Transcript CPR

DENTAL ANESTHESIA
COMPLICATIONS IN THE DENTAL
CHAIR
SAAD A. SHETA
Assistant Professor
Consultant Anesthesia
Dental College
KSU
Dental Anesthesia
 Out-Patient Anesthesia (Dental Chair Anesthesia)
 Day-Case Anesthesia
 In-Patient Anesthesia
 Complete Dental rehabilitation
 Complicated oral surgery procedures
 Major Maxillofacial surgeries
 In addition, Sedation
Complications
 Out-Patient Anesthesia (Dental Chair Anesthesia)
 Sedation Techniques
Out-Patient Dental Anesthesia
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Dental Chair Anesthesia
Out-Patient dental extraction
Children (4-10 years): high incidence of URTI
Steadily decreased
Out-patient Dental Anesthesia (Sedation)
Patient Selection (&Indications)
• ASA grade I&II
• Disability (mental& physical)
Review:
coexisting disease
current medications
• Fearful adults
rather sedation
• Procedure
short
not so extensive
Out-Patient Dental Anesthesia (Sedation)
Contraindications
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Serious cardiopulmonary diseases
COPD
Diabetes or other endocrinological diseases
Neuromuscular disorders
Coagulopathies & Hemoglobinopathies
Marked oro-facial swelling (edema& trismus)
Potential difficult airways
Marked congenital heart defects
Extreme obesity
Drugs: MAOIs , Anticoagulant
Not fasting
Out-Patient Dental Anesthesia (Sedation)
Equipment (Up to the standards of in-patient GA)
 Dental Chair
 Anesthetic Equipment
 Monitoring
 Resuscitation Equipment
 Dental Chair
 Adjustable:
horizontal (supine)
Head down
 Manual release
 Adjustable head rest
 Hospital out-patient:operating table
 Anesthesia Equipment
 Continuous flow anesthesia machine
 Quantiflex (Relative Analgesia)
 Mouth props, packs, gags, nasopharyngeal airway,
rubber dam
 Separate suction unit
 Scavenging system
 Monitoring
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Pulse
ECG
NIBP
Pulse Oximetry
Capnography
 Resuscitation Equipment
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Full range of tracheal tubes& accessories
Two working laryngoscope
IV agents: Succinylcholine& atropine
Emergency drugs
Defibrillator
Training: B&ALS
Out-Patient Dental Anesthesia
Induction
 Inhalational (mask) induction
 Intravenous Induction
Out-Patient Dental Anesthesia
Induction
 Inhalational (mask) induction
N2O/O2
+
Halothane
Enflurane
Isoflurane
Sevoflurane
Common, smooth
Less potent
Respiratory irritation
New, smooth, less potent
Out-Patient Dental Anesthesia
Induction
 Intravenous Induction
Advantages
Avoidance of face mask
Less salivation
Less atmospheric pollution
Disadvantages
CV depression
Drugs
Methohexitone
Low incidence of nausea & vomiting
Good recovery
Pain on injection,
Involuntary movements, hiccups
Propofol
Out-Patient Dental Anesthesia
Maintenance
 Inhalational agents/N2O
 Nasal mask, mouth gag, pack
 Maintain airway
Posture
(Supine Position)
 Less hypotension
 less bradycardia
However
 high risk of aspiration
 Airway obstruction&
 Decrease ERV
Out-Patient Dental Anesthesia
Recovery
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Left lateral position
100% O2
Suction Observation & monitoring
Discharge criteria
Instructions
Analgesia (NSAIDs)
Sedation
It is a technique where one or more drugs are used to
Depress the Central Nervous System of a patient thus reducing
the awareness of the patient to his surrounding.
According to the degree of CNS depression:
Conscious Sedation
Deep Sedation
General Anesthesia
Conscious Sedation
It is a controlled, pharmacologically Induced, minimally
depressed level of consciousness that retains the patient’s
ability to maintain a patent airway independently and
continuously and respond appropriately to physical and/or
verbal command
Deep Sedation
It is a controlled, pharmacologically induced state of
depressed level of consciousness. from which the patient is
not easily aroused and which may be accompanied by a partial
loss of protective reflexes,including the ability to maintain a
patent airway independently and/or respond purposefully
to physical stimulation or verbal commands
General Anesthesia
It is defined as :
unconsciousness
no response to pain
labile vital signs
GA is defined separately, however for the purpose of of
describing management, the two phrases (GA & Deep
Sedation) refer to one physiologic state
Sedation
Fundamental Concepts
 It is easy to drift from one state to another.
 Patient state is considered in terms of the level of
consciousness rather than the technique involved.
Sedation
Fundamental Concepts
 Sedation techniques are not pain-control techniques
 One should guard against becoming comfortable with a
single method. The treatment should fit the patient
rather than the converse
Sedation Techniques
Non Titrable Technique
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Oral Sedation
Rectal Sedation
Intramuscular Sedation
Submucosal Sedation
Intranasal Sedation
Titrable Technique
 Inhalational Sedation
 Intravenous Sedation
Combination Of Two
Combination of Methods and Techniques
AUGMENTATION OF THE EFFECT + REDUCE THE DOSE OF STONGER
DRUGS.
Most complications occurred with polypharmacology in
the hands of untrained personnel
Dental Chair Complications
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Respiratory Complications
Cardiovascular Complications
Allergic Reaction
Miscellaneous
 Respiratory Complications
 Airway Obstruction
 Respiratory Depression
 Respiratory complications
Airway Obstruction
Respiratory Depression
Causes
 Tongue
 Blood, debris
 Laryngeal spasm
 Narcotics
 Over-sedation
Clinical Picture
 A-W Obstruction
 Hypoxia
 Hypoventilation
 Hypercapnia
 Hypoxia
Management
 Patent airway
 Oxygenation
 Ventilation
 Reversal Agents
Airway Obstruction
Most common cause: tongue and/or epiglottis
Open the Airway
Position
Jaw thrust
Head tilt–chin lift
Open the Airway
Oropharyngeal Airway
Open the Airway
Nasopharyngeal Airway
Open the Airway
Endotracheal Intubation “Aligning Axes of the Airway”
Open the Airway
Endotracheal Intubation “ Laryngoscopes ”
Open the Airway
Endotracheal Intubation “ Visualization of the Cord ”
Open the Airway
Laryngeal Mask Airway (LMA)
Open the Airway
Esophageal-Tracheal Combitube
Oxygenation
Adjunct Devices
Ventilation
Bag-Mask Ventilation
 Key ventilation volume: “enough to produce obvious chest rise”
1 Person
difficult, less effective
2 Persons
easier, more effective
 Cardiovascular Complications
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Hypotension
Bradycardia
Dysrhythmia
Fainting
 Hypotension
Induction of anesthesia
Carotid sinus compression
Over sadation
 Bradycardia
Tooth extraction
Halothane (nodal rhythm)
 Dysrhythmias
Aetiology
(Tachy-arrhythmias)
(Tooth extraction)
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High preoperative catecholamines
Light anesthesia
Airway obstruction & hypoxia
Halothane & local anesthesia
Local anesthesia with vasopressors
Significance
 Controversial
 Significant with unexpected cardiac disease(viral
myocarditis)
 Fainting
Causes
Previous factors (CV, allergic,..)
Emotional factors (more common)
Aetiology
limbic cortex-hypothalamus-reflex vasodilatation
Increase parasympathetic activity-bradycardia
Management
Head down-leg elevated
100% O2
Cessation of anesthesia
 Allergic Reaction
Incidence
 Very rare
 More commonly (vaso-vagal, toxic
reaction, epinephrine)
Aetiology
 Ig E-mediated reaction
 Easter-linked: p-amino benzoic acid
 Amide-linked: preservatives (Paraben)
Manifestations
 Hypotension, tachycardia, arrhythmias
 Bronchospasm, cough, dyspnea, pulmonary
oedema, laryngeal oedema, hypoxia
 Urticaria, facial oedema, pruritus
Management
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Discontinue drug
100% O2
Epinephrine (0.01-0.5 mg IV or IM)
Intubation
IV fluids (LRS 1-2 liters)
Diphenhydramine
Hydrocortisone (up to 200mg IV)
 Miscellaneous
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Nasal Trauma, Epistaxis
Pulmonary Aspiration
Diffusion Hypoxia
Continued Bleeding
Post operative Sore Throat
Post operative Nausea & vomiting
Post operative Pain & swelling
THANK YOU