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CHAPTER 126 ■ Dental Procedures: Anesthetic Considerations 2087 Figure 126-8. Throat pack with a radio-opaque lining. Figure 126-7. Flexible laryngeal mask airway with rubber dam placed for the mandibular arch. is generally placed in the throat or hypopharynx behind the tonsillar fauces to prevent any debris from migrating to the hypopharynx. Any debris left behind can potentially be aspirated by the patient upon extubation. However, complications have arisen when the throat pack was accidentally left behind, which has led to airway obstruction or ingestion 28 and has even resulted in death. 29 The anesthesiologist must also be cognizant of the throat pack should unanticipated extubation occur during the procedure. At this time, the dentist must remove all of his/her dental equipment and the anesthesiologist may attempt positive pressure mask ventilation prior to throat pack removal. Clearly, ventilation will be suboptimal. To minimize this occurrence, many institutions have devised methods to remind them of the intact throat pack. Some of the suggestions have been to: 29–31 1. Leave part of the throat pack outside the mouth 2. Tie a piece of dental floss to the pack and tape the floss to the face 3. Tie part of the throat pack to the tracheal tube 4. Tape a sign to the forehead 5. Tape a sign to the ventilator switch 6. Have the person responsible for placing the tube be the one who removes the pack 7. Have all members of the team witness the removal of the pack 8. Include the pack as part of the scrub nurse’s count 9. Visually inspect the pharynx with the laryngoscope prior to extubation Using a throat pack with a radio-opaque lining (Figure 126–8) would be advisable and can be helpful in cases where the pack has become unaccounted for and an x-ray is needed to determine whether it was left in the patient. 28 Surgical Issues and Pain Management Typically, restorative dentistry on pediatric patients under general anesthesia does not require local anesthesia. Local anesthesia with epinephrine may allow improved hemostasis for extractions, however. The most stimulating procedures for the pediatric patient intraoperatively are placement of the rubber dam, where the oral cavity and tongue are stretched; removal of the dental pulp (pulpotomy); and extractions. It is helpful for the dentist to alert the anesthesiologist to these procedures. Regardless of whether or not extractions are performed during the dental procedure, the dental patient still requires postoperative pain management. Placement of stainless steel crowns can be very painful for the child, because the crowns are placed well under the gum line and can fit together very tightly. The dentist may use local anesthesia intraoperatively, which may provide acceptable pain control postoperatively. Many dentists, however, do not wish to give local anesthesia, particularly to younger children who may bite their lips, cheeks or tongue, as this can lead to severe mutilation of the oral soft tissues. NSAIDs are effective in controlling mild to moderate levels of dental pain 32 and are a good choice for pain management in dental patients. Ketorolac tromethamine, a parenterally available NSAID, has been shown to be very effective in the management of dental pain. Purday et al. showed no difference between intravenous ketorolac and morphine for postoperative pain in children undergoing dental surgery, with the added benefit of reducing postoperative nausea and vomiting in the 24-hour postoperative period. 33 Dsida et al. showed that 0.5 mg/kg of I.V. ketorolac in children produced plasma blood levels similar to adults for therapeutic concentrations. 34 Some pediatric hospitals allow 1 mg/kg of I.V. ketorolac as a single dose followed by acetaminophen for continued postoperative pain control. Opioids can also be considered, with the most commonly used being morphine sulfate at a dose of 0.05 to 0.1 mg/kg. Extubation If oral bleeding or heavy secretions are expected at case completion, deep extubation may lead to an increased risk of laryngospasm during anesthetic emergence. Additionally, extubation of a nasotracheal tube may lead to nasal bleeding into the oral cavity, with increased risk of laryngospasm if deep extubation is planned. This can occur despite apparent atraumatic intubation. Epistaxis can also occur. Nasal bleeding may have an anterior or posterior component. The use of ketorolac tromethamine may
2088 PART 5 ■ Anesthetic, Surgical, and Interventional Procedures: Considerations exacerbate this adverse event. Frequently, placement of a soft nasopharyngeal airway can temporarily tamponade nasal bleeding and allow for hemostasis to take place. In rare cases, a nasal tampon (Merocel or Doyle sponge; Laubscher, Germany) may be needed. Uncontrolled posterior bleeding is usually controlled with a balloon catheter and provided by an otolaryngologist. In summary, the anesthesiologist should consult as needed with the dentist preoperatively regarding behavioral challenges, type of intubation needed, and any airway concerns that the anesthesiologist may recognize, as well as postoperative pain control choices to provide optimal patient care. POSTOPERATIVE CONSIDERATIONS Some unique postoperative considerations may be associated with anesthesia for dental or oral surgery in addition to typical postoperative complications. These include: 1. Increased incidence of postoperative nausea and vomiting during oral and maxillofacial surgery due to passive ingestion of blood during the procedure or active swallowing of blood during recovery. 2. Miscellaneous dental debris inadvertently left behind after the completion of the procedure and possibly aspirated during extubation. Dental debris left behind by the surgeon and/or assistant can include but are not limited to such items as cotton pellets, pieces of amalgam or other dental filling materials, stainless steel crowns, other small dental equipment and/or pieces of a tooth. 3. Retained throat pack; this has the potential to be swallowed or to obstruct the patient in recovery. 4. Although maxillomandibular fixation is not used as frequently as in the past for jaw fracture, if this has occurred, immediate availability of wire scissors and other instruments for immediate release of fixation should be available in the recovery room. AMBULATORY SURGERY IN THE OFFICE VS HOSPITAL/AMBULATORY SURGERY CENTER Office-based general anesthesia started with dentists, Horace Wells and William T.G. Morton, who discovered nitrous oxide and ether anesthesia, respectively. Later, with the introduction of intravenous barbiturates, oral surgeons were the leaders for many years in intravenous office-based anesthesia, promoting the methohexital bolus technique for short tooth extraction procedures long before the medical community was comfortable with office-based anesthesia and surgery. Today, with improved anesthetic medications and monitoring techniques, there is an increasing trend toward office-based surgery in both medicine and dentistry, paralleling the increase in overall outpatient surgery to greater than 75% of total surgical procedures. 35 In the United States, this is driven mainly by cost considerations, with unique circumstances for dentistry. Many U.S. medical insurance plans do not reimburse for anesthesia, facility fees, and additional routine hospital/ASC charges for needed dental procedures as they do for medical procedures. This is particularly problematic for the pediatric patient who is unable to cooperate with delicate dental treatment on very small oral structures. With the average global cost of a 2-hour operating room visit, excluding the dental charges, ranging from $8000 to $12,000, many parents are unable to afford this expense. The child frequently lives with chronic dental pain 36 or eventually may find an oral surgeon willing to provide operator–anesthetist general anesthesia or sedation for extraction of abscessed teeth, the only procedure the oral surgeon is trained to provide. In other countries, such as Canada and the United Kingdom, there may be long waits for treatment resulting in continued patient suffering, lost time from school, and in some cases, hospitalization due to facial cellulitis formation. 36 With the increasing number of dentist anesthesiologists providing anesthesia services in the dental office, as well as physician anesthesiologists gradually making their way into the office venue, more parents and pediatric patients are able to afford dental care under general anesthesia as there are no facility fees. Anesthesia costs for a 2-hour case range from $750 to $1500 depending on the region of the United States and exclusive of dental surgical costs. For pediatric patients, these office procedures are usually for routine dental care and limited dentoalveolar surgery, such as extraction of impacted teeth. Anesthesiologists who provide treatment in dental offices many times do not have the “luxury” of an anesthesia machine. Most commonly, general anesthesia is provided via a total intravenous anesthesia (TIVA) technique with an unsecured airway but with a gauze throat partition to minimize the risk of small objects and fluids reaching the hypopharynx. Anesthesia for uncooperative pediatric patients, for whom obtaining I.V. access is challenging, is most commonly induced with 2 to 3 mg/kg or more of ketamine I.M., frequently with the addition of midazolam and possibly an anticholinergic. This allows for adequate dissociation within 3 to 6 minutes in order to place monitors, establish I.V. access, position the patient with a shoulder roll to maintain airway patency, and allow incremental doses or a continuous infusion of propofol to be used. Local anesthesia of the oral cavity is used, except for very short or relatively nonstimulating procedures, minimizing anes - thetic requirements as surgical stimulation is kept to a minimum. Variations of this technique include the use of bolus opioids or remifentanil infusion in combination with propofol or ketamine with propofol. At times, a nasopharyngeal airway is used to help maintain airway patency and an LMA can be considered. Where I.V. access can be obtained, frequently with nitrous oxide–oxygen or oral midazolam premedication for younger children, with or without common topical skin anesthetics, I.V. induction can be performed. Because most dental offices have a nitrous oxide delivery system, an intubated, nontriggering, TIVA technique can also be provided, using this gas delivery system with a single limb circuit or with specialized disposable carbon dioxide absorbers, which allow a circle system. If nitrous oxide is used, proper scavenging must be maintained. Alternatively, a flexible LMA can be used, with or without nitrous oxide, to aid in securing the airway. As with all office-based surgery, patient selection, surgeon selection, and surgical procedure determine the anticipated safety of providing general anesthesia in this setting. Patients are generally American Society of Anesthesiologists (ASA) classification I or II, but select ASA III patients, generally without cardiopulmonary compromise, can also be considered. For instance, a patient with persistent seizures despite optimal treatment, but for whom the neurologist would not admit the patient after general anesthesia, may be quite acceptable for anesthesia in the office setting with an adequate postoperative observation period. Alternatively, a child with obstructive sleep apnea secondary to tonsillar hypertrophy who is ASA II may not be a
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Chapter 126

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