Dental anesthesia Flashcards
Anesthetic consideration for dentals
Aspiration Pneumonia
Regurgitation
Length of procedure
Hypothermia
Mouth gags
Eye trauma
Post-operative pain
Deafness post-operatively
Why is the airway so important for a dental
SECURE AND PROTECT THE AIRWAY!
Why is it important to protect the airway?
Increased risk of aspiration
Fluids, tartar and debris collect in the back of the mouth oral procedures
Regurgitation risks increased due to pharyngeal stimulation
Gauze packing, x-rays, extracting and cleaning molars
ETT disconnect, extubation or tracheal trauma
Manipulating the oral cavity during cleaning and extractions, and patient position changes multiple times during the procedure
How to Prevent Airway Complications for a dental
Know ETT length at intubation
Inflate ETT cuff but do not over inflate
Pharyngeal packing with gauze
Use Capnography if available
Disconnect patient from breathing circuit when repositioning
Recheck inflation of ETT when patient is repositioned
How do you do pharyngeal packing
Moisten gauze before placement to avoid irritation of mucous membranes
Don’t pack too tightly, can cause the tongue to swell
Need to be sure that all gauze is removed prior to extubation
Tie gauze to ETT or leave ends visible from outside the mouth
Capnography and ETT Assessment is done how
Capnography can be used to assess patency of airway and to confirm correct placement of the ETT (ex. Esophageal intubation)
Helps to avoid and detect obstruction, ETT cuff leaks, disconnect, or extubation of ETT
The Importance of a Cuffed ETT
All dental procedures should be performed with a secure, properly inflated cuffed ETT
Check ETT cuff for leaks prior to intubation
Red rubber ETT is not ideal because the pilot balloon can snag and deflate accidentally
Complications Associated with Procedure Length
Hypothermia
Repeat dosing of analgesics (ex. Opioids, local blocks)
Patient positioning
arthritis, compression of limbs or nerves, atelectasis of lungs
Organ damage due to prolonged hypotension
Try to minimize time under anesthesia
Increase anesthetic time=increased anesthetic risk
Why is hypothermia increased risk in dentals
Risk of hypothermia increases in dentals due to:
geriatric, malnourished, or under-weight patients
Soaking the head with water coming from the ultrasonic equipment
Monitor temperature regularly and keep your patient warm!
Temperature should be maintained between 37.5-38.5 ⁰C (Normothermic)
Actively warm the patient throughout the procedure
Warm water bottles, Bair hugger, hot dog units, warm water blankets
Take care not to cause burns due to heating devices
Mouth gags and cats
“Spring held mouth gags can cause cerebral ischemia and blindness in cats”
Post-operative prognosis is guarded
Vision may return after 1-2 weeks
The mouth can be held open by hand
What can you use as a mouth gag
If a mouth gag must be used, there are alternative options
Cut off piece of ETT
Needle cap cut
1 ml syringe cut to appropriate length
These need to be shorter than conventional mouth gag to not cause the same problem
Foreign body risk?
Why should you be extra careful of the eyes during a dental
Dental debris can deflect into the eyes
Surgeon may have their hands inadvertently in the eye socket
Proptosed eye
Oculocardiac reflex
Lubricate eyes at least every 15 minutes
Don’t forget about post-operative care
Can a dental cause an animal to go deaf
Unknown cause but associated with geriatric patients
Uncommon but can be a complication of dentals or ear cleanings
Deafness was permanent
Important to keep in mind for post-operative follow-up
Why are dental patients at a higher ASA risk than other patients?
There is a direct relationship between age and dental disease
Geriatric patients are most common dental patients (prophylaxis is uncommon)
Some systemic diseases are associated with dental disease
Proper case management is essential to a healthy, positive patient outcome
Diseases associated with dental disease:
Heart disease (murmurs progressing to heart failure)
Renal failure (common in cats)
Diabetes
Potential for systemic infection
Malnutrition
Immunodeficiency diseases
Anesthetic Protocols for a Routine Dental
Due to increased risk of concurrent diseases; a thorough history, physical exam and pre-anesthetic diagnostics prior to the procedure is vital
Preform an oral exam:
note any difficulty opening the mouth, any oral masses
Is the patient guarded or painful during oral exam
Pre-anesthetic diagnostics may include:
Up to date blood work and urinalysis
Thoracic Radiographs, Echocardiogram and ECG (heart work-up)
What should you use for a premed in a dental
Pre-emptive analgesia for all dentals, even if it is “Just a cleaning”
Mu-opioids (ex. Hydromorphone, methadone)
Depending on systemic disease of the patient, a sedative can be added to the premedication to decrease the amount of induction and inhalant required for the procedure
How should you induce for a dental
Pre-oxygenate (difficult intubation, geriatric)
All patients under-going dental procedures should be intubated and airway should be protected using a cuffed ETT
Induction drugs are dependant on concurrent diseases but standard protocols are: Alfaxalone, Propofol, or Ketamine/Diazepam IV to effect
What is used for maintenance in a dental
Patient should be at a good plane of anesthesia before preforming oral exam or radiographs to avoid gag reflex or regurgitation
Minimum monitoring includes: blood pressure, temperature, heart rate and respiratory rate regularly throughout the procedure
Add more equipment depending on the patient: capnograph, ECG, mechanical ventilator, pulse oximeter
Use a balanced, multimodal anesthesia to decrease need for inhalant anesthetic and its side effects and to control pain throughout the procedure
Intraop analgesia in a dental
Top-up opioid as needed
Local anesthetic blocks using bupivacaine
Blocks can be preformed multiple times if the local wears off or the block does not work well
Calculate safe and toxic doses of local anesthetic for all patients
In feline patients, need to take into account lidocaine used during intubation
How do you recover a dental patient
Clean and check the back of the mouth prior to deflating ETT and extubating the patient
Remove gauze packing in the back of the mouth
Extubate with ETT partially inflated (Controversial)
Elevate neck with nose down to help to drain fluid from the mouth (ex. excessive or continued bleeding from extractions)
Monitor patient closely for the first few hours of recovery
Assess temperature and actively warm the patient until temperature is >37.5*C
Recheck that patient is maintaining its temperature
Perform a pain assessment and repeat analgesia as needed
