Anesthesia Progress Volume 65: Issue 4

Dental treatment of young pediatric patients can be confounded by lack of cooperation for dental rehabilitation procedures and even examination and/or radiographs. With the recent US Food and Drug Administration warning applied to many anesthetic/sedative agents for children less than 3 years old, a retrospective review of general anesthesia (GA) cases from 1 private pediatric dental practice was studied for age, gender, body mass index, anesthetic duration, airway management used, extent of dental surgical treatment, recovery time, and cardiac/pulmonary complications. For the 2016 calendar year, 351 consecutive GA cases were identified with patients aged 2–13 years. Of these, 336 underwent nasal endotracheal intubation. Forty-six of 351 patients (13%) were younger than 3 years. Median anesthesia duration was approximately 1.7 hours for all age groups. Dental treatment consisting of 8–9 teeth including crowns, fillings, and extractions was most frequently encountered. One hundred sixty-eight patients (48%), however, required care for 10–18 teeth. There were no episodes of significant oxygen desaturation. The overall complication rate was 1.1%, with 2 cases of postextubation croup, 1 case of mild intraoperative bronchospasm, and 1 case of intraoperative bradycardia. Complications did not correlate with children being overweight or obese.

There is evidence that the Computer-Controlled Local Anesthetic Device (CCLAD) decreases the pain of oral injections. The purpose of this study was to evaluate injection pain of the inferior alveolar nerve block (IANB) using the CCLAD in an upright position versus a supine position. Additionally, we evaluated solution deposition pain with the CCLAD when compared to previous studies using a traditional syringe. One hundred ten asymptomatic subjects were randomly given IANBs using 2% lidocaine with 1:100,000 epinephrine while in an upright sitting position and supine position, at 2 different appointments, spaced at least 2 weeks apart. Each subject rated the pain for needle insertion, needle placement, and solution deposition on a Heft-Parker visual analogue scale. Pain ratings were compared between the upright and supine positions using a repeated-measures analysis of variance with post hoc testing using the Tukey-Kramer procedure. Moderate to severe pain was reported by 10% to 13% of the patients for needle insertion, 74% to 75% for full needle placement, and 8% to 10% for solution deposition. There was no significant difference between groups for phases of the injection. When comparing the injection phases within the groups, the needle placement phase of the injection was statistically more painful than both the needle insertion phase and solution deposition phase (p = .0001). Using the CCLAD, IANB injection pain of the supine and upright positions was not statistically different. Needle placement was the most painful phase of the injection. Solution deposition pain was less with the CCLAD when compared to other studies of the IANB using a traditional syringe.

Intubation for pediatric patients is frequently performed with an uncuffed endotracheal tube (ETT), which may result in an incomplete tracheal seal, resulting in gas leakage (leak). The purpose of this study was to assess the effect of (1) mouth opening and (2) throat pack placement in sealing and/or minimizing this leak to an acceptable level while providing adequate tidal volumes in mechanically ventilated patients. This prospective study of 2- to 6-year-olds undergoing general anesthesia with nasal intubation for dental procedures in the New York University–Lutheran Medical Center operating room was conducted between March 2015 and October 2015. Three sequential tidal volume (V_T) measurements were recorded: postintubation with the neck extended, with mouth opened, and after throat pack placement. Twenty-five subjects were included in the analyses. For subjects in whom no leak was detected, only throat pack placement statistically improved V_T. This is in marked contrast to numerically large, statistically significant effects, relative to baseline, for mouth opening (±23.2 mL, p < .009, 21% increase from baseline) and throat pack placement (±46 mL, p < .009, 41% increase from baseline) when a leak was detected. In children 2–6 years of age, nasal intubation with uncuffed ETTs that have incomplete tracheal seal have improved V_T with mouth opening and throat pack placement. This finding suggests that the intubation procedure is a process that extends through positioning, mouth opening, and throat pack placement.

Conscious sedation is widely used for dental treatment in Japan. This type of procedural sedation is associated with minimal risk because physiological reflexes are well-maintained as the patient remains conscious. As used in Japan, “conscious sedation,” is equivalent to “minimal to moderate sedation” in the American Dental Association guidelines and “minimal to moderate sedation/analgesia” in the American Society of Anesthesiologists guidelines.

Dental anesthesiologists occasionally need to induce transient deeper sedation, and therefore loss of consciousness, because of uncontrollable patient behavior. Deep sedation is associated with additional risks, such as airway obstruction and aspiration. Therefore, thorough training in the management of

Pichler LP, Poeran J, Zubizarreta N, et al. Liposomal bupivacaine does not reduce inpatient opioid prescription or related complications after knee arthroscopy. Anesthesiology. 2018;129:689–699.

This study analyzed the impact of liposomal bupivacaine (regardless of administration route) on inpatient opioid use, resource utilization, and opioid-related complications among patients undergoing knee arthroplasty with a peripheral nerve block. A total of 88,830 surgeries from the Premier Healthcare Database were examined. Liposomal bupivacaine was used in 18,817 of these surgeries (21.2%). No association was found between the use of liposomal bupivacaine and clinically meaningful reduction in inpatient opioid use, opioid-related complications, or

The Future of Anesthesia Progress

Pediatric Dental Surgery Under General Anesthesia: Uncooperative Children

Inferior Alveolar Nerve Block Injection Pain Using a Computer-Controlled Local Anesthetic Device (CCLAD): A Prospective, Randomized Study

The Effects of Mouth Opening and Throat Pack Placement on Uncuffed Nasal Endotracheal Tube Leakage and Delivered Tidal Volumes in Mechanically Ventilated Pediatric Patients Undergoing Dental Procedures

A Histological Study of Vasoconstriction by Local Anesthetics in Mandible

Practice Guidelines for Intravenous Conscious Sedation in Dentistry (2nd Edition, 2017) Developed for Dentists in Japan by the Japanese Dental Society of Anesthesiology

Difficult Nasal Intubation Using Airway Scope^® for a Child With Large Tumor

Endotracheal Tube Obstruction via Turbinectomy During Nasal Intubation

Sudden Tachycardia Due to Submucosal Migration of an Epinephrine-Soaked Swab During Nasal Intubation

Office-Based Sedation/General Anesthesia for COPD Patients, Part I

Letter to the Editor

Reply

Literature Review for Office-Based Anesthesia

Pichler LP, Poeran J, Zubizarreta N, et al. Liposomal bupivacaine does not reduce inpatient opioid prescription or related complications after knee arthroscopy. Anesthesiology. 2018;129:689–699.

IFDAS 2018 Meeting News

Practice Guidelines for Intravenous Conscious Sedation in Dentistry (Second Edition, 2017)

A Review of Current Literature of Interest to the Office-Based Anesthesiologist

Experience Using a New Gastric Tube Tip Localization System (Tumguide)

Anaphylaxis After a Third Exposure to Sugammadex

Effects of Remimazolam With or Without Remifentanil on Oral Tissue Blood Flow and Oxygen Tension in Rabbits

Limited Nasal Intubation Route After Pharyngeal Flap Surgery: A Case Report