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Anesthetic Treatment plan Development

David L. basi, dmd, PhD

Case Presentation 128 yo male with 5 day

history of right facial swelling. PMHx= not significantMeds= noneAllergies= NKDA

Physical Exam

• Unable to palpate right inferior border of the mandible

• MIO=25• No FOM swelling• + Vestibular swelling• Gross caries, 30, 19

Diagnosis

• NR # 19 and 30 secondary to caries• Vestibular space abscess• Submandibular space abscess

Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia

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Local anesthetic pharmacokinetic considerations

• The pKa of local anesthetics is such that at physiologic pH (7.4) approximately 1/2 exists in a lipid-soluble non-ionized form (the base)

• Lipid solubility is a main determinant of local anesthetic potency (onset)

Pharmacokinetics and Infection

• When local tissue is acidotic (infection) more ionized form of the local anesthetic exists which limits amount of drug able to reach and act on sodium channels = poor anesthesia

Difficult anesthesia

• Discuss with patient• Use liberal amount of

anesthesia• Allow longer time for the

onset of anesthesia • Use block anesthesia • Consider adjuncts

– Nitrous oxide sedation– Intravenous sedation

• You are having a consultation with a 72 yo male about a simple tooth extraction

• PMH: HTN, h/o MI• Meds: Atenolol

Case Presentation 2 What what else do you want to know???

• When was his MI• What is his activity level

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Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia

Anesthetic considerations

• Maximum EPI dose??

Percent Solution for Epinephrine

• Epinephrine percent is designated by a ratio– 1:1000– 1:10,000– 1:100,000– 1:200,000 etc.

Percent Solution for Epi

• 1:1000 = 1gram/1000ml• =1000mg/1000ml• =1mg/1ml

Percent Solution for Epinephrine

• 1:100,000 = 1gram/100,000ml• =1000mg/100,000ml• =1mg/100ml• =.01mg/1ml

• So how many mg of Epinephrine in a 1.8ml carpule of a 1:100,000 solution?

0.018mg

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Milligrams per milliliter1.00.40.10.05

0.0330.020.01

0.005

Concentration1:10001:25001:10,0001:20,0001:30,0001:50,0001:100,0001:200,000

Vasoconstrictor General Guidelines

• Maximum doses (Epinephrine)• Normal patient .2mg• Cardiac compromised patient .04mg

– ASA III or ASA IV

How many carpules can we give this patient?

0.04 mg /0.018mg/carp

2.2 carps

=

How can we give more??

Medically Compromised: Cardiovascular Disease

• Anxiolysis• Minimal risk of hypoxia• Used in patients with angina, heart

failure, dysrhythmia, MI

• You are having a consultation with a 72 yo male about a simple tooth extraction

• PMH: HTN, h/o MI• Meds: Atenolol and NTG• Complains of CP once a month

Case Presentation 3

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What what else do you want to know???

• When was his MI• What is his activity level

Should you change your anesthetic treatment plan??

• A 45 year old woman is in for a consultation.

• You determine she needs a total odontectomy and alveoloplasty– PMHX : Type I diabetes– Meds: Regular Insulin and NPH

Case Presentation 4 Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia

Should you alter her insulin regiment? Consider

• Length of procedure• Type of procedure• Type of anesthesia you will be using• Will the patient be NPO??

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Diabetes Mellitus: Traditional Management

• NIDDM: (D/C oral hypoglycemic agent day prior)

• IDDM: 30-50% a.m. dose NPH/ Lente, (hold regular); post operative insulin sliding scale

• Consider plasma glucose check day of surgery

• A 45 year old woman is in for a consultation.

• You determine she needs # 19 extracted– PMHX : Type I diabetes– Meds: Regular Insulin and NPH

Case Presentation 5

Should you alter her insulin regiment? Consider

• Length of procedure• Type of procedure• Anxiety level of patient

• A 14 year old presents for premolar extraction prior to ortho tx.

• She is very anxious

• PMHx : Asthma • Meds: Albuterol • Allergies : NKDA

Case Presentation 6 Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia

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Can you use Nitrous Oxide?? Asthma

• Nitrous - non-irritating to respiratory mucosa• no increased bronchospasm• NOT contraindicated

Treatment Plan?? Use Nitrous Oxide / Oxygen

Topical Anesthesia

• Topical Anesthetic• 30 seconds or

greater of contact with mucosa

Administer Local Anesthesia

• Aspirating syringe• 25, 27 or 30 gauge

needle• Long (40mm) or

short (25mm)

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• A 8 year old presents for extraction of retained primary teeth She is very anxious

• ASA I

Case Presentation 7 Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia• Also, Consider PO, IM sedation

What kind of Local Anesthesia will you use??

Commonly used local anesthetics without

vasoconstrictors• 2% Lidocaine 5-10 minutes• 3% Mepivicaine 20-40 minutes• 4% Prilocaine 5 minutes

(infiltration)– Up to 60 minutes (block anesthesia)

• A 32 year old pregnant woman presents with extremely painful tooth # 32

• ASA I

Case Presentation 8 Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia

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Nitrous Oxide Contraindications

• Pregnancy– spontaneous abortion– birth defects

Nitrous Oxide and Pregnancy

• Oxidized Vitamin B12

• Vitamin B12 needed for folate metabolism

• Folate essential for thymidine, a base nucleic acid for DNA

• A 32 year old man presents with extraction of # 32

• PMHX : Seizers • Meds: Dilantin

Case Presentation 9 Treatment options???

• Local Anesthesia• Nitrous oxide / oxygen + local

Anesthesia• IV sedation + local Anesthesia

Neurologic Disease

• Increased risk of seizure with hypoxia– nitrous-oxide mixture prevents hypoxia

• A 32 year old man presents with extraction of # 32

• PMHX : Seizers • Meds: Dilantin, tegretol

• Has seizures 3-4x / week

Case Presentation 10

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Change your anesthetic treatment plan?? Consider

• ASA Classification • Use of Local Anesthesia• OR