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DENTAL ANESTHESIA
COMPLICATIONS IN THE DENTAL CHAIR
SAAD A. SHETA
Associate Professor Consultant Anesthesia
Dental CollegeKSU
Dental Anesthesia
Out-Patient Anesthesia (Dental Chair Anesthesia)
Sedation Techniques
Day-Case Anesthesia
In-Patient AnesthesiaComplete Dental rehabilitationComplicated oral surgery proceduresMajor Maxillofacial surgeries
Complications in Dental Anesthesia
Out-Patient Dental Anesthesia“Dental Chair Anesthesia
Office-Based Dental Sedation
Out-Patient Dental Anesthesia
“Dental Chair Anesthesia”
Out-Patient Dental Anesthesia “Dental Chair Anesthesia”
Out-Patient dental extractionChildren (4-10 years): high incidence of URTISteadily decreased
Out-Patient Dental AnesthesiaInduction
Inhalational (mask) inductionIntravenous Induction
Out-Patient Dental Anesthesia Maintenance
Inhalational agents/N2O
Nasal mask, mouth gag, packMaintain airway
Supine Position
Less hypotension less bradycardia
high risk of aspirationAirway obstruction&Decrease ERV
Out-Patient Dental Anesthesia Recovery
Left lateral position100% O2
Suction Observation & monitoringDischarge criteriaInstructionsAnalgesia (NSAIDs)
Office-Based Dental Sedation
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 SedationDeep SedationGeneral 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
Sedation Techniques
Non Titrable Technique
Oral SedationRectal SedationIntramuscular SedationSubmucosal SedationIntranasal Sedation
Titrable Technique
Inhalational SedationIntravenous Sedation
Combination Of Two
Combination of Methods and Techniques
Most complications occurred with polypharmacology in the hands of untrained personnel
AUGMENTATION OF THE EFFECT + REDUCE THE DOSE OF STONGER DRUGS.
Pre-requirements: (Essentials to reduce the risk)
Pre-requirements
Proper training and familiarity with the technique (including support personals)
Patients selectionClear instructions MonitoringDocumentationEmergency Back-up
Patients Selection Contraindications
Serious cardiopulmonary diseases, COPDDiabetes or other endocrinological diseasesNeuromuscular disordersCoagulopathies & HemoglobinopathiesMarked oro-facial swelling (edema& trismus)Potential difficult airwaysExtreme obesityDrugs: MAOIs , AnticoagulantNot fasting
Monitoring
Clinical ObservationPulse OximetryPrecordial/pretracheal
StethoscopeBPECG
Equipment
Dental ChairAnesthetic EquipmentsMonitoringResuscitation Equipments
“ Up to the standards of In-Patient GA ”
Dental Chair
Adjustable: ( horizontal /Head down)
Manual release
Adjustable head rest
Hospital out-patient: operating table
Anesthesia Equipments
Continuous flow anesthesia machine
Quantiflex (Relative Analgesia)
Mouth props, packs, gags, nasopharyngeal airway, rubber dam
Separate suction unit
Scavenging system
Equipment
Continuous flow design with flow metersSafe delivery of O2 and N2O (fail safe
mechanism)10 l/min for 60 minE cylinder(650 litres)
Pin-indexed yoke systemEfficient scavenger
Oxygen (Central)
Emergency Equipment
Airway Adjuncts : Airways, Masks and Nasal prongs
Bag-valve- mask
High Volume Suction Device Oxygen Source
Others: Crash Cart
Airway Adjuncts
If breathing adequately spontaneously
Bag-valve-Mask
built-in colorimetric ETCO2 detector
If Artificial ventilation necessary
Crash Cart
Crash Cart
Intravenous Line: Cannulae Syringes NeedlesAirway AdjunctsEndotracheal IntubationCricothyrotomyEmergency Drugs
Emergency Drugs
Drugs to treat AllergyBenzodiazepine AntagonistAnticonvulsantsNarcotic AntagonistsSteroidsAntihypoglycemicVasopressorsAnalgesicsACLS drugs
Dental Chair Complications
Respiratory Complications
Cardiovascular Complications
Miscellaneous
Respiratory Complications
AIRWAY OBSTRUCTION
RESPIRATORY DEPRESION
BRONCHEAL ASTHMA
HYPERVENTILATION
Respiratory Complications
Airway ObstructionRespiratory 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 (“A”)
Airway Obstruction
Most common cause: tongue and/or epiglottis
Open the Airway
Jaw thrust Head tilt–chin lift
Head Tilt/Chin Lift
Jaw-Thrust Maneuver
Jaw-Lift Maneuver
Four Sharp back blows (Rapid successions)
Abdominal Thrust HEIMLICH MANEUVER
Chest Thrust
Ventilate Via Mask
An unconscious patient, these maneuvers are followed be sweeping a finger from the side of the patient’s mouth
Airway Obstruction By Foreign Body
Direct visualization of the larynx with a laryngoscope may enable the removal of
an obstructing foreign body
Direct visualization of the larynx with a laryngoscope may enable the removal of
an obstructing foreign body
Open the Airway
Oropharyngeal Airway
Insert oropharyngeal airway with tip facing palate
Rotate airway 180º into position
Open the Airway
Nasopharyngeal Airway
Nasopharyngeal Airway
Advanced Airway Management
Endotracheal Intubation is the Most Preferred Method of Advanced Airway Management
Engaging laryngoscope blade and handle
Activating laryngoscope light source
Laryngoscope Blades
Open the Airway
Endotracheal Intubation “ Laryngoscopes ”
ETT and Syringe
ETT
ETT, Stylet, and Syringe “unassembled”
ETT, Stylet, and Syringe “assembled for intubation”
Endotracheal Intubation “Technique”
Position
Endotracheal Intubation “Aligning Axes of the Airway”
Hyperventilate patient
Prepare equipment
Apply Sellick’s Maneuver and insert laryngoscope
Endotracheal Intubation “ Visualization of the Cord
Glottis visualized through laryngoscopy
Visualize larynx and insert the ETT
Inflate cuff, Ventilate, and Auscultate
Secure tube
Reconfirm ETT placement
Laryngeal Mask Airway
Laryngeal Mask Airway
Laryngeal Mask Airway (LMA)
The Only Indication of a Surgical Airway is the inability to establish
Airway by Any Other Method
Breathing (“B”)
Oxygenation
Adjunct Devices
Bag-valve-mask ventilation
Ventilation
Bag-Mask Ventilation
Key ventilation volume: “enough to produce obvious chest rise”
1 Persondifficult, less effective
2 Personseasier, more effective
HYPERVENTILATION
Management
early recognitionreassuranceOxygenBreathe into a paper bagAnxiety agent
Bronchial ASTHMA
AetiologyIn Children : Allergic (Ig E) or Extrinsic In adults: Extrinsic
(Stress)
Clinical Picture
HistoryMild wheezingCoughing to severe dyspnea ,
Cyanosis and death
Bronchial ASTHMA
ManagementOxygen Aerosolized adrenergic agentsEpinephrine (0.01 mg/kg SC)Emergency transport to the hospital
!!!intravenous amnophyllinedose of 5.6 mg/kg is infused over 10 minutes, fol1owed by a continuous intravenous infusion of 1 mg/kg/hour
early administration of corticosteroid
Cardiovascular Complications
HYPOTENSION
BRADYCARDIA
DYSRYTHMIAS ( Tachy-dysrhythmia)
SYNCOPE
ALLERGIC REACTION
HYPOTENSION
Induction of AnesthesiaCarotid sinus compressionOver-sedation
BRADYCARDIA
Tooth extraction
Halothane (nodal rhythm)
DYSRHYTHMIAS
Aetiology (Tooth extraction)
High preoperative catecholaminesLight anesthesiaAirway obstruction & hypoxiaHalothane & local anesthesiaLocal anesthesia with vasopressors
SignificanceControversialSignificant with unexpected cardiac disease
(viral myocarditis)
SYNCOPE
CausesFactors (CV, allergic,..)Emotional factors (more common)
Aetiology
limbic cortex-hypothalamus-reflex vasodilatationIncrease parasympathetic activity-bradycardia
Less common in childrenSympathetic nervous systemEndogenous epinephrine and nor epinephrine
SYNCOPE
Clinical PictureCold, pale, and sweaty skinFeels dizzy of faint
ManagementFlat, Head down-leg elevated
100% O2
Ammonia inhalantAtropine / VasopressorsMedical assistance “ if Recovery of consciousness is Delayed beyond 5 minutes Incomplete after 15 to 20 minutes”
ALLERGIC REACTION
IncidenceVery rareMore commonly (vaso-vagal, toxic reaction, epinephrine)
AetiologyHistamineIg E-mediated reaction Easter-linked: p-amino benzoic acidAmide-linked: preservatives (Paraben)
ALLERGIC REACTION
Clinical Picture “ Skin, Respiratory and Cardiovascular System”
Mild erythematous rash to urticaria (hives) to angioedema
Bronchospasm, cough, dyspnea, pulmonary oedema, laryngeal oedema, hypoxia
Hypotension, tachycardia, arrhythmias, Eventually C. arrest
ALLERGIC REACTION
Management
100% O2 Epinephrine (0.01-0.5 mg IV or IM)
IV fluids (LRS 1-2 liters) Intubation
Diphenhydramine “Orally at 6-hr intervals for 24-48 hrs”
Hydrocortisone (up to 200mg IV) Aerosolized sympathomimetic agent
“Epinephrine, Isoproterenol, or Metaproterenol”
Transported to the hospital
Miscellaneous
SEIZURES
Clinical Picture TONIC-CLONIC “FOUR PHASES”
Pro-dromal phaseThe auraThe convulsiveThe post-ictal phase
A significant degree of CNS depression is usually present during this post-ictal phase
Increased oxygen consumption, tachycardia, hypertension, impairedventilation, and cardiac arrhythmias
SEIZURES
Management
Prevent self-injuryAirway management &Adequate ventilation
Intravenous diazepamSupportive careHyperthermia
DIABETES MELLITUS
AetiologyJuvenile onset diabetes, Worst prognosis
Poor Insulin Production Clinical Picture
Hypoglycemia or hyperglycemiaDiabetic ketoacidosis (Coma &Death)
“Hypoglycemia ” Deteriorating Cerebral FunctionNauseaSympathetic NS Stimulation (Tachycardia, Hypertension, ArrhythmiasMental Obtundation, Loss of Consciousness, Seizures
DIABETES MELLITUS
Management
Oxygen Fully Conscious, Oral Sugar containing Food or DrinksDextrose 50% “IV”, Till regain ConsciousnessGlucagon “IM”
Miscellaneous
Nasal Trauma, Epistaxis Pulmonary AspirationDiffusion HypoxiaContinued BleedingPost operative Sore ThroatPost operative Nausea & vomitingPost operative Pain & swelling
THANK YOU