The purpose of this study was to test the null hypothesis that children with environmental tobacco smoke (ETS) exposure (also known as passive smoke exposure) do not demonstrate an increased likelihood of adverse respiratory events during or while recovering from general anesthesia administered for treatment of early childhood caries. Parents of children (ages 19 months–12 years) preparing to receive general anesthesia for the purpose of dental restorative procedures were interviewed regarding the child's risk for ETS. Children were observed during and after the procedure by a standardized dentist anesthesiologist and postanesthesia care unit nurse who independently recorded severity of 6 types of adverse respiratory events—coughing, laryngospasm, bronchospasm, breath holding, hypersecretion, and airway obstruction. Data from 99 children were analyzed. The children for whom ETS was reported were significantly older than their ETS-free counterparts (P = .03). If the primary caregiver smoked, there was a significantly higher incidence of smoking by other members of the family (P < .0001) as well as smoking in the house (P < .0005). There were no significant differences between the adverse respiratory outcomes of the ETS (+) and ETS (−) groups. The ETS (+) children did have significantly longer recovery times (P < .0001) despite not having significantly more dental caries (P = .38) or longer procedure times. ETS is a poor indicator of post–general anesthesia respiratory morbidity in children being treated for early childhood caries.
Passive smoke exposure; Dental caries
Pediatric dental patients who cannot receive dental care in the clinic due to uncooperative behavior are often referred to receive dental care under general anesthesia (GA). At Stony Brook Medicine, dental patients requiring treatment with GA receive dental care in our outpatient facility at the Stony Brook School of Dental Medicine (SDM) or in the Stony Brook University Hospital ambulatory setting (SBUH). This study investigates the time and cost for ambulatory American Society of Anesthesiologists (ASA) Class I pediatric patients receiving full-mouth dental rehabilitation using GA in these 2 locations, along with a descriptive analysis of the patients and dental services provided. In this institutional review board–approved cross-sectional retrospective study, ICD-9 codes for dental caries (521.00) were used to collect patient records between July 2009 and May 2011. Participants were limited to ASA I patients aged 36–60 months. Complete records from 96 patients were reviewed. There were significant differences in cost, total anesthesia time, and recovery room time (P < .001). The average total time (anesthesia end time minus anesthesia start time) to treat a child at SBUH under GA was 222 ± 62.7 minutes, and recovery time (time of discharge minus anesthesia end time) was 157 ± 97.2 minutes; the average total cost was $7,303. At the SDM, the average total time was 175 ± 36.8 minutes, and recovery time was 25 ± 12.7 minutes; the average total cost was $414. After controlling for anesthesia time and procedures, we found that SBUH cost 13.2 times more than SDM. This study provides evidence that ASA I pediatric patients can receive full-mouth dental rehabilitation utilizing GA under the direction of dentist anesthesiologists in an office-based dental setting more quickly and at a lower cost. This is very promising for patients with the least access to care, including patients with special needs and lack of insurance.
Pediatric dentistry; Dental anesthesia; Cost analysis; Operating room; Office-based anesthesia; Health economics
For several decades, anesthetic gases have greatly enhanced the comfort and outcome for patients during surgery. The benefits of these agents have heavily outweighed the risks. In recent years, the attention towards their overall contribution to global climate change and the environment has increased. Anesthesia providers have a responsibility to minimize unnecessary atmospheric pollution by utilizing techniques that can lessen any adverse effects of these gases on the environment. Moreover, health care facilities that use anesthetic gases are accountable for ensuring that all anesthesia equipment, including the scavenging system, is effective and routinely maintained. Implementing preventive practices and simple strategies can promote the safest and most healthy environment.
Volatile anesthetics; Environmental pollution; Greenhouse warming potential; Ozone depletion potential
Autonomic drugs are used clinically to either imitate or inhibit the normal functions of the sympathetic and parasympathetic nervous systems. A large number of additional drug classes also interact with these systems to produce a stunning number of possible side effects. This article reviews the basic function of the autonomic nervous system and the various drug classes that act within these neural synapses.
Autonomic drugs; Sympathomimetics; Adrenergic agonists; Adrenergic antagonists; Cholinergic drugs; Anticholinergic drugs
This study aimed to compare continuous intravenous infusion combinations of propofol-remifentanil and propofol-ketamine for deep sedation for surgical extraction of all 4 third molars. In a prospective, randomized, double-blinded controlled study, participants received 1 of 2 sedative combinations for deep sedation for the surgery. Both groups initially received midazolam 0.03 mg/kg for baseline sedation. The control group then received a combination of propofol-remifentanil in a ratio of 10 mg propofol to 5 μg of remifentanil per milliliter, and the experimental group received a combination of propofol-ketamine in a ratio of 10 mg of propofol to 2.5 mg of ketamine per milliliter; both were given at an initial propofol infusion rate of 100 μg/kg/min. Each group received an induction loading bolus of 500 μg/kg of the assigned propofol combination along with the appropriate continuous infusion combination . Measured outcomes included emergence and recovery times, various sedation parameters, hemodynamic and respiratory stability, patient and surgeon satisfaction, postoperative course, and associated drug costs. Thirty-seven participants were enrolled in the study. Both groups demonstrated similar sedation parameters and hemodynamic and respiratory stability; however, the ketamine group had prolonged emergence (13.6 ± 6.6 versus 7.1 ± 3.7 minutes, P = .0009) and recovery (42.9 ± 18.7 versus 24.7 ± 7.6 minutes, P = .0004) times. The prolonged recovery profile of continuously infused propofol-ketamine may limit its effectiveness as an alternative to propofol-remifentanil for deep sedation for third molar extraction and perhaps other short oral surgical procedures, especially in the ambulatory dental setting.
Propofol; Ketamine; Remifentanil; Deep sedation; TIVA
The goal of this study was to investigate the effect of an epinephrine continuous infusion on muscle blood flow in rabbits. Sixteen male Japan White rabbits were randomly allocated to 1 of 2 groups: epinephrine continuous infusion at 0.01 μg/kg/min (Ep-0.01 group, n = 8) and at 0.1 μg/kg/ min (Ep-0.1 group, n = 8). The observed variables were heart rate, femoral artery blood pressure, common carotid artery blood flow (CCBF), masseter muscle blood flow (MBF), and quadriceps muscle blood flow (QBF). In the Ep-0.01 group, CCBF, MBF, and QBF were increased by 14, 22, and 21% from respective control values. In contrast, in the Ep-0.1 group, CCBF, MBF and QBF were decreased by 10, 30, and 27% from respective control values. There were no differences in the percentage change between MBF and QBF during epinephrine continuous infusion. Positive correlations were observed between CCBF and MBF and between CCBF and QBF. In conclusion, skeletal muscle blood flow was increased during the small-dose epinephrine infusion, whereas it was decreased during large-dose infusion.
Epinephrine; Skeletal muscle blood flow; Rabbits
Bronchospasm and status asthmaticus are two of the most dreaded complications that a pediatric anesthesiologist may face. With the occurrence of severe bronchospasm and the inability to ventilate, children are particularly vulnerable to apnea and ensuing hypoxia because of their smaller airway size, smaller lung functional residual capacity, and higher oxygen consumption rates than adults. Nebulized medication delivery in intubated children is also more difficult because of smaller endotracheal tube internal diameters. This case demonstrates the potentially lifesaving use of a vibrating-mesh membrane nebulizer connected to the anesthesia circuit for treating bronchospasm.
Asthma; Bronchospasm; Nasal intubation; Pediatric dental anesthesia; Vibrating-mesh; nebulizer
An earlier paper by Becker and Reed provided an in-depth review of the pharmacology of local anesthetics. This continuing education article will discuss the importance to the safe and effective delivery of these drugs, including needle gauge, traditional and alternative injection techniques, and methods to make injections more comfortable to patients.
Local anesthetics; Dentistry; Techniques; Needle gauge; Warming; Buffering; Novel devices
The aim of this present study was to evaluate the irritative potential of 2 topical anesthetics used in intrapocket anesthesia for periodontal scaling/root planing when applied in subcutaneous tissue of rats. Sixty animals were divided into 4 groups: group 1, saline solution (control); group 2, poloxamer gel (thermosetting vehicle); group 3, lidocaine and prilocaine poloxamer thermosetting gel; group 4: EMLA, a lidocaine and prilocaine dermatological cream. Injections of 2% Evans blue were administrated intravenously into the lateral caudal vein. In order to analyze vascular permeability, the tested substances were injected intradermally. The rats were sacrificed 3, 6, and 9 hours after injection of the substances. The dorsal skin was dissected and removed. The vascular permeability was evaluated by the measurement of area of dye extravasation and the dye was subsequently extracted after immersion in formamide. Statistical analyses were made by ANOVA with Bonferroni's post hoc test and Pearson correlation. The 2 methods to analyze the exudative phase of the inflammatory process showed statistically significant difference among the groups and periods of evaluation (P < .05). Both methods had a significant correlation (P < .0001). Under the tested conditions, the anesthetic agents showed mild initial inflammatory response when implanted in subcutaneous connective tissue.
Biocompatibility testing; Anesthetics local; Lidocaine; Prilocaine
Dexmedetomidine (DEX) has a minimal respiratory depressive effect, which is beneficial for dentistry; however, it has the disadvantage of permitting an intraoperative arousal response such that the patient appears to be suddenly no longer sedated, and it has a variable amnestic effect. Since midazolam (MDZ) in an appropriate dose has a profound amnesic effect, we investigated whether additional MDZ compensates for the disadvantage of DEX and enables a better quality of sedation. Forty-three subjects were randomly divided into 4 groups. In group 1, MDZ (0.02 mg/kg) was administered intravenously, followed by a dose of 0.01 mg/kg every 45 minutes. After the first dose of MDZ, preloading with DEX (2 µg/kg/h for 10 minutes) was started and maintained with a dosage of 0.5 µg/kg/h. In group 2, MDZ was infused in the same manner as in group 1, followed by preloading with DEX (1 µg/kg/h for 10 minutes) and maintenance (0.3 µg/kg/h). In group 3, MDZ was infused 0.03 mg/kg, and a dose of 0.01 mg/kg was given every 30 minutes; DEX was administered at the same as in group 2. In group 4, DEX was infused using the same method as in group 1 without MDZ. The sedation levels, amnesia, and patient satisfaction were also investigated. Group 2 had a lower sedation level and a poor evaluation during the first half of the operation. Group 4 did not exhibit an amnesic effect at the beginning of the operation. An evaluation of the degree of patient satisfaction did not reveal any differences among the groups. Optimal sedation was achieved through the combined use of MDZ (0.02 mg/kg with the addition of 0.01 mg/kg every 45 minutes) and DEX (2 µg/kg/h for 10 minutes followed by 0.5 µg/kg/h).
Dexmedetomidine; Midazolam; Sedation; Dental treatment; Implant; Amnesia
We audited the recovery characteristics of 51 patients who had undergone orthognathic maxillofacial surgery at a single center. Patients whose anesthesia had been maintained with intravenous propofol and remifentanil (n = 21) had significantly higher pain scores during the first 4 hours after surgery than those whose anesthesia was maintained with volatile inhalational agents and longer-acting opioids (n = 30) (P = .016). There was a nonsignificant trend towards shorter recovery times in the former group, while there were no differences in early postoperative opioid usage, hemodynamic parameters, or postoperative nausea and vomiting . Given that our data were collected retrospectively and without the ability to control for potential confounders, we interpret the results with caution. Notwithstanding these limitations, we believe this is the first report comparing the effects of different opioid-based anesthetic regimens on early recovery from orthognathic surgery, and we believe this report may be used as the starting point for a controlled study.
Propofol; Remifentanil; Inhalation anesthesia; Orthognathic surgery
The effects of infiltration anesthesia with ropivacaine on the dental pulp are considered to be weak. This may be partly associated with its permeation into the oral tissue. With the objective of investigating the local pharmacokinetics of ropivacaine and lidocaine following infiltration anesthesia, we injected 3H-ropivacaine or 14C-lidocaine to the palatal mucosa in rats, measured distributions of radioactivity in the maxilla, and compared the local pharmacokinetics of these agents. The animals were sacrificed at various times and the maxillas were removed. The palatal mucosa and maxillary nerve were resected, and the bone was divided into 6 portions. We measured radioactivity in each tissue and calculated the level of each local anesthetic (n = 8). Lidocaine diffused to the surrounding tissue immediately after the injection, whereas ropivacaine tended to remain in the palatal mucosa for a longer period. Lidocaine showed a higher affinity for the maxillary bone than ropivacaine. There was a correlation between the distribution level of local anesthetics in the maxillary bone and that in the maxillary nerve. The lower-level effects of infiltration anesthesia with ropivacaine on the dental pulp may be because ropivacaine has a high affinity for soft tissue, and its transfer to bone is slight.
Ropivacaine; Lidocaine; Infiltration anesthesia; Local pharmacokinetics
We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.
Lingual tonsil hypertrophy; Endotracheal intubation; Laryngospasm; Anesthesia; Sedation; Complication; Intubation
We read with great interest the anesthetic technique of using a gum elastic bougie (GEB) for nasal intubation in a recent issue of Anesthesia Progress. The authors recommend the use of GEB for the first attempt of nasotracheal intubation in patients with a difficult airway. We agree that this is an excellent alternative. We also have found an excellent variation of this method that utilizes a double bougie technique for insertion of a nasotracheal tube if the difficult airway can be secured initially with an orotracheal tube.
Dual bougie technique; Nasotracheal intubation
Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new disease entity characterized by limited mouth opening due to contracture of the masticatory muscles, resulting from hyperplasia of tendons and aponeuroses. In this case series, we report what methods of airway establishment were conclusively chosen after rapid induction of anesthesia. We had 24 consecutive patients with MMTAH who underwent surgical release of its contracture under general anesthesia. Rapid induction of anesthesia with propofol and rocuronium was chosen for all the cases. In 7 cases, intubation using the Macintosh laryngoscopy was attempted; however, 2 of those cases failed to be intubated on the first attempt. Finally, intubation using the McCoy laryngoscopy or fiber-optic intubation was alternatively used in these 2 cases. In 7 cases, the Trachlight was used. In the remaining 10 cases, fiber-optic intubation was used. Limited mouth opening in patients with MMTAH did not improve with muscular relaxation. “Square mandible” has been reported to be one of the clinical features in this disease; however, half of these 24 patients lacked this characteristic, which might affect a definitive diagnosis of this disease for anesthesiologists. An airway problem in patients with MMTAH should not be underestimated, which means that other intubation methods rather than direct laryngoscopy had better be considered.
Masticatory muscle tendon-aponeurosis hyperplasia; Square mandible; Difficult airway management
Local anesthetics have an impressive history of efficacy and safety in medical and dental practice. Their use is so routine, and adverse effects are so infrequent, that providers may understandably overlook many of their pharmacotherapeutic principles. The purpose of this continuing education article is to provide a review and update of essential pharmacology for the various local anesthetic formulations in current use. Technical considerations will be addressed in a subsequent article.
Local anesthetics; Pharmacology; Drug toxicity; Dentistry