The Failed Sedation: Solutions for the Oral and Maxillofacial Surgeon.

Due to wide variation in patient responses, both intended and adverse, it is impossible to successfully sedate all patients. Choosing the right drug and dose regimen can be challenging, especially in patients who are naïve to anesthesia. Underdosing can lead to pain perception, patient movement and combativeness, awareness with recall, and the sympathetic neuroendocrine stress response. Overdosing can lead to unintended loss of upper airway tone, hypoventilation/apnea, adverse cardiovascular changes, and prolonged sedation (with its attendant problems).

Monitoring for the Oral and Maxillofacial Surgeon.

Parenteral medications are titrated in the oral and maxillofacial surgery office to achieve moderate sedation, deep sedation, or general anesthesia while continuously maintaining spontaneous ventilation with an open airway. After initial drug administration, the provider assesses and interprets both the level of anesthesia and the presence/severity of adverse side effects, both of which guide further drug titration, cessation, reversal, or medical management. This assessment is called monitoring, which guides the conduct of anesthesia delivery and becomes the essence of this art.

Patient fire during dental care: A case report and call for safety.

BACKGROUND AND OVERVIEW: Fire risk is present whenever there is a convergence of fuel, oxidizer, and an ignition source, which is called the fire triangle. A heightened awareness of fire risk is necessary whenever a fire triangle is present. The authors provide a sentinel event case report of fire in a dental office. CASE DESCRIPTION: A 72-year-old woman received second-degree facial burns from a fire that ignited near the nasal hood supplying a nitrous oxide-oxygen mixture. The presumed ignition source was heat generated during the preparation of a titanium post with a high-speed, irrigated carbide bur. The patient was transferred to the local emergency department and subsequently discharged after possible pulmonary complications were ruled out. The patient was then transferred to a regional burn unit and was discharged home with second-degree burns. CONCLUSIONS AND PRACTICAL IMPLICATIONS: When the source of a fuel cannot be removed from the immediate area, soaked with water, or covered with a water-soluble jelly, the dentist should stop the open flow of oxygen or nitrous oxide-oxygen mixtures to the patient for 1 minute before the use of a potential ignition source, and intraoral suction should be used to clear the ambient atmosphere of oxidizer-enriched exhaled gas.

How safe is deep sedation or general anesthesia while providing dental care?

BACKGROUND: Deep sedation and general anesthesia are administered daily in dental offices, most commonly by oral and maxillofacial surgeons and dentist anesthesiologists. METHODS: The goal of deep sedation or general anesthesia is to establish a safe environment in which the patient is comfortable and cooperative. This requires meticulous care in which the practitioner balances the patient's depth of sedation and level of responsiveness while maintaining airway integrity, ventilation, and cardiovascular hemodynamics. RESULTS: Using the available data and informational reports, the authors estimate that the incidence of death and brain injury associated with deep sedation or general anesthesia administered by all dentists most likely exceeds 1 per month. CONCLUSIONS: Airway compromise is a significant contributing factor to anesthetic complications. The American Society of Anesthesiology closed claim analysis also concluded that human error contributed highly to anesthetic mishaps. The establishment of a patient safety database for anesthetic management in dentistry would allow for a more complete assessment of morbidity and mortality that could direct efforts to further increase safe anesthetic care. PRACTICAL IMPLICATIONS: Deep sedation and general anesthesia can be safely administered in the dental office. Optimization of patient care requires appropriate patient selection, selection of appropriate anesthetic agents, utilization of appropriate monitoring, and a highly trained anesthetic team. Achieving a highly trained anesthetic team requires emergency management preparation that can foster decision making, leadership, communication, and task management.