Oral and Maxillofacial Surgeons: Providing Safe, Effective Anesthesia Services in the Ambulatory Setting

1. Oral and Maxillofacial Surgeons:Providing Safe, Effective Anesthesia Services in the Ambulatory Setting

2. Table of Contents • What are the Levels of Sedation? • What are the Levels of Sedation? • OMSs are Well Qualified to Administer All Levels of Anesthesia/Sedation • OMSs are Competent in Administering/Monitoring Anesthesia • OMS Education & Training • State Regulations • Parameters of Care • Enviable Record of Safety • Enviable Record of Safety • Practicing OMSs Continue to Hone Their Skills • AAOMS Office Anesthesia Evaluation Program • Prospective Outcome Study Supports OMS Anesthesia Administration • Support for OMS Anesthesia Administration • Oral and Maxillofacial Anesthesia Assistants Program (OMA... • OMS Anesthesia Assistant Training

3. What are the Levels of Sedation? Return to Table of Contents Local Anesthesia (LA): Local, or regional, anesthesia involves the injection or application of an anesthetic drug to a specific area of the body. It eliminates sensation and pain in a local area of the body without loss of consciousness. Non-Intravenous Conscious Sedation (CS): Non-Intravenous Conscious Sedation includes the administration of sedative and/or analgesic agent(s) by a route other than IV. These routes may involve (PO, PR, Intranasal, IM) and include appropriate monitoring. Conscious sedation medically controls a state of depressed consciousness while maintaining the patient’s airway, protective reflexes and the ability to respond to stimulation or verbal commands. Patients retain the ability to breathe on their own and can respond to physical or verbal stimulation.

4. What are the Levels of Sedation? Return to Table of Contents Intravenous Sedation/Analgesia A medically controlled state of depressed consciousness while maintaining the patient’s airway, protective reflexes and the ability to respond to stimulation or verbal commands. It includes intravenous administration of sedative and/or analgesic agent(s) and appropriate monitoring. DeepSedation/General Anesthesia (DS/GA): An induced state of unconsciousness, accompanied by partial or complete loss of protective reflexes, including the ability to independently maintain the airway and respond purposefully to physical stimulation or verbal command.

5. OMSs are Well Qualified to Administer All Levels of Anesthesia/Sedation Return to Table of Contents OMSs have the ability to provide safe, effective anesthesia to patients in outpatient facilities. They are thoroughly trained and competent to: • Diagnose and treat the source of pain and anxiety within the scope of their discipline; and • Use appropriate techniques of local (regional) anesthesia, conscious sedation and deep sedation/general anesthesia..

6. OMSs are competent in: Return to Table of Contents • Airway management; • Endotracheal intubation; • Establishing and maintaining intravenous and arterial lines, and invasive monitors; • Managing complications and emergencies associated with the administration of anesthesia.

7. OMS Education & Training Return to Table of Contents • 4 + years post-doctoral, hospital-based surgical residency training alongside medical and surgical residents, including general surgery, anesthesia and others. • At least 4 months on an anesthesia service rotation at the anesthesia resident’s level of competence. • Ongoing experience throughout the residency in administration of CS and DS/GS to pediatric & adult patients. • Training must include appropriate patient monitoring modalities and certification in Advanced Cardiac Life Support.

8. State Regulations Return to Table of Contents Regulations on the administration of sedation versus anesthesia in dental offices vary among states. In general, state regulations require: • Anesthesia, whether office-based or in a hospital, should be performed by doctors based on their education and training. • Appropriate training and continuing medical education should be documented and readily available to patients and the Boards of medicine or dentistry. • Nearly all states require dentists/OMSs to procure a permit to administer anesthesia based on documented education, training and competence. Many states also require accreditation of outpatient surgical facilities.

9. Parameters of Care Return to Table of Contents Clinical Practice Guidelines for Oral and Maxillofacial Surgery • General criteria, standards and considerations anesthesia in outpatient settings. Includes: • Documentation of objective findings, diagnoses and patient management interventions. • Evaluation of the OMS office, completion of ACLS course and equipped to meet ACLS standards • Preanesthetic patient evaluation and assessment • Equipment and drugs to address anesthesia-related complications and emergencies • General anesthesia therapeutic goals for outpatient facilities • General factors affecting risk during outpatient anesthesia • General favorable therapeutic outcomes for outpatient anesthesia • General known risks and complications • Specific considerations for LA, CS, DS/GA, pregnant patient, pediatric patient

10. Enviable Record of Safety Return to Table of Contents Total number of office anesthetics 1988 - 2004 = 29,608,316 Statistics provided by: OMS National Insurance Co.

11. Enviable Record of Safety Return to Table of Contents Incidence of in-office anesthesia deaths/brain damage 1 704,960 Statistics provided by: OMS National Insurance Co.

12. Practicing OMSs Continue to Hone Their Skills Return to Table of Contents • Practicing OMSs must comply with the rules and regulations of the states in which they are licensed and practice. • OMSs must comply with the AAOMS Office Anesthesia Evaluation Program to retain membership in their state societies. • Office anesthesia evaluation and re-evaluation must be completed every 5 years. • AAOMS recommends the following indicators be monitored continuously or at regular intervals during sedation and general anesthetic procedures: • Blood pressure; • Heart rate and rhythm (ECG); and • Monitoring oxygenation by continuous use of pulse oximetry. • Monitoring ventilation by auscultation of breath sounds or other methods

13. AAOMS Office Anesthesia Evaluation Program Return to Table of Contents Program requires on-site office anesthesia evaluation and reevaluation every 5 years, including: • Evaluation of Office facility, drugs, equipment and records • Simulation of response to emergencies by the anesthesia team. • Observation of Office Anesthesia and Surgical Procedure, where possible. • Discussion Period. Requirements often exceed those mandated by state law.

14. Prospective Outcome Study Supports OMS Anesthesia Administration & Patient Satisfaction Return to Table of Contents The sample was composed of 34,191 patients, of whom • 71.9% received DS/GA, • 15.5% received CS, • 12.6% received LA. • Before Procedure - 80.3% reported some degree of anxiety. • After Procedure - 61.2% reported having no anxiety about future operations. • Overall, 94.3% of patients reported satisfaction with the anesthetic, and • More than 94.7% of all patients would recommend the anesthetic technique to a loved one. Perrott, DH, et al,Office-Based Ambulatory Anesthesia: Outcomes of Clinical Practice of Oral and Maxillofacial Surgeons, J Oral Maxillofac Surg, 2003 61:983-995,

15. Support for OMS Anesthesia Administration Return to Table of Contents

16. Oral and Maxillofacial Anesthesia Assistants Program(OMAAP) Return to Table of Contents OMAAP - a two-part continuing education program designed for OMS assistants or assistants employed by a dentist with a valid anesthesia permit. • Study materials and a reading list • A practice test follows each module. • At the conclusion of the coursework, a comprehensive examination. • Those who successfully complete the exam receive a certificate of completion and a lapel pin.

17. OMS Anesthesia Assistant Training Return to Table of Contents AAOMS Anesthesia Assistants Review Course A continuing education course to improve the anesthesia knowledge and skills of OMS clinical staff who have completed the OMAAP program. Two-day program focuses on: • Principles of anesthesia • Latest innovations • Basic sciences • Patient evaluation and preparation • Anesthetic drugs and techniques • Patient Monitoring • Emergency procedures