Evaluation of sedation in oral and maxillofacial surgery in ambulatory patients: failure and complications

Outcomes With Moderate and Deep Sedation in an Oral and Maxillofacial Surgery Training Program

PURPOSE

The purpose of the present study was to determine the complication rate associated with the administration of intravenous (IV) sedation in an oral and maxillofacial surgery (OMS) residency training program.

MATERIALS AND METHODS

We performed a prospective cohort study that enrolled patients who had received IV sedation for various oral surgery procedures in the clinic setting of an oral and maxillofacial surgery residency training program. The composition of the anesthesia team included residents who had completed their anesthesia rotation, ranging from postgraduate year (PGY)-1 to PGY-4. Each trainee chose their own anesthetic technique and completed a form that included demographic data, types and amounts of anesthetic used, and any intraoperative or postoperative complications encountered. All sedations were performed by a single provider with oversight by an attending oral and maxillofacial surgeon. The demographic and medication data were used as predictor variables. The outcome variables included any reported complications. The Fisher exact test was used to compare the complication rate by subgroup.

RESULTS

The study included 1005 patients treated during an 18-month period. The overall complication rate was 2.29%. The most common complication reported was postoperative nausea (n = 10; 0.99%), with 1 patient experiencing emesis. Other complications included laryngospasm (n = 1), prolonged recovery (n = 3), failed sedation because of agitation (n = 1), intraoperative hypertension (n = 1), postoperative hypertension (n = 1), ST elevation (n = 1), IV infiltration (n = 2), syncope during IV access (n = 1), and respiratory depression (n = 2). No deaths or no adverse events requiring escalation of the level of care occurred. Ketamine use resulted in a greater rate of postoperative nausea (1.21%), and propofol was associated with a lower rate of postoperative nausea (0.68%). Male patients experienced a greater rate of complications compared with female patients overall (2.4 vs 2.2%). However, the female patients had a greater rate of postoperative nausea and vomiting (0.96 vs 1.19%). Of those who had reported a previous history of postoperative nausea and/or vomiting (PONV), 50% experienced symptoms after sedation. The average length of the procedure was longer in the group that had experienced complications compared with those who had not (37.5 vs 31.6 minutes). None of these reported differences were statistically significant.

CONCLUSIONS

The results of the present study have demonstrated that the modern IV sedation anesthesia technique used in OMS training programs is safe and the complication rate is low. Postoperative nausea was the most common complication. Ketamine can increase the risk of PONV, and propofol can reduce the risk of PONV. However, larger studies are required for conclusive findings. A history of PONV is a good predictor of PONV. The length of the procedure might increase the risk of complications.

The Failed Sedation: Solutions for the Oral and Maxillofacial Surgeon

Due to wide variation in patient responses, both intended and adverse, it is impossible to successfully sedate all patients. Choosing the right drug and dose regimen can be challenging, especially in patients who are naïve to anesthesia. Underdosing can lead to pain perception, patient movement and combativeness, awareness with recall, and the sympathetic neuroendocrine stress response. Overdosing can lead to unintended loss of upper airway tone, hypoventilation/apnea, adverse cardiovascular changes, and prolonged sedation (with its attendant problems).

Complications associated with intravenous midazolam and fentanyl sedation in patients undergoing minor oral surgery

Background

Anxiety control remains an important concern in dental practice. We evaluated the incidence, nature, and sequelae of complications during and after minor oral surgeries performed under intravenous midazolam and fentanyl sedation using the titration technique.

Methods

The medical records of patients who had undergone minor oral surgeries under moderate intravenous midazolam and fentanyl sedation at our institution between January 1, 2015 and December 31, 2015 were retrospectively evaluated. Age, sex, body mass index, medical history, American Society of Anesthesiologists (ASA) classification, indications for sedation, amount of sedative used, surgical duration, and recovery time were evaluated for all patients.

Results

In total, 107 patients aged 9–84 years were included. ASA class I and class II were observed for 56.1% and 43.9% patients, respectively. Complications associated with sedation occurred in 11 (10.2%) patients. There were no serious adverse events. Oxygen saturation reached 95% during the procedure in six patients; this was successfully managed by stimulating the patients to take a deep breath. Two patients exhibited deep sedation and one exhibited paradoxical excitement. After the procedure, one patient experienced nausea without vomiting and one exhibited a prolonged recovery time. The surgical procedures were completed in all patients. Obesity was found to be significantly associated with sedation-related complications.

Conclusions

Our results suggest that complications associated with intravenous midazolam and fentanyl sedation using the titration technique for minor oral surgeries are mostly minor and can be successfully managed with no prolonged sequelae.

Does Psychological Profile Influence Third Molar Extraction and Postoperative Pain?

PURPOSE

Our purposes were to determine the influence of psychological profile on hemodynamic changes in patients who undergo surgical removal of the third molars under intravenous sedation and to evaluate the effect on patients' anxiety and postoperative recovery.

PATIENTS AND METHODS

We performed a prospective study of 100 patients (American Society of Anesthesiologists classes I and II; aged ≥18 years) seen in the CIMIVClinic (Department of Oral Surgery, Casa de Salud University Hospital, Valencia, Spain) who underwent extractions of all third molars under intravenous sedation. All patients were administered the Symptom Checklist 90 Revised (SCL-90-R). The following parameters were monitored at different times during the surgical interventions: systolic blood pressure, diastolic blood pressure, oxygen saturation, and heart rate. Position and depth of impaction of the tooth (Pell and Gregory classification and Winter classification), surgery duration, and surgical technique also were recorded. Finally, the degree of pain experienced the week after the surgical intervention was measured using a visual analog scale.

RESULTS

Patients' anxiety levels preoperatively were significantly higher in patients with psychological distress (P = .023). Postoperative pain significantly decreased from the first day to the seventh day in healthy patients but not in patients with altered psychological conditions (P < .05). Nevertheless, the hemodynamic changes were not correlated with the psychological impairment.

CONCLUSIONS

Intravenous sedation enables the control of hemodynamic changes in all patients independently of their psychological profile. Patients with psychological distress present with higher levels of dental anxiety and postoperative pain. Future studies are needed to further clarify this interaction.

Cohort study of pain symptoms and management following impacted mandibular third molar extraction

OBJECTIVE

The aim of this study was to investigate the possibility of intravenous sedation as a useful pain-relieving option for impacted third molar extractions.

SUBJECTS AND METHODS

A prospective cohort study was conducted among patients who underwent bilateral mandibular third molar extractions under local anaesthesia and intravenous sedation (sedation group) and patients who underwent unilateral mandibular third molar extraction under local anaesthesia alone (local anaesthesia group). The frequency of use of postoperative oral analgesia and the intensity of pain assessed using the full cup test were compared between the two groups.

RESULTS

The maximum pain intensity (0-100) on postoperative day 1 in the sedation and local anaesthesia groups was 72.8 ± 16.98 and 84.8 ± 15.84, respectively, and the mean pain intensity was 42.2 ± 16.00 and 49.6 ± 18.94. The maximum and mean pain intensities in the sedation group were significantly milder than those in the local anaesthesia group. The number of oral analgesic doses in the sedation group was significantly smaller on the day of surgery and on postoperative day 1 than in the local anaesthesia group.

CONCLUSIONS

The results of this study suggest that bilateral impacted mandibular third molar extractions under intravenous sedation could be a recommended treatment option.

Dexmedetomidine intravenous sedation using a patient-controlled sedation infusion pump: a case report

Dental treatment under sedation requires various sedation depths depending on the invasiveness of the procedure and patient drug sensitivity. Inappropriate sedation depth may cause patient discomfort or endangerment. For these reasons, patient-controlled sedation (PCS) pumps are commonly used. Patients are able to control the sedation depths themselves by pushing the demand button after the practitioner sets up the bolus dose and lock-out time. Dexmedetomidine is an α-2 adrenoreceptor agonist with sedative, analgesic, and anxiolytic properties. It has been widely used for sedation for its minimal respiratory depression; however, there are few studies on PCS using dexmedetomidine. This study assessed the applicability of dexmedetomidine to PCS.

Comparative study of hemodynamic changes caused by diazepam and midazolam during third molar surgery: a randomized controlled trial

The aim of the present study was to compare hemodynamic changes using midazolam 7.5 mg and diazepam 10.0 mg during the surgical removal of symmetrically positioned third molars. A prospective, randomized, double-blind, clinical trial was carried out involving 120 patients divided into three groups: Group 1 (diazepam and placebo), Group 2 (midazolam and placebo), and Group 3 (diazepam and midazolam). Each subject underwent two surgeries on separate occasions under local anesthesia. The following parameters were assessed at five different times (T0, T1, T2, T3, and T4): systolic, diastolic, and mean blood pressure (SBP, DBP, and MBP, respectively); heart rate (HR); oxygen saturation (SpO(2)); rate pressure product (RPP); and pressure rate quotient (PRQ). Statistically significant differences were found regarding heart rate at T2 and T3 (p < 0.005) in Group 2, with a higher rate occurring during midazolam administration. Moreover, significant differences in rate pressure product were found at T2, T3, and T4 in this group, with higher values also occurring during midazolam administration. In Group 3, significant differences in diastolic blood pressure were found at T3 and T4, with higher values occurring during diazepam administration, whereas a higher heart rate occurred at T3 with midazolam. Midazolam 7.5 mg and diazepam 10.0 mg exert an influence on some hemodynamic parameters without perceptible clinical changes in healthy patients undergoing lower third molar surgery.