1. DENTAL ANESTHESIA COMPLICATIONS IN THE DENTAL CHAIR SAAD A. SHETA Associate Professor Consultant Anesthesia Dental College KSU

3. Dental Anesthesia Out-Patient Anesthesia (Dental Chair Anesthesia) Sedation Techniques Day-Case Anesthesia In-Patient Anesthesia Complete Dental rehabilitation Complicated oral surgery procedures Major Maxillofacial surgeries

4. Complications in Dental Anesthesia Out-Patient Dental Anesthesia “ Dental Chair Anesthesia Office-Based Dental Sedation

5. Out-Patient Dental Anesthesia “Dental Chair Anesthesia”

6. Out-Patient Dental Anesthesia “ Dental Chair Anesthesia” Out-Patient dental extraction Children (4-10 years): high incidence of URTI Steadily decreased

7. Out-Patient Dental Anesthesia Induction Inhalational (mask) induction Intravenous Induction

8. Out-Patient Dental Anesthesia Maintenance Inhalational agents/N 2 O Nasal mask, mouth gag, pack Maintain airway Supine Position Less hypotension less bradycardia high risk of aspiration Airway obstruction& Decrease ERV

9. Out-Patient Dental Anesthesia Recovery Left lateral position 100% O 2 Suction Observation & monitoring Discharge criteria Instructions Analgesia (NSAIDs)

10. Office-Based Dental Sedation

11. 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

12. According to the degree of CNS depression: Conscious Sedation Deep Sedation General Anesthesia

13. 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

14. 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

15. Sedation Techniques Non Titrable Technique Oral Sedation Rectal Sedation Intramuscular Sedation Submucosal Sedation Intranasal Sedation Titrable Technique Inhalational Sedation Intravenous Sedation Combination Of Two

16. 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.

17. Pre-requirements: (Essentials to reduce the risk )

18. Pre-requirements Proper training and familiarity with the technique (including support personals) Patients selection Clear instructions Monitoring Documentation Emergency Back-up

19. Patients Selection Contraindications Serious cardiopulmonary diseases, COPD Diabetes or other endocrinological diseases Neuromuscular disorders Coagulopathies & Hemoglobinopathies Marked oro-facial swelling (edema& trismus) Potential difficult airways Extreme obesity Drugs: MAOIs, Anticoagulant Not fasting

20. Monitoring Clinical Observation Pulse Oximetry Precordial/pretracheal Stethoscope BP ECG

21. Equipment Dental Chair Anesthetic Equipments Monitoring Resuscitation Equipments “ Up to the standards of In-Patient GA ”

22. Dental Chair Adjustable: ( horizontal /Head down) Manual release Adjustable head rest Hospital out-patient: operating table

23. Anesthesia Equipments Continuous flow anesthesia machine Quantiflex (Relative Analgesia) Mouth props, packs, gags, nasopharyngeal airway, rubber dam Separate suction unit Scavenging system

24. Equipment Continuous flow design with flow meters Safe delivery of O 2 and N 2 O (fail safe mechanism) 10 l/min for 60 min E cylinder(650 litres) Pin-indexed yoke system Efficient scavenger

25. Oxygen (Central)

26. Emergency Equipment Airway Adjuncts : Airways, Masks and Nasal prongs Bag-valve- mask High Volume Suction Device Oxygen Source Others: Crash Cart

27. Airway Adjuncts If breathing adequately spontaneously

28. Bag-valve-Mask built-in colorimetric ETCO2 detector If Artificial ventilation necessary

29. Crash Cart

30. Intravenous Line: Cannulae Syringes Needles Airway Adjuncts Endotracheal Intubation Cricothyrotomy Emergency Drugs

31. Drugs to treat Allergy Benzodiazepine Antagonist Anticonvulsants Narcotic Antagonists Steroids Antihypoglycemic Vasopressors Analgesics ACLS drugs

32. Dental Chair Complications Respiratory Complications Cardiovascular Complications Miscellaneous

33. Respiratory Complications

34. AIRWAY OBSTRUCTION RESPIRATORY DEPRESION BRONCHEAL ASTHMA HYPERVENTILATION

35. 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

36. Airway (“A”)

37. Airway Obstruction Most common cause: tongue and/or epiglottis

38. Open the Airway Jaw thrustHead tilt–chin lift

39. Head Tilt/Chin Lift

40. Jaw-Thrust Maneuver

41. Jaw-Lift Maneuver

42. 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

43. Direct visualization of the larynx with a laryngoscope may enable the removal of an obstructing foreign body

44. Open the Airway Oropharyngeal Airway

45. Insert oropharyngeal airway with tip facing palate

46. Rotate airway 180º into position

47. Open the Airway Nasopharyngeal Airway

48. Nasopharyngeal Airway

49. Advanced Airway Management

50. Endotracheal Intubation is the Most Preferred Method of Advanced Airway Management

51. Engaging laryngoscope blade and handle

52. Activating laryngoscope light source

53. Laryngoscope Blades

54. Open the Airway Endotracheal Intubation “ Laryngoscopes ”

55. ETT and Syringe

56. ETT

57. ETT, Stylet, and Syringe “unassembled”

58. ETT, Stylet, and Syringe “assembled for intubation”

59. Endotracheal Intubation “Technique”

60. Position Endotracheal Intubation “Aligning Axes of the Airway”

61. Hyperventilate patient

62. Prepare equipment

63. Apply Sellick’s Maneuver and insert laryngoscope

64. Endotracheal Intubation “ Visualization of the Cord

65. Glottis visualized through laryngoscopy

66. Visualize larynx and insert the ETT

67. Inflate cuff, Ventilate, and Auscultate

68. Secure tube

69. Reconfirm ETT placement

70. Laryngeal Mask Airway

72. Laryngeal Mask Airway (LMA)

73. The Only Indication of a Surgical Airway is the inability to establish Airway by Any Other Method

74. Breathing (“B”)

75. Oxygenation Adjunct Devices

76. Bag-valve-mask ventilation

77. Ventilation Bag-Mask Ventilation Key ventilation volume: “enough to produce obvious chest rise” 1 Person difficult, less effective 2 Persons easier, more effective

78. HYPERVENTILATION Management early recognition reassurance Oxygen Breathe into a paper bag Anxiety agent

79. Bronchial ASTHMA Aetiology In Children : Allergic (Ig E) or Extrinsic In adults: Extrinsic (Stress) Clinical Picture History Mild wheezing Coughing to severe dyspnea, Cyanosis and death

80. Bronchial ASTHMA Management Oxygen Aerosolized adrenergic agents Epinephrine (0.01 mg/kg SC) Emergency transport to the hospital !!! intravenous amnophylline dose 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

81. Cardiovascular Complications

82. HYPOTENSION BRADYCARDIA DYSRYTHMIAS ( Tachy-dysrhythmia) SYNCOPE ALLERGIC REACTION

83. HYPOTENSION Induction of Anesthesia Carotid sinus compression Over-sedation

84. BRADYCARDIA Tooth extraction Halothane (nodal rhythm)

85. DYSRHYTHMIAS Aetiology (Tooth extraction) High preoperative catecholamines Light anesthesia Airway obstruction & hypoxia Halothane & local anesthesia Local anesthesia with vasopressors Significance Controversial Significant with unexpected cardiac disease (viral myocarditis)

86. SYNCOPE Causes Factors (CV, allergic,..) Emotional factors (more common) Aetiology limbic cortex-hypothalamus-reflex vasodilatation Increase parasympathetic activity-bradycardia Less common in children Sympathetic nervous system Endogenous epinephrine and nor epinephrine

87. SYNCOPE Clinical Picture Cold, pale, and sweaty skin Feels dizzy of faint Management Flat, Head down-leg elevated 100% O 2 Ammonia inhalant Atropine / Vasopressors Medical assistance “ if Recovery of consciousness is Delayed beyond 5 minutes Incomplete after 15 to 20 minutes”

88. ALLERGIC REACTION Incidence Very rare More commonly (vaso-vagal, toxic reaction, epinephrine) Aetiology Histamine Ig E-mediated reaction Easter-linked: p-amino benzoic acid Amide-linked: preservatives (Paraben)

89. 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

90. 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

91. Miscellaneous

92. SEIZURES Clinical Picture TONIC-CLONIC “FOUR PHASES” Pro-dromal phase The aura The convulsive The post-ictal phase A significant degree of CNS depression is usually present during this post- ictal phase Increased oxygen consumption, tachycardia, hypertension, impaired ventilation, and cardiac arrhythmias

93. SEIZURES Management Prevent self-injury Airway management &Adequate ventilation Intravenous diazepam Supportive care Hyperthermia

94. DIABETES MELLITUS Aetiology Juvenile onset diabetes, Worst prognosis Poor Insulin Production Clinical Picture Hypoglycemia or hyperglycemia Diabetic ketoacidosis (Coma &Death) “ Hypoglycemia ” Deteriorating Cerebral Function Nausea Sympathetic NS Stimulation (Tachycardia, Hypertension, Arrhythmias Mental Obtundation, Loss of Consciousness, Seizures

95. DIABETES MELLITUS Management Oxygen Fully Conscious, Oral Sugar containing Food or Drinks Dextrose 50% “IV”, Till regain Consciousness Glucagon “IM”

96. Miscellaneous Nasal Trauma, Epistaxis Pulmonary Aspiration Diffusion Hypoxia Continued Bleeding Post operative Sore Throat Post operative Nausea & vomiting Post operative Pain & swelling

97. THANK YOU