Perfect Time for a Fresh Perspective

Throughout those parts of the country that experience all 4 seasons, spring is a natural time for growth, renewal, and expansion. Gone are the perma-gray days of late winter and the bitter cold that cuts bone deep when trudging in from the car while sporting thin noninsulated scrub pants. The influx of fresh air that accompanies the arrival of warmer weather and the opening of windows brings with it a sense of excitement that serves to reinvigorate the senses.

Naturally, the change in seasons also provides an opportune time to pause and critically evaluate our own clinical practices and processes. Although self-assessment and professional reflection is ideally done on a continual basis, a more introspective “deeper dive” into the ways we choose to practice can be quite fruitful. Such a thorough review would likely include a multifaceted approach, incorporating not only the usual drug and equipment inventory queries but also extending into other areas of clinical practice, such as emergency preparedness and quality of care. In short, when was the last time you stopped to critically assess the way you practice sedation or general anesthesia? Such an exercise can reinvigorate your practice, your team members, and yourself, preventing your clinical practice from growing overly repetitive and robotic.

Arguably, one of the critical areas of attention must be ensuring continued adherence to ever-evolving standards of care along with any revised state rules and regulations. This is a critical aspect of practice to monitor as several states are considering or have enacted legislative modifications that may significantly impact the practice of anesthesia for dentistry. In California, for example, Senate Bill 501 specifically states, in addition to other provisions, the required number and training of personnel (2) who must be present along with the anesthetic provider whenever deep sedation/general anesthesia is utilized for a patient younger than 13 years of age, as well as who can provide deep sedation/general anesthesia to those 7 years of age and younger. Also, many states now have newly enacted continuing education requirements tied to controlled substance prescribing that specifically address opioid prescribing and abuse. As significant external attention and pressure persists despite many of these legislative changes, further anesthesia guideline updates may impact providers in states where specific guidelines are explicitly referenced within state rules and regulations. What exactly the future holds in terms of any additional regulatory updates remains to be seen. However, all providers of anesthesia for dentistry must remain attentive and adhere to state rules and regulations that direct our clinical practices.

In addition to the usual replacement of all expired drugs and supplies, it is a good time to consider incorporating new or alternative anesthetic techniques, drugs, or equipment. For example, administration of a small single intravenous bolus of dexmedetomidine (eg, 0.25–0.5 mcg/kg) soon after induction of an anesthetic case may help prevent emergence delirium in pediatric patients. Although Exparel (Pacira Pharmaceuticals, Inc, Parsippany, NJ; liposomal-encapsulated bupivacaine) received Food and Drug Administration approval in 2011, it continues to be substantially underutilized in dentistry as a long-acting nonopioid analgesic alternative. This is7 especially true for routine oral surgery procedures on young adults despite many parents and patients willing to pay an additional amount to avoid opioid prescription. The added benefits of using Exparel are clear in certain high-risk patient groups where opioids may be relatively contraindicated, such as severe obstructive sleep apnea or a history of opioid abuse. Consider upgrading old conventional laryngoscopes and their small screw-in bulbs that often become loose over time or might no longer be functional with fiber optic LED laryngoscopes. These newer LED systems not only produce brighter quality light but also are reasonably priced, last substantially longer, and use considerably less battery power. Video laryngoscopes are yet another available upgrade to consider, although these newer systems can have a steep learning curve. It is a good time to evaluate your emergency supraglottic airway device—is it still the best one for your practice? Although laryngeal mask airways (LMAs) have long been part of the difficult airway algorithm, consider replacing conventional LMAs that must be inflated to seal properly with i-gel® (Intersurgical, Inc, Berkshire, UK) LMAs that do not. Such upgrades may ultimately make the difference during an airway crisis, especially if advanced airway management (eg, intubation, laryngoscopy, or placing a supraglottic airway) is performed infrequently in your clinical practice.

Annually revisiting the current available emergency drug formulations can be quite useful, particularly in light of the numerous ongoing drug shortages and periodic changes made by drug manufacturers. Prefilled 10-mL syringes of epinephrine (1:10,000) have been in short supply for a protracted period forcing many clinicians to make alternative plans, such as properly diluting a 1-mL vial or ampule of epinephrine (1:1000) in the case of an emergency. Albuterol is yet another example in which certain manufacturers have opted to utilize designs that preclude the easy separation of the drug cannister from the metered dose inhaler apparatus. This situation would be problematic for a clinician attempting to load the albuterol cannister onto specialized adapters, or even into a 60-mL syringe, for delivery into the lumen of an endotracheal tube, for example. Even if you do not routinely intubate, the need for intubation and albuterol use during an unexpected aspiration event may arise.

Critically evaluating our emergency response plans on an annual basis with our team can help strengthen our emergency management systems. Additionally, formalizing emergency drills with team members on a scheduled basis, such as monthly or quarterly, will almost certainly improve emergency preparedness. Mock drills covering sedation/general anesthesia and medical emergencies serve as a phenomenal opportunity to refresh our knowledge-base and comfort managing emergencies.

As healthcare providers and stewards of sedation and anesthesia for dentistry, we must remain unsatisfied with the status quo, always searching for ways to improve the care we provide. This is especially critical in light of the increased attention being given to sedation and anesthesia as practiced in the office-based environment. The arrival of spring provides an ideal opportunity to look introspectively and evaluate our approaches to patient care with fresh perspectives.