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DENTAL ANESTHESIA
COMPLICATIONS IN THE DENTAL CHAIR
SAAD A. SHETA
Associate Professor Consultant Anesthesia
Dental CollegeKSU
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Dental Anesthesia
Out-Patient Anesthesia (Dental Chair Anesthesia)
Sedation Techniques
Day-Case Anesthesia
In-Patient AnesthesiaComplete Dental rehabilitationComplicated oral surgery proceduresMajor Maxillofacial surgeries
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Complications in Dental Anesthesia
Out-Patient Dental Anesthesia“Dental Chair Anesthesia
Office-Based Dental Sedation
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Out-Patient Dental Anesthesia
“Dental Chair Anesthesia”
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Out-Patient Dental Anesthesia “Dental Chair Anesthesia”
Out-Patient dental extractionChildren (4-10 years): high incidence of URTISteadily decreased
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Out-Patient Dental AnesthesiaInduction
Inhalational (mask) inductionIntravenous Induction
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Out-Patient Dental Anesthesia Maintenance
Inhalational agents/N2O
Nasal mask, mouth gag, packMaintain airway
Supine Position
Less hypotension less bradycardia
high risk of aspirationAirway obstruction&Decrease ERV
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Out-Patient Dental Anesthesia Recovery
Left lateral position100% O2
Suction Observation & monitoringDischarge criteriaInstructionsAnalgesia (NSAIDs)
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Office-Based Dental Sedation
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Sedation
It is a technique where one or more drugs are used to Depress the Central Nervous System of a patient thus reducing the awareness of the patient to his surrounding
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According to the degree of CNS depression:
Conscious SedationDeep SedationGeneral Anesthesia
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Conscious Sedation
It is a controlled, pharmacologically Induced, minimally depressed level of consciousness that retains the patient’s ability to maintain a patent airway independently and continuously and respond appropriately to physical and/or verbal command
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Deep Sedation
It is a controlled, pharmacologically induced state of depressed level of consciousness. from which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes,including the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal commands
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Sedation Techniques
Non Titrable Technique
Oral SedationRectal SedationIntramuscular SedationSubmucosal SedationIntranasal Sedation
Titrable Technique
Inhalational SedationIntravenous Sedation
Combination Of Two
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Combination of Methods and Techniques
Most complications occurred with polypharmacology in the hands of untrained personnel
AUGMENTATION OF THE EFFECT + REDUCE THE DOSE OF STONGER DRUGS.
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Pre-requirements: (Essentials to reduce the risk)
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Pre-requirements
Proper training and familiarity with the technique (including support personals)
Patients selectionClear instructions MonitoringDocumentationEmergency Back-up
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Patients Selection Contraindications
Serious cardiopulmonary diseases, COPDDiabetes or other endocrinological diseasesNeuromuscular disordersCoagulopathies & HemoglobinopathiesMarked oro-facial swelling (edema& trismus)Potential difficult airwaysExtreme obesityDrugs: MAOIs , AnticoagulantNot fasting
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Monitoring
Clinical ObservationPulse OximetryPrecordial/pretracheal
StethoscopeBPECG
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Equipment
Dental ChairAnesthetic EquipmentsMonitoringResuscitation Equipments
“ Up to the standards of In-Patient GA ”
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Dental Chair
Adjustable: ( horizontal /Head down)
Manual release
Adjustable head rest
Hospital out-patient: operating table
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Anesthesia Equipments
Continuous flow anesthesia machine
Quantiflex (Relative Analgesia)
Mouth props, packs, gags, nasopharyngeal airway, rubber dam
Separate suction unit
Scavenging system
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Equipment
Continuous flow design with flow metersSafe delivery of O2 and N2O (fail safe
mechanism)10 l/min for 60 minE cylinder(650 litres)
Pin-indexed yoke systemEfficient scavenger
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Oxygen (Central)
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Emergency Equipment
Airway Adjuncts : Airways, Masks and Nasal prongs
Bag-valve- mask
High Volume Suction Device Oxygen Source
Others: Crash Cart
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Airway Adjuncts
If breathing adequately spontaneously
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Bag-valve-Mask
built-in colorimetric ETCO2 detector
If Artificial ventilation necessary
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Crash Cart
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Crash Cart
Intravenous Line: Cannulae Syringes NeedlesAirway AdjunctsEndotracheal IntubationCricothyrotomyEmergency Drugs
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Emergency Drugs
Drugs to treat AllergyBenzodiazepine AntagonistAnticonvulsantsNarcotic AntagonistsSteroidsAntihypoglycemicVasopressorsAnalgesicsACLS drugs
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Dental Chair Complications
Respiratory Complications
Cardiovascular Complications
Miscellaneous
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Respiratory Complications
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AIRWAY OBSTRUCTION
RESPIRATORY DEPRESION
BRONCHEAL ASTHMA
HYPERVENTILATION
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Respiratory Complications
Airway ObstructionRespiratory Depression
Causes Tongue Blood, debris Laryngeal spasm
Narcotics Over-sedation
Clinical Picture
A-W Obstruction Hypoxia
Hypoventilation Hypercapnia Hypoxia
Management Patent airway Oxygenation
Ventilation Reversal Agents
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Airway (“A”)
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Airway Obstruction
Most common cause: tongue and/or epiglottis
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Open the Airway
Jaw thrust Head tilt–chin lift
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Head Tilt/Chin Lift
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Jaw-Thrust Maneuver
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Jaw-Lift Maneuver
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Four Sharp back blows (Rapid successions)
Abdominal Thrust HEIMLICH MANEUVER
Chest Thrust
Ventilate Via Mask
An unconscious patient, these maneuvers are followed be sweeping a finger from the side of the patient’s mouth
Airway Obstruction By Foreign Body
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Direct visualization of the larynx with a laryngoscope may enable the removal of
an obstructing foreign body
Direct visualization of the larynx with a laryngoscope may enable the removal of
an obstructing foreign body
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Open the Airway
Oropharyngeal Airway
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Insert oropharyngeal airway with tip facing palate
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Rotate airway 180º into position
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Open the Airway
Nasopharyngeal Airway
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Nasopharyngeal Airway
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Advanced Airway Management
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Endotracheal Intubation is the Most Preferred Method of Advanced Airway Management
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Engaging laryngoscope blade and handle
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Activating laryngoscope light source
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Laryngoscope Blades
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Open the Airway
Endotracheal Intubation “ Laryngoscopes ”
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ETT and Syringe
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ETT
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ETT, Stylet, and Syringe “unassembled”
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ETT, Stylet, and Syringe “assembled for intubation”
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Endotracheal Intubation “Technique”
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Position
Endotracheal Intubation “Aligning Axes of the Airway”
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Hyperventilate patient
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Prepare equipment
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Apply Sellick’s Maneuver and insert laryngoscope
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Endotracheal Intubation “ Visualization of the Cord
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Glottis visualized through laryngoscopy
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Visualize larynx and insert the ETT
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Inflate cuff, Ventilate, and Auscultate
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Secure tube
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Reconfirm ETT placement
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Laryngeal Mask Airway
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Laryngeal Mask Airway
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Laryngeal Mask Airway (LMA)
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The Only Indication of a Surgical Airway is the inability to establish
Airway by Any Other Method
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Breathing (“B”)
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Oxygenation
Adjunct Devices
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Bag-valve-mask ventilation
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Ventilation
Bag-Mask Ventilation
Key ventilation volume: “enough to produce obvious chest rise”
1 Persondifficult, less effective
2 Personseasier, more effective
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HYPERVENTILATION
Management
early recognitionreassuranceOxygenBreathe into a paper bagAnxiety agent
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Bronchial ASTHMA
AetiologyIn Children : Allergic (Ig E) or Extrinsic In adults: Extrinsic
(Stress)
Clinical Picture
HistoryMild wheezingCoughing to severe dyspnea ,
Cyanosis and death
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Bronchial ASTHMA
ManagementOxygen Aerosolized adrenergic agentsEpinephrine (0.01 mg/kg SC)Emergency transport to the hospital
!!!intravenous amnophyllinedose of 5.6 mg/kg is infused over 10 minutes, fol1owed by a continuous intravenous infusion of 1 mg/kg/hour
early administration of corticosteroid
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Cardiovascular Complications
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HYPOTENSION
BRADYCARDIA
DYSRYTHMIAS ( Tachy-dysrhythmia)
SYNCOPE
ALLERGIC REACTION
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HYPOTENSION
Induction of AnesthesiaCarotid sinus compressionOver-sedation
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BRADYCARDIA
Tooth extraction
Halothane (nodal rhythm)
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DYSRHYTHMIAS
Aetiology (Tooth extraction)
High preoperative catecholaminesLight anesthesiaAirway obstruction & hypoxiaHalothane & local anesthesiaLocal anesthesia with vasopressors
SignificanceControversialSignificant with unexpected cardiac disease
(viral myocarditis)
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SYNCOPE
CausesFactors (CV, allergic,..)Emotional factors (more common)
Aetiology
limbic cortex-hypothalamus-reflex vasodilatationIncrease parasympathetic activity-bradycardia
Less common in childrenSympathetic nervous systemEndogenous epinephrine and nor epinephrine
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SYNCOPE
Clinical PictureCold, pale, and sweaty skinFeels dizzy of faint
ManagementFlat, Head down-leg elevated
100% O2
Ammonia inhalantAtropine / VasopressorsMedical assistance “ if Recovery of consciousness is Delayed beyond 5 minutes Incomplete after 15 to 20 minutes”
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ALLERGIC REACTION
IncidenceVery rareMore commonly (vaso-vagal, toxic reaction, epinephrine)
AetiologyHistamineIg E-mediated reaction Easter-linked: p-amino benzoic acidAmide-linked: preservatives (Paraben)
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ALLERGIC REACTION
Clinical Picture “ Skin, Respiratory and Cardiovascular System”
Mild erythematous rash to urticaria (hives) to angioedema
Bronchospasm, cough, dyspnea, pulmonary oedema, laryngeal oedema, hypoxia
Hypotension, tachycardia, arrhythmias, Eventually C. arrest
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ALLERGIC REACTION
Management
100% O2 Epinephrine (0.01-0.5 mg IV or IM)
IV fluids (LRS 1-2 liters) Intubation
Diphenhydramine “Orally at 6-hr intervals for 24-48 hrs”
Hydrocortisone (up to 200mg IV) Aerosolized sympathomimetic agent
“Epinephrine, Isoproterenol, or Metaproterenol”
Transported to the hospital
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Miscellaneous
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SEIZURES
Clinical Picture TONIC-CLONIC “FOUR PHASES”
Pro-dromal phaseThe auraThe convulsiveThe post-ictal phase
A significant degree of CNS depression is usually present during this post-ictal phase
Increased oxygen consumption, tachycardia, hypertension, impairedventilation, and cardiac arrhythmias
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SEIZURES
Management
Prevent self-injuryAirway management &Adequate ventilation
Intravenous diazepamSupportive careHyperthermia
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DIABETES MELLITUS
AetiologyJuvenile onset diabetes, Worst prognosis
Poor Insulin Production Clinical Picture
Hypoglycemia or hyperglycemiaDiabetic ketoacidosis (Coma &Death)
“Hypoglycemia ” Deteriorating Cerebral FunctionNauseaSympathetic NS Stimulation (Tachycardia, Hypertension, ArrhythmiasMental Obtundation, Loss of Consciousness, Seizures
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DIABETES MELLITUS
Management
Oxygen Fully Conscious, Oral Sugar containing Food or DrinksDextrose 50% “IV”, Till regain ConsciousnessGlucagon “IM”
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Miscellaneous
Nasal Trauma, Epistaxis Pulmonary AspirationDiffusion HypoxiaContinued BleedingPost operative Sore ThroatPost operative Nausea & vomitingPost operative Pain & swelling
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THANK YOU