General Anaesthesia for Dental Procedures

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General Anaesthesia for Dental Procedures

• By Dr. Mahmoud Al-mustafa
• Associate Professor
• Dept of Anaesthesia
• Faculty of Medicine The University of Jordan
• 24 December 2013

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Sensations

• Peripheral
• Pain
• Temperature
• Touch
• deep
• light
• Proprioception
• Special senses
• Central Awareness ? Apprehension Fear and
  Anxiety

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Anaesthesia

• In Surgery it implies reversibly rendering the
  patient unconscious by drugs for the execution of
  a painful operative procedure - in a titrable and
  controlled way.

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Surgery

• Trauma ? stress on the living body
• Metabolic Response to stress
• Neural Component ? Autonomic system
• -
  Sympathetic
• -
  Parasympathetic
• Endocrine Component ? Hormonal System
• - Growth
  Hormone
• - Cortisol
• - glucagon
• - Antidiuretic
  hormone
• - Renin
  Aldosterone
• - etc

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Anaesthesia

• Modulates the stress response by blocking the
  afferent limb of the response .
• Pain and awareness are blocked by anesthetic
  drugs , but other afferent limb factors are not (
  e.g. Hypovolemia, hypoxemia, etc)
• ? complete medical management of the patient
  peri -operative Medical management

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Anaesthesia

• Modern Anaesthesia is Composed of
• Hypnosis Inducing Controlled Loss of
• Awareness
• Analgesia Inducing Controlled Loss of Pain
• (/-) Muscle Relaxation( Controlled muscle
  Paralysis)

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Hypnosis In Anaesthesia

• Hypnosis The state of being asleep
• Pharmacologically induced
• A non-physiological very deep level of
• sleep that deprives the patient from critical
  facullties.
• Can and should be titrated according to the level
  of surgical stimulus

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Analgesia

• State of freedom from pain
• Analgesia vs. anaesthesia
• Analgesia can be brought about by local or
  regional techniques, or drugs with specific pain
  receptors action
• ( e.g. Opioids) without Loss of
  consciousness.

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Muscle relaxation

• Paralyzing the patients muscles by use of drugs
  that block the acetylcholine receptors at the
  Neuromuscular junction
• Purposes
• Facilitation of airway management
• Control of Ventilation
• Facilitation of Surgery
• Patient should be artificially ventilated !!

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Stages of Anesthesia

• 1- Stage of analgesia
• Diminished pain perception, verbal contact
• maintained, laryngopharyngeal reflexes and
• voluntary control Present
• 2- Stage of uninhibited response (Excitement)
• Consciousness lost, verbal contact and voluntary
• control lost ? uncontrolled, exaggerated,
  withdrawal
• type response to any stimulus
• Protective laryngopharyngeal reflexes maintained
  !

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Stages of Anesthesia(continued)

• 3- Stage of Surgical Anaesthesia
• Centers of the medulla become
• progressively depressed (vomiting, striated
• muscle tone, respiratory)
• Autonomic reflexes depressed
• It is the stage at which anaesthesia has
  depressed both the reticular activating system
  and perhaps selectively the pain synapses of the
  spinal cord and is the stage at which operations
  may be performed
• Divided into Four planes according to the depth
  of anaesthesia and marked by cessation of
  breathing at its lower end.

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Stages of Anesthesia(continued)

• Stage 4 Stage of Respiratory Arrest
• Cessation of Respiration ? Cardiac Arrest
• Anoxia
• Direct Cardiac effects e.g. arrhythmias
• Danger of Death
• Should not be reached by anaesthetist

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Anesthesia in Dentistry

• 1- Local Anaesthesia
• 2- Sedation
• 3- General Anaesthesia

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Dental Procedures Requiring Sedation or General
Anesthesia

• 1- Oral Surgery
• Removal of impacted teeth
• Multiple Dental extractions
• - Preprosthetic Surgery (Vestibuloplasties)
• Insertion of Osteointegrated plants
• Others.

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Dental Procedures Requiring Sedation or
General Anesthesia (CONTINUED)

• 2- Restorative Dentistry
• Multiple dental restorative procedures
• (e.g. Rampant Caries)
• - Procedures performed on Mentally Retarded
  Patients

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Dental Procedures Requiring Sedation or
General Anesthesia (CONTINUED)

• 3-Temporomandibular Joint
• Arthroscopy
• - Arthroplasty

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Dental Procedures Requiring Sedation or
General Anesthesia (CONTINUED)

• 4- Maxillofacial Surgery
• - Trauma
• - Tumor
• - Reconstructive

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Dental Procedures Requiring Sedation or
General Anesthesia (CONTINUED)

• 5- Special patient Groups
• Young Children esp. some with systemic Diseases
  (hemophilia,CHD)
• Mentally retarded
• Patients with poorly controlled Seizure activity
• - Those with an oral septic focus

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Problems Related to Dental Anaesthesia

• 1- In / Outpatient selectivity
• 2- Competition for the Airway by both Dentist and
  Anaesthetist
• 3- Patients are often children
• 4- Mentally handicapped patients

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Conduct of Anaesthesia

• 1- Pre-Operative Assessment
• 2- Intra-Operative Management
• 3- Post-Operative Management

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Pre-Operative Assessment

• - History medical,surgical,Anaesthetic,
  Allergy
• - Medical Examination
• - Investigations as per case
• - Informed Consent signed by patient or
• guardian

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Risk classification

• ASA I A normal Healthy patient
  0.06-0.08
• ASA II A patient with mild systemic disease
  0.27-0.40
• ASA III A patient with severe systemic disease
  1.8 - 4.3
• ASA IV A patient with severe systemic disease
• that is a constant threat to
  life 7.8 - 23
• ASA V Moribund patient who is not expected to
• survive without the operation
  9.4-51
• ASA VI A declared brain dead patient whose
• organs are being removed for
  donor purposes
• E For Emergency surgery

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Intra-Operative Management

• 1- Establishing Monitoring
• Heart Rate, Blood Pressure, Electrocardiogram,
  Pulse Oxymetry,
• End Tidal CO2 Monitoring
• 2- Induction of Anesthesia
• - Hypnosis gt - Intravenous Drugs (e.g.
  Sodium Thiopentone ,
• Propofol,
  Etomidate, Ketamine )
• - Analgesia gt - Nitrous Oxide gas
• - Opioid Drugs
  Morphine, Pethidine,
• Fentanyl,
  Alfentanyl, Sufentanyl,
• Remifentanyl
  .
• - Muscle Relaxation gt
• - short Acting Suxamethonium( used for
  rapid sequince induction)
• - Intermediate acting Atracurium, Cis-
  atracurium,
  Vecuronium,
  Rocuronium,
• - Long Acting d-tudocurarine, Pancuronium

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Monitoring
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End Tidal CO2

• Value less than arterial CO2 3-5 mmHg

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Intraoperative Management
continued

• 3- Maintenance of Anaesthesia gt
• - Intravenous drug infusion for short acting
• drugs
• - Inhalational Agents for Hypnosis
• (e.g. Halthane,Sevoflurane,Isoflurane ,
  Enflurane,desflorane, Nitrous Oxide, etc.. )
• - Intermittent doses for intermediate or long
  acting muscle relaxants and analgesics

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Intraoperative Management continued

• 4- Securing the Airway
• Using a Cuffed Endotracheal Tube
• - Orally
• - Nasally Better surgical
  access
• Throat pack
• Meticulous Suctioning

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Endotracheal Tube
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laryngeal mask airway
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Intraoperative Management continued

• 5- Securing Ventilation
• - Spontaneous Breathing
• - Manual ventilation
• - Using a mechanical
  Ventilator
• 6- Surgery Starts
• Continuous Monitoring
  for
• - A,B,C
• - Adequate
  Anaesthesia
• -Necessary
  medical management

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Intra-operative Issues

• Loose Teeth
• Surgical Debris
• Bleeding
• Secretions
• Use of Throat Pack
• Endocarditis Prophylaxis

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PostOperative Management

• 1- Emergence from Anesthesia
• Patient in Left Lateral Position
• Turn Anaesthetics off
• Reversal of residual Muscle
  relaxation
• Anti-dote drug e.g.
  Neostigmine
• Extubation of the airways
• 2- Sending patient to Recovery Room
• 3- Recovery Room Nursing
• Monitoring and Management
• 4- Assessment of Patient before Discharge
• By anaesthetist

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Recovery Room Issues

• Recovery Room Issues
• - Nursing in Lateral position
• - Management of complications Pain, Nausea,
  Vomiting, Hypoxia, etc
• - Assessment by Anaesthetist before Discharge
• - prescribing oral analgesic drugs if patient is
  sent home
• - Advice NOT to Drive or operate machinery for 24
  hours at least
• - making sure that there is somebody to escort
• patient home

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Thank You