Anesthesia Progress Volume 66: Issue 4

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EDITORIAL

Announcing a New Annual Feature for the Journal

DDS, MS

Today's modern lifestyle frequently seems to be all about speed, convenience, and constant forward motion, rarely providing moments to stop and either enjoy the present or reflect upon the past. As busy parents, partners, students, clinicians, teachers, and researchers, we are all too frequently looking forward to the next “big thing,” be that a promotion, a graduation, or a much-needed vacation. Such a common approach can easily rob us of the ability to fully appreciate and enjoy life. Furthermore, I believe there is great benefit in periodically looking to the past, as it is often capable of providing additional clarity,

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SCIENTIFIC REPORTS

Impact of Instituting General Anesthesia on Oral Sedation Care in a Tertiary Care Pediatric Dental Clinic

MD,

PhD,

MS, and

DMD, PhD

DOI: 10.2344/anpr-66-02-02

Tertiary pediatric medical centers disproportionately care for low-income, underserved children with significant dental needs. Long wait times for hospital operating room treatment increase tooth loss rather than restoration. Oral sedation has commonly been provided to avoid the long waits for operating room treatment. However, this can be challenging with young, anxious patients. High failure rates and repeat visits for oral sedation have resulted in continued waiting for definitive dental services in the operating room. The Division of Dentistry requested the Department of Anesthesiology to create a general anesthesia program in the dental clinic to increase the use of anesthesia services but align the cost of the anesthetic with the revenue stream. Our aim was to objectively measure the performance of a dental clinic anesthesia service by comparing the percentage of case completions, percentage of complete radiographs, and number of serious adverse events to clinic-based oral sedations. We were also interested in total number of cases completed. We retrospectively studied data regarding an in-office general anesthesia (IOGA) program for dentistry and compared it to oral sedations before and after instituting the IOGA program. Patients received either a general endotracheal anesthetic or nonintubated total intravenous general anesthesia. Successful case completion increased from 88.6% (oral sedation) to 99.5% (IOGA). One hundred percent of IOGA cases had complete radiographs, as opposed to 63.4% for oral sedation. This was an increase from 53.5% from the previous 2 years with oral sedation. Serious adverse event rate was 0% (0/508) for oral sedation and 0.2% (1/418) for IOGA. Comparing 2 years before and after IOGA revealed a decrease in oral sedations from 930 to 508, whereas IOGA increased from 0 to 418 cases. Anesthesia services in dental clinic increased complete dental care and complete radiographs, reduced failed sedations, and were performed safely.

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An Evaluation of Ibuprofen Versus Ibuprofen/Acetaminophen for Postoperative Endodontic Pain in Patients With Symptomatic Irreversible Pulpitis and Symptomatic Apical Periodontitis

DDS, MS,

DMD, MS, and

DDS, MA

DOI: 10.2344/anpr-66-03-06

The purpose of this investigation was to compare ibuprofen versus an ibuprofen/acetaminophen combination for postoperative pain control in a patient model specific to teeth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis. One hundred and two patients presenting with moderate to severe pain from a maxillary or mandibular posterior tooth diagnosed with symptomatic irreversible pulpitis and symptomatic apical periodontitis were included. Following local anesthetic administration, complete endodontic cleaning and shaping was performed. Patients were randomly assigned to receive identically appearing tablets of ibuprofen 200 mg or a combination of ibuprofen 200 mg/acetaminophen 216.7 mg with instructions to take 3 tablets every 6 hours as needed for pain. Patients were also given a prescription for an escape medication to take if the study medications did not adequately control their pain. A 4-day diary was used to record pain ratings and medication use. Moderate to severe pain was experienced by 59–61% of the patients on postoperative day 1 and 50–57% of the patients on day 2, with the pain ratings decreasing over the next 2 days. There were no statistically significant differences between the 2 groups in postoperative pain, percussion pain, or medication use. There was no difference between ibuprofen and the combination of ibuprofen/acetaminophen in the reduction of postoperative pain following endodontic debridement in patients with symptomatic irreversible pulpitis and symptomatic apical periodontitis.

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CASE REPORTS

Malignant Hyperthermia: A Case Study in the Dental Ambulatory Surgery Setting

DDS, MBA, MPH,

DDS,

DMD,

DDS,

BDS, MS,,

DDS, MS, FACS,, and

DDS, MS

DOI: 10.2344/anpr-66-04-03

Historically, patients who developed malignant hyperthermia had an extremely high rate of mortality. Today, if treated appropriately, patients who experience an episode of malignant hyperthermia will most likely survive. This dramatic decrease in mortality associated with malignant hyperthermia is due to several factors, including an increased understanding of the disease, improved diagnostic and monitoring equipment, and the development of lifesaving pharmacologic agents. This article presents the very likely case of acute malignant hyperthermia in a 24-year-old man with special needs, who presented for restorative dentistry under general anesthesia in the outpatient clinic of The Ohio State University's College of Dentistry.

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Acute Management of Massive Epistaxis After Nasotracheal Extubation

DDS, PhD,

DDS,

DDS, PhD,

MD, PhD, and

MD, PhD

DOI: 10.2344/anpr-66-02-09

Epistaxis is one of the most common complications of nasotracheal intubation and can be life-threatening. However, there is little discussion in the current literature on the acute management of massive epistaxis after nasotracheal extubation. This is a report of 2 patients who experienced severe unanticipated nasal bleeding immediately after extubation, 1 after a surgical procedure for oral cancer and another after restorative dental treatment. In both cases the significant epistaxis was managed successfully with a Foley balloon catheter used to pack the posterior nasal cavity. The Foley catheter technique may be useful for managing and arresting sudden postextubation epistaxis.

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Anesthetic Management of a Patient With Fanconi Anemia

DDS,

DDS, PhD, and

DDS, PhD

DOI: 10.2344/anpr-66-02-06

Fanconi anemia (FA) is a type of bone marrow failure syndrome based on an autosomal recessive inherited trait with increased predisposition for other cancers. It is extremely rare and is characterized by short stature, polydactyly, and pancytopenia. At present, the only effective treatment for FA is allogeneic hematopoietic stem cell transplantation (SCT). Chemotherapy is necessary prior to allogeneic SCT. Dental treatment is usually performed before chemotherapy to reduce potential infections. We experienced the anesthetic management of a 4-year-old boy diagnosed with FA, who underwent extensive dental extractions before chemotherapy for SCT. In the preoperative examination, the platelet count was decreased to less than 3.0 × 10⁴ cells/μL because of chronic pancytopenia. The patient received 20 units of platelet transfusion over 3 days prior to anesthesia. Dental surgery and multiple dental extractions were successfully completed under general anesthesia with sevoflurane, fentanyl, and remifentanil, and chemotherapy started 3 days postoperatively.

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CLINICAL TECHNIQUE

Comparison of Patient Comfort During the First Stage of Conventional Versus Modified Two-Stage Inferior Alveolar Nerve Blocks in Pediatric Patients

BDS,

MDS,

MDS, and

MDS

DOI: 10.2344/anpr-66-03-03

Our aim was to compare the comfort of pediatric patients during the first stage of the conventional 2-stage inferior alveolar nerve block (IANB) versus the modified 2-stage IANB. This was a parallel group, single-blinded, randomized controlled trial. Pediatric patients meeting the inclusion criteria were randomly allocated to 1 of the 2 groups receiving IANB, group 1 (31 subjects) utilized a conventional 2-stage technique, and group 2 (33 subjects) utilized a modified 2-stage approach. Patient comfort was assessed indirectly by 2 observers using the Face, Legs, Activity, Cry, Consolability (FLACC) scale during the first stage of the injections. FLACC score data between the 2 groups were analyzed using the chi-square test, and interobserver reliability was measured using kappa statistics. During the first stage of the injections, lower FLACC scores of 0 indicating a relaxed/comfortable patient experience were found in 57.6% of group 2 subjects compared with only 25.8% group 1 subjects, which was a statistically significant difference (p-value .013). Interobserver reliability assessed using kappa coefficients (κ = 0.812) indicated excellent agreement. FLACC scores for the pediatric patients during the first stage of the modified 2-stage IANB technique were significantly lower than during the first stage of the conventional 2-stage IANB technique.

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LANDMARK ARTICLES IN DENTAL ANESTHESIOLOGY WITH COMMENTARY IN HONOR OF JOEL M. WEAVER, DDS, PhD

Analgesia in Dentistry Now and in the Future ¹

M.S., D.D.S.

DOI: 10.2344/0003-3006-66.4.227

The use of so called analgesia by both inhalation and intravenous methods has been the subject of a tremendous amount of discussion within the past few years. Perhaps it would have been more correct to have said re-discussion, as the present interest in so called analgesia is a resurgence of what has occurred at intervals over the years. And yet, little seems to be gained from experiences of the past. It has been said that those who do not learn from mistakes of the past, are doomed to repeat them; and we seem to be repeating them.

One of our

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Monheim LM. Analgesia in dentistry now and in the future. Anesth Prog. 1971;18(5):100–106 and J Am Analg Soc. 1971:9:1(abstract).

DMD,

DMD, and

DMD

DOI: 10.2344/anpr-66-04-09

The evolution and history of dental sedation and anesthesia offers perspectives and insights on our present practice. This commentary, honoring Dr Joel Weaver, has additionally and uniquely been made possible through the labors of Joel and Barbara Weaver. They scanned decades worth of Anesthesia Progress content into the now readily available archives for future generations seeking this background information, which represents only a small fraction of Dr Weaver's legacy in dental anesthesia.

Upon reviewing these archives, the paper by Dr Leonard Monheim, “Analgesia in Dentistry Now and in the Future,” stands out as being a seminal treatise on

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DEPARTMENTS

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

DDS, PhD

DOI: 10.2344/0003-3006-66.4.235

Broens S, Boon M, Martini C, Niesters M, van Velzen M, Aarts L, Dahan A. Reversal of Partial Neuromuscular Block and the Ventilatory Response to Hypoxia. Anesthesiology. 2019;131:467–476.

The ventilatory response to hypoxia is a lifesaving chemoreflex originating at the carotid bodies that is impaired by nondepolarizing neuromuscular blocking agents. This single-center, randomized, controlled experimental study evaluated the effect of 3 strategies for reversal of a partial neuromuscular block on ventilatory control in 34 healthy male volunteers on the chemoreflex. The hypothesis was that the hypoxic ventilatory response is fully restored following the return to a train-of-four ratio

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