Anesthesia complications in the dental office

Anesthesiacomplications in thedental officeEditors:

Robert C. Bosack, DDSClinical Assistant ProfessorCollege of DentistryUniversity of IllinoisChicago, Illinois, USA

Private PracticeOral and Maxillofacial SurgeryChicago, Illinois, USA

Stuart Lieblich, DMDClinical ProfessorDepartment of Oral and Maxillofacial SurgeryUniversity of ConnecticutAvon, Connecticut, USA

Private PracticeOral and Maxillofacial SurgeryAvon, Connecticut, USA

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Library of Congress Cataloging-in-Publication Data

Anesthesia complications in the dental office / editors, Robert C. Bosack, Stuart Lieblich.p. ; cm.

Includes bibliographical references and index.ISBN 978-0-470-96029-5 (cloth)I. Bosack, Robert C., editor. II. Lieblich, Stuart E., editor.[DNLM: 1. Anesthesia, Dental–adverse effects. 2. Anesthesia, Dental–contraindications. 3. Intraoperative Complications–prevention & control.

4. Postoperative Complications–prevention & control. 5. Risk Factors. WO 460]RK510617.9’676–dc23

2015000738

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Set in 9/11pt MinionPro-Regular by Laserwords Private Limited, Chennai, India

1

This edition first published 2015 ©2015 by John Wiley & Sons, Inc.

Reporting Service are ISBN-13: 978-0-470-96029-5 / 2015.

2015

To my family, with special remembrance for my Dad, S. Richard Bosack,DDS (1921–2011), to whom I promised this dedication.Robert C. Bosack

To my family, teachers, and students; but most importantly to thepatients who have trusted me with their care.Stuart Lieblich

In memory of John Yagiela, DDS (1947–2010).

Contents

Contributors, ixForeword, xiiiPreface, xvAcknowledgment, xvii

Section 1: Introduction

1 Anesthetic complications—how bad things happen, 3Robert C. Bosack

Section 2: Patient risk assessment

2 History and physical evaluation, 9Kyle Kramer, Trevor Treasure, Charles Kates, Carrie Klene,and Jeffrey Bennett

3 Laboratory evaluation, 15Kyle Kramer and Jeffrey Bennett

4 NPO guidelines, 19Kyle Kramer and Jeffrey Bennett

Section 3: Anesthetic considerations forspecial patients

5 Anesthetic considerations for patients withcardiovascular disease, 25Erik Anderson and Robert Bosack

6 Anesthetic considerations for patients with respiratorydisease, 49Robert C. Bosack and Zak Messieha

7 Anesthetic considerations for patients withendocrinopathies, 61Daniel Sarasin, Kevin McCann, and Robert Bosack

8 Anesthetic considerations for patients with psychiatricillness, 71Daniel L. Orr, Robert C. Bosack, and John Meiszner

9 Anesthetic considerations for patients with neurologicdisease, 79Joseph A. Giovannitti

10 Anesthetic considerations for patients with hepaticdisease, 85Jeffrey Miller and Stuart Lieblich

11 Anesthetic considerations for patients with renal disease, 89Marci H. Levine and Andrea Schreiber

12 Anesthetic considerations for pediatric patients, 93Michael Rollert and Morton Rosenberg

13 Anesthetic considerations for geriatric patients, 97Andrea Schreiber and Peter M. Tan

14 Anesthetic considerations for patients with bleedingdisorders, 103O. Ross Beirne

15 Anesthetic considerations for patients with cancer, 113Andrea M. Fonner and Robert C. Bosack

16 Anesthetic considerations for pregnant and earlypostpartum patients, 117Robert C. Bosack

Section 4: Review of anesthetic agents

17 Clinical principles of anesthetic pharmacology, 123Richard C. Robert

18 Local anesthetic pharmacology, 129Roy L. Stevens and Robert C. Bosack

19 Enteral sedation agents, 133Richard C. Robert

20 Parenteral anesthetic agents, 135Richard C. Robert

21 Inhalational anesthetic agents, 143Charles Kates, Douglas Anderson, Richard Shamo,and Robert Bosack

22 Antimuscarinics and antihistamines, 151Richard C. Robert

23 Drug interactions, 155Kyle Kramer and Richard C. Robert

Section 5: Monitoring

24 Limitations of patient monitoring during office-basedanesthesia, 163Robert C. Bosack and Ken Lee

Section 6: Preparation for adversity

25 Crisis resource management, 173Joseph Kras

26 Simulation in dental anesthesia, 177Joseph Kras

27 Airway adjuncts, 181H. William Gottschalk

28 Intravenous fluids, 185Cara Riley, Kyle Kramer, and Jeffrey Bennett

29 Emergency drugs, 189Daniel A. Haas

vii

viii Contents

Section 7: Anesthetic adversity

30 Failed sedation, 201Roy L. Stevens and Kenneth L. Reed

31 Complications with the use of local anesthetics, 207M. Anthony Pogrel, Roy L. Stevens, Robert C. Bosack,and Timothy Orr

32 Anesthetic adversity – cardiovascular problems, 219Robert C. Bosack and Edward C. Adlesic

33 Anesthetic adversity—respiratory problems, 231Charles F. Cangemi, Edward C. Adlesic, and Robert C. Bosack

34 Allergy and anaphylaxis, 251H. William Gottschalk and Robert C. Bosack

35 Anesthetic adversity–neurologic problems, 257Michael Trofa and Robert C. Bosack

36 Acute, adverse cognitive, behavioral, andneuromuscular changes, 261Edward Adlesic, Douglas Anderson, Robert Bosack,Daniel L. Orr, and Steven Ganzberg

37 Anesthetic problems involving vasculature, 271Stuart Lieblich

Section 8: Post-anesthetic adversity

38 Nausea and vomiting, 277Edward Adlesic

39 Post-anesthetic recall of intraoperative awareness, 283Robert C. Bosack

40 Delayed awakening from anesthesia, 287Stuart E. Lieblich

41 Safe discharge after office-based anesthesia, 291Stuart Lieblich and Peter M. Tan

Section 9: When bad things happen

42 Morbidity and mortality, 295Lewis Estabrooks

43 Death in the chair: a dentist’s nightmare, 299Glen Crick

44 Legal issues of anesthesia complications: risks ormalpractice, 307Arthur W. Curley

Section 10: When should you say no

45 When should you say no? 315Andrew Herlich and Robert C. Bosack

Section 11: Appendices

Appendix A A pilot’s perspective on crisis resourcemanagement, 323David Yock

Appendix B Medical emergency manual for the generalpractitioner, 325Robert C. Bosack

Appendix C Malignant hyperthermia Q & A, 337Edward C. Adlesic and Steven I. Ganzberg

Index, 339

Contributors

Edward C. Adlesic, DMDAssistant Clinical ProfessorDepartment of Oral and Maxillofacial SurgeryUniversity of Pittsburgh School of Dental MedicinePittsburgh, PAUSA

Douglas W. Anderson, DMDClinical Assistant Professor (Ret)Department of Anesthesiology and Peri Operative MedicineOregon Health Sciences UniversityPortland, ORUSA

Erik P. Anderson, MDAssistant ProfessorDepartment of AnesthesiologyUniversity of Vermont College of MedicineBurlington, VTUSA

O. Ross Beirne, D.M.D., Ph.D.ProfessorDepartment of Oral and Maxillofacial SurgeryUniversity of WashingtonSeattle, WAUSA

Jeffrey D. Bennett, DMDProfessorDepartment of Oral Surgery and Hospital DentistryIndiana UniversityIndianapolis, INUSA

Robert C. Bosack, DDSClinical Assistant ProfessorUniversity of IllinoisCollege of DentistryChicago, IL,USAPrivate PracticeOral and Maxillofacial SurgeryOrland Park, IL,USA

Charles F. Cangemi Jr., DDS, MSDentist-AnesthesiologistPrivate Practice, Dental AnesthesiologyCharlotte, NCUSA

Glen Crick, esq. (dec.)Chicago, ILUSA

Arthur W. Curley, JDPresident and Managing PartnerBradley, Curley, Asiano, Barrabee, Abel & Kowalski, PCLarkspur, CAUSA

Lewis N. Estabrooks DMD, MSBoard of DirectorsOMSNICRosemont, ILUSA

Andrea M. Fonner, DDSDentist AnesthesiologistPrivate PracticeSeattle, WAUSA

Steven Ganzberg, DMD, MSDirector of AnesthesiologyCentury City Outpatient Surgery CenterClinical Professor of AnesthesiologyUCLA School of DentistryLos Angeles, CAUSA

Joseph A. Giovannitti, Jr., DMDProfessorDepartment of Dental AnesthesiologyUniversity of Pittsburgh School of Dental MedicinePittsburgh, PAUSA

H. William Gottschalk, DDSAssistant Clinical ProfessorUniversity of Southern California School of DentistryLos Angeles, CAUSA

Daniel A. Haas, DDS, PhD, FRCD(C)Professor and DeanFaculty of DentistryUniversity of TorontoToronto, ONCanada

Andrew Herlich, DMD, MD, FAAPProfessor and Vice-Chair for Faculty DevelopmentDepartment of AnesthesiologyUniversity of Pittsburgh School of MedicineStaff Anesthesiologist, UPMC MercyPittsburgh, PAUSA

ix

x Contributors

Charles H. Kates, DDSAssociate Professor, Anesthesiology and SurgeryDepartments of Anesthesiology and SurgeryUniversity of Miami Miller School of MedicineChief of Anesthesiology and Pain Management, Section ofOral/Maxillofacial Surgery, Department of SurgeryJackson Memorial HospitalMiami, FLUSA

Carrie Klene, DDSProgram DirectorClinical Assistant ProfessorOral and Maxillofacial SurgeryIndiana UniversityIndianapolis, INUSA

Kyle J. Kramer, DDS, MSAssistant Clinical ProfessorDepartment of Oral Surgery and Hospital DentistryIndiana UniversityIndianapolis, INUSA

Joseph F. Kras, MD, DDS, MAAssociate ProfessorDepartment of AnesthesiologyWashington University in St. LouisSt. Louis, MOUSA

Kenneth K. Lee, DDSAttending in Dental Anesthesia, NYU-Lutheran Medical CenterAssociate Clinical ProfessorOstrow School of Dentistry at USCLos Angeles, CAUSA

Marci H. Levine, DMD, MDClinical Assistant ProfessorDepartment of Oral and Maxillofacial SurgeryNew York University College of DentistryNew York, NYUSA

Stuart Lieblich, DMDClinical ProfessorOral and Maxillofacial SurgeryUniversity of ConnecticutFarmington, CTPrivate PracticeAvon Oral and Maxillofacial SurgeryAvon, CT,USA

Kevin J. McCann, DDS, FRCD(C)Private PracticeWaterloo, ONCanada

John W. Meiszner, MDPrivate Practice in General and Addiction PsychiatryForensic Psychiatrist for State of Illinois, retiredOrland Park, ILUSA

Zakaria Messieha, DDSClinical Professor of AnesthesiologyColleges of Dentistry & MedicineUniversity of Illinois at ChicagoPrivate Practice, Dental AnesthesiologyChicago, ILUSA

Jeffrey Miller, DMD, MD, MPHChief ResidentDepartment of Oral and Maxillofacial SurgeryUniversity of Connecticut Health CenterFarmington, CTUSA

Daniel Orr II, DDS, PhD, JD, MDProfessor and DirectorOral and Maxillofacial Surgery and Advanced Pain ControlUNLV School of Dental MedicineClinical ProfessorOral and Maxillofacial Surgery and Anesthesiology for DentistryUniversity of Nevada School of MedicineLas Vegas, NVUSA

Timothy M. Orr, DMDDentist AnesthesiologistAustin, TXUSA

M. Anthony (Tony) Pogrel, DDS, MDProfessorDepartment of Oral and Maxillofacial SurgeryUniversity of CaliforniaSan Francisco, CAUSA

Kenneth Reed, DMDAssociate Program DirectorDental AnesthesiologyLutheran Medical CenterBrooklyn, NYUSA

Cara J. Riley, DMD, MSAssistant ProfessorChildren’s Hospital ColoradoDepartment of AnesthesiologyAurora, COUSA

Richard C. Robert, DDS, MSClinical ProfessorDepartment of Oral and Maxillofacial SurgeryUniversity of California at San FranciscoSan Francisco, CAUSA

Michael K. Rollert, DDSPrivate PracticeDenver, COUSA

Morton Rosenberg, DMDProfessor of Oral and Maxillofacial SurgeryHead, Division of Anesthesia and Pain ControlTufts University School of Dental MedicineAssociate Professor of AnesthesiologyTufts University School of MedicineBoston, MAUSA

Contributors xi

Daniel S Sarasin, DDSPrivate Practice OMFSCedar Rapids, IAUSA

Andrea Schreiber DMDAssociate Dean for Post-Graduate and Graduate ProgramsClinical Professor of Oral and Maxillofacial SurgeryNew York University College of DentistryNew York, NYUSA

Rick Shamo DDS, MDDirector of Oral & Maxillofacial SurgeryMemorial Hospital of Sweetwater CountyRock Springs, WYUSA

Roy L. Stevens, DDSPrivate PracticeGeneral Dentistry for Patients with Special Health Care NeedsOklahoma City, OKUSA

Peter M. Tan DDS, MSHSMid-Maryland Oral and Maxillofacial Surgery, P.A.Frederick, MDUSA

Trevor E. Treasure, DDS, MDAssistant ProfessorDepartment of Oral and Maxillofacial SurgeryUniversity of Texas – School of DentistryHouston, TXUSA

Michael Trofa, DMD, MDDepartment of Oral and Maxillofacial SurgeryUniversity of ConnecticutFarmington, CTUSA

Captain David Yock, ATPSouthwest AirlinesDallas, TXUSA

Foreword

The publication Anesthesia Complications in the Dental Office cov-ers a wide range of topics beneficial to all levels of anesthesia careproviders, be they students, residents, academics, or clinical prac-titioners. The book begins with the preoperative issues that play arole in evaluating the difficulties in safeguarding the patients, manyof whom present with medical problems that were far less commona couple of years ago. Modern medicine has extended our longevitybut now the patients present to our offices with an extended listof medications for diseases that were less recognized in the pastdecades and they are often diagnosed with behavioral and obesityissues.

Pharmacology of anesthesia practice has frequently met thechallenges of modern societal problems with newer, more efficientshorter acting agents than what was available in the 1960s and1970s. These are discussed in the middle chapters of the book.While basic physiology has not changed much, our understandingof the new drugs available and the way they affect the safety ofpatients under anesthesia has. Since the 1980s, monitoring theeffects of all anesthesia drugs with pulse oximetry, capnography,and even bispectral analysis for special situations has set the scenefor improved safety.

Despite the improvement in airway management techniques andskills learned, complications, both common and far less common,

are still of great concern. The final chapters in the book deal withthe need for prompt recognition and treatment of anesthesia-relatedurgencies and emergencies. While death “is not an option” so tospeak, it is discussed and put in proper perspective when compar-ing the risks of air travel, driving, and even exercising to those ofundergoing anesthesia in the office.

This first edition of Anesthesia Complication in the Dental Officeoffers a wide variety of subject material and should be on thelibrary shelf of every anesthesia care provider working in thedental office. The names of the contributors are well known inacademia and in clinical practice and have great credibility in thefield of office-based anesthesia practice to make this book worthy ofacquiring.

Robert Campbell DDSEmeritus Professor of Anesthesiology and Oral

and Maxillofacial SurgeryDepartments of Anesthesiology and Oral

and Maxillofacial SurgeryVirginia Commonwealth University/

Medical College of VirginiaRichmond, Virginia, USA

xiii

Preface

Anesthesia is a unique discipline in dentistry. We all take it forgranted, yet little can be done without it. The only time we everreally pay attention to it is when it does not work as planned.Anesthetic complications, which range from simple annoyancesto patient mortality, are inevitable, given the many and complexinteractions of doctor, patient, personnel, and facility. Our intentis to minimize the frequency and severity of adverse events, byproviding concise and clinically relevant information that can beput to everyday use.

This book is intended for all dental professionals, who alreadyhave a working knowledge of anesthesia at their level of practice.Most of the 10 sections are relevant to all levels of anesthesiapractice – including patient risk assessment (Section II) and areview of common pathophysiologic problems (Section III). Thereview of anesthetic agents includes chapters on local anesthesia,nitrous oxide analgesia, and both enteral and parenteral agents.Emphasis in Section IV is placed on pharmacology, with the hopethat appropriate and successful use of these agents will limit adverseand sometimes unexpected side effects. Sections V–X are morerelevant to parenteral techniques, with the notable exception of therobust Chapter (31) on problems associated with the use of localanesthesia. We were pleased to have the opportunity to review theStanding Medical Orders of the Emergency Medical System froma major metropolitan region. Knowing what paramedics woulddo when called validated our recommendations for the initialmanagement of anesthesia-related emergencies.

The appendices contain an interesting submission on crisisresource management by an airline pilot. We have learned muchfrom the groundbreaking safety protocols that have transformedthe airline industry. A brief emergency manual, suitable for generalpractitioners, has also been provided.

We have taken several liberties with this publication. Focus hasbeen directed to the office setting, with its obvious and inherent

limits on diagnosis and treatment. We have used the words anes-thesia and sedation interchangeably, with the understanding thatdrug use may be limited by training or license. Wherever possible,we have attempted to include references to key or seminal articles,to provide direction to those practitioners seeking further informa-tion.

Over the years, we have been given the wonderful opportunity topresent to and interact with a great number of dentists of all special-ties on the topic of anesthesia. Interest always piqued with the word“complication,” so that fueled the content of this project. Over thepast 32 years, we have accumulated a fair amount of practice experi-ence, either first hand or by listening to your sometimes painful sto-ries, which many have unabashedly shared. We have learned morethan we taught and it is our hope to share all of this informationwith you. We are grateful and humbled to be among our 43 contrib-utors, who so graciously accepted the invitation to also share theirknowledge, experience, and expertise with us.

If but one life can be saved, or one patient managed better, thenthis book is well worth the effort. We both assiduously embrace thestatement: “Patient Safety through Education.” Thank you for yourinterest and dedication to improving the delivery of anesthesia inthe dental office. Our best wishes to your continued successful pro-fessional practice.

Robert C. BosackUniversity of IllinoisCollege of Dentistry

Chicago, Illinois, USA

Stuart LieblichUniversity of Connecticut

Department of Oral and Maxillofacial SurgeryFarmington, Connecticut, USA

xv

Acknowledgment

Mr. Brian Stafford, who so patiently created many of the illustrations in this book making “comprehensionat a glance” an art form.

Unless otherwise indicated, all pictures are courtesy of Dr. Robert C. Bosack.

xvii

SECT ION 1

Introduction

1 Anesthetic complications—howbad things happenRobert C. BosackUniversity of Illinois, College of Dentistry, Chicago, IL, USA

The delivery of anesthesia in any setting is not without risk. Theenvironment is complex, uncertain, and ever-changing. Humanperformance of this potentially hazardous task can be unpre-dictable and imperfect, especially in times of urgency, intensity,and time pressure. Risk and human error cannot be eliminated,but can be reduced and managed by eliminating a culture of blameand punishment and replacing it with a culture of vigilance andcooperation to expose and remediate system weaknesses, which, incombination, often lead to error and injury.

The concept is straightforward. Most patients do not enjoy goingto the dentist. Although patients understand that pain can be elim-inated with local anesthesia, fear and anxiety still fuel avoidance ofnecessary care. Dentistry has responded to these issues by providingoptions for various levels of sedation, analgesia, or general anesthe-sia in the dental office. Usually, all goes well. Patients are satisfied;necessary dental work gets done. Sometimes, however, things do notgo well.

Complications (adverse events, sentinel events) are defined asunplanned, unexpected, unintended, and undesirable patientoutcomes: death, physical/psychological injury, or any unexpectedvariation in a process or outcome that demands notice. Errors aredeviations from accuracy or correctness, usually, caused by a fault(mistake) for example, carelessness, misjudgment, or forgetfulness.Most errors have no obvious effect on patients, yet most (82%) pre-ventable complications in the past involved human error (Cooperet al., 1978).

Errors are categorized according to persons or systems (Reason,2000). Person approach refers to individual human error: forgetful-ness, inattention, lapses (temporary failure of memory), preoccupa-tion, violation (conscious deviation from a rule), loss of situationalawareness, and fixation errors. Human errors lead to specific tech-nical, judgmental, or monitoring mistakes, examples of which aregiven in Table 1.1. System approach refers to practice conditions:staff training, equipment, schedule density, health history gather-ing, policies, procedures, checklists, and so on. Latent errors can laydormant in practices for years, only to be exposed during a trigger-ing event, which then leads to an adverse outcome in a susceptiblepatient.

Although it is tempting to blame a complication on a singlehuman error (e.g., the practitioner gave the wrong drug and thepatient died), seldom is this the case. Most complications are nowknown to be due to an unfortunate temporal alignment of a series oferrors, which results in injury. These errors can arise from multiple

Anesthesia Complications in the Dental Office, First Edition. Edited by Robert C. Bosack and Stuart Lieblich.© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.

sources, which include latent errors (overbooking, failure to updatemedical histories, failure to check equipment, lack of training,poor communication), psychological precursors (fear of lawsuit,embarrassment), system defects (staff not trained in emergencyprotocols, failure to use checklists, failure to update medicalemergency drugs), triggering factors (loss of airway, unintendeddrug overdose, hypotension, etc.), atypical conditions (key staffmember absent), and outright unsafe acts (lack of knowledge, errorsof the moment, ignoring a monitor, failure to address a problem,wrong drug given, etc.)

Scope of errorsUnfortunately, errors are a normal part of human behavior, and theircauses are not obscure. Habit intrusion, stress, anger, fatigue, bore-dom, fear, time urgency, illness, and haste increase the odds of faultyperformance.

The extent of errors documented to have contributed to anestheticcomplications is great. All six major areas of anesthetic practiceare implicated: inadequate pre-anesthetic evaluation, faulty patientselection, poor anesthetic management, inadequate monitoring,hurried recovery, and faulty recognition and inappropriate man-agement of complications. Specific examples of errors are noted inTable 1.2.

The human conditionHomo sapiens is the only species that understands the concept ofrisk; however, habituation blunts this worry. The sense of havingcontrol over risk feeds the illusion of preparedness and prompts feel-ings of denial – “it won’t happen (to me)”; or “if it happens to me,it won’t be that bad”.

Once the error cascade begins, numerous opportunities arise tostop its progression. Many times, however, these opportunities areignored. Impending doom, coupled with the high stakes environ-ment and time urgency, overwhelms and short circuits the humanmind, which makes the most conservative (not necessarily correct)decision more attractive, ultimately leading to situational paralysis.Individuals with increased “cognitive horsepower” tend to be moresusceptible to this shortfall, as worry about legal recourse, shame,and personal doom overpower rational thoughts and interfere withconcentration on the task at hand (Bielock, 2010; Figure 1.1). Man-agement of these “necessary fallibilities” is possible with repeated

3

4 Chapter 1

Table 1.1 Triggering events.

• Technical

° Drug overdose

° Failed airway management technique

° Oxygen source disconnection

° Equipment failure• Judgmental

° Inadequate patient history

° Wrong drug/technique

° Wrong airway management technique

° Delay or failure to adequately treat abnormality• Monitoring/vigilance

° Failure to detect abnormality

° Failure to accept abnormality

° Alarm “saturation”

Table 1.2 Examples of anesthetic errors (Cooper et al., 1984).

• Loss of oxygen supply (tanks empty, not turned on, tubesdisconnected)

• Drug error – wrong drug, wrong dose, syringe swap (unlabeled)• Wrong choice of airway maintenance• Careless, lack of vigilance haste• Faulty information gathering and assimilation• Lack of preparation, scenario rehearsal• Poor communication among team members• Unreliable intravenous access• Unfamiliarity with drugs

LowPoor

Good

Moderate

Arousal

High

Per

form

ance

Figure 1.1 Performance decrement at extremes of arousal. Adapted from(Bielock, 2010).

practice under stress, periodic “pauses” to collect thoughts, a focuson outcome rather than mechanics, continual self-assurance of one’sability, and the use of memory guides.

Currently, there is a national focus on checklists (Gawande, 2009)as part of a cognitive safety net to provide protection against neces-sary fallibility by outlining the minimum necessary steps, especiallyimportant during times of adversity and complexity, when worryshort-circuits the brain.

Scope of complicationsThe dental community provides a wide range of anesthesia: localanesthesia only, local anesthesia with nitrous oxide, enteral seda-tion, parenteral sedation, and anesthesia. It naturally follows that the

Table 1.3 Examples of anesthetic complications.

• Syncope• Laryngospasm• Bronchospasm• Upper airway obstruction• Allergy• Seizure• Tachycardia/bradycardia• Cardiac arrhythmia• Hypertension/hypotension• Myocardial infarction/cardiac death• Malignant hyperthermia• Aspiration• Post-anesthetic recall of intraoperative awareness

complications associated with these techniques are also highly vari-able. These complications range from inability to anesthetize, failedsedation, syncope, and pressure or rhythm disorders to hypoxia anddeath.

It remains impossible to accumulate complete data on the natureand frequency of anesthetic errors/complications in the dentaloffice. Errors are often managed without patient injury. Most dentalanesthetics are administered in private practices (often by solopractitioners) which have sparse reporting requirements. Voluntaryreporting is stifled due to fear of further inquiry and punishment.Learning from errors including changing of systems does not occur.Insurance companies also have no obligation to report closedclaims, and many malpractice cases are settled and sequestered.

Perianesthetic complications are rare in the dental office,with most reports showing similar data. Perrott et al. (2003)reported on a prospective study of 34,391 ASA I and II patientsand showed a complication rate of 1.3 per 100 cases. Theseincluded, in approximate order of decreasing frequency, vomit-ing, laryngospasm/bronchospasm, prolonged recovery, vascularinjury, syncope, arrhythmia, seizure, and neurologic impairment.D’Eramo et al. (2008) reported similar complication rates from asurvey of 169 oral and maxillofacial surgeons. Other examples ofcomplications are noted in Table 1.3. However, a true mortality rateis not readily obtainable. The most current data from OMSNIC (themalpractice insurance company that covers approximately 80%of US oral and maxillofacial surgeons) estimates the likelihood ofan office-anesthetic-related death to be 1/365,554 anesthetic cases(Estabrooks, 2011).

The prevention, diagnosis, and management of anesthetic com-plications are the focus of this book, and are addressed from mul-tiple perspectives. Patient evaluation and selection, with emphasison common comorbidities, knowledge of drug action, limitations ofoffice-based anesthesia, monitoring, and preparation and manage-ment of adversity are addressed. Crisis resource management duringerror/complication evolution is not taught in dental school or resi-dency programs. It is included here as the most important asset forcomplication management.

ReferencesBielock, S. Choke: What the Secrets of the Brain Reveal about Getting it Right When You

Have to. New York: Free Press, 2010.Cooper, J. B., et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiol

49: 399–406, 1978.

Anesthetic complications—how bad things happen 5

Cooper, J. B., et al. An analysis of major errors and equipment failures in anesthesiamanagement : considerations for prevention and detection. Anesthesiol 60: 34–42,1984

Reason, J. Human Error. New York: Cambridge University Press, 1990.Reason, J. Human Error: models and management. Br Med J 320: 768–770, 2000.D’Eramo, E. M., et al. Anesthesia morbidity and mortality experience among mas-

sachusetts oral and maxillofacial surgeons. J Oral Maxillofac Surg. 66: 2421–2433,2008.

Estabrooks, L. Redefining the standards of office anesthesia: supporting data to adapthigher standards. Presented at the 93rd AAOMS annual meeting, Philadelphia, PA,2011.

Gawande A. The Checklist Manifesto: How to Get Things Right. New York: MetropolitanBooks, 2009.

Perrott, D. H., et al. Office-based ambulatory anesthesia : outcomes of clinical practiceof oral and maxillofacial surgeons. J Oral Maxillofac Surg 61: 983–995, 2003.

SECT ION 2

Patient risk assessment

2 History and physical evaluation

Kyle Kramer1, Trevor Treasure2, Charles Kates3,Carrie Klene4, and Jeffrey Bennett1

1Indiana University, Department of Oral Surgery and Hospital Dentistry, Indianapolis, IN, USA2University of Texas–School of Dentistry, Department of Oral and Maxillofacial Surgery, TX, USA3University of Miami Miller School of Medicine, Departments of Anesthesiology and Surgery, FL, USA4Indiana University, Indianapolis, IN, USA

IntroductionThe risks associated with office-based anesthesia are greater thanthe risk of dental surgery. Preanesthetic patient evaluation andappropriate case selection maximize safety, efficacy, and efficiencyof office-based anesthesia and surgery. It provides a basis for caserefusal or limit setting on the depth of anesthesia.

Accurate patient evaluation requires effective communicationwith patients by ensuring complete patient comprehension by“repeat back” questions, enhanced listening skills of the doctor, andeffective team communication. Unfortunately, some patients willbe less than forthright in disclosing their diseases or medicationadherence. In other cases, patients may be unaware of their diseaseor will have yet-to-be-diagnosed disease. Suspicion of any diseasein the dental patient should help diagnosis and trigger appropriatereferral as necessary.

Cardiovascular, pulmonary, and upper airway complications arethree major causes of morbidity and mortality in the dental office.Together with NPO status, these comprise the core elements of pre-anesthesia patient evaluation.

The American Society of Anesthesiologists recommends the fol-lowing sequence for preoperative evaluation:

• Patient interview and review of the medical/surgical/anesthetichistory

• Physical examination• Assigning of an ASA physical status score• Formulation and discussion of the anesthetic plan

Consideration of the anticipated physiologic and anatomic dis-ruptions of both surgery and anesthesia is the first aspect of patientevaluation. Preoperative patient evaluation is an opportunity toidentify previously diagnosed diseases; to assess patients for signsand symptoms of occult diseases; to determine the need for focusedpreoperative laboratory or diagnostic studies; and to review patientmedications. This is done in order to preoperatively optimize thepatient and prevent exacerbation of existing disorders. Ultimately,this will guide decisions regarding refusal of anesthesia, limitsetting on the depth of anesthesia, and location of care. This processis called risk assessment.

The ASA physical status is assigned to a patient in order to strat-ify the risk of the anesthesia and planned surgery. In the operatingroom setting, where the majority or anesthetics are given, the ASA

Anesthesia Complications in the Dental Office, First Edition. Edited by Robert C. Bosack and Stuart Lieblich.© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.

score (Table 2.1) is known to correlate with morbidity and mortality,unplanned ICU admissions, longer hospital stays, and adverse car-diopulmonary outcomes (Sweitzer et al., 2008). Though the majorityof outpatient dental procedures may be minor in comparison to aninpatient surgical procedure, the anesthetics given (and thus the riskprofile) in either setting may be similar.

Cardiovascular risk assessment

HistoryDirect office-based anesthetic cardiovascular risks include adverseheart rate and blood pressure changes, with tachycardia andhypotension being more worrisome in the adult patient. Patientswith coronary artery disease (diagnosed or undiagnosed) areless able to tolerate increased oxygen demand associated withtachycardia. Any decrease in oxygen delivery to vital organs, due toa decrease in cardiac output or blood pressure, is also worrisome.

Cardiovascular evaluation for dental patients undergoingoffice-based anesthesia is used to screen those patients with majorissues who will benefit from further testing and disease optimiza-tion management prior to surgery and anesthesia. The presenceof “minor” symptoms also may prompt a delay in office-basedanesthesia, pending further evaluation.

Direct questions should screen for the presence of preexistingdiseases, including hypertension, coronary artery disease, priormyocardial infarction, heart failure, arrhythmias, valvulopathy,hyperlipidemia, and prior cardiac intervention (stents, bypassgrafts, cardiac implantable electronic device). Physical symptoms ofangina, shortness of breath, level of exercise tolerance, palpitations,irregular heartbeat, cough, dizziness, orthostatic hypotension,syncope, smoking, sedentary life style, and family history of suddencardiac death are significant findings (Table 2.2). The patient’s med-ication list can also provide insight into the presence of disease state.

Case selection and management are guided by estimates ofpatient resilience and patient reserve. Resilience refers to thepatient’s ability to tolerate hypoxia and heart rate and/or bloodpressure changes without decompensation. The ability to tolerateadversity depends on both the duration and the severity of thechallenge. As an example, a patient with obesity and coronary artery

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10 Chapter 2

Table 2.1 ASA physical status score (American Society of Anesthesiologists,available at www.asahq.org).

ASA I Healthy patient without organic, biochemical, or psychiatric diseaseASA II Mild systemic disease, without significant impact on daily activity,

e.g., mild asthma or well-controlled hypertension. Unlikely impacton anesthesia and surgery

ASA III Significant or severe systemic disease that limits normal activity.Likely impact on anesthesia and surgery

ASA IV Significant and severe systemic disease that is a constant threatto life.

ASA V A moribund patient that is not expected to survive without theoperation

ASA VI A patient declared brain-dead whose organs are being harvestedfor donation

disease is challenged by decreased functional residual capacity(due to cephalad displacement of the diaphragm, especially duringanesthesia) leading to quick onset hypoxemia with apnea and aninability to tolerate the subsequent sustained tachycardia. Reserverefers to the ability to physiologically compensate hypoxemiaand/or adverse cardiovascular changes via arousal and ventilatoryand/or cardiovascular changes. As examples, the elderly may beunable to compensate for hypoxemia with tachycardia, while theinfants have an invariate stroke volume and will be unable totolerate a bradycardia.

Cardiovascular disease (hypertension, atherosclerosis (coronaryartery disease, CAD, and ischemic heart disease), valvulopathy,heart failure, and rhythm disorders) affects up to one-third ofpatients presenting for dental care, which puts them at increasedrisk for cardiovascular complications (Pasternak, 2002). As“Baby Boomers” age and thresholds for performing procedures

on the elderly ease, increased numbers of patients with car-diovascular disease will be presenting for dental care underanesthesia.

Goldman et al. (1977) was the first to prospectively evaluate1001 patients over age 40 who underwent non-cardiac surgery.They documented nine preoperative variables that were associatedwith a higher risk of cardiac events in the perioperative period.These findings, revised in 1999 by Lee (known as the RevisedCardiac Risk Index), led to the 2007 American College of Car-diology/American Heart Association guidelines on perioperativecardiovascular evaluation for non-cardiac surgery (Fleisher et al.,2007). These guidelines help estimate the risk of a cardiac eventduring non-cardiac surgery, help define risk with selective test-ing, suggest intervention to lower risk as necessary, and assesslong-term risk and modify risk factors. Three elements are assessedto determine the extent of risk – the presence of active cardiacconditions, exercise capacity, and surgery-specific risk (Table 2.3).This algorithm suggests immediate referral and refusal of all electivesurgery for patients with active cardiac conditions and referraland refusal for intermediate risk surgery for patients who cannotfunction at least at a 4 MET level. Further action or referral forpatients without active cardiac conditions and low risk surgery(office-based dental surgery) is seldom required.

There are, however, other factors that can introduce unnecessaryrisk during office-based anesthesia (Kheterpal et al., 2009). Thesefactors include age >68 years, BMI > 30 kg/m2, previous cardiacintervention, cerebrovascular disease, hypertension, and operativeduration >3.8 hours. Obesity, obstructive sleep apnea, and diabetesmellitus are also strongly associated with cardiovascular disease.

Cardiovascular examinationCore elements of cardiovascular examination include inspection,palpation, and auscultation. Vital signs, including blood pressure,

Table 2.2 Significance of screening questions.

Disease Select cardiovascular concerns

Atherosclerosis, coronary artery disease (CAD) Inability to tolerate increased cardiac work (increased rate or force of contraction)Hypertension Increased cardiac workload, known risk factor for CAD, MI, HF; perianesthetic

hypotensionPrior myocardial infarction (MI) Post infarct irritability, arrhythmia, re-infarction with recent MI (<30 days)Heart failure (HF) Level of compensation, exercise toleranceArrhythmias Level of control, side effects of anti-arrhythmic medication, symptoms, possibility

of recurrence during anesthesiaValvulopathy Increased cardiac workload, aortic stenosis limits cardiac outputHyperlipidemia Atherosclerosis, CADPrior cardiac intervention – stents, bypass, CIED Stent re-thrombosis, compliance with anti-platelet therapy, device efficacy, battery

lifeAngina Never normal, could indicate coronary artery diseaseShortness of breath Never normal, non-specific symptom, cardiac and/or pulmonary originLevel of exercise tolerance Should be able to take care of self, ascend one flight of stairs (4 METS)Palpitations; unprovoked episodic tachycardia Atrial fibrillation, PVCs, supraventricular tachycardiaIrregular heart beat Atrial fibrillation, PVCsCough Non-specific symptom, decompensated heart failure, COPDDizziness Arrhythmia, pre-syncope, hypotensionOrthostatic hypotension Side effect of anti-hypertensive medicationsSyncope Vasovagal syncope, carotid sinus hypersensitivitySmoking Atherosclerosis, COPD, increased airway irritability, sympathomimetic, falsely

elevated SpO2

Sedentary life style Atherosclerosis, obesityFamily history of sudden cardiac death Hereditary long QT syndrome