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