Symposia

SYMPOSIUM ON ANESTHESIA PHARMACOLOGY AND TECHNIQUES

Presented on Saturday, September 15, 2001, 8:00 am-12:00 noon Moderator: Morris S. Clark, DDS, Denver, CO

Benzodiazepines
Daniel S. Sarasin, DDS, Cedar Rapids, IA Benzodiazepines are used for premedication, induction, and maintenance of general anesthesia, supplementation of regional and local anesthesia, and relief of postoperative anxiety states. Oral and maxillofacial surgeons as well as anesthesiologists commonly administer these agents. They have a wide therapeutic margin of safety and provide reliable sedative, anxiolytic, and amnestic effects. Benzodiazepines produce their general effect by binding to the benzodiazepine receptor, facilitating the inhibitory action of GABA on neuronal transmission. Although more is known about the mechanism of action of benzodiazepines than many other general anesthetic agents, it is still not understood how the different effects (amnesic, anticonvulsant, anxiolytic, and sedative) are mediated. The termination of action is primarily a result of redistribution of these drugs from the central nervous system to other tissues. Metabolism of the benzodiazepines occurs in the liver. The 2 principal biotransformation pathways involve either hepatic microsomal oxidation or glucuronide conjugation. Oxidation can be impaired by certain population characteristics, disease states, or the administration of other drugs than can impair oxidizing capacity. Conjugation is less susceptible to these factors. The metabolites of some benzodiazepines are active, which can prolong the drugs effect. Benzodiazepine administration results in a variety of systemic responses. In the central nervous system, these drugs reduce the cerebral metabolic rate of oxygen consumption and cerebral blood ow in a dose-related manner. The predominant cardiovascular change is a slight reduction in arterial blood pressure due to a decrease in systemic vascular resistance. Maintenance of a relatively stable hemodynamic state involves the preservation of homeostatic reex mechanism, although the baroreex is impaired by both midazolam and diazepam. Benzodiazepines cause a depression of central respiratory drive that are both dose- and rate-dependent. Benzodiazepines are administered in a variety of routes and doses for many clinical situations. They are frequently combined with other anesthetic agents to provide a balanced anesthesia to optimize patient care and surgery.
AAOMS 2001

References Reves JG, Glass PSA, Lubarsky DA: Nonbarbiturate intravenous anesthetics, in Miller RD (ed): Anesthesia (ed 5). Philadelphia, PA, Churchill Livingstone, 2000, pp 228-237 Coleman RI, Temo J: Benzodiazepines, in White PF (ed): Textbook of Intravenous Anesthesia. Baltimore, MD, Williams & Wilkins, 1997, pp 77-92

Perioperative Opioids
James Q. Swift, DDS, Minneapolis, MN (no abstract provided)

Ketamine
Mark W. Ochs, DMD, MD, Pittsburgh, PA Ketamine is a dissociative anesthetic with profound amnesia and analgesic properties. It is water soluble and nonirritating when given either IV or IM. It is highly lipid soluble, readily crossing the blood-brain barrier and this accounts for its rapid onset of action (IV, 1 to 2 minutes; IM, 2 to 5 minutes). The recommended IM dissociative dose range is 2 mg/kg to 10 mg/kg with the dose of 4 mg/kg best-suited for pediatric anesthetic induction. Supplemental dosing at 15 to 20 minute intervals is usually required for maintenance of anesthesia, unless other agents are administered. Several investigators have described use of subanesthetic or low-dose ketamine given IV for ambulatory anesthesia in nonintubated patients. Typically, adult patients are given a short-acting narcotic such as fentanyl (1.5 g/kg IV), then have a benzdiazapine titrated intravenously to a sedation endpoint. Low-dose ketamine (0.5 mg/kg) is administered intravenously. This regimen provides absolute amnesia, good analgesia, and supports respiratory and cardiovascular function. The lower dose of ketamine in this regimen helps decrease or nearly eliminate undesirable emergence phenomena. Practitioners should be aware that although ketamine supports spontaneous respirations, maintains muscle tone, and helps keep the airway open, it stimulates salavation, which in turn can reexively cause laryngospasm. Glycopyrrolate as a premedicant can minimize this risk. Even at lower doses, ketamine stimulates the cardiovascular system increasing heart rate, systolic blood pressure, and systemic vascular resistance. Given the fact that glycopyrrolate generally increases the heart rate as well, ketamine poses an added risk to patients with
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Symposia baseline hypertension and/or coronary artery disease in whom increases in myocardial oxygen demand may not be tolerated. Ketamine is inexpensive, relatively safe, and a useful adjunct to the oral and maxillofacial surgeons and anesthesiologists armamentarium in managing a variety of patients.
References Gouty AA: Ketamine: A new look at an old drug. Oral Maxillofac Surg Clin North Am 4:815, 1992 Blankstein KC, Anderson JA: A double-blind comparison of low-dose intravenous ketamine and methohexital in adults. J Oral Maxillofac Surg 49:468, 1991 Ochs MW: Sedation Agents. Oral and Maxillofacial Surgery Knowledge Update 1:77, 1994

Reversal Agents
Jeffrey D. Bennett, DMD, Farmington, CT (no abstract provided)

Barbiturates/Propofol
Michael J. Buckley, DMD, MS, Pittsburgh, PA The use of intravenous agents to induce general anesthesia is well documented in the literature and their use by oral and maxillofacial surgeons over the years has been proven very safe and effective. The agent of choice has been barbiturates, which have a long history of safety and effectiveness. Recently, the use of agents such as propofol has gained in popularity, and has also proven effective and safe. This talk will outline the pharmacokinetics of both agents, and suggest different clinical situations in which one agent may be superior to another.
References Meyers C, Eisig S, Kraut R: Comparison of propofol and methohexital for deep sedation. J Oral and Maxillofac Surg 52:499, 1994 White P, Negus J: Sedative infusions during local and regional anesthesia: A comparison of midazolam and propofol. J Clin Anesth 3:32, 1991

Inhalation Agents
James C. Phero, DDS, Cincinnati, OH In the mid-1990s, medicine began to appreciate the benets of fast-tracking patients in the ambulatory surgery setting. For decades preceding this, oral and maxillofacial surgeons used the concepts surrounding this approach with inhalation anesthesia being a keystone to their anesthetic management. Ambulatory oral and maxillofacial surgery requires that the characteristics of inhalation anesthetic agents should be optimized for cardiovascular stability, minimal metabolism, stability in soda lime, lack of central nervous system excitation, and rapid, uneventful
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recovery prole. Agent properties related to safety, efcacy, cost, induction, and recovery times now temper the practitioners choice of using nitrous oxide, halothane, isourane, desurane, and sevourane. Inhalation induction is a consideration where an alternative to intravenous induction is indicated. Although cyclopropane did provide a rapid, smooth inhalation induction, the risk of explosion led to its withdrawal. Halothane was then accepted as the least pungent of the inhalation agents available for this technique. Unfortunately, halothane has problems with myocardial irritability especially in the presence of epinephrine and hypercarbia, depression of myocardial and respiratory function, cerebral vasodilation, and biotransformation potentially leading to hepatoxicity that can offset the lower cost of using the agent. Of the newer agents available, sevourane at 8% can be a good alternative as compared with an equi-MAC concentration of halothane at 5%. Sevourane, due to its properties of a low bloodgas partition coefcient of 0.68, pleasant smell, and non-irritant effect on the airway produces less induction failures, less laryngospasm, less cardiac side-effects, and a faster recovery than halothane. Isourane and desurane are not recommended for inhalaton induction due to their irritating smell that can lead to breath-holding, coughing, laryngospasm, and reduction in oxygen saturation. Desurane with the lowest blood-gas partition coefcient of 0.42 and the lowest tissue solubility of any other agent does offer the practitioner remarkable control during the maintenance phase and the fastest emergence of any inhalation agent. Additionally, emergence is faster when compared with intravenous propofol (Philip, 1999). It does require a nonconventional vaporizer due to a boiling point of 22.8 Centigrade and a saturated vapor pressure approaching 1 atmosphere at room temperature. Fortunately, in addition to the unique desurane vaporizer, the design of the entire anesthesia machine has evolved to keep pace with the development and the properties of the inhalation agents now available. Low gas ows can accurately be delivered due to agent vaporizers that function at these settings. These low gas ows permit decreased agent use resulting in signicant cost savings to help offset the additional cost per milliliter of the newer agents. After intravenous induction, gas ow can be stepped down rapidly to a 1 L per minute for all agents except desurane, which can be used at one-half L per minute. Switching to the newer agents from halothane or isourane toward the end of an anesthetic to further reduce anesthesia costs does not reduce recovery time or add to cost savings. This occurs because partial rebreathing through a semiclosed circuit limits elimination of the initial agent during the crossover period (Neumann, 1998). The use of the newer inhalation agents desurane and
AAOMS 2001

Symposia sevourane combined with the newer intravenous agents propofol and remifentanil in the ambulatory setting can optimize fast-tracking. However, agents with rapid on and off properties still require the practitioner to carefully consider prevention of potential complications such as postoperative pain, hypertension, delirium, delayed recovery, nausea, and vomiting.
References Neumann MA, Weiskopf RB, Gong DH, et al: Changing from isourane to desurane toward the end of anesthesia does not accelerate recovery in humans. Anesthesiology 88:914, 1998 Philip BK, Lombard LL, Roaf ER, et al: Comparison of vital capacity induction with sevourane to intravenous induction with propofol for adult ambulatory anesthesia. Anesth Analg 89:623, 1999 References Lieblich SE, Horswell BH: Attenuation of anxiety in ambulatory oral surgery patients with triazolam. J Oral Maxillofac Surg 49:792, 1991 Greenberg JA, Davis PJ: Premedication and induction of anesthesia in pediatric surgical patients. Anesth Clin North Am 14:781, 1996 Karl HW, Rosenberger JL, Larach MG, et al: Transmucosal administration of midazolam for premedication of pediatric patients: Comparison of the nasal and sublingual routes. Anesthesiology 78:885, 1993

B401
NPO Guidelines/Fluid Management
David P. Lustbader, DMD, Quincy, MA Signicant trends in oral and maxillofacial surgery have shifted surgical procedures from the hospital to the outpatient setting, usually the ofce. Traditional hospital procedures are now routinely performed in an ofce setting. To do this, the oral and maxillofacial surgeon must look at areas traditionally reserved for the anesthesiologist-NPO guidelines and uid management. Past concepts of NPO status are shifting to a more humanistic approach. NPO after midnight is now not the only rule for preoperative fasting. New research supports the use of clear uids up to 2 hours before surgery, especially in children. While making fasting preoperatively easier for our patients, this approach may actually neutralize the acidic environment of the stomach and decrease the risk of aspiration. Until recently, uid management was not critically looked at in the oral and maxillofacial surgery literature, probably because the more signicant surgical procedures were performed in the operating room. Bennett has demonstrated the benets of rehydration in ambulatory anesthesia during third molar removal. Patients who were hydrated had less nausea and vomiting and quicker recovery times. As trends in ofce-based surgery continue to increase, the role of uid management must continue to be emphasized in our practice.
References Warner-Mark, et al: Practice guidelines for pre-operative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Application to healthy patients undergoing elective procedures. A report by the American Society of Anesthesiologists, 1999 Bennett J, et al: A prospective randomized study of the benets of perioperative rehydration in ambulatory anesthesia for dentoalveolar surgery. Oral Surg Oral Med Oral Radiol Endod (in press) Lustbader DP: Perioperative uid management in oral and maxillofacial surgery. Oral Maxillofac Surg Clin North Am 2:625, 1999

Premedications: Management of Preoperative Anxiety for Ambulatory Oral Surgical Patients

Stuart E. Lieblich, DMD, Avon, CT The oral and maxillofacial surgeon is well versed in the management of anxiety during surgery through the administration of parenteral forms of sedation and general anesthesia. However, many patients have signicant anxiety that is not addressed because it occurs before the time of presentation to the ofce. Studies have shown that anxiety that occurs outside of the ofce can cause signicant elevation in heart rate and tachydysrhythmias in susceptible patients. This preoperative anxiety is usually not addressed until the ofce anesthetic is initiated. The preoperative administration of an oral sedative can have many advantages for the surgeon. A more relaxed patient preoperatively may require fewer anesthetic agents, allowing an earlier discharge. In addition, because anxious patients are reported to cancel their appointments at a 3 times greater rate, a more relaxed patient may be more likely to show up for their appointment. Finally, a more relaxed patient may permit treatment with just local anesthesia or local anesthesia supplemented with nitrous oxide. Also, with anxiolysis, the patient may be accepting of the starting of an intravenous line if needed to administer additional medications. Various agents have been used in the past to premedicate patients including barbiturates, narcotics, antihistamines, and even alcohol. However, the benzodiazepines are the prototypical drugs for anxiolysis and have many properties that make them ideally suited for this role in patient management. The recent formulation of oral midazolam has made this agent a suitable drug for oral use as well. In summary, intraoperative anxiety has been treated by titration of medications, whereas preoperative anxiety has typically been ignored. This discussion briey reviews the indications for preoperative anxiolysis and the medications available to the practitioner.
AAOMS 2001

B402
Airway Management/Guidelines
Charles H. Kates, DDS, North Miami Beach, FL Despite the advances in technology and pharmacology, airway events are still the number one cause of anesthesia mortality and morbidity.
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Symposia As we have moved from inhalation anesthesia to intravenous anesthesia, we have become less observant of impending airway problems in our OMFS practices. To help improve our already excellent safety record, a thorough review of airway techniques and skills is considered in this presentation. Emphasis is placed on practical assessment modalities, problem solving, and emergency management. Newer methods of airway control will be presented using a problem-oriented approach. The extensive use of video will allow the practitioner to observe correct airway techniques and application in a dynamic learning environment.
References Mallampati SR, Gatt SP, Gugino LD et al: A clinical sign to predict difcult intubation: A prospective study. Can Anesth Soc J 32:429, 1985 Purcell T: Fiberscopic assisted intubation, in Daily RH, Simon B, Young GP et al (eds): The airway: Emergency management, St Louis, MO, Mosby, 1992 American Society of Anesthesiologists: Practice guidelines for management of the difcult airway: A report by the ASA task force on management of the difcult airway. Anesthesiology 78:597, 1993

have been established and are periodically reviewed and revised. Denitions concerning the depth of sedation, monitors to be used during these procedures, and recovery guidelines are included in these documents. Denitions used include anxiolysis, conscious sedation (sedation and analgesia), combination inhalation and enteral conscious sedation, deep sedation and general anesthesia. Monitors discussed include the use of pulse oximetry, noninvasive blood pressure and pulse, and various methods of evaluating ventilation including the use of a precordial stethoscope, plethysmography, or capnography. Proper monitoring often includes recommendations for postoperative care and discharge criteria are often discussed in these documents. The purpose of this presentation is to directly compare and contrast the most recent guidelines for outpatient anesthesia as stated by the American Society of Anesthesiologists, the American Academy of Pediatrics, the American Dental Association, and the American Academy of Pediatric Dentistry. Recent changes in these guidelines are highlighted. Based on these guidelines, suggestions for patient management by oral and maxillofacial surgeons will be provided.
References American Society of Anesthesiologists: Guidelines for ofce-based anesthesia. Approved October 13, 1999 American Dental Association: Guidelines for the use of conscious sedation, deep sedation and general anesthesia for dentists. Adopted October, 2000 Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 89:1110, 1992

B403
Outpatient Anesthesia Monitoring Guidelines
Noah A. Sandler, DMD, MD, Minneapolis, MN In an attempt to deliver outpatient anesthesia in a safe and predictable manner, state and national guidelines

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AAOMS 2001