There is a pressing shortage of anesthesiologists in Alberta and Canada, and this is a global issue.
Compounding this shortage, there is not enough hospital capacity now or in the foreseeable future to perform all of the dental surgery needed in a timely manner. Thus, other solutions are necessary to meet this growing demand in a time-sensitive fashion.
Using internationally accepted and Health Canada-approved Target Controlled Infusion pump technology can increase capacity while reducing overall costs. Broadening the scope of healthcare professionals trained to use this technology for intravenous sedation allows anesthesiologists to focus their expertise on the most complex and urgent care.
What is Target Controlled Infusion (TCI)?
And why is it important for healthcare in Alberta?
TCI involves the use of propofol (sedative/hypnotic) and remifentanil (opioid analgesic) administered with Target Controlled Infusion (TCI) pump technology. Drug-specific AI software controls these pumps and performs the complex calculations necessary to provide stable and steady-state drug concentrations in the brain.
It is a mature and proven international standard of care for sedation or anesthesia that provides:
- Minimal and moderate sedation utilizing a trained sedation team of three. An anesthesiologist is not generally required.
- Deep sedation and general anesthesia require an anesthesiologist.
- Sedation and anesthesia can be accomplished with the same TCI technology using the same pumps and drugs. Each stage of sedation or anesthesia is achieved by varying the drug concentration or dosage level.
- Health Canada approved the drugs and TCI pumps for dental and medical use in 2006.
- TCI is an ideal and preferred solution for intravenous sedation in dentistry. It is portable and can be used in dental offices throughout Alberta.
- In dentistry, New Zealand dentists have the most experience with this technology. TCI was first pioneered there in 2004, and they now have over 100,000 combined patient treatment cases.
- The New Zealand Society for Sedation in Dentistry and the Alberta Dental Society of Anesthesiology have collaborated for over 12 years.
TCI can provide beneficial solutions for intravenous sedation or intravenous anesthesia for Albertans.
Dental Healthcare
- Sedation treatment is provided in dental offices by trained sedation teams.
- Access to timely care is improved, especially in rural Alberta, when patients do not have to travel significant distances to receive treatment.
- Safety is improved, and risks are reduced with this innovative sedation solution because it reduces the human error of hand-bolus injection and is fully supported by competency-based training.
- Scope of care expands as dentists and other allied healthcare providers provide these services. What does this mean? Costs can be reduced, and access to care can be improved when dentists, registered nurses, and respiratory therapists, with adequate training, can provide these services in local dental offices or community care centers.
- Overall, oral health improves for Albertans because comprehensive sedation and dental care can be completed in their community.
- The equipment is portable and can be utilized in varying sizes of facilities, including remote locations.
Medical Healthcare
- TCI for medical procedures will have the same benefits of increasing capacity and expanding the scope of care without increasing costs.
- For non-hospital surgical facilities, TCI sedation or anesthesia is an ideal option over inhalation anesthesia with benefits such as:
- Rapid, clearheaded recovery and early home readiness
- Minimal postoperative nausea or vomiting (PONV)
- Very little cognitive impairment, especially in our elderly population
- The availability of TCI equipment and trained healthcare providers opens up solutions for remote communities and rural Alberta.
- Cost-effective solutions that benefit patient care and lower overall healthcare costs
- Separate and independent control of drugs providing analgesia (Remifentanil) and sedation/anesthesia (Propofol).
- TCI pump software takes into consideration the patient’s age, gender, height, and weight during its drug administration.
- It is environmentally friendly and does not contribute to the significant CO2 greenhouse gas production as inhalation anesthesia does. Unused propofol should be disposed of in appropriate medical waste.
Benefits of TCI Sedation for Albertans
For the healthcare system:
- This is the only intravenous sedation system whereby the drug level can be increased or decreased in real-time. For example, more profound than intended sedation levels can easily be reduced by adjusting the pump to a more manageable level. The drug levels rapidly decline and can be reset to a lower level, allowing the procedure to continue rather than relying on reversal agents and ending the procedure as is done with benzodiazepines.
- Stable, steady-state drug levels without limitations to the length of the treatment.
- Rapid, pleasant, and clear-headed recovery with minimal cognitive impairment, nausea, or vomiting.
- Superior sedation properties when compared to benzodiazepine drugs.
- Improved safety and reduced risk when compared to hand-bolus administration.
- Health Canada-approved drugs and TCI pumps.
- Independent control of the sedation level and pain management level to meet patient needs or individual variability.
- Improved access to care in rural locations.
Implementation in Dentistry
- The Alberta Dental Society of Anesthesiology seeks a collaborative approach that includes the Alberta Government, the College of Dental Surgeons of Alberta, the Alberta Dental Society of Anesthesiology, and Albertans.
- The Alberta Dental Society of Anesthesiology proposes a Pilot Project to demonstrate and provide proof of concept/assessment of its developed competency-based training program.
- Upon the successful completion of the pilot project, the Alberta Dental Society of Anesthesiology recommends that Total Intravenous Sedation with Target Controlled Infusion pump administration (TIVS-TCI) be incorporated into the College of Dental Surgeons of Alberta’s Sedation Standards of Practice.
References:
- Dr. Lee Darichuk, President of the College of Dental Surgeons of Alberta (CDSA); Vol. 1; Issue 5; Nov. / Dec. 2022: He has recognized “the ongoing shortage of physician anesthesiologists in Alberta and the ongoing surgical backlog following COVID-19.” The CDSA supports the recognition of a specialty in dental anesthesia.
- Dr. Keith Anderson’s statement in the chapter he authored in Total Intravenous Anesthesia and Target Controlled Infusions A Comprehensive Global Anthology; Absalom A. R., Mason K. P.; Spinger 2017; page 370 “Given the large numbers of patients receiving sedation, it is not practical that anesthetists provide all sedation. Indeed, it seems that anesthetists already do not provide the majority of sedation.”
- The Netherlands trains registered nurses to provide TCI sedation within their hospitals because the country has insufficient anesthetists to meet all needs.
- Rural Alberta has a chronic shortage of anesthesia services, most provided by one-year-anesthesia-trained Family Practitioners. Many small towns and communities throughout Alberta have no anesthesia or sedation services.