General Anesthesia for the Provision of Dental Treatment: METHODS & RESULTS

In: Dental treatment

19 Mar 2010

METHODS

After approval from the institutional review board, the medical records of patients treated in this program between 1992 and 1994 were reviewed to determine the patient profiles, the anesthetic management, and any peri- or postoperative complications.

RESULTS

One hundred thirty-nine patients underwent 149 dental procedures ranging from oral examination, intraoral radiographs, scaling, restorations, and extractions under general anesthesia. The mean age was 29.5 yr (range 13 to 58), and males predominated females by a ratio of 2:1. All of the patients were too uncooperative to have a comprehensive dental examination performed preoperatively in a clinic setting. There was a wide range of diagnoses on the charts. However, the most common diagnosis for the majority of the patients was mental retardation, which ranged from mild to severe. There were 23 patients with Down’s Syndrome and four with schizoaffective disorders. The secondary diagnoses were seizure disorder (n = 42), hypothyroidism (n = 11), heart disease (n = 7), respiratory disease (n = 4), and central nervous system and neuromuscular disorders (n = 14), which included spasticity, ataxia, and hemiplegia. There were also patients with rare syndromes such as Lowe, Tourette, Rubella, Cornelia de Lange, Angelman and Cri du Chat syndromes, and San-doffs Disease.

One hundred patients had intravenous induction of general anesthesia. The lack of cooperation required in-halational induction in 25 patients and another 24 patients had intramuscular ketamine (Ketalar®) induction outside the operating room. Uneventful nasotracheal intubation was accomplished in 139 patients. Five patients experienced difficult visualization of the larynx and intubation. Two fiberoptic intubations were performed, one for difficult intubation and the other because of an unstable cervical region of the spine, which was secondary to rheumatoid arthritis. Ten patients experienced intraoperative complications (dysrhythmia, hypotension, or hypertension), four of them had laryngos-pasm. In the Post Anesthesia Care Unit (PACU) five patients experienced minor airway problems resulting in desaturation and one experienced a seizure.

Most patients suffered from additional diseases and some had more than one disease. Table 1 summarizes the findings.

Table 1. Diagnoses and Diseases Documented on the Charts of Patients Included in This Study

Disease Number of Patients
Down’s syndrome

23

Hypothyroidism

11

Seizure disorders

42

Schizo affective disorders

4

Cerebral palsy

16

Autism

7

Spastic hemiplegia

2

Asthma

5

Cardiac disease (Total):

7

Cardiac murmurs

2

PDA

1

Congenital

1

MVP

1

VSD repair

1

Pulmonic stenosis

1

Manic depression

1

Rare syndromes

11

Lowe
Tourette
Rubella
Sandoff’s
Cornelia de Lange
Angelman
Cri du Chat
Undiagnosed miscellaneous
borderline retardation

10

The majority of patients were taking some form of drug therapy to manage a primary medical problem and may also have been taking secondary medications to control behavior as shown in Table 2.

All of the patients took their regular medications with 30 to 60 ml of water or clear juice on the morning of surgery. A cardiologist’s opinion was obtained for cardiac patients regarding the nature of the cardiac problem and the need for prophylactic antibiotic coverage. There were seven patients with documented cardiac disease on their charts as shown in Table 1. Medically necessary blood work (complete blood count and hemoglobin) was done by the family physician for cooperative patients. Blood was drawn from uncooperative patients under general anesthesia for tests requested by their physicians that they were not otherwise able to complete (eg, thyroid levels, blood levels of seizure drug).

Table 2. Preoperative Drugs Taken by the Patients Included in This Study

Medications Number of Patients
 

12

L

8

3

Phenobarbital

6

Cogentin

6

Valproic acid

6

 

5

Haldol

6

Rivotril

5

Clobazem

4

Oxytryptilline

2

 

2

Mogadon

4

Beconase

2

Folic acid

4

Nozinon

2

Largactil

3

Lithium

3

The majority of patients had uneventful intravenous induction with pentothal (Thiopental®) or propofol (Di-privan®) and muscle paralysis with succinylcholine (Anectine®) and were intubated via the nasal route. Of the 149 anesthetized patients, 100 had intravenous (IV) induction, 25 had inhalation induction with a mask with N20, 02, and halothane (Fluothane®), and 24 had intramuscular (IM) induction with Ketalar® in a dose range of 4 to 12 mgAg. Subsequently, all patients were maintained on IV agents or inhalational agents. The common induction agents were thiopental (Pentothal®) and Dipriyan® with small doses of the following benzodiazepines: diazepam (Diazemuls®) (an emulsified form of diazepam) (2.5 to 5 mg), midazolam (Versed®) (0.5 to 1 mg), or fentanyl (Sublimaze®) (0.05 to 0.1 mg). The majority of patients received succinylcholine for intubation and were maintained with small doses of non-depolarising relaxants such as vecuronium (Norcuron®), or dtu-bocurarine (Tubarine®), or mivacurium (Mivacron®). Despite airway abnormalities, the airway was secured by the nasal route for 139 anethetized patients without any problems. Five intubations were documented as difficult and three nasal intubations failed. These patients were then intubated orally. Two patients needed fiberoptic intubation. It is surprising that although these patients had problems with difficult airways only two needed fiberoptic intubation in the 2 yr surveyed. Common maintenance agents were nitrous oxide-oxygen 183, isoflu-rone (Forane®) enflurane 47 (Ethrane®), and halothane 12. The average duration of the general anesthetic was 2.5 hr with a range of 1 to 6.5 hr.

There were no major complications in the operating room, except that two patients experienced a slight lowering of their blood pressures, three had nonfatal unifocal ventricular arrhythmia, one had hypertension, andfour had wheezing. If dental extractions were required, the dental surgeon would also administer a local anesthetic with epinephrine, 0.5% bupivacaine (Marcaine®) with epinephrine 1:200,000 or 2% lidocaine (Xylo-caine®) with epinephrine 1:100,000 for the management of postoperative pain as well as local hemostasis. No complications related to the local anesthetic or epinephrine were reported on the charts.
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During the immediate postoperative period while in the PACU the following minor morbidities were recorded: nausea/vomiting, 37; restlessness, 26; dizziness, 18; shivering, 5; desaturation <90%, 5. The mean stay in the PACU was 3 hr. Four patients had to stay in the PACU for 4.5 hr, but these patients had operative procedures that took more than 4 hr to complete. In spite of the associated medical problems that many of these patients have, the majority of them did very well and none needed to be admitted postoperatively in the 2 yr surveyed.

Finally, note that most individuals had successful management under general anesthesia whether or not a complete preoperative medical evaluation with blood work was obtained.

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