Intraoperative seizure and cerebrospinal fluid leak during adult cochlear implant surgery.

OBJECTIVE AND IMPORTANCE: To report a rare case of cerebrospinal fluid gusher and subsequent seizure immediately after cochlear implant electrode insertion. CLINICAL PRESENTATION: After the cochlear implant electrode was inserted, brisk flow of 10 mL of cerebrospinal fluid was seen. The electrode was promptly inserted and the leak was additionally sealed with fascia. Seconds later, the patient had a tonic-clonic seizure lasting 30 seconds. Two additional episodes occurred during the case. Her postoperative course was uneventful with no subsequent seizures. The device has been successfully activated. Intervention & Technique: Postoperative imaging showed correct intracochlear placement of the electrode as well as an incidental enlarged vestibular aqueduct. Neurology consultation including electroencephalogram was unremarkable. CONCLUSION: To our knowledge, this is the first report of a seizure temporally associated with cochlear implant electrode insertion. The significance and possible casual relationship between these two events is discussed.

Essentials of Airway Management, Oxygenation, and Ventilation: Basic Equipment and Devices.

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of U.S. dental offices, per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia, as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice, whether providing local anesthesia alone or in combination with procedural sedation.

Airway Assessment for Office Sedation/Anesthesia.

Whenever a patient is about to receive sedation or general anesthesia, no matter what the technique, the preoperative assessment of the airway is one of the most important steps in ensuring patient safety and positive outcomes. This article, Part III in the series on airway management, is directed at the ambulatory office practice and focuses on predicting the success of advanced airway rescue techniques.

A novel index of hypoxemia for assessment of risk during procedural sedation.

BACKGROUND: Procedural sedation is essential for many procedures. Sedation has an excellent safety profile; however, it is not without risks. Assessment of risk using clinical outcomes in clinical studies is difficult due to their rare occurrence. Therefore, surrogate end points are frequently used in a clinical study in lieu of clinical outcomes. As a clinician integrates multiple aspects of a physiological variable to determine potential risk, a surrogate end point should consider a similar approach. In this study, we identified and tested the appropriateness of a new surrogate end point that may be used in clinical studies, area under the curve of oxygen desaturation (AUCDesat). A review of patient sedation records by anesthesiologists was conducted to assess its relationship to the anesthesia professional perception of risk. METHODS: This study was a post hoc analysis and assessment of perceived risk by anesthesiologists. It consisted of 13 U.S.-trained board-certified anesthesiologists ranking physiological variables as indicators of risk and then reviewing 204 records from 3 completed sedation studies involving the SEDASYS System. After review, each anesthesiologist assigned a Likert score based on his or her perception of risk for oversedation-related sequelae in each record. These scores were analyzed to determine their relationship to desaturation presence/absence, duration, depth, number of events, and AUCDesat that incorporates each component. RESULTS: Anesthesiologists ranked arterial oxygenation to be the most important factor in assessing risk post hoc (mean rank of 4.69 of 5, P = 0.0007 compared with next highest ranked factor-respiratory rate, N = 13). AUCDesat was better correlated to the Likert scores (rs = 0.85) when compared with the individual elements of AUCDesat, binary assessment of desaturation (rs = 0.73), desaturation depth (rs = -0.70), desaturation duration (rs = 0.70), and incidence of desaturations (rs = 0.55) (all 4 comparisons versus rs = 0.85, P < 0.0001). CONCLUSIONS: Anesthesiologists determined arterial oxygenation to be the most important physiological variable in assessing sedation risk and the potential for adverse clinical outcomes. AUCDesat, a composite index that incorporates duration, incidence, and depth of oxygen desaturation, was better correlated to the Likert scores. AUCDesat, given that it is a single numerical variable, is an ideal end point for assessment of risk of adverse clinical outcomes in clinical sedation studies. Future studies using AUCDesat and actual physiological outcomes may be useful in further defining this end point.

Essentials of airway management, oxygenation, and ventilation: part 1: basic equipment and devices.

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management (CRM) involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of US dental offices per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice whether providing local anesthesia alone or in combination with procedural sedation. Part 2 of this series will address advanced airway devices, including supraglottic airways and armamentarium for tracheal intubation and invasive airway procedures.

Adult airway evaluation in oral surgery.

Patients with a history of difficult intubation or with conditions associated with difficult airway should be approached with organized primary and secondary plans for airway management. When these potential problems are detected, patient safety may be improved with use of advanced airway management techniques and equipment. Additionally, patient referral for consultation and/or management at facilities where advanced airway management practitioners and equipment are available may be beneficial in some cases.

Management of allergy and anaphylaxis during oral surgery.

Minor and major allergic reactions occur during oral and maxillofacial treatment. Immediate diagnosis and pharmacologic intervention are imperative. Signs and symptoms may be variable. The early administration of epinephrine is critical.

Pharmacology of local anesthetics used in oral surgery.

This article provides a comprehensive review of the pharmacology of local anesthetics as a class, and provides details of the individual drugs available in dental cartridges. Maximum recommended doses of local anesthetics and vasoconstrictors are presented for healthy adult and pediatric patients, and for patients with cardiovascular system impairments. Various complications and reasons for failure of local anesthesia effectiveness are discussed, and current and future trends in local anesthesia are presented to provide an overview of current research in local anesthesia.

The first Research Consensus Summit of the Society for Simulation in Healthcare: conduction and a synthesis of the results.

INTRODUCTION: In this article, we describe the preparation and execution of the first Research Consensus Summit (Summit) of the Society for Simulation in Healthcare (SSH) held in January 2011 in New Orleans, Louisiana. The goals of the Summit were to provide guidance for better simulation-related research, to broaden the scope of topics investigated, and to highlight the importance of simulation-related research. METHOD: An international Core Group (the authors of this article) worked with the SSH Research Committee to identify 10 topic areas relevant for future research that would be examined by the 10 Topic Groups composed of Topic Chairs and Topic Group Members. Each Topic Group prepared a monograph and slide presentation on their topic which was presented at the 2-day Summit. The audience provided feedback on each presentation. Based on this feedback, the Topic Groups revised their presentations and monographs for publication in this supplement to Simulation in Healthcare. The Core Group has synthesized an overview of the key Summit themes in this article. RESULTS: In some groups, the agreement was that there is currently no consensus about the state of the science in certain topic aspects. Some key themes emerged from the Topic Groups. The conceptual and theoretical bases of simulation-related research, as well as the methods used and their methodological foundations, need to be more explicitly described in future publications. Although no single method is inherently better, the mix of research methods chosen should match the goal of each study. The impact of simulation, whether direct or indirect, needs to be assessed across different levels of training, and larger, more complex contexts need to be taken into account. When interpreting simulation-related research, the ecological validity of the results needs to be taken into consideration. The scope of simulation-related research can be widened from having simulation as the focus of research (research about simulation), to using simulation to investigate other research questions (research with simulation). Simulation-related research can benefit from an improved understanding of structural differences and similarities with other domains. The development of simulation equipment and concepts will benefit from applying known and available science-based design frameworks. Overall, the context of simulation-related research needs to be better understood. The progress of research depends on building overarching and sustainable research programs that relate individual studies with each other. DISCUSSION: The Summit was successful in taking a snapshot of the state of the science. Future summits might explore these topics further, monitor progress, and address new topics.

Drug therapy in dental practice: nonopioid and opioid analgesics.

To prevent patient pain, the clinician may chose from opioid and nonopioid analgesics. It is rational for the practitioner to combine drugs from these classes when managing moderate to severe pain. To select combination regimens wisely, it is necessary to understand the significant pharmacological features of each category alone. Careful selection of an effective analgesic regimen based on the type and amount of pain the patient is expected to have can prevent the stress and anxiety associated with breakthrough pain. The clinician can and should develop a variety of effective, safe analgesic regimens, based on estimates of anticipated pain intensity that use sound pharmacological principles.

Contemporary trends in acute pain management.

PURPOSE OF REVIEW: In the management of acute pain, the ability to prevent the onset of pain in the immediate postoperative period, lessen its intensity, and interfere with the development of sensitization contributing to hyperalgesia for days following a procedure can greatly benefit the patient, rather than postoperative attempts to decrease pain after it has reached full intensity. RECENT FINDINGS: Patients benefit from receiving optimal NSAID doses. These agents are effective, relatively safe, and reduce the need for opioids. In situations where pain can be anticipated, the NSAID may be optimized by preoperative administration and continuing to dose the NSAID on a regular schedule to minimize pain and inflammation. Selective COX-2 inhibitors can also prevent pain but without concern for effects on platelet function and have a longer duration of action than traditional NSAIDs. Once the dose of NSAID has been optimized, but pain persists, opioid use may be a consideration. A commercially available combination product containing opioid and acetaminophen may be a good option and is easy to prescribe. Acetaminophen's site of action differs from that of NSAIDs, and acetaminophen's analgesic effect is considered synergistic when combined with NSAIDs and opioids. When prescribing combination opioid and acetaminophen analgesic products or acetaminophen alone, the practitioner must caution the patient not to exceed 4 g of acetaminophen per day due to concerns with hepatic injury. Given that the patient has already been prescribed an optimal and/or ceiling dose of NSAID, combination products containing aspirin, an NSAID, should be avoided. As opioids have no ceiling dose, there are some situations where opioid dosing is better done with the opioid prescribed separately. This permits increasing the opioid to the needed analgesic dose with no concerns for acetaminophen toxicity. SUMMARY: Careful selection of an effective analgesic regimen can prevent the stress and anxiety associated with acute postoperative pain and breakthrough pain. Pain prevention has greater benefits than attempts at rescue therapy when pain exacerbation occurs. A variety of pain management regimens are presented based on empirical estimates of pain intensity and an application of sound pharmacological principles.

Pharmacological management of head and neck pain.

Careful selection of an effective analgesic regimen based on the amount and type of pain the patient is expected to have can prevent the stress and anxiety associated with breakthrough pain. When analgesics fail, it is not unusual for patients to go to desperate lengths to seek relief. The clinician can and should develop various effective, safe analgesic regimens based on estimates of anticipated pain intensity that apply sound pharmacological principles.

Regional anesthesia and invasive techniques to manage head and neck pain.

Regional anesthesia of the head and neck is an effective method of obtaining surgical anesthesia for various procedures. Diagnostic and therapeutic head and neck blocks can also assist with the diagnosis and management of many chronic pain conditions, including headache, postherpetic neuralgia, and cancer pain in this region. Gamma knife surgery offers a unique approach to the management of refractory trigeminal neuralgia. Because of the proximity of so many critical structures adjacent to these nerves, a solid understanding of the anatomical basis of these nerve blocks is necessary. Appropriate patient selection, monitoring, proper injection technique, knowledge of the pharmacokinetics and pharmacodynamics of local anesthetics and vasoconstrictors, possible drug interactions, and recommended doses will ensure safe and successful application of head and neck nerve blockade.

Clinical evaluation of patients with temporomandibular joint implants.

PURPOSE: An undetermined number of patients with temporomandibular joint (TMJ) symptoms have been treated with intra-articular disc implants composed of Teflon ethylene/propylene or Teflon polytetrafluoroethylene and aluminum oxide (Proplast-Teflon; Vitek, Houston, TX). These implants have shown the potential to fragment in situ resulting in nonbiodegradable particles that stimulate a giant cell reaction and lead to degeneration of local structures, pain, and limitation of mandibular opening. We examined the possible relationship between TMJ implants and persistent pain, responses to sensory stimuli, quality of life, and systemic immune dysfunction. PATIENTS AND METHODS: This case series (32 patients) were referred from university-based orofacial pain centers and private practices from across the United States. Laboratory and clinical assessments evaluated orofacial pain symptoms, neurologic function, clinical signs and symptoms of rheumatologic disease, physical function, systemic measures of immune function, and behavioral measures. RESULTS: We found that TMJ implant patients appeared to have altered sensitivity to sensory stimuli, a higher number of tender points with a diagnosis of fibromyalgia, increased self-report of chemical sensitivity, higher psychologic distress and significantly lower functional ability. Systemic illness or autoimmune disease was not evident in this series of TMJ implant patients. CONCLUSIONS: Significant problems were noted on clinical assessment of TMJ implant patients. This is a US government work. There are no restrictions on its use.

Rational use of analgesic combinations.

Careful selection of an effective analgesic regimen based on the amount and type of pain the patient is expected to have can prevent the stress and anxiety associated with breakthrough pain. When analgesics fail, it is not unusual for patients to go to desperate lengths to seek relief. The clinician can and should develop a variety of effective, safe analgesic regimens based on estimates of anticipated pain intensity that apply sound pharmacologic principles.