Everyone makes mistakes, and we must all learn from them so that we do not repeat them. We hope that the cost of our mistakes is not overwhelming. Some mistakes that occur early in our educational experience help shape our philosophy of life for the future. I vividly remember one such mistake that occurred when I was in pharmacy school. Dr Albert C. Smith, our professor for advanced physical chemistry, gave our class an unannounced quiz one morning and returned the graded papers to us the following day. It was a very difficult quiz that involved multiple mathematical calculations. Everyone
The aim of this study was to evaluate the influence of 2 anesthetic agents on patients' postoperative pain perception after periodontal surgery. For this parallel-group, double-blinded, randomized clinical trial, 36 open flap debridement surgeries were performed on patients who presented with periodontal disease with clinical signs of inflammation after nonsurgical treatment on at least 1 quadrant. Patients were allocated to 1 of the following groups: group 1, 2% lidocaine with 1 ∶ 100,000 epinephrine; group 2, 2% mepivacaine with 1 ∶ 100,000 norepinephrine. Pain intensity was assessed using the visual analog scale during the first 8 hours after surgery. All patients received 750-mg acetaminophen tablets, which they were instructed to take as a rescue medication if necessary. The results demonstrated that postoperative pain intensity was statistically lower in group 2 than in group 1 at the 1-, 2-, and 3-hour periods after surgery, although the pain intensity for all groups could be considered mild. In conclusion, patients in both groups reported similar mild pain after periodontal surgery.Abstract
The aim of the present study was to assess injection flow rates of metal syringes, with an emphasis on injection speed and the generation of flow pulsations. A cohort of 64 operators (32 practitioners and 32 students) performed 3 consecutive ex vivo simulated injections (SIs) of 1.8-mL cartridges of anesthetic solution. Two needle diameters were tested (27-gauge and 30-gauge). Each SI was filmed and analyzed using a computer. In most cases, the SI lasted longer than 60 seconds with the 30-gauge needle (75%) but not with the 27-gauge needle (47.9%) (P < .0001). Practitioners and men delivered a full cartridge significantly faster than students and women, respectively (P = .0007 in both cases). All operators generated 1 pulse in at least 1 of the 3 SIs with both types of needles, especially during the first 3 seconds (254/384; 66.1%). Pulses occurred more frequently with practitioners (P = .0176) and with the 27-gauge needle (P = .005). Within its methodological limits, the present study showed how difficult it is to control injection pressure when using a metal syringe, especially at the beginning of the injection. Computerized systems may help overcome this problem.Abstract
The bispectral index (BIS) monitor records electroencephalogram waveforms and provides an objective measure of the hypnotic effect of a sedative drug on brain activity. The aim of this pilot study was to use the BIS monitor to evaluate the depth of procedural sedation in pediatric dental patients and to assess if the BIS monitor readings correlate with a validated pediatric sedation scale, the University of Michigan Sedation Scale (UMSS), in determining the level of sedation in these patients. Thirty-five pediatric dental patients requiring sedation were studied prospectively. A baseline BIS reading was obtained and during the procedure an independent observer recorded the BIS every 5 minutes. The operator, who was blinded to the BIS results, determined the UMSS scale at the same 5-minute interval. The patients were monitored postoperatively for 1 hour. There was a significant but moderate correlation between BIS values and UMSS scores (Spearman's rank correlation r = −0.574, P < .0001). Percentage of agreement and kappa coefficient using all the observations were also calculated. The percentage of agreement was 37.8%, the kappa coefficient was 0.18 (P < .0001), and the weighted kappa coefficient 0.26 (P < .0001). A lack of correlation was noted between the deeper levels of UMSS sedation scores and BIS values. This study demonstrated a significant correlation between BIS values and the UMSS score in pediatric dental patients undergoing mild to moderate sedation. Based on our results, it appears that the BIS monitor may be useful during mild or moderate sedations to establish the level of sedation objectively without the need to stimulate the patient.Abstract
Dyloject is a novel formulation of diclofenac intended for intravenous (IV) administration. This formulation employs the solubilizing agent hydroxypropyl-β-cyclodextrin to permit bolus IV administration. The efficacy and safety of 5 dose levels of IV diclofenac were compared with IV ketorolac and placebo following third molar extraction. This was a single-dose, randomized, double-blind, placebo- and comparator-controlled, parallel-group study. A total of 353 subjects with moderate to severe pain received placebo; ketorolac 30 mg; or IV diclofenac 3.75, 9.4, 18.75, 37.5, or 75 mg (N = 51 for all groups, except N = 47 for ketorolac). The primary endpoint was total pain relief over 6 hours (TOTPAR6) as measured by the visual analog scale (VAS). Secondary endpoints included multiple measures of pain intensity and relief; patient global evaluation; and times to pain relief and rescue medication. Dropouts and adverse effects (AEs) were also monitored. IV diclofenac was superior to placebo as measured by TOTPAR6 (P < .0001 for all doses except 3.75 mg, for which P = .0341). IV diclofenac 3.75 mg was statistically superior to placebo for TOTPAR2 and TOTPAR4. IV diclofenac at both 37.5 and 75 mg was superior to placebo (P < .05) at the earliest (5 minute) assessments of pain intensity and pain relief, but ketorolac was not. The proportion of patients reporting 30% or greater pain relief at 5 minutes was significantly greater after IV diclofenac 37.5 and 75 mg than after ketorolac 30 mg or placebo. Secondary endpoints confirmed the primary findings. Treatment-related AEs were generally mild to moderate and were typical for nonsteroidal anti-inflammatory drugs (NSAIDs). The more rapid onset of action of IV diclofenac compared with the reference injectable NSAID ketorolac suggests additional clinical benefit. If confirmed in larger series, these findings may improve the safety and efficacy of postoperative NSAID analgesia.Abstract
The risk for complications while providing any level of sedation or general anesthesia is greatest when caring for patients having significant medical compromise. It is reassuring that significant untoward events can generally be prevented by careful preoperative assessment, along with attentive intraoperative monitoring and support. Nevertheless, we must be prepared to manage untoward events should they arise. This continuing education article will review respiratory considerations and will be followed by a subsequent article addressing cardiovascular considerations.Abstract
Please see the pdf version for the Continuing Education Program Answer Sheet.
Yasuya Kubota, Professor Emeritus of Tokyo Medical and Dental University, passed away due to pneumonia in December, 2010. He was born in Mie Prefecture, Japan, in 1928. In 1950, he graduated from the Faculty of Medicine of Tokyo Medical and Dental University, and obtained a medical license. He immediately entered the Faculty of Dentistry of the University and
Wong A, Subar P, Witherell H, Ovodov KJ: Reducing Nasopharyngeal Trauma: The Urethral Catheter–Assisted Nasotracheal Intubation Technique. Anesth Prog 2011;58:26–30. The job title and degrees for Allen Wong were stated incorrectly. The correct information is as follows: Allen Wong, DDS, EdD, Associate Professor, Director of Hospital Dentistry, Department of Dental Practice, University of the Pacific Arthur A. Dugoni School of Dentistry, San Francisco, California. Allen Press apologizes for this error.