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Airway Management
Symposia
ANESTHESIA UPDATE FOR THE OMS Monday, October 8, 2007, 7:00am—2:30pm
Preoperative Behavioral Stress Response in Children: Is There a Role (What Is the Role) for Oral PreMedication in Out Patient Surgery? Robert Moynihan, MD, Sacramento, CA Preoperative anxiety and behavioral stress response in children is a common and vexing problem in the surgical arena as well as other heath care environments. Risk factors associated with this response include: Young age, especially pre-school, previous surgery, especially one associated with a “poor quality encounter,” lack of pre-operative visit/orientation, shy and inhibited temperament, anxious parents, and parental prediction of uncooperative behavior. The stress response has been shown repeatedly to be undesirable on the day of surgery for the child, family and hospital personnel but also to have long-term psychologically traumatic consequences. A general and reasonable assumption has been made that any procedure that will reduce the child’s fear of the anesthesia/surgical experience will tend to reduce its traumatic effect. Approaches to reduce anxiety fall into two categories: psychological and pharmacological. Psychological factors tend to focus on pre-operative preparation/orientation programs for child and family, parental presence during the induction of anesthesia, and induction sequence techniques, including a variety of distraction methods. Pharmacological factors include using a sedative or anxiolytic agent. All of the above psychological approaches effectively reduce anxiety and therefore improve the surgical/anesthetic experience for all involved. Preoperative preparation programs tend to enhance coping skills and provide a sense of control and mastery over the procedures. Techniques incorporated include modeling play therapy, tours, printed materials, videos, role reversal, relaxation, etc. Much research has gone into the specific offerings of such programs, what type of professional delivers the program, and the timing of the program presentation as well as variations according to the age of the patient. A natural extension of any pre-op preparation program would be the option to have a parent present during the actual induction of anesthesia—widely recognized as a point of maximum potential anxiety. Here again the data shows a generally improved lessening of anxiety despite the fact that the parent present during the induction may well experience greater degrees of stress and anxiety. Lastly the induction techniques used by the anesthesiologist/anesthetists for reducing the “terror” of anesthesia include the use of stories, music, flavors on AAOMS • 2007
the mask, and “pretending,” constituting the unpublished but recognized part of the “art of anesthesia.” Breakthrough anxiety and a “Butane” anesthetic induction is in my opinion a failed anesthesia induction sequence. In the most general terms there is approximately 20% of the young pediatric population who will demonstrate anxiety and behavioral distress no matter how much pre-op preparation/orientation is done and no matter what creative induction choreography is presented. And parents present will not help these children either. 40% of the population will tolerate the preoperative sequence well with minimal preparation and lastly 40% will be unpredictable. In this last group the psychological preparation techniques will have the most impact. However, looking across the spectrum a good percentage of children (20.3%) will have emotional upset and therefore “failed” induction sequences when psychological preparation methods are employed alone. Sedation covers this exposure. When sedative premedication were directly compared to parental presence, however, it was found that children receiving oral Midazolam are significantly less anxious and more compliant during the induction process. A recent study examined whether a combination of parental presence and oral Midazolam is more effective than oral Midazolam alone or parental presence alone. The investigators found that parental presence has no additive anxiolytic effects for children who received oral Midazolam preoperatively. Parents who accompany these sedated children into the operating rooms, however, are significantly less anxious and more satisfied both with the separation process and with the overall anesthetic, nursing and surgical care provided. Reference Vessey JA et al. Another pandora’s box? Parental participation in anesthetic induction. Children’s Healthcare 19(2), 116-118, 1990 McCann M, ZN K. Management of Preoperative Anxiety in Children: An Update. Anes Analg 2001:93:98-105. Kain ZN. Myths in Pediatric Anesthesia. ASA Annual Meeting Refresher Course Lectures. 2006: 127:1-5
Review of Inhalation Anesthesia Roger P. Byrne, DDS, MD, Houston, TX No abstract provided.
Airway Management Michael K. Rollert, DDS, Denver, CO Successful airway management is the cornerstone of safe anesthesia practice. The fundamental responsibility of the anesthesia provider is to maintain adequate gas exchange. 29
Symposia Morbidity and mortality studies overwhelmingly conclude that respiratory events are the most common emergent anesthetic events and result in the worst outcomes when not properly treated. We will review the airway management tools available to the oral and maxillofacial surgeon. These will include the endotracheal tube, laryngeal mask airway, combitube, and cricothyroidotomy. Advantages, contraindications, and instructions for placement will be covered. Tools of early airway management detection and treatment will be reviewed. Emergency treatment of respiratory complications, including foreign body obstruction, laryngospasm, bronchospasm, aspiration, and pulmonary edema will be covered. Finally, the ‘cannot ventilate, cannot intubate’ scenario will be discussed in detail. The goal of the presentation is to help the clinician avoid airway complications and solve airway problems. References Benumof JL: Airway management principles and practice. Mosby 1996 Practice guidelines for management of the difficult airway – A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 78:597;1993 Verghese C, Brimacombe JR: Survey of laryngeal mask airway usage in 11,910 patients: Safety and efficacy for conventional and nonconventional usage. Anesth Analg 82:129;1996
The Obese and Morbidly Obese Patient Guillermo E. Chacon, DDS, Columbus, OH Purpose: The number of obese patients in the general population has increased dramatically over the past 20 years. This increase has highlighted concerns in treating these patients surgically in the office setting due to the increased likelihood of concomitant co-morbid conditions. With more and more surgical procedures being performed on an outpatient basis using deep sedation and general anesthesia techniques, it is critical for the oral and maxillofacial surgeon to be familiar with the physical condition of the surgical candidate. Thorough
review of the patient’s health history and obtaining appropriate consultations can minimize associated risks and potential complications. Considerations concerning airway management and pharmacological issues need to be determined prior to the procedure to ensure both patient safety and operator efficiency. Conclusion: The oral and maxillofacial surgeon will increasingly be called upon to treat the obese patient. By reviewing the complexities of the obese patient from a physiological and pharmacological standpoint, considerations involved in the surgical and anesthetic management of these patients can be appreciated. Initiating appropriate protocols for the surgical and anesthetic management of these patients can improve patient outcome and safety. References National Institute of Health, National Heart, Lung, and Blood Institute. Clinical guidelines for the identification, evaluation, and treatment of overweight and obesity in adults-the evidence report. Obes Res 1998; 6(suppl 2): 51S-209S [Published erratum appears in Obes Res 1998; 6:464]. Retrieved August 2001 from: http://nhlbi.nih.gov/ guidelines/obesity/ob_home.htm Lyznicki JM, Young DC, Riggs JA, Davis RM: Obesity: assessment and management in primary care. Am Fam Physician 11:2185, 2001 Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL: Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord 22:39, 1998
Allergies and Anaphylaxis David M. Grogan, DDS, MSD, Dallas, TX No abstract provided.
Anatomy of a Disaster Lester Machado, DDS, MD, San Diego, CA A detailed discussion of real life scenarios pointing out the issues and events that lead to anesthetic related morbidity and mortality. A formal abstract would not be appropriate.
ANESTHESIA UPDATE FOR THE OMS Tuesday, October 9, 2007, 7:00am—2:30pm
Anesthetic Management of the Geriatric Patient Jeffrey B. Dembo, DDS, Lexington, KY We have entered an era where life expectancy can easily exceed 100 years. This has resulted in an increase in the number of elderly patients who might require surgical and anesthetic care. By itself, increased age does not necessarily increase the risk of anesthesia. However, aging is associated with ana30
tomic, physiologic, mental, and emotional changes and these add complexity to the anesthetic plan and must be taken into consideration. Ethical issues associated with providing anesthetic care to the elderly may also require consideration. The goals of this session are to answer three questions: 1) How are the elderly different from younger patients; 2) what should be included in their evaluation; and 3) what modifications should be made regarding their anesthetic care? AAOMS • 2007
ANESTHESIA UPDATE FOR THE OMS Monday, October 8, 2007, 7:00am—2:30pm
Preoperative Behavioral Stress Response in Children: Is There a Role (What Is the Role) for Oral PreMedication in Out Patient Surgery? Robert Moynihan, MD, Sacramento, CA Preoperative anxiety and behavioral stress response in children is a common and vexing problem in the surgical arena as well as other heath care environments. Risk factors associated with this response include: Young age, especially pre-school, previous surgery, especially one associated with a “poor quality encounter,” lack of pre-operative visit/orientation, shy and inhibited temperament, anxious parents, and parental prediction of uncooperative behavior. The stress response has been shown repeatedly to be undesirable on the day of surgery for the child, family and hospital personnel but also to have long-term psychologically traumatic consequences. A general and reasonable assumption has been made that any procedure that will reduce the child’s fear of the anesthesia/surgical experience will tend to reduce its traumatic effect. Approaches to reduce anxiety fall into two categories: psychological and pharmacological. Psychological factors tend to focus on pre-operative preparation/orientation programs for child and family, parental presence during the induction of anesthesia, and induction sequence techniques, including a variety of distraction methods. Pharmacological factors include using a sedative or anxiolytic agent. All of the above psychological approaches effectively reduce anxiety and therefore improve the surgical/anesthetic experience for all involved. Preoperative preparation programs tend to enhance coping skills and provide a sense of control and mastery over the procedures. Techniques incorporated include modeling play therapy, tours, printed materials, videos, role reversal, relaxation, etc. Much research has gone into the specific offerings of such programs, what type of professional delivers the program, and the timing of the program presentation as well as variations according to the age of the patient. A natural extension of any pre-op preparation program would be the option to have a parent present during the actual induction of anesthesia—widely recognized as a point of maximum potential anxiety. Here again the data shows a generally improved lessening of anxiety despite the fact that the parent present during the induction may well experience greater degrees of stress and anxiety. Lastly the induction techniques used by the anesthesiologist/anesthetists for reducing the “terror” of anesthesia include the use of stories, music, flavors on AAOMS • 2007
the mask, and “pretending,” constituting the unpublished but recognized part of the “art of anesthesia.” Breakthrough anxiety and a “Butane” anesthetic induction is in my opinion a failed anesthesia induction sequence. In the most general terms there is approximately 20% of the young pediatric population who will demonstrate anxiety and behavioral distress no matter how much pre-op preparation/orientation is done and no matter what creative induction choreography is presented. And parents present will not help these children either. 40% of the population will tolerate the preoperative sequence well with minimal preparation and lastly 40% will be unpredictable. In this last group the psychological preparation techniques will have the most impact. However, looking across the spectrum a good percentage of children (20.3%) will have emotional upset and therefore “failed” induction sequences when psychological preparation methods are employed alone. Sedation covers this exposure. When sedative premedication were directly compared to parental presence, however, it was found that children receiving oral Midazolam are significantly less anxious and more compliant during the induction process. A recent study examined whether a combination of parental presence and oral Midazolam is more effective than oral Midazolam alone or parental presence alone. The investigators found that parental presence has no additive anxiolytic effects for children who received oral Midazolam preoperatively. Parents who accompany these sedated children into the operating rooms, however, are significantly less anxious and more satisfied both with the separation process and with the overall anesthetic, nursing and surgical care provided. Reference Vessey JA et al. Another pandora’s box? Parental participation in anesthetic induction. Children’s Healthcare 19(2), 116-118, 1990 McCann M, ZN K. Management of Preoperative Anxiety in Children: An Update. Anes Analg 2001:93:98-105. Kain ZN. Myths in Pediatric Anesthesia. ASA Annual Meeting Refresher Course Lectures. 2006: 127:1-5
Review of Inhalation Anesthesia Roger P. Byrne, DDS, MD, Houston, TX No abstract provided.
Airway Management Michael K. Rollert, DDS, Denver, CO Successful airway management is the cornerstone of safe anesthesia practice. The fundamental responsibility of the anesthesia provider is to maintain adequate gas exchange. 29
Symposia Morbidity and mortality studies overwhelmingly conclude that respiratory events are the most common emergent anesthetic events and result in the worst outcomes when not properly treated. We will review the airway management tools available to the oral and maxillofacial surgeon. These will include the endotracheal tube, laryngeal mask airway, combitube, and cricothyroidotomy. Advantages, contraindications, and instructions for placement will be covered. Tools of early airway management detection and treatment will be reviewed. Emergency treatment of respiratory complications, including foreign body obstruction, laryngospasm, bronchospasm, aspiration, and pulmonary edema will be covered. Finally, the ‘cannot ventilate, cannot intubate’ scenario will be discussed in detail. The goal of the presentation is to help the clinician avoid airway complications and solve airway problems. References Benumof JL: Airway management principles and practice. Mosby 1996 Practice guidelines for management of the difficult airway – A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 78:597;1993 Verghese C, Brimacombe JR: Survey of laryngeal mask airway usage in 11,910 patients: Safety and efficacy for conventional and nonconventional usage. Anesth Analg 82:129;1996
The Obese and Morbidly Obese Patient Guillermo E. Chacon, DDS, Columbus, OH Purpose: The number of obese patients in the general population has increased dramatically over the past 20 years. This increase has highlighted concerns in treating these patients surgically in the office setting due to the increased likelihood of concomitant co-morbid conditions. With more and more surgical procedures being performed on an outpatient basis using deep sedation and general anesthesia techniques, it is critical for the oral and maxillofacial surgeon to be familiar with the physical condition of the surgical candidate. Thorough
review of the patient’s health history and obtaining appropriate consultations can minimize associated risks and potential complications. Considerations concerning airway management and pharmacological issues need to be determined prior to the procedure to ensure both patient safety and operator efficiency. Conclusion: The oral and maxillofacial surgeon will increasingly be called upon to treat the obese patient. By reviewing the complexities of the obese patient from a physiological and pharmacological standpoint, considerations involved in the surgical and anesthetic management of these patients can be appreciated. Initiating appropriate protocols for the surgical and anesthetic management of these patients can improve patient outcome and safety. References National Institute of Health, National Heart, Lung, and Blood Institute. Clinical guidelines for the identification, evaluation, and treatment of overweight and obesity in adults-the evidence report. Obes Res 1998; 6(suppl 2): 51S-209S [Published erratum appears in Obes Res 1998; 6:464]. Retrieved August 2001 from: http://nhlbi.nih.gov/ guidelines/obesity/ob_home.htm Lyznicki JM, Young DC, Riggs JA, Davis RM: Obesity: assessment and management in primary care. Am Fam Physician 11:2185, 2001 Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL: Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord 22:39, 1998
Allergies and Anaphylaxis David M. Grogan, DDS, MSD, Dallas, TX No abstract provided.
Anatomy of a Disaster Lester Machado, DDS, MD, San Diego, CA A detailed discussion of real life scenarios pointing out the issues and events that lead to anesthetic related morbidity and mortality. A formal abstract would not be appropriate.
ANESTHESIA UPDATE FOR THE OMS Tuesday, October 9, 2007, 7:00am—2:30pm
Anesthetic Management of the Geriatric Patient Jeffrey B. Dembo, DDS, Lexington, KY We have entered an era where life expectancy can easily exceed 100 years. This has resulted in an increase in the number of elderly patients who might require surgical and anesthetic care. By itself, increased age does not necessarily increase the risk of anesthesia. However, aging is associated with ana30
tomic, physiologic, mental, and emotional changes and these add complexity to the anesthetic plan and must be taken into consideration. Ethical issues associated with providing anesthetic care to the elderly may also require consideration. The goals of this session are to answer three questions: 1) How are the elderly different from younger patients; 2) what should be included in their evaluation; and 3) what modifications should be made regarding their anesthetic care? AAOMS • 2007