Decision-making in awake fibre optic intubation for patients with severe dentofacial infection: which patients will require fibre optic intubation?

BACKGROUND: Risk factors for advanced airway intervention among patients with dentofacial infection (DFI) are poorly understood. The appropriate delivery of clinical care to this patient group raises challenging anaesthetic service provision issues. The purpose of this study was to identify factors which may predict a requirement for an awake fibre optic intubation (AFOI) technique for airway management in this patient population. METHODS: A retrospective analysis of data for consecutive patients admitted with DFI were analysed at the Oral & Maxillofacial department at St James's Hospital, Dublin from July 2014-July 2015 was carried out. Receiver operating characteristic analysis determined optimal cut-off values predictive of AFOI, and multivariate logistic regression determined independent risk factors for AFOI. RESULTS: One hundred and twenty-five patients (64 male, 61 female) were admitted with DFI. The mean age was 35.9 years (range 16-91). AFOI was carried out in 58 (67.4%) patients who required GA. Increasing age was associated with an increase likelihood of AFOI (P = 0.047 95% CI 1.07(1.00-1.14). Reduced mouth opening was significantly associated with requirement for AFOI (28.8 ± 8.6 vs. 14.8 ± 8.6 mm, P < 0.0001). On receiver operating characteristic (ROC) analysis, mouth opening predicted requirement for AFOI with 87% accuracy (AUC 0.87 [95% CI 0.80-0.95], P < 0.0001). Using a cut-off value of 16.5 mm predicted subsequent AFOI with 96.7% (95% CI 78.1-100.0%) specificity and 65.6% (95% CI 51.4-77.8%) sensitivity. Initial C-reactive protein (CRP) was significantly associated with requirement for AFOI (60.1 ± 40.0 vs. 121.3 ± 89.8, P = 0.002). A CRP value of over 110 mg/L predicted subsequent AFOI with 95.8% (95% CI 78.9-100.0%) specificity. CONCLUSION: Increasing age, reduced mouth opening < 16.5 mm, and an increased serum admission CRP > 100 mg/L on admission significantly increase the requirement for AFOI on multivariate and univariate regression analysis. The availability of anaesthetists experienced in AFOI is essential for safe management of these patients.

The surgical management of severe dentofacial infections (DFI)-a prospective study.

Dentofacial infections (DFI) lead to morbidity and rarely, mortality. We hypothesised that certain clinical and laboratory parameter factors may be associated with a more severe course and an increased length of stay. We designed a prospective study that included all patients admitted with a DFI to the Oral and Maxillofacial Department between July 2014 and July 2015. A total of 125 were enrolled. We found that serum concentration of CRP on admission and increasing number of fascial spaces involved by the infection were significant predictors of hospital stay (p = 0.02 and p = 0.01, respectively). The average length of stay for a dentofacial infection requiring admission was 4.5 days. Most patients require surgical intervention in combination with intravenous antibiotics for successful resolution. Improved and timely access to primary dental care is likely to reduce the burden for patients their families and the acute hospital service as a consequence of advanced DFI.

Does access to general dental treatment affect the number and complexity of patients presenting to the acute hospital service with severe dentofacial infections?

AIM: This is a retrospective study to review the treatment and management of patients presenting with odontogenic infections in a large urban teaching hospital over a four-year period, comparing the number and complexity of odontogenic infections presenting to an acute general hospital in two periods, as follows: Group A (January 2008 to March 2010) versus Group B (April 2010 to December 2011). The background to the study is 'An alteration in patient access to primary dental care instituted by the Department of Health in April 2010'. OBJECTIVES: a) to identify any alteration in the pattern and complexity of patients' presentation with odontogenic infections following recent changes in access to treatment via the Dental Treatment Services Scheme (DTSS) and the Dental Treatment Benefit Scheme (DTBS) in April 2010; and, b) to evaluate the management of severe odontogenic infections. METHOD: Data was collated by a combination of a comprehensive chart review and electronic patient record analysis based on the primary discharge diagnosis as recorded in the Hospital In-Patient Enquiry (HIPE) system. RESULTS: Fifty patients were admitted to the National Maxillofacial Unit, St James's Hospital, under the oral and maxillofacial service over a four-year period, with an odontogenic infection as the primary diagnosis. There was an increased number of patients presenting with odontogenic infections during Group B of the study. These patients showed an increased complexity and severity of infection. Although there was an upward trend in the numbers and complexity of infections, this trending did not reach statistical significance. CONCLUSIONS: The primary cause of infection was dental caries in all patients. Dental caries is a preventable and treatable disease. Increased resources should be made available to support access to dental care, and thereby lessen the potential for the morbidity and mortality associated with serious odontogenic infections. The study at present continues as a prospective study.