(1) A licensed dentist is required to hold a permit of authorization to administer moderate sedation with parenteral agents. A moderate sedation with parenteral agents permit allows the holder to deliver moderate sedation with enteral agents without obtaining a separate permit.

(2) To obtain a moderate sedation with parenteral agents permit, a licensed dentist shall:

(a) Comply with the permitting and renewal requirements in WAC 246-817-774;

(b) Successfully complete a postdoctoral course or courses of 60 clock hours or more which includes:

(i) Basic moderate sedation;

(ii) Physical evaluation;

(iii) Venipuncture and intravenous drug administration, training is a hands-on skill and must be completed in-person;

(iv) Technical administration;

(v) Recognition and management of complications and emergencies, training is a hands-on skill and must be completed in-person;

(vi) Monitoring; and

(vii) Supervised experience in providing moderate sedation with parenteral agents to 20 or more patients.

(c) Training in adult sedation, if treating an adult; and

(d) Training in pediatric sedation, if treating a pediatric patient.

(3) In addition to meeting the criteria in subsection (2) of this section, the licensed dentist shall hold and maintain a current certification in ACLS or PALS.

(a) If treating an adult, the dentist must have ACLS certification.

(b) If treating a pediatric patient, the dentist must have PALS certification.

(4) The use of any drugs classified under the Food and Drug Administration as general anesthetic agents including, but not limited to, Propofol, Ketamine, Sevoflurane, Halothane, and Isoflurane are considered outside the scope of a moderate sedation with parenteral agents permit.

(5) The drugs, drug amounts, and techniques used must carry a margin of safety wide enough to render unintended loss of consciousness highly unlikely.

(6) A licensed dentist shall:

(a) Ensure a patient receiving moderate sedation with parenteral agents receives the sedation from an anesthesia provider qualified under this chapter.

(b) Ensure the patient is evaluated for moderate sedation with parenteral agents prior to the administration of any sedative.

(i) Review, at an appropriate time, the patient's medical history and medication use and NPO or nothing by mouth status.

(ii) Consult with the patient's primary care physician or consulting medical specialist for a patient with significant medical considerations whom have American Society of Anesthesiologists patient classification of III or IV.

(iii) Patient's body mass index must be assessed as part of a preprocedural workup.

(iv) A focused physical examination to include vital signs, evaluation of the airway, and auscultation of the heart and lungs is required before administration of any sedative or anesthesia agent.

(c) Ensure a patient is not left alone in a room and is continually monitored by an anesthesia provider or trained anesthesia monitor as defined in WAC 246-817-772.

(d) Ensure an intravenous infusion is maintained during the administration of a parenteral agent. Two exceptions for intravenous infusion may occur, but reasons why intravenous infusion was not used must be documented for:

(i) Pediatric sedation cases using agents for brief procedures; and

(ii) When the pediatric patient is uncooperative or the emotional condition is such that intravenous access is not possible.

(e) Ensure when the operative dentist is also the provider administering the moderate sedation with parenteral agents, the operative dentist is continuously assisted by a trained anesthesia monitor as defined in WAC 246-817-772. The trained anesthesia monitor may function as the dental or surgical assistant.

(i) If treating an adult, the additional individual must have experience or training in adult sedation.

(ii) If treating a pediatric patient, the additional individual must have experience or training in pediatric sedation.

(f) Ensure a patient is visually and tactilely monitored either by themselves or an individual trained in monitoring sedated patients. Patient monitoring must include:

(i) Heart rate;

(ii) Blood pressure;

(iii) Respiratory rate;

(iv) Oxygen saturation;

(v) Continuous electrocardiographic monitoring when the patient has clinically significant cardiovascular disease.

(A) Clinically significant cardiovascular disease can be classified, but not limited to, coronary artery disease, arrhythmias, congenital heart defects, heart valve disease, disease of the heart muscle, and heart infection.

(B) Electrocardiographic monitoring of a pediatric patient is not required when the pediatric patient is uncooperative, the emotional condition is such that monitoring is not possible, or who does not tolerate the monitor pads or wiring. Reasons why electrocardiographic monitoring was not used must be documented.

(vi) End-tidal CO2. Monitoring is not required when:

(A) A pediatric sedation case uses agents for a brief procedure; or

(B) A pediatric patient is uncooperative or the emotional condition is such that end-tidal CO2 monitoring is not possible.

(C) Reasons why end-tidal CO2 monitoring was not performed must be documented.

(g) Comply with requirements of immobilization devices for pediatric patients.

(i) Immobilization devices, such as, papoose boards, must be applied in such a way as to avoid airway obstruction or chest restriction.

(ii) The pediatric patient head position and respiratory excursions must be checked frequently to ensure airway patency.

(iii) If an immobilization device is used, a hand or foot must be kept exposed.

(h) Ensure the patient's blood pressure, heart rate, pulse oximetry, and respiration rate is recorded every five minutes.

(i) Ensure the patient's level of consciousness is recorded prior to the dismissal of the patient.

(j) Ensure patient is accompanied by a responsible adult upon departure from the treatment facility.

(k) Ensure the patient is returned to a level of moderate sedation as quickly as possible, if the patient unintentionally enters a deeper level of sedation. While returning the patient to the moderate level of sedation, periodic monitoring of pulse, respiration, blood pressure and continuous monitoring of oxygen saturation must be maintained. In such cases, these same parameters must be taken and recorded at appropriate intervals throughout the procedure and vital signs and level of consciousness must be recorded during the sedation and prior to dismissal of the patient.

(7) A licensed dentist shall document in the patient record appropriate medical history and patient evaluation. Sedation records must be recorded during the procedure in a timely manner and must include:

(a) Blood pressure;

(b) Heart rate;

(c) Respiration;

(d) Pulse oximetry;

(e) End-tidal CO2. Monitoring is not required when:

(i) Pediatric sedation case uses agents for brief procedure; or

(ii) A pediatric patient is uncooperative or the emotional condition is such that end-tidal CO2 monitoring is not possible.

(iii) Reasons why end-tidal CO2 monitoring was not performed must be documented.

(f) Drugs administered including amounts and time administered;

(g) Length of procedure; and

(h) Any complications of sedation.

(8) A licensed dentist shall comply with the following recordkeeping, equipment, and emergency medication requirements:

(a) Equipment used for monitoring patients must be calibrated or performance verified according to manufacturer's instructions.

(b) An operating theater must be large enough to adequately accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least two individuals to freely move about the patient;

(c) An operating table or chair must permit the patient to be positioned so the operating team can maintain the airway, quickly alter patient position in an emergency, and provide a firm platform for the administration of basic life support;

(d) A lighting system must be adequate to permit evaluation of the patient's skin and mucosal color and a backup lighting system of sufficient intensity to permit conclusion of any procedure underway at the time of general power failure;

(e) Suction equipment capable of aspirating gastric contents from the mouth and pharyngeal cavities. A backup suction device must be available;

(f) An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate portable backup system;

(i) If treating an adult, the equipment must be appropriate for adult sedation;

(ii) If treating a pediatric patient, the equipment must be appropriate for pediatric sedation;

(iii) Appropriate sized laryngeal mask airway must be ready for emergency use;

(g) A blood pressure cuff or sphygmomanometer of appropriate size and stethoscope; or equivalent monitoring devices;

(h) End-tidal CO2 monitor;

(i) Pulse oximetry; and

(j) An emergency drug kit with minimum contents of:

(i) Sterile needles, syringes, and tourniquet;

(ii) Narcotic antagonist;

(iii) Alpha and beta adrenergic stimulant;

(iv) Vasopressor;

(v) Coronary vasodilator including, but not limited to, nitroglycerin;

(vi) Antihistamine including, but not limited to, diphenhydramine;

(vii) Parasympatholytic;

(viii) Intravenous fluids, tubing, and infusion set;

(ix) Sedative antagonists for drugs used, if available;

(x) Bronchodilator agent including, but not limited to, albuterol;

(xi) ACLS or PALS emergency drugs; and

(xii) Anti-hypoglycemic agent.

(9) A licensed dentist who holds a valid moderate sedation with parenteral agents permit and administers moderate sedation with parenteral agents in another licensed dentist office, must have a contract in place that contains the provisions described in WAC 246-817-778 (1)(a) through (c).

(10) A licensed dentist who holds a valid moderate sedation with parental agents permit shall complete 14 hours of continuing education every three years as required in WAC 246-817-773.

(11) A licensed dentist who holds a valid moderate sedation with parenteral agents permit must hold a current and valid ACLS certification.

[Statutory Authority: RCW 18.32.0365 and 18.32.640. WSR 24-01-033, § 246-817-760, filed 12/11/23, effective 1/11/24; WSR 17-07-037, § 246-817-760, filed 3/8/17, effective 4/8/17; WSR 16-06-106, § 246-817-760, filed 3/1/16, effective 4/1/16; WSR 09-04-042, § 246-817-760, filed 1/30/09, effective 3/2/09. Statutory Authority: RCW 18.32.035. WSR 95-21-041, § 246-817-760, filed 10/10/95, effective 11/10/95.]