, age 6 – in California dental offices. Unfortunately, they aren’t the first children to die during dental procedures, and unless things change, they probably won’t be the last.

State Senator Jerry Hill has asked the Dental Board of California (DBC) to review California’s present laws and regulations concerning pediatric dental anesthesia, and determine if they’re adequate to assure patient safety. Assemblymember Tony Thurmond has sponsored “Caleb’s Law”, seeking improved informed consent for parents.

On July 28, I had the opportunity to attend a stakeholder’s meeting at the Department of Consumer Affairs in Sacramento, to hear a presentation of the DBC’s report, and to be part of the delegation offering comments on behalf of the California Society of Anesthesiologists (CSA). We hope this is the beginning of some long overdue upgrades to the current regulations.

By long-standing California state law, dentists and oral surgeons are able to provide anesthesia services in their offices even for very young children or children with serious health issues. They may apply for one of four different types of permits for anesthesia:

General anesthesia

Adult oral conscious sedation

Pediatric oral conscious sedation

Parenteral conscious sedation.

But the route of administration – oral or intravenous – isn’t the point, especially for small children, and oral sedation isn’t necessarily safer. Sedation is a continuum, and there is no way of reliably predicting when a patient will fall asleep. Relaxation may turn into deep sedation, and deep sedation into a state of unresponsiveness which is equivalent to general anesthesia. Oral medications have led to deaths in children, sometimes even before the dental procedure has begun or well after it has finished. There’s no logic in California’s lower standards of emergency equipment and monitoring for procedures done under sedation as opposed to under general anesthesia.

Isn’t a little sedation enough?

In an older child or adult, mild sedation and local anesthesia are enough for nearly all dental care. But any parent knows that this won’t work for a young child who can’t hold still. There really isn’t any such thing as “conscious sedation” for a toddler of 2 or 3. Deep sedation or general anesthesia are the only choices for a child who needs extensive dental treatment.

Small children have small airways. Every parent knows not to give a small child big chunks of hot dog, or toys with small parts, because of the risk of choking. During dental work, a child’s breathing can be blocked by swelling or bleeding. Just a few drops of blood may irritate a child’s vocal cords, causing them to snap shut and preventing air from getting to the lungs. In the time it might take to gather emergency equipment, a child can suffer permanent brain damage or death from lack of oxygen. General anesthesia often is safer, since the airway is protected with a breathing tube from start to finish.

One of the problems with current California regulations is the use of outdated terminology. The ASA, the American Academy of Pediatrics (AAP), and the American Academy of Pediatric Dentistry (AAPD) all agree on standard definitions and rules concerning minimal, moderate, and deep sedation. California dental laws and regulations, however, use the words “conscious sedation” and “moderate sedation” interchangeably, causing confusion about which rules apply.

By California definition, moderate sedation should use “drugs and techniques that have a margin of safety wide enough to render unintended loss of consciousness unlikely.”  But California doesn’t restrict sedation permit holders from using potent anesthesia medications including propofol, associated with the deaths of Michael Jackson and Joan Rivers, and fentanyl, associated with the death of Prince. Especially when these medications are used in combination with others — ketamine, methohexital, Demerol, hydroxyzine, midazolam — the risk goes up for unintended deep sedation and lethal consequences.

Who’s monitoring the child’s breathing?

By national standards of care, a surgeon can’t take out your child’s tonsils or perform any procedure requiring anesthesia without a separate qualified professional to give medications and monitor the patient. Even an anesthesiologist performing an interventional pain procedure can’t legally direct sedation at the same time.

Yet in the offices of dentists and oral surgeons, it’s perfectly acceptable for the same person to perform the dental procedure and direct sedation to be given by a second person who also assists with the procedure. That person is likely to be a “dental sedation assistant”, who in California has completed only one year of experience as a dental assistant, 40 hours of didactic education, and 28 hours of laboratory instruction. In some states, the training requirements are even less.

No state at this time requires the presence of a physician anesthesiologist, a registered nurse, or any other medical professional during sedation or anesthesia for dental treatment, even for small children. At present, 29 states require the presence of a third person to serve as a “dedicated anesthesia monitor” in addition to the dentist and dental assistant; California does not.

Parents should question the concept that sedation and anesthesia should be given to a young child — or for that matter to any patient — without a qualified person whose only job is to watch the patient and to administer sedation or anesthesia. This is the opinion of the ASA and CSA, clearly defined in our guidelines on sedation. I’m very pleased to see our opinion shared – and expressed in the strongest terms – by Paula Whitehead, MD, who attended the stakeholders’ meeting on behalf of the AAP, and by Michael Mashni, DDS, a past president of the American Society of Dental Anesthesiologists.

The July 28 meeting was solely for the purpose of gathering opinions from interested parties. The DBC will be preparing a second report with recommendations for changes to California laws and regulations concerning pediatric dental anesthesia. The state legislature and the Department of Consumer Affairs are watching with keen interest.

It’s high time California and other states modified their laws to bring the practice of anesthesia and sedation in dental offices into line with the rules followed in every hospital and outpatient surgery center. Too many children have died already. There shouldn’t need to be more.

7 COMMENTS

Sam

I don't think this skims that point, in dact, I think it presses for that point. That dental anesthesiologists are available, just not in most dental practices and offices. If that were the case, then this wouldn't be an issue. But it is. A real issue. Because people die, all too often, and in ways and cases where it could and should have easily been avoided- by way of a legitimate anesthesiologist being present to monitor the patient and their airway.
Dear Dr. Weaver, Thank you so much for writing. Your points are right on target. I don't know who was looking after the anesthesia medications in these tragic cases, but can only assume that something was wrong with either the staffing, the monitoring, or both. Do you have any information about who was giving anesthesia? My point is that the current laws are inadequate. Children and other patients would be fortunate to have someone with your qualifications looking after them. Best, Karen Sibert

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Kennedy and Frost

Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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2 COMMENTS

Physician on FIRE

I found this article in the ASA Monitor, which led me here to visit your site and the sites of the other great bloggers you listed for us. Thank you for introducing me to a bevy of talented anesthesiologist writers. I'll be busy reading for some time. Cheers! -Physician on FIRE
Thanks for the shout out!. Haven't written for awhile - you've inspired me to get something out there.

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D-Day beach

When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

That’s right. The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists, in the VA system. This new policy in the Nursing Handbook would make it mandatory for these nurses to practice independently. Physician anesthesiologists wouldn’t be needed at all, according to this proposal, even in the most complicated cases – such as open-heart surgery.

If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect. In all 100 of the top hospitals ranked by US News & World Report, physician anesthesiologists lead anesthesia care, most often in a team model with residents and/or nurses.

The new policy isn’t a done deal yet. The proposal is open for comment in the Federal Register until July 25. Already thousands of veterans, their families, and many other concerned citizens have visited the website www.safeVAcare.org and submitted strongly worded comments in opposition. I urge you to join them.

Physician-led care teams have an outstanding record of safety, and they have served veterans proudly in VA hospitals for many years. Many university medical centers have affiliations with their local VA hospitals, where their faculty physicians deliver clinical care and conduct research. UCLA, for example, sends anesthesiologists to the VA hospital in Los Angeles, so that our veterans get the same high-quality care as wealthy patients from the enclaves of Brentwood.

Many of our veterans aren’t in good health. They suffer from a host of service-related injuries, and they have high rates of chronic medical disease. Some have been among the most challenging patients I’ve ever anesthetized. Their care required all the knowledge I was able to gain in four years of medical school, four years of residency training in anesthesiology, and countless hours of continuing medical education.

No VA shortage of anesthesia care

It’s clear, of course, why the VA is proposing the change in the Nursing Handbook. The reason is the scandal over long waiting times for primary care. Proponents argue that giving nurses independent practice will expand access to care for veterans.

But there’s no shortage of physician anesthesiologists or nurse anesthetists within the VA system. The shortages exist in primary care. A solution that might help solve the primary care problem shouldn’t be extended to the complex, high-tech, operating room setting, where a bad decision may mean the difference between life and death.

The VA’s own internal assessment has identified shortages in 12 medical specialties, but anesthesiology isn’t one of them. The VA’s own quality research questioned whether a nurse-only model of care would really be safe for complex surgeries, but this question was ignored. The proposed rule in the Federal Register lists as a contact “Dr. Penny Kaye Jensen”, who in fact is not a physician but an advanced practice nurse who chooses not to list her nursing degrees after her name. The lack of transparency in the proposal process is disturbing.

In 46 states and the District of Columbia, state law requires physician supervision, collaboration, direction, consultation, agreement, accountability, or direction of anesthesia care. The proposed change to the VA Nursing Handbook would apply nationally and would override all those state laws, which were put in place to protect patients.

In Congress, many senators and representatives on both sides of the aisle recognize the need to continue physician-led anesthesia care for veterans. Representatives Julia Brownley of California’s 26th District and Dan Benishek, MD, of Michigan’s 1st District are strong advocates for veterans’ health. They have co-authored a letter (signed by many in Congress) to VA Secretary Robert McDonald, urging him not to allow the destruction of the physician-led care team model as it currently exists within the VA system.

Governor Schwarzenegger’s heart surgery is a matter of public record. He has spoken about it openly on television, and he graciously invited the whole operating room team to his next movie premiere. I was lucky enough to go to the premiere too, because his anesthesiologist, Dr. Haddy, happens to be my husband.

But I didn’t set out to write this column on behalf of my husband. I’m writing on behalf of my father, who is now 93, landed on the beach at Normandy on D-Day, and miraculously survived the rest of the war as a sniper. And I’m writing on behalf of all the men and women who have served our country, and who deserve the best possible anesthesia care from physicians and nurses who want to work together to take care of them. If we don’t defeat the proposed change in the VA Nursing Handbook, they all lose.

3 COMMENTS

Rick Novak MD

Terrific column, Karen. I loved the twist about Arnold's anesthesiologist being your husband. I agree wholeheartedly. And my 95-year-old father, like yours a WWII veteran, would agree as well.

Andrew Kadar, MD

Another timely message from Dr. Sibert. I hope that many readers will support her call for helping to maintain physician directed anesthesia in the VA.

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Fame and fentanyl

poppies

Poppies, the original source of opium…  

A fentanyl overdose led to the recent death of musician and singer Prince, according to the medical examiner’s report released June 2. The drug seems likely to become as notorious as propofol did after the death of Michael Jackson in 2009.

For all of us in anesthesiology who’ve been using fentanyl as a perfectly respectable anesthetic medication and pain reliever for as long as we can remember, it’s startling to see it become the cause of rising numbers of deaths from overdose.  Fentanyl is a potent medication, useful in the operating room to cover the intense but short-lived stimulation of surgery. The onset of action is very fast, and the time that the drug effect lasts is relatively brief.

But fentanyl was never intended for casual use. Fentanyl is many times more potent than morphine; 100 micrograms, or 0.1 mg, of IV fentanyl is roughly equivalent to 10 mg of IV morphine. In March, the LA Times reported that 28 overdoses — six of them fatal — occurred in Sacramento over the course of just one week. The victims had taken pills that resembled Norco, a common pain reliever, but in fact the pills were laced with fentanyl. Even tiny amounts were enough to be lethal.

Like all opioids, fentanyl reduces the drive to breathe, and after a large enough dose a patient will stop breathing entirely. In addition to its effect on respiratory drive, fentanyl may also produce rigidity of the muscles in the chest and abdomen, severe enough to hamper attempts to ventilate or perform CPR.

What exactly is fentanyl?

Fentanyl is an inexpensive member of a class of drugs called “opioids”, which are powerful pain relieving medications. The word “opium” is derived from the Greek word for juice, because the juice of the poppy flower was the original source of opium. Starting in Mesopotamia, the opium poppy has been cultivated since at least 3000 BC. The term “opiate” is used to designate drugs derived from opium. Morphine was the first of these, isolated in 1803, followed by codeine in 1832.

The development of techniques to synthesize drugs in a laboratory, as opposed to the cultivation of poppy fields, has led to the use of the term “opioids” to refer to any and all substances that treat pain by acting on opioid receptors in the central nervous system. The term “narcotic” is often used as a synonym. It’s derived from the Greek word for stupor, and is used to refer to any morphine-like drug with the potential for addiction.

Fentanyl is cheap, and the powdered form is being synthesized in clandestine laboratories in the U.S. and Mexico according to news reports. What’s leading to the spate of new overdoses is the fact that some dealers are quietly adding fentanyl to heroin to increase the “high”. A user injects what he thinks is his usual quantity of heroin, not realizing that it may be mixed with fentanyl. The mixture is far more potent and may be deadly.

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4 COMMENTS

bradjohnsnow

Another of your consistently superb essays translating medical jibberish into information easily understood by the public.PLEASE gather these into a book sometime in the future!

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AAAA small logo

Certified Anesthesiologist Assistants (CAAs) are superbly trained anesthesia caregivers, loyal supporters of physician anesthesiologists, and eager to come to work in every state if we can just get state legislatures to grant them licenses to practice!

That was the message I heard clearly in Denver this past weekend, as a guest faculty member at the 40th annual meeting of the American Academy of Anesthesiologist Assistants (AAAA). More than 600 CAAs and student AAs from across the country made the journey to Colorado, one of the 18 states where CAAs are currently able to practice their profession, to hear lectures, promote advocacy, and attend workshops.

Anyone who still doubts that CAAs are champions of our profession should have been there! The ASA cosponsored the meeting, and ASA President-Elect Jeff Plagenhoef, MD, delivered this year’s Gravenstein Memorial Lecture, a powerful talk on “Professional Citizenship” in anesthesiology.

Ready to relocate!

“Many experienced CAAs are telling me they are ready to drop everything and relocate to California whenever we can work there,” said Megan Varellas, CAA, the immediate past president of the Academy. Her viewpoint was echoed by other CAAs I spoke with, including Maria Williamson, CAA, and her fiancé, Jeff Carroll, CAA, who currently practice in Florida. Ms. Williamson’s parents live in southern California, and the couple would be eager to move here if they could work.

The ASA strongly supports CAAs as members of the physician-led anesthesia care team. Their master’s level educational programs are located at medical schools, not nursing schools, and physician anesthesiologists direct their training. CAAs work exclusively within the anesthesia care team, under physician anesthesiologist supervision. Their services are attractive to many physician-only practices that want to move toward a care team model.

At present, though, despite a shortage of qualified anesthesia practitioners in California, CAAs can’t yet work here. Last year, CSA sponsored AB 890, a bill championed by Assembly Member Sebastian Ridley-Thomas (D-Los Angeles), which would have recognized CAA practice in California. The bill stalled in the Appropriations Committee, but CSA hasn’t given up. We plan to introduce a new bill to authorize full CAA licensure, and realize that it’s typical for these legislative efforts to take more than one attempt to pass.

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