Chair Dental Anaesthesia
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1 Dental Anaesthesia Dr E Rawlings Anaesthetic Directorate Chair Dental Anaesthesia Day Stay Surgery! Dental chair! Isolated site! Brief duration! Shared airway! Young children/nervous adults! Rapid recovery
2 History " General anaesthesia & dentistry closely associated 157 years " Nitrous oxide # Analgesic properties noted Humphrey Davy Suffering from gingivitis " Surgical potential noted # Gardner Quincy Colton # Horace Wells (Dentist) Horace Wells Great - success 1st patient extraction Colton of wisdom (24,000 tooth GA s + N2O no fatalities) History " 1868 Nitrous available in cylinders " Hewitt # - Designed apparatus for administering N2O N O & O2 O mixtures " invention of nasal mask " Demand flow apparatus McKesson
3 " 1920 s s Walton machine # Demand flow # Remained in service until 1970 s Nitrous oxide Commonly used
4 100% nitrous patient cyanosed/twitching (cerebral hypoxia) 100% oxygen Patient pink (5-10 mins. for extractions) Still practised in late 1950 s " Halothane " 1955/6 Klock & Tom - oxygen restriction unnecessary " Methohexitone Methohexitone! Better than thiopentone # Popular Rapid induction induction agent. # Shorter duration of action Sedation (Drummond Jackson 1965) # Rapid recovery popular minimal incremental technique Narrow therapeutic margin sedation & anaesthesia
5 " Operator anaesthetist banned " 1996 introduction of Sevoflurane Standards! " 1981 Wylie report " 1991 Poswillo report " 1998/9 General Dental Council & Royal College of Anaesthetists
6 " November - Committee on Safety of Medicines! Halothane withdrawn from use outside hospital setting " 31st December 2001 Department of Health! All chair dentals must be administered in hospital setting Statistics on general anaesthetics for Minor Dental procedures " 1950 s 2 million GA s per annum " million dental GA s " dental GA s Overall reduction of caries "Why the reduction? % children caries free % children caries free
7 " 1948 Health service started # All treatment free " 1950 s sweets off ration # Large increase in need for dental treatment Dental Health - improvements " Improved dental hygiene & education " fluoride # st advert Gibbs SR # toothpaste (fluoride) # naturally occurring # added to water # tablets & drops
8 Dental health improvements (cont). " Conservation # lignocaine 1948 # air rotor drill (1960) High speed " Sedation techniques # Intravenous - midazolam # Inhalational relative analgesia (nitrous & oxygen) " Improvements in general health & diet! 30 s s poverty & poor nutrition! Poor dental health " Dentists no longer giving GA s! No longer training dentists to give GA s
9 Dental anaesthetists qualifications & experience? " Before 1998 variable # Dental surgeons # General medical practitioners # Consultant anaesthetists Dental Anaesthesia Technique " Induction - inhalation/iv # nasal mask " Adequate anaesthesia # open mouth # insert pack + prop # extract teeth " Recovery # lateral position # head down
10 Anaesthetic considerations Sitting potential cause of mortality
11 Posture Considerable Differentiate debate over merits true of posture sitting & semi-reclining position
12 Sitting Position Pro s " Reduces likihood of passive regurgitation of gastric contents " Airway maintenance easier " Floor of mouth angles forwards facilitates suction " Extraction easier + counterpressure applied Cons " Reduction of venous return reduced cardiac output, cerebral hypoperfusion " Unrecognised vasovagal syncope " Debris passing posterior to tongue - laryngeal spasm & aspirated Supine position
13 Supine position Pro s " Venous return lower limbs - unimpeded " Reduced incidence of cerebral hypoperfusion " Operator & anaesthetist can sit Cons " Compromised respiratory mechanics " Fluids & solid debris more likely to pass into the oropharynx " Passive regurgitation & and aspiration may occur Anaesthetic Machine " Intermittent flow
14 Anaesthetic Machine " Continuous flow Shared airway " Nasal mask " Laryngeal mask airway " Intubation
15 Nasal mask & oral pack Oral pack prevents aspiration Nasal mask & oral pack Anterior airway leakage/air entrainment aspiration saliva/blood/debris
16 Nasal mask & oral pack Posterior airway obstruction Shared airway " Laryngeal mask airway Good control of airway Surgeon works around it Airway protection - Good - blood, teeth, debris Fewer hypoxic episodes - In theatre & recovery Pollution - reduced
17 Age of patient? " Majority children ASA I & II " Median age (Birmingham Dental Hospital) # 6 years " Low incidence # co-existing systemic disease " High incidence # Respiratory tract infections # Adenotonsillar hypertrophy # Nasal obstruction Nitrous oxide exposure! " Occupation exposure N2ON! Exceeding 100 ppm " High fresh gas flow " Inhalational induction " Poor airway seal Active scavenging Optimal Sevoflurane ventilation of surgery LMA reduces + pollution oxygen
18 Volatile Agents " Halothane # good induction agent # associated with arrhythmia's Nov Halothane withdrawn from use outside Halothane slows conduction > 30 between Trigeminal % arrhythmias atria & ventricle stimulation hospital setting (ventricular) -allowing re-entrant activity - arrhythmias Volatile Agents " Enflurane! Less arrhythmias! Difficult to use " Isoflurane! No ventricular arrhythmias! High incidence Coughing Excess salivation Laryngospasm
19 Volatile Agents " Sevoflurane (1996) # Good induction agent # Pleasant smell # No ventricular arrhythmias Intravenous agents " Methohexitone # Withdrawn 1998 " Propofol Recovery times significantly less Causes than thiopentone hypotension Introduced with caution
20 Analgesics " Non-steroidal! Diclofenac! Ibuprofen Oral Rectal " Paracetamol Analgesics " Local anaesthesia! Infiltration! Nerve block Lignocaine + adrenaline (not suitable with Halothane)
21 Analgesics " Local anaesthesia! Infiltration! Nerve block Prevents - surgically induced arrhythmias Analgesics Third molar extraction " Dexamethasone! Diminished post-operative swelling! Decreased demand - analgesia
22 Recovery High incidence of hypoxaemia Pulse oximetry Supplemental(1982) oxygen Coplans & Curson 50% deaths occurred in recovery period Complications " Minor " Major # PONV # Dental damage # Bruising # discomfort temperomandibular joint # airway obstruction,hypoxia # inhalation foreign material # arrhythmias,cardiac arrest
23 70 s 80 s - Safety concerns " Deaths! Healthy children! Simple procedures " Substandard! Monitoring! Assistance! Resuscitation equipment Equipment Available in Dental Surgeries 1990 A Survey of Dental Practice in two Cities Equipment Sheffield Bristol Laryngoscope 41% 27% ET tubes 35% 50% ECG Pulse oximeter Defibrillator 0% 0%
24 Machine No. Mean age yrs. Time since serviced A& E Cyprane Airmed McKesson Types of anaesthetic machine found in dental surgeries MIE Salisbury 2 1 Piped gas & vapouriser Walton s 80 s - Safety concerns " Patients! Poorly prepared " Dental remuneration poor! Encouraged high throughput of patients
25 Poswillo Report " Working party! Recommendations for safe provision of general anaesthesia in dentistry outside hospital Poswillo - Recomendations " General anaesthesia! avoided where possible " Uniform standards hospital or dental surgery! monitoring! personnel
26 Poswillo " Dental surgeries! inspected! registered " Doctors & dentists sufficient competence allowed to continue practicing! Variable competancies Recommendations not taken up Increase in anaesthetics & deaths Continued mortality " ! Deaths in dental chair 8! Children 5 Investigations & inquiries Critical Preoperative assessment Peri-operative monitoring Resuscitation Transfer to critical care facility
27 Decade GA s Deaths Ratio m 134 1;182, :299, ;243,000 1:329, year total :258,000 1:235,000 Cause of death " Respiratory difficulty " Sudden cardiovascular collapse! Coroner s s report # Unexpected cardiac arrest # No precipitating factor # Resistant to resuscitation # Postmortem - no evidence of cause " Posture not implicated
28 Halothane & Cardiac Arrest " Incidence of arrhythmias - Halothane! 18-75%! mainly ventricular! Risk of progression - ventricular fibrillation Volatile anaesthetic agents - halothane Hypoxia Hypercarbia " Slows conduction between atria & bundles of His Inadequate! Possibly allows anaesthesia re-entrant activity - arrhythmias General Dental Council 1998 Maintaining Standards - General anaesthesia " Referring Dentist " Treating Dentist " Anaesthetic support staff " Recovery & discharge " Monitoring & Resuscitation Consultation with RCA
29 RCA report " General Anaesthetics in Dentistry increasing " Deaths continue to occur " Standards - same as other aspects of anaesthesia Royal College of Anaesthetists 1999 General anaesthesia in dentistry strictly limited to the following! Local anaesthesia inappropriate - infection! Problems related to age/maturity physical/mental disability! Long-term dental phobia induced prolonged long term aim treat with sedation & then local
30 RCA report 1999 " Patient assessment # screened referring dentist " Final decision medical history discuss risks & benefits with patient # Patient # Parent or guardian # Operating dentist/anaesthetist RCA report 1999 " Clinical setting # NHS District General Hospital " Outwith DGH # clear protocols # additional support if resuscitation/transfer " Location # easy access to emergency services
31 RCA report 1999 " Suitable # equipment # monitoring # drugs " apparatus # checked # maintained # spares # storage supply facilities RCA report 1999 " Staffing " Team " Recovery Anaesthetists - specialist register of GMC Trainees - accredited programme RCA Non-consultant career grade responsibility of named consultant Anaesthetist & dedicated assistant Dentist & dental nurse Appropriate monitoring anaesthetist/suitably trained individual
32 RCA report 1999 " Aftercare " Audit " Training home - responsible legally competent adult clear instructions anaesthetist to assess fitness for discharge # Basic/advanced life support # Trainee anaesthetists to have instruction # Record in log book RCA report Future " Patient education # relative risks of GA # reduce number of GA s s given " Training anaesthetists " Centralise services " Audit of activity # improve service
33 Department of Health Report A A conscious Decision Recommendation - Chair Dental Anaesthetics must be administered in a hospital setting after 31st December 2001 Alternative techniques " Anxiety control # Psychological # Pharmacological " Relative analgesia # Nitrous oxide " Intravenous sedation # Midazolam # TCI propofol Morbidity/mortality Conscious sedation associated with sedation not clearly defined
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