Cardiac Rhythm Disturbances During Office-Based Anesthesia

Symposia to assay the impact of the anesthetic upon cognitive function, dysfunction, and impairment. Although most of the studies have involved a population undergoing major surgery with postoperative admission to the hospital, ambulatory patient populations have also been studied and assessment tools have been proposed. Anesthetic agents and techniques may be causative or related to the etiology of postoperative cognitive deficits and dysfunction. The ability to perform complex tasks and depression are discussed in recent anesthesia literature. Concerns were raised more than 15 years ago; however, recognition of specific risk factors has not occurred until recently. Agents that reduce dyslipidemia may help in the reduction of postoperative delirium. Even maintenance of mean arterial pressure above a certain level has been associated with reduced postoperative neurocognitive dysfunction. Studies have shown that neurocognitive impairment and hence function may persist after surgery and anesthesia with reduced quality of life. Postoperative cognitive dysfunction and 1 year mortality relationships have been established; none have been established beyond one year. A recent paper suggests that this dysfunction leads to early forced retirement and the need for public financial support. Are these problems restricted to the aging population? The answer seems to be no! One prospective study suggests it may happen from age 18 and upward. The age 18 in this study was only significant because of informed consent and the age at which the investigators were able to perform the prospective study. Another study suggests that early exposure to repeated anesthetics, but not a single anesthetic, may increase the risk of learning disabilities in young children. What are the potential implications for the oral and maxillofacial surgeon? The implications may include the location of the procedure, the choice of anesthetic and sedative medications, and in the case of children, the addition of another procedure that may impair or alter learning if it is one of many procedures. Suggested strategies will be discussed as well as evidence-based approaches to anesthetic care to reduce both the incidence and impact of cognitive dysfunction and impairment. References Steinmetz J, Christensen KB, Lund T, et al: Long-term Consequences of Postoperative Cognitive Dysfunction. Anesthesiology 2009; 110: 548-555 Wong J, Tong D, De Silva Y, et al: Development of the Functional Recovery Index for Ambulatory Surgery and Anesthesia. Anesthesiology 2009; 110: 596-602 Greene NH, Attix DK, Weldon C, et al: Measures of Executive Function and Depression Identify Patients at Risk for Postoperative Delirium. Anesthesiology 2009; 110: 788-795 Monk TG; Weldon BG, Garvan CW, et al: Predictors of Cognitive Dysfunction after Major Noncardiac Surgery. Anesthesiology 2008; 108: 18-30

AAOMS • 2009

Wilder RT, Flick RP, Sprung J, et al: Early Exposure to Anesthesia and Learning Disabilities in a Population-based Birth Cohort. Anesthesiology 2009; 110: 796-804

Interactive Morbidity and Mortality: Simulated Office Emergencies David W. Todd, DMD, MD, Lakewood, NY Andrew Herlich, DMD, MD, Pittsburgh, PA This lecture will discuss a variety of office emergencies utilizing a Sim Man vital signs display and case descriptions. The audience will participate and interact with the presentation using the audience response system. After each scenario, a debriefing will be performed to discuss various aspects of the emergency and correct responses. References ACLS Handbook of Emergency Cardiac Care, 2008 American Heart Association AAOMS Office Emergency Manual, AAOMS 2007 PALS Handbook of Pediatric Emergency Care, 2008 American Heart Association

Cardiac Rhythm Disturbances During Office-Based Anesthesia Robert C. Bosack, DDS, Orland Park, IL A wide variety of cardiac rhythm disturbances often present during deep sedation / general anesthesia in spontaneously breathing patients. Etiologies range from “variant of normal,” to underlying chemical / electrolyte imbalance, drug abuse, drug effect, underlying cardiac pathology or “peri-anesthetic issues,” such as laryngospasm, hypoxia, hypercarbia, or light anesthesia with attendant autonomic instability. The significance of peri-anesthetic dysrhythmias is quite variable, as is their duration and consequence. These disturbances can have varying effects on cardiac output and may presage or deteriorate to more severe disturbances, especially when triggering agents, if present, are not recognized or treated promptly and adequately. Outcomes and effects on patients can be difficult to predict as cardiopulmonary reserve varies greatly among patients and can be difficult to adequately assess even in ideal situations. This reserve directly influences the ability to tolerate the abnormality. The approach for this presentation will follow the format of understand, prevent, diagnose and manage. Salient features of the cardiac history will be reviewed. Problems will be approached clinically with the use of real time, dynamic rhythms–similar to what is seen on office monitors, complete with blood pressure, oxygen saturation and end-tidal CO2. Treatment options and triage suggestions will be provided. 25

Symposia To complete the comprehension of these issues, key topics in cardiac physiology, dysrhythmia recognition, pathology, pharmacology and electricity will be interspersed, providing a segue to the concluding discussion on office management strategies for patients with implanted cardiac rhythm management devices.

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References Balser, J. R. New Concepts in Antiarrhythmic Therapy. 59th Annual Refresher Course Lectures, American Society of Anesthesiology, 2008 Latif, S., et. al. Ventricular Arrhythmias in Normal Hearts. Cardiol Clin 26: 367-380, 2008 Libby, P., et. al., eds. Braunwald’s Heart Disease. A Textbook of Cardiovascular Medicine. Philadelphia: Elsevier, 2008

AAOMS • 2009