General Anesthesia for the Provision of Dental Treatment: DISCUSSION part 2

In: Dental treatment

21 Mar 2010

General AnesthesiaAt our center, induction was accomplished in the majority of patients using IV access with the help of patient restraint by the dental surgeon, assistants, registered nurse, and patient’s guardians, parents, or caretakers. Once the IV was established, induction was achieved with either 2.5 to 3 mgAg thiopental and 0.2 to 0.4 mg glycopyrrolate or 0.6 mg of atropine. After induction, the guardians or caretakers leave the operating room (OR). In the rare situation of the very combative patient, IM ketamine has been successfully employed at a dose of 4 to 12 mgAg, usually in the recovery room or reception area. The patients are then brought into the OR in a wheelchair or on a stretcher, and, once they are drowsy, are transferred onto the OR table. Close communication and cooperation among the anesthesiologist, dental surgeon, caretaker and nurse are essential to provide this service. The anesthesiologist must be prepared for possible difficulties in maintaining an airway and other complications. In most of the cases, suc-cinylcholine has been successfully employed, except when there is a specific contraindication. In our center, succinylcholine appears to be the most commonly selected muscle relaxant, followed by mivacurium at a dose of 200 to 250 |xgAg, and occasionally other relaxants such as atracurium and vecuronium. At the end of the procedure, the patients are extubated when their protective reflexes have returned. This is after the reversal of muscle relaxation resulting from a combination of anticholinergic and anticholinesterase usually 1.2 mg of atropine and 2.5 mg of neostigmine.

Keenan and Boyan reported 27 cardiac arrests caused solely by anesthesia among 163,240 patients over a 15-yr period (1969 through 1983); resulting in an incidence of cardiac arrests of 1.7 per 10,000 ane-thesized patients. The death rate in their study was 0.9 per 10,000 anethesized patients, which agrees with other studies. The only study that suggests that the incidence of death may be lower is that of Holland who reported an anesthetic mortality in New South Wales, Australia of 1 per 10,250 in 1970 and 1 per 26,000 in 1984. Keats questions the premise that better monitoring has caused a reduction in mortality. There are no such statistics available for mentally challenged patients. The data studied showed that there was no mortality or major morbidity even with minimal preoperative assessment, indicating that these procedures can be safely undertaken in a well-equipped facility by trained personnel.

A survey in 1990 in Ontario estimated that approximately 130,000 dental patients are administered general anesthetics on an annual basis for conscious sedation or general anesthesia. There were four fatalities be tween 1986 and 1995 following anaesthetics given by dentists. The resulting 10-yr mortality rate was 3.5 per 1,000,000 cases. Secondary data analysis dating back to 1973 gave a mortality rate of 1.4 per 1,000,000 cases. However, there are no statistics available that compare the mortality rate resulting from anesthetics given to the mentally challenged population with the mortality rate resulting from anesthetics given to the general population. Statistical analysis of dental anesthesia regarding the incidence of morbidity and mortality in the United Kingdom and the United States show that they are comparable. It is noteworthy that with respect to morbidity and mortality there is no statistical difference between the hospital and dental office setting. (Nkansah, personal communication, 1996).

Mentally challenged patients who are otherwise healthy can be treated in properly equipped dental offices with competent anesthesiologists, but it is prudent to treat patients who suffer from other diseases in a hospital setting with full medical facilities and with the ready availability of multiple specialized consultants. In either of these settings, there should be good communication between all personnel involved to ensure the provision of safe and efficient treatment to this segment of the population. Kamagra Oral Jelly

At our center, all these patients are evaluated preop-eratively in the family-practice clinic or by their community physicians and by members of the anesthesiology department. If problems are detected or suspected, then the appropriate medical professionals are consulted. The majority of the dental procedures were done with minimal preoperative investigation and the majority of patients tolerated the procedure under general anesthesia quite well. The patients’ caretakers were given written and verbal instructions regarding preoperative drug therapy and поп per os (NPO) status. If the patient is very aggressive then sedation is accomplished in the waiting area with IM ketamine (sometimes injected through the clothing), while the patient is seated and restrained in a lounge chair or wheelchair. After a sufficient level of sedation has occurred the patient is either wheeled in the chair or transferred to a stretcher and taken to the OR where the complete induction and intubation is accomplished conventionally. During the recovery period, 02 is blown on the patient’s face because mentally challenged patients often do not keep masks or tents on once they are alert and awake. The caretakers are brought to the PACU during the recovery period in an attempt to keep the patient calm. As soon as the patients recover completely from the anesthetic, they are given clear fluids. If they can tolerate the fluids, they are then discharged with the caretaker only after appropriate evaluation by the recovery room nurse and anesthetist.

CONCLUSION

This review supports the position that mentally chal lenged patients can be managed safely under general anesthesia as outpatients with minimal morbidity and minimal preoperative evaluation. The main criteria used to determine medical suitability for treatment under general anesthesia is the physical evaluation of the patient and a report from both the caregiver and primary physician concerning the patient’s present state of daily health. A person who is determined to be healthy will in most cases be able to tolerate dental care under general anesthesia. Significant cost savings can be realized by ordering only pertinent tests and treating these patients as day care patients. Finally, facilities should be available for patients who need other medical consultations and investigations, and possibly admission, to provide their dental care under general anesthesia in a safe manner. This review supports the position that mentally challenged adults can receive their required dental care in a safe and predictable manner under general anesthesia in a day-surgery facility, and that such facilities should be maintained to meet the demands for dental care for this select group of individuals. A dedicated team of individuals can play an important role in the provision of required dental care under general anesthesia and the necessary follow-up for these individuals with developmental disabilities.
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Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.

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