Review of the intraoperative management and hemodynamic goals for patients with aortic stenosis, mitral stenosis, aortic insufficiency, and mitral valve regurgitation.
Diagnostic considerations for asymptomatic patients who present in the outpatient setting with known or unknown disease (auscultatory exam / preoperative echocardiogram)
The objectives of this course are:
This presentation will introduce new medications, discuss their pharmacologic properties, and dive into clinical applications useful for the Dentist Anesthesiologist.
Attendees will come away with an introduction to the following novel medications:
An introduction to perioperative alternatives to opioids for general anesthesia, and a discussion of how reduced opioid use impacts patient care.
Attendees will come away with:
It’s 1987 and the term virtual reality was coined. Thirty-three years later, this technology is still young. What is this used for other than gaming and how can you apply it to anesthesiology?
Attendees will come away with:
The COVID-19 pandemic has shifted the landscape of anesthesia care to involve telehealth, a tool that includes phone- and video-conferencing. Traditionally, pre-anesthesia consultations involve in person medical history-taking; laboratory testing or investigations; focused physical examination; and referral to other medical services to optimize the patient’s health prior to anesthetic procedures. The transition to incorporate virtual visits for not only patients living in rural and remote areas, but also local patients, prompts anesthesiologists to adapt their traditional practices to a new digital platform.
This lecture highlights best practices for virtual pre-anesthesia consultations.
The objectives of this course are:
Dr. Michelle Wong, Assistant Professor of Dental Anesthesiology at the University of Toronto’s Faculty of Dentistry, is a dental anesthesiologist who obtained her Doctor of Dental Surgery degree in 2010, Master of Science in Dental Anesthesia in 2014, and Doctor of Education in Educational Leadership in 2020. Dr. Wong is a Diplomate of the American Dental Board of Anesthesiology. She performs special care dentistry and anesthesia in an active hospital practice at Sunnybrook Health Sciences Centre’s Department of Dental Maxillofacial Sciences and in private practices in the Greater Toronto Area.
Dr. Andrea Fonner is a Diplomate of the American Dental Board of Anesthesiology and the National Dental Board of Anesthesiology. After graduating from the University of the Pacific School of Dentistry in 2004, she completed a GPR at the University of Washington. After two years in private practice, she entered the UCLA Dental Anesthesiology training program where she trained with Dr. John Yagiela and Dr. Christine Quinn.
She has maintained her mobile anesthesia practice in Bellevue, WA since graduating from her dental anesthesiology program 10 years ago, and she trains residents from various programs on a frequent basis.
Her current positions include: Board of Directors, American Dental Society of Anesthesiology (ADSA), Board of Directors, American Dental Board of Anesthesiology (ADBA), President & Co-founder, Washington State Society of Mobile Dental Anesthesia (WSSMDA), President and Delegate, Washington State American Dental Society of Anesthesiology (ADSA), Faculty & Clinical Instructor, Parenteral Moderate Sedation, Oregon Academy of General Dentistry (OAGD) Co-Director, High Fidelity Human Simulation (SimMan), American Dental Society of Anesthesiology (ADSA), Course Director of the Assistant’s Course, American Dental Society of Anesthesiology (ADSA) and Editorial Advisory Board, Decisions in Dentistry
Dr. Fonner has published several articles in national newsletters and journals and has been a contributing author for two textbooks (Anesthesia Complications in the Dental Office and Complications of Regional Anesthesia: Principles of Safe Practice in Local and Regional Anesthesia). She frequently gives continuing education courses to local dentists interested in sedation dentistry, and she has a passion in medical emergency training for the dental community.
This session will be an amazing opportunity to teach and learn as a community through a live interactive panel discussion with our Dentist Anesthesiologist experts Dr. Andrea Fonner, Dr. Steve Ganzberg and Dr. Joe Giovannitti.
Join us to see how some of our esteemed colleagues approach interesting cases. These may be cases that may not be appropriate to be treated in the office and/or patients with complex medical issues.
Dr. Naftalin is a ADBA board-certified dentist anesthesiologist who provides hospital-quality anesthesia and sedation services in dental offices through his mobile anesthesiology practice. He earned his DDS degree from the Herman Ostrow School of Dentistry at USC and completed a general practice residency at the Veteran’s Administration in West Los Angeles. He then completed the UCLA Dental Anesthesia residency.
He teaches part time at the UCLA School of Dentistry in both the dental anesthesia and pediatric dental departments, where he trains future dentist anesthesiologists. He is treasurer of the American Society of Dentist Anesthesiologists. He serves on the board of the California Society of Dentist Anesthesiologists and the California Dental Society of Anesthesia. He is past president and former editor for the Southern California Society of Dentistry for Children.
Dr. Naftalin is dedicated to a program that provides anesthesia for dental patients with special needs in Nicaragua. Without this program these patients would have no access to dental care. A sought-after expert, he lectures nationally and internationally on oral sedation, anesthesia and dental office emergency management.
A dedicated family man, he is the proud father to two energetic daughters. As a family, they enjoy beach time, biking, hiking, and skiing in the mountains.
In 1990, Ken Kromash made the decision to move to Chicago to attend a training program in anesthesia for dentists at Illinois Masonic Medical Center. He only expected to stay a year or two at the most. Thirty years later, he is the Program Director of the youngest training program for one of the newest specialties in dentistry. He is honored to be invited to speak to his colleagues at the ASDA Fall Virtual Meeting. Stay safe, be well, and keep fighting!
Dr. Giovannitti is a dentist anesthesiologist and Professor and Chair of the Department of Dental Anesthesiology at the University of Pittsburgh School of Dental Medicine, and the Anesthesia Director of the school’s Center for Patients with Special Needs. He is the recipient of the Leonard M. Monheim Distinguished Service Award from the American Society of Dentist Anesthesiologists and the Jay A. Heidbrink Award from the American Dental Society of Anesthesiology. He has been actively involved in teaching at all levels of dental education, has authored numerous scientific articles, book chapters and a textbook pertaining to pain and anxiety control in dentistry, has lectured at professional seminars nationally and internationally, and is active in national dental anesthesiology professional organizations.
Dr. Ganzberg, Clinical Professor of Anesthesiology at the UCLA School of Dentistry, is a dentist anesthesiologist with over 30 years of experience in pain management. Dr. Ganzberg graduated from M.I.T. in 1977 and the University of Pennsylvania School of Dental Medicine in 1981. He completed his pain management training at New York University and his anesthesiology training and Master’s degree at O.S.U. Dr. Ganzberg is a Diplomate of the American Dental Board of Anesthesiology and the American Board of Orofacial Pain.
Dr. Ganzberg taught at The Ohio State University medical and dental schools for 17 years before coming to UCLA. Dr. Ganzberg is a past president of the American Society of Dentist Anesthesiologists and the American Dental Board of Anesthesiology and past editor of Anesthesia Progress. He is active clinically as Director of Anesthesiology for the Century City Outpatient Surgery Center, a Joint Commission accredited surgery center focusing on dentoalveolar, maxillofacial and facial plastic surgery. He has published over 70 original research articles and book chapters in the field. His research focuses on out-patient anesthesia techniques and clinical pharmacology.
Sickle cell disease (SCD) is the most common group of inherited red blood cell disorders, with a prevalence of an estimated 70,000 – 100,000 individuals in North America, and an additional 3.5 million individuals as heterozygous carriers. At low oxygen tensions, hemoglobin in patients with SCD changes conformation to a sickle shape, which can potentially lead to vaso-occulsive crises. Sequelae of these crises include stroke and cranial symptoms, with 11% of SCD children presenting with overt stroke symptoms and another 30% presenting with silent cerebral infarcts. Anesthetic goals for the perioperative management of these patients are to avoid acidosis, hypotension, hypoxia, infection, hypothermia, vaso-constriction and venous stasis, all of which can precipitate a vaso-occlusive crisis.
The following case describes the successful management of a 12-year-old girl with a past medical history (PMHx) of sickle cell anemia who presented for extraction of several supernumerary teeth and biopsy with enucleation of lower left mandibular cyst under general anesthesia. The use of cerebral oximetry in the intraoperative management of sickle cell patients has not yet to date been described in the literature. Cerebral oximeters such as the INVOSTM Cerebral/Somatic Oximeter (Medtronic) which was used in this case are able to estimate regional tissue oxygenation of the frontal cortex, and therefore detect changes in oxygen supply and demand. Utilization of cerebral oximetry in the intraoperative period, can help provide early recognition of signs of ischemia facilitating early interventions to reduce postoperative morbidity and mortality.
Malignant hyperthermia (MH) is a potentially life threatening event in response to specific triggers during anesthesia. In particular, it is triggered by volatile anesthetic and succinylcholine which a depolarizing paralytic used to facilitate intubation. Clinical signs include increased end-tidal carbon dioxide, muscle rigidity, tachycardia, tachypnea, acidosis and hyperthermia. Furthermore, there are several other syndromes that can mimic MH such as serotonin syndrome, pheochromocytoma, thyrotoxicosis and neuroleptic malignant syndrome.
The COVID-19 Pandemic has changed the world as we know it. COVID-19, shown to be caused by the SARS-CoV-2 virus has led many severely ill patients to undergo acute respiratory distress leading to emergent intubations. Many of the signs and symptoms leading up to intubation in COVID-19 patients often resemble MH, such as hypercarbia, tachypnea, acidosis. These signs may mask a true MH event and thus may not be diagnosed and treated in time.
In this case report, a 37 year old male patient with COVID-19 induced acute respiratory distress received succinylcholine prior to intubation, at which point he became rigid and went into cardiac arrest. Prior to arrest, the patient was hypercarbic, tachypneic, hypoxic and bradycardic. We compare several hypermetabolic conditions including, Neuroleptic malignant syndrome, sepsis, hyperkalemic cardiac arrest and rhabdomyolysis.
Malignant hyperthermia is a potentially fatal pharmacogenetic disorder, triggered by volatile anesthetics or succinylcholine.1 An otherwise healthy 6 year old boy presented to our clinic for a full mouth rehabilitation under anesthesia. The MH episode was detected as the end-tidal carbon dioxide read “+++” and peaked with the patient displaying masseteric and generalized rigidity which was immediately treated with dantrolene administration. The patient was transferred to the pediatric intensive care unit and discharged to home soon thereafter. The successful management of this case was not the singular accomplishment of one clinician or simply attributable to the knowledge of MH but rather a perfect storm of systemic and cultural factors of the team and clinic that enabled the team to implement their knowledge into timely clinical interventions.
It is possible that most dentist anesthesiologists will encounter an adverse event regardless of whether the contributing factors leading to the event is within their control. The key to a successful outcome rests on more than just the didactic knowledge and clinical skills of that individual provider. Just culture explores the role of systems and organizational cultures while balancing the role of individual accountability.2 A root cause analysis (RCA) can identify the contributing factors and improve systems to prevent and promote best practices. In this case, a success cause analysis (SCA) was conducted to identify areas of strength and areas for improvement as they relate to the treatment of an MH episode in a dental clinic setting including appropriate people, methods/processes, materials, equipment, and environment.
Acknowledgements: We would like to acknowledge Dr Nathan Carillo (Class of 2020) for his role in the care of this patient.
Chronic pain and opioid-dependent patients express higher resting pain scores, hyperalgesia and tolerance which may lead to increased analgesic requirements peri- and post-operatively. This case report presents a 37-year-old female with fibromyalgia and chronic back-pain requiring twice-daily Percocet (acetaminophen 325 mg and oxycodone 5 mg) use. Additionally, her medical history includes chronic anxiety, depression, and post-traumatic stress disorder requiring daily lorazepam use. General anesthesia for dental treatment was indicated for dental phobia. Her treatment was performed in the ambulatory setting at the University of Toronto’s Faculty of Dentistry. Previous attempts to provide non-intubated general anesthesia with fentanyl, midazolam, and propofol resulted in high dosages and infusion rates (>230 mcg/kg/min propofol) which led to hemodynamic instability and respiratory depression. An anesthetic strategy that targeted receptors other then those affected by her daily opioid and benzodiazepine medications was designed. This strategy utilized the NMDA antagonist ketamine with an infusion of the α2-agonist dexmedetomidine. Due to the extensive dental treatment required, there was concern that a single bolus of dexmedetomidine during induction would provide inadequate working time. Therefore, dexmedetomidine in addition to propofol was used in two separate infusion pumps to allow control of the anesthetic duration. Induction was performed with ketamine (0.7 mg/kg), midazolam (0.03 mg/kg), and dexmedetomidine (1.0 mcg/kg) over 10 mins, followed by infusion at 0.6 mcg/kg/hr (0.01 mcg/kg/min). Concurrently in the second infusion pump, plain propofol infusion was initiated and maintained at 120 mcg/kg/min. During the procedure, the patient did not experience any adverse events such as hypotension, bradycardia, hypercapnia, or delayed emergence. Likewise, adequate depth of anesthesia was achieved as demonstrated through acceptable blood pressure, heart rate, respiration rate and absence of limb movement. Overall, we demonstrated that dexmedetomidine infusion was feasible and effective in a chronic pain and opioid-dependent patient with history of high-anesthetic requirement.
Airway management is one of the most important responsibilities of an anesthesiologist. Some may even argue that anticipating and preparing for a difficult airway is the crux of our role. As advancements are made in surgical procedures and equipment, the anesthesiologist must develop ways to adapt. Fortunately, many tools and techniques already exist in our armamentarium.
According to the American Society of Anesthesiologists’ difficult airway algorithm, the first step is to identify patients who may be difficult to ventilate . More specifically, an aspect of this is determining whether a patient will have a poor mask seal, whether it be due to edentulism, facial hair, or a dentofacial deformity . In this presentation, we evaluate the difficulty of achieving a good mask seal on patients undergoing robotic implant placement with a Yomi robot, in an outpatient ambulatory setting. We demonstrate the process of establishing and securing the airway via nasal-tracheal intubation prior to ventilating patients. A large component of our decision-making is influenced by the requirement of the Yomi technique to insert either an Edentulous Patient Splint (EPS) or a Chairside Patient Splint (CPS) prior to taking a cone beam CT scan and inducing the patient. Our ability to provide this service allows our surgical colleagues to use a new technique to advance implant placement in a more precise manner. Ultimately, we align with certain recommendations that can be broadly applied to intubated general anesthesia cases in an outpatient setting .
1. Updated by the Committee on Standards and Practice Parameters, et al. “Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.” Anesthesiology 118.2 (2013): 251-270.
2. Williams, W. Bradford, and Yandong Jiang. “Management of a difficult airway with direct ventilation through nasal airway without facemask.” Journal of oral and maxillofacial surgery 67.11 (2009): 2541-2543.
3. Law, J. Adam, et al. “The difficult airway with recommendations for management–part 2–the anticipated difficult airway.” Canadian Journal of Anesthesia/Journal canadien d’anesthésie 60.11 (2013): 1119-1138.
Hemodynamic resuscitation in critically ill trauma patients receiving massive blood transfusions
have a 35% increased chance of developing trauma-induced coagulopathy, a secondary event that drastically increases mortality rates. As a multifactorial system, trauma-induced coagulopathy or acute traumatic coagulopathy (ATC) encompasses an array of complex
mechanisms including: consumption coagulopathy and blood loss; dilution; hormonal disruption; coagulation disruption; hypoxia; metabolic acidosis; hypothermia; and immune activation. As a potentially life-threatening event, ATC must be identified as early as possible to prevent death by massive hemorrhage.
This is a case report of acute traumatic coagulopathy following post-operative secondary
hemorrhage and resuscitation.
This patient is a 70 year-old male with a past medical history of hypertension, hepatitis C, peripheral artery disease with bilateral femoral-popliteal occlusion, and polysubstance abuse presenting for right groin exploratory, endovascular balloon occlusion of aorta, control of hemorrhage, patch angio right CFA/EIA following lower left extremity angioplasty with stunting and graft bypass under general anesthesia. Symptoms of intraoperative hemodynamic instability were observed after several units of blood, plasma, and platelet transfusions.
Intravenous sites including the triple lumen port, arterial line, and peripheral lines had excessive bleeding. Areas around the mouth and membranous tissues were also bleeding. Arterial blood gas samples were obtained confirming metabolic acidosis, hyperkalemia, hypovolemia, severe blood loss, and dilution. Once the patient arrived at the surgical intensive care unit, cryoprecipitate was transfused and all bleeding sites were controlled with pressure until clotting was observed. He recovered in the SICU until he was hemodynamically stable.
Identifying the presentation of ATC and making a collective effort in managing this secondary event is critical in prognostic outcome. In this particular case, the resulting presentation of ATC followed collective factors of iatrogenic origin and post-operative vascular complications.
Anesthesia providers must be vigilant in monitoring the patient for clinical symptoms such as excess bleeding from IV access sites, central venous lines, arterial lines, and delicate membranous tissues; follow ATC resuscitation with cryopercipitate, fresh frozen plasma, and platelet; maintain core temperatures; and evaluate arterial blood gas findings for volume overload, hyperkalemia, and metabolic acidosis. Maintenance of hemodynamic stability following massive blood loss and management traumatic coagulopathy is key in preventing fatal outcomes.
Cap, A., Hunt, B. J., (2015), The pathogenesis of traumatic coagulopathy. Anaesthesia. 2015
Jan; 70 Suppl 1:96-101, e32-4.
Clinical Case Report
The following case report will address the local anesthetic toxicity considerations of a 63-year-old healthy female, undergoing a lengthy full mouth surgical case under general anesthesia.
In the case report, local anesthesia was administered during the procedure and a long lasting anesthetic (EXPAREL) intended to be given at the end of a lengthy (6 hour) surgical case. This report will review the following:
Local anesthetic overview:
When intravenous medications are indicated for patient care, the appropriate administration of those medications is necessary for safe and efficient outcomes. The anesthetic management of a patient continuously evolves as resources and data become more available.
Scientific evidence has rarely (if at all) been reported in the literature demonstrating analytical confirmation of the physical compatibility and stability of glycopyrrolate and rocuronium combined. The evaluation of the compatibility of glycopyrrolate with rocuronium is the subject of this research.
Glycopyrrolate and rocuronium were combined in various containers, observed over a 60-minute period, statistically analyzed, and compared against positive and negative controls to determine their physical compatibility. In the research environment through which the test protocol was performed, it was determined that glycopyrrolate and rocuronium are physically compatible.
Although no current information indicates inappropriateness of the coadministration of glycopyrrolate with rocuronium, additional testing (e.g., chemical and therapeutic compatibility testing) may be considered for improving completeness of data.