1.4k likes | 3.79k Views
Dental Anesthesia. I. Out-Patient anesthesia II. Day-Case anesthesiaIII. In-Patient anesthesiaV. Emergency Surgery. Out-Patient Dental Anesthesia Dental Chair Anesthesia . Out-Patient Dental Anesthesia Dental Chair Anesthesia. Out-Patient dental extractionChildren (4-10 years): URTISteadily decreased.
E N D
1. ANESTHESIA for Dental& MAXILLOFACIAL SURGERY SAAD A. SHETA
MBChB, MA, MD
Associate Professor, Anesthesia
Dental College
KSU
2. Dental Anesthesia I. Out-Patient anesthesia
II. Day-Case anesthesia
III. In-Patient anesthesia
V. Emergency Surgery
3. Out-Patient Dental Anesthesia Dental Chair Anesthesia
4. Out-Patient Dental Anesthesia Dental Chair Anesthesia
Out-Patient dental extraction
Children (4-10 years): URTI
Steadily decreased
5. Out-Patient Dental AnesthesiaInduction Inhalational (mask) induction
Intravenous Induction
6. Out-Patient Dental AnesthesiaMaintenance Inhalational agents/N2O
Maintain airway
Posture (Supine Position)
Less hypotension
less bradycardia
However
high risk of aspiration
high risk of Airway obstruction
7. Out-Patient Dental AnesthesiaRecovery
Left lateral position
100% O2
Suction Observation & monitoring
Discharge criteria
Instructions
Analgesia (NSAIDs)
8. Out-Patient Dental AnesthesiaComplications Respiratory Complications
Cardiovascular Complications
Syncope
Allergic Reaction
9. Respiratory Complications
Airway Obstruction
Respiratory Depression
10. Cardiovascular Complications
Hypotension
Bradycardia
Dysrhythmias (Tachy-arrhythmias)
Aetiology (Tooth extraction)
High preoperative catecholamines
Light anesthesia
Airway obstruction & hypoxia
Halothane & local anesthesia
Local anesthesia with vasopressors
11. Syncope Causes Previous factors (CV, allergic,..)
Emotional factors (more common)
Aetiology
limbic cortex-hypothalamus-reflex vasodilatation
Increase parasympathetic activity-bradycardia
Management
Head down-leg elevated
100% O2
Cessation of anesthesia
12. Allergic Reaction
Incidence
Very rare
More commonly (vaso-vagal, toxic reaction, epinephrine)
Aetiology
Ig E-mediated reaction
Easter-linked: p-amino benzoic acid
Amide-linked: preservatives (Paraben)
Manifestations
Management
13. Day-Case Dental Anesthesia Minor Oral Surgery& Conservative Dentistry
14. Day-Case Dental AnesthesiaConcerns Rapid Recovery
Minimal Postoperative Morbidity
Remote Location
15. Day-Case Dental Anesthesia Minor oral surgery and conservative dentistry
Limited surgery
No significant risk of complications
Standard criteria of patient selection (ASAI&II)
16. Day-Case Dental AnesthesiaAnesthetic Technique Induction
Inhalational (pediatrics) or Intravenous (propofol)
Airway Nasal Endotracheal tube
Oral intubation
LMA
Nasal mask& Nasophryngeal airway
Intubation NDMR (short acting)
Suxamethonium (Postoperative Mylegia)
Deep Inhalational Anesthesia
Propofol & Alfentanil
Moist Pharyngeal Pack
17. Day-Case Dental AnesthesiaAnesthetic Technique Maintenance
Inhalational Sevoflurane
Isoflurane
Halothane (slow recovery & cardiac arrhythmias)
Ventilation Spontaneous (Short procedure)
Controlled ventilation
Extubation
Throat pack removed
Very light anesthesia (recommended)
Patient turned to one side
18. Day-Case Dental AnesthesiaAnesthetic Technique Recovery& PO
Minimum 2 hrs
Pain Control NSAIDs (IM diclofenac)
Short acting opioids
Local analgesic block (2Quadrants only )
Preoperative Dexamethazone
Discharge Assessment (Morbidity)
Written instructions
Contact telephone number
Possible overnight admission
19. In-Patient Dental Anesthesia Major Oral & Fasciomaxillary Surgery
20. In-Patient Dental Anesthesia Classifications:
Major Orthognathic Surgery
Tumor Surgery
Palate Surgery
21. In-Patient Dental AnesthesiaConcerns:
22. Airway Management
Anesthetic Management
24. Airway Management Choice of the technique depends on several factors:
Patient safety
Experience of the anesthetist
Known difficult airway
Requirement: nasal or oral
Post operative jaw wiring
25. Airway Management
History
Physical Examination
Further Evaluation
Difficult Airway & Algorism
Airway Strategies
26. History
Documented History of Difficulties with general anesthesia or, more specifically, mask ventilation or endotracheal intubation
Congenital Syndromes Associated With Difficult Endotracheal Intubation
Pathologic States That Influence Airway Management
31. Physical Examination Inspection (Obvious Problems)
Mouth Opening (3 4cm)
Oral Cavity Examination
Mallampati Score
Thyromental Distance (3 large fingers = 5 cm)
Neck Movement
33. Further Evaluation PRE-OPERATIVE ASSESSMENT OF THE AIRWAY
Indirect or Fiberoptic Laryngoscopy
X ray: Chest , Cervical Spine
CT or MRI
Flow- Volume Loops
Pulmonary Function Tests
35. Difficult Airway Difficult airway
The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both
Difficult mask ventilation
1) inability of unassisted anesthesiologist to maintain SpO2 > 90% using 100% oxygen and positive pressure mask ventilation in a patient whose SpO2 was 90% before anesthetic intervention;
Or
2) inability of the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation
36. Difficult Airway Difficult Laryngoscopy
Not being able to see any part of the vocal cords with conventional laryngoscopy
Difficult Intubation
Proper insertion with conventional laryngoscopy requires either :
a) > 3 attempts
b) > 10min
41. AWAKE TECHNIQUES
Glosso-Pharyngeal Nerve IX Nerve
Posterior pharyngeal fold at its midpoint, 1 cm deep to the mucosa of the lateral pharyngeal wall
42. AWAKE TECHNIQUES
Superior Laryngeal Nerve
Pyriform Fossa
External :1 cm medial to the superior cornu of the Hyoid Bone to pierce the thyrohyoid membrane
43. AWAKE TECHNIQUES
Trachea & Vocal Cord
Atomizer
Injection
44. Laryngoscope Blades
47. AWAKE TECHNIQUES FIBER OPTIC INTUBATION
50. Laryngoscope Blades
52. GA TECHNIQUES Laryngeal Mask Airway (LMA)
53. GA TECHNIQUES LIGHTED STYLETS/LIGHTWAND
56. GA TECHNIQUES FIBER OPTIC INTUBATION
58. GA TECHNIQUES BULLARD LARYNGOSCOPE
60. Classification According to Mouth Opening
65.
NEVER PARALYSE UNTILL POSSIBLE VENTILATION HAS BEEN ESTABLISHED
RECENT SUCCESSFUL INTUBATION DOESNOT MEAN FUTURE POSSIBLE INTUBATION
FULL RANGE OF DIFICULT INTUBATION EQUIPMENT MUST BE AVAILABLE
66. ALL PHYSICIANS RESPONSIBLE FOR AIRWAY MANAGEMENT SHOULD BE PRACTICED IN AT LEAST ONE ALTERNATE TO BAG & MASK VENTILATION. THESE ALTERNATIVE INCLUDES THE FOLLOWING:
LARYNGEAL MASK AIRWAY
COMBI TUBE
TRANSTRACHEAL TECHNIQUES
LMA PROVIDE RESCUE VENTILATION IN 94% OF CASES OF UNANTICIPATED DIFFICULT INTUBATION
67. HAVING DISCUSSED ALL THE MANAGEMENT STRATEGIES AWAKE TECHNIQUE IN GENERAL & AWAKE FIBER OPTIC TECHNIQUE ESPECIALLY, IS THE MOST COMMONLY USED & SAFE TECHNIQUE
69. Special Consideration
Preoperative Management
Intraoperative Management
Post operative Management
70. PRE-OPERATIVE PROBLEMS Elderly, Chronically Debilitated Patients
Malnourished
H/O Heavy Smoking with Resultant COPD
H/O Alcoholism
Co-existing disease such as HTN,D.M, IHD, etc.
71. PRE-OPERATIVE MANAGEMENT
Adequate pre-operative work-up of Cardiac Status & Pulmonary Functions should be carried out using various diagnostic modalities with the objective of optimizing patients condition
72. RECONSTRUCTIVE MAXILLOFACIAL SURGERY Problems:
Major problem: Airway Management
Extensive, long operation
Significant blood loss
Poor nutritional status
Micro-vascular surgery
Caution with Vasoconstrictors
Caution with Transfusion
Caution with Diurresis
Blood Rheology (Hct:25-27)
73. INTRA-OPERATIVE Routine
Monitoring
NIBP
ECG
SPO2
ETCO2
TEMPERATURE
Choice of Volatile Agent
Choice of Anesthesia
74. INTRA-OPERATIVE MANAGEMENT
75. INTRA-OPERATIVE MANAGEMENT Two Large Bore Canulae
After induction of anesthesia, two large bore canulae can be put in large veins so that rapid fluid replacement can be carried out in case need arises.
76. INTRA-OPERATIVE MANAGEMENT Invasive Blood Pressure Monitoring
is indicated due to following reasons :
Blood loss may be rapid secondary to
Neck dissection
Pre operative radiotherapy
Surgery close to big vessels of neck
Frequent fluctuations in the blood pressure due to manipulation in the area of carotid body and sinus.
77. INTRA-OPERATIVE MANAGEMENT
Central Venous Pressure Monitoring
Risk of venous air embolism during neck dissection
As a guide to the management of fluid therapy
The site of insertion is either:
Antecubital vein
Femoral vein
78. INTRAOPERATIVE MANAGEMENT Use of Muscle Relaxants
During surgery IPPV is carried out without muscle relaxant as surgeons need to identify the nerves during surgery
79. INTRAOPERATIVE MANAGEMENT
Induced Hypotension
Mild degree of hypotension is required during surgery to reduce the blood loss. This can be achieved by following:
15-30 degree head up tilt
Increasing the conc. of volatile anesthetics
Use of peripheral vasodilators
Use of beta blockers
80. INTRAOPERATIVE MANAGEMENT Blood Transfusion
Before the decision of blood transfusion the following points should be considered
Patients underlying medical condition
Possibility of risks of transfusion hazards
Increased risk of post-transfusion cancer recurrence as a result of immune suppression
81. INTRAOPERATIVE MANAGEMENT
Haemodynamic Changes
During radical neck dissection, the traction or pressure on the carotid sinus and / or stellate ganglion can cause following:-
Brady-dysrhythmias
Sinus arrest leading to asystole
Wide swings in blood pressure
Prolonged QT Interval
82. INTRAOPERATIVE MANAGEMENT Haemodynamic Changes Treatment
Immediate cessation of the stimulus
Blockage of the sinus with local anesthetic by the surgeon
Vagolysis by atropine
83. INTRAOPERATIVE MANAGEMENT Venous Air Embolism
When the venous pressure in neck veins is low and these veins are open to atmosphere, air is sucked in causing air embolism.
Diagnosis
Early Detection
Hypoxia
Hypotension
Hypocarbia
84. Venous Air Embolism
Treatment
Compression of neck veins
Positive pressure ventilation
Place the patient in the left lateral position
Aspiration of air through the central venous catheter
Ionotropes
85. POST-OPERATIVE CARE
ROUTINE CARE
SPECIAL CONSIDRATIONS
ICU care & Possible mechanical Ventilation
Hemodynamic Instability
Analgesia
Tracheostomy
86. POST-OPERATIVE CARE ICU Care & Possible Mechanical Ventilation
Patient should be kept in the intensive care unit for 24-48 hours
Prolonged Surgery
Airway Oedema
Co-existing diseases
Risk of bleeding and/or neck hematoma
87. POST-OPERATIVE CARE Haemodynamic Instability
As bilateral neck dissection may result in post-operative hypertension and hypoxic drive because of the denervation of the carotid sinus and carotid body
88. POST-OPERATIVE CARE
Analgesia
Non Steroidal Anti-inflammatory Agents should be used as opioids cause respiratory depression in spontaneously breathing patients
When patient is on ventilator opioid analgesia can be given
89. POST-OPERATIVE CARE
Tracheostomy Care
Humidified Oxygen
Intermittent Suction
Sterile Precautions
Adjustment of cuff pressure to15-20 mmHg
Complications
90. THANK YOU