Advancements in office-based anesthesia in oral and maxillofacial surgery

An Alternative Airway Intervention to Preserve the Surgical Field in Oral and Maxillofacial Surgery

Background/need. Office-based sedation has become increasingly commonplace in dental offices in recent years, allowing for practitioners to provide broader scope of care for their patients. Maintaining high standards of safety is of utmost importance when sedation is utilized in the office-based setting, especially for patients deemed at a higher-risk for intraoperative airway obstruction. This demographic includes but is not limited to individuals with a medical history significant for obstructive sleep apnea, chronic obstructive pulmonary disease, and morbid obesity. Presently, a wide variety of airway devices exist for use in the event of airway obstruction. However, in the context of oral and maxillofacial surgery, placement of these devices can encroach upon the surgical field, extending the perioperative period and putting the patient at greater long-term risk for maintaining adequate oxygenation. Methodology. The authors describe a preliminary technique trialed in our offices which utilizes a size 5.0 endotracheal tube (5OET) as an adjunct supraglottic airway to help mitigate the issue of oxygen saturation maintenance, as well as unimpeded access to the oral cavity. Implementation of the device requires identifying appropriate candidates during preoperative screening and placing the device through the nare and securing it above the glottis. Device Description. The 'tube kit' is comprised of a standard size straight 5.0 cuffed oral ETT, a 5-mL syringe for inflation of the cuff post insertion, lubricant, flex extension tubing, end tidal sampling line for capnography, tape for securement of the 5OET, and an anesthesia breathing circuit. Optional equipment pieces include an elbow connecter and a foam piece for comfort. Results/Current Status. Preliminary results have demonstrated oxygen saturations maintained above 98% when the 5OET is placed preoperatively. Continued use of the trial device will inform the development of a tube by our clinicians, and its efficacy will be studied in our offices. The next steps will be to start developing a pilot cuff that will be submitted for patent approval after its use in IRB-approved clinical studies.

Prospective evaluation of remifentanil-propofol mixture for total intravenous anesthesia: A randomized controlled study

Application of total intravenous anesthesia (TIVA) may be considered as unpractical when compared with inhalational anesthesia. Although it is mostly not recommended, mixing intravenous agents is popular in clinical practice. The aim of the present study was to investigate the suitability of using remifentanil-propofol mixture (MIXTIVA) for TIVA. Adult patients with an American Society of Anesthesiologists grade of I-II scheduled for elective thyroidectomy were randomly allocated to 3 groups (n=32 for each) to receive TIVA with remifentanil and propofol infusions separately (control group, Group I) or with MIXTIVA infusion that contained remifentanil/propofol at a proportion of 2/1,000 or 3/1,000 (remifentanil concentration, 20 or 30 µg/ml in 1% propofol in Group II or Group III, respectively). The extubation time (the primary outcome of the study), the orientation time and number of patients in whom intraoperative hypotension, hypertension or bradycardia episodes were encountered during anesthesia were comparable among the groups. The mean remifentanil infusion rate in Group III was significantly higher than that in the other groups. The mean propofol infusion rates and mean bispectral index (BIS) scores during anesthesia were comparable among groups. Hypotension accompanied with a high BIS was encountered in one patient in Group III. In conclusion, compared to the standard TIVA technique using separate drug infusions, MIXTIVA infusion used for thyroidectomies did not result in any statistically significant difference in recovery and clinical outcomes. This technique may be considered as a practical implementation for busy ambulatory centers performing general anesthesia. The present study was retrospectively registered at clinicaltrials.gov (trial registration no. NCT04394897).

Benefits and harms of capnography during procedures involving moderate sedation: A rapid review and meta-analysis

BACKGROUND

Patient safety is a priority in dentistry. Evaluating the benefits and harms associated with the addition of capnography to standard monitoring during moderate sedation for adult patients in the dental practice setting is needed.

TYPES OF STUDIES REVIEWED

The authors used rapid review methodology to identify relevant systematic reviews, which they updated through a systematic search by using the same search strategy as the identified reviews. The authors searched PubMed and Google Scholar and through the references of the identified systematic reviews, which yielded 2,892 studies. Inclusion criteria were that the article was available in English, was original research in adult humans who had undergone moderate procedural sedation, and involved comparing standard monitoring with the addition of capnography.

RESULTS

Sixteen studies were eligible, involving 3,866 adults undergoing procedural sedation. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the evidence and rate it as being of moderate to low quality because of high risk of bias and heterogeneous effects for the outcomes of hypoxemia and adverse respiratory events. Capnography had higher sensitivity to detect adverse respiratory events than did standard monitoring alone (0.92; 95% confidence interval, 0.65 to 0.99) and may reduce the risk of developing hypoxemia by 31% (risk ratio, 0.69; 95% confidence interval, 0.57 to 0.82). Capnography did not affect the risk of developing serious adverse events, procedure time, sedation quality, or patient satisfaction.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Adding capnography to standard monitoring of adults during moderate sedation may reduce the risk of developing hypoxemia, increase detection of adverse respiratory events, and is not associated with additional harms. These findings suggest routine use of capnography during moderate sedation has the potential to reduce adverse anesthetic outcomes in dental practice.

Anesthetic Pump Techniques Versus the Intermittent Bolus: What the Oral Surgeon Needs to Know

The most popular agents in use for office-based anesthesia are propofol, ketamine, and remifentanil, which have the desirable properties of rapid onset and short duration of action. A useful parameter in assessing these agents is the context-sensitive half-time. These anesthetic agents demonstrate relatively low, flat plots compared with older agents. For delivery of intravenous anesthetics, oral and maxillofacial surgeons have relied small incremental boluses with great success. However, relatively simple syringe infusion pumps can provide an even "smoother" anesthetic. This article familiarizes oral and maxillofacial surgeons with the advantages of infusion pumps and provides examples of their use.