In: Dental treatment20 Mar 2010
The majority of dental procedures may be done in the office usually without sedation or general anesthesia. More complicated procedures and/or patients who are uncooperative or suffering from phobias may require a general anesthetic to provide their dental treatment. Providing anesthesia for the mentally challenged, combative, and uncooperative patient presents a unique challenge to the health care team. The increased fear and anxiety caused by their separation from familiar surroundings, parents, and/or guardians often leads to an aggressive, noncompliant, combative behavior.
Moreover, the association of previous visits to healthcare facilities with bad experiences may further increase their anxiety. Apprehension of the guardian or parent can significantly affect the patient’s behavior. In all cases, communication, preoperative education, and de-sensitization of the patient and parent or guardian have proven helpful. Mentally challenged patients frequently have multiple medical problems, which may include cardiac disease, notably conduction defects associated with Down’s Syndrome. Patients with neuromuscular disease may have a history of aspiration and chronic pneumonitis. Macroglossia, hypoplasticity of the maxilla/mandible, palatal abnormalities, and mandibular protrusion are the usual airway abnormalities encountered in paients with Down’s Syndrome.
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The ideal technique for general anesthesia should allow for a rapid, safe, and smooth induction with easy airway management, followed by a stable uncomplicated maintenance throughout the procedure, and concluding with an uneventful reversal and extubation. Standard patient monitoring should be employed which includes an electrocardiogram (ECG), blood pressure, pulse oximetry, capnography, and a provision for the measurement of temperature. The airway is shared between the anesthesiologist and dental surgeon and must be protected at all times. A number of anesthetic strategies have been suggested to facilitate induction and maintenance of general anesthesia.
Ketamine has been recommended for use as a primary agent or to facilitate induction. It can be administered orally, intramuscularly, or intravenously. In addition, because it maintains some pharyngeal and laryngeal reflexes, it makes it an ideal induction agent. However, tracheal intubation cannot be achieved without the use of muscle relaxants. Although intravenous access for induction is preferred, it may not be possible to secure this access in the anxious or hostile, combative patient. In such patients, IM doses of up to 12 mgAg ketamine may provide sufficient anesthesia to secure IV access. Oral ketamine in doses of 0.5 to 8 mgAg has also been employed. Oral midazolam has recently become popular for preoperative sedation. Midazolam has a bitter taste. However, when mixed with a sugar-based drink such as Kool Aid® or chocolate syrup, it can be administered orally and can provide sufficient preoperative amnesia and sedation (Clarke, personal communication). This technique avoids the use of needles or masks and renders the anxious and uncooperative patient amenable to an IV induction. A number of IV techniques have been employed using IV ketamine, barbiturates, alfentanil, and recently propofol. A disadvantage of ketamine is over activity of the sympathetic nervous system and secretions that can be minimized by the preoperative (PO) or IM administration of atropine (0.6 to 1 mg) or the IM administration of gly-copyrrolate (0.4 to 0.6 mg) (Robinul®) 1 hr before surgery.
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Although scopalamine (Hyoscine®) has been recommended, its use is not advisable in the mentally challenged patient because of its sedative properties and sometimes unpredictable recovery profile. Dissociative emergence can also occur with scopalamine and ketamine. Barbiturates such as methohexital (Brietal®), thiopental, and thiamylal (Surital®) have been successfully employed for induction of anesthesia. Thiopental at doses of 2.5 to 4 mgAg and methohexital in doses of 1 to 1.5 mgAg have been recommended. Methohexital is 1.5 to 2 times as potent as thiopental and has a rapid onset and offset time. However, occasionally it does produce involuntary movement. Propofol is a very popular induction agent. It is usually given IV at a dose of 1.5 to 3 mgAg mixed with 20 to 30 mg of lidocaine, to minimize pain on injection. With the use of IV hypnotics, one can also combine small doses of benzodiazepines, such as diazepam (Valium®), emulsified diazepam, or midazolam together with a small dose of 0.5 to 1.5 ixgAg fentanyl or 25 to 50 ixgAg of alfentanil (Alfenta®). The drawback in the use of opioids is an increased incidence of nausea and vomiting. The problems resulting from nausea and vomiting, which are common with any opioid, can be minimized by the administration of 0.5 to 0.75 mg of droperidol (Inapsine®) or 25 to 50 mg of dimenhydrinate (Gravol®). Once induction is accomplished, any muscle relaxant can be employed as long as the airway is not compromised and anesthesia is maintained with inhalational agents, such as halothane, isoflurane, enflurane, or with a totally IV technique such as propofol. Induction excitement is often a problem with the inhalational technique. Comined techniques of IV induction with barbiturates or ketamine together with inhalational agents are often associated with a prolonged recovery.
An alternative to the IV technique and IM sedation is inhalational induction with N20, 02, and vapor anesthetic. Halothane was an ideal inhalational agent with a pleasant odor that was readily accepted by most patients. However, a new inhalation agent, sevoflurane (Ultane®), is now available. It is less irritating and pungent than halothane, has a faster induction, and has a shorter recovery period once it has been discontinued. After the induction is completed and an IV line is established, muscle relaxants are given and then intubation can be performed. If desired, a different inhalational agent can then be used for the duration of the case. canadian antibiotics
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.