ACE-Inhibitor or ARB-Induced Refractory Hypotension Treated With Vasopressin in Patients Undergoing General Anesthesia for Dentistry: Two Case Reports.

Two case reports present the use of vasopressin for treating refractory hypotension associated with continued angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to general anesthesia for oral surgery. Both patients were treated in an ambulatory dental surgery clinic and took either their ACEI or ARB medication for hypertension within 24 hours prior to undergoing an intubated general anesthetic. Persistent profound hypotension was encountered intraoperatively that was refractory to treatment with traditional methods. However, the ACEI- or ARB-induced refractory hypotension was successfully managed with the administration of vasopressin.

Anesthesia for off-floor dental and oral surgery.

PURPOSE OF REVIEW: Anesthesia for dentistry is commonly performed outside the operating room. The combination of a shared airway between surgeon and anesthetist, the variety of open airway techniques, and the out-of-operating room setting often results in anxiety and avoidance of dental cases among anesthesia personnel. This review attempts to demystify dental treatment and facilitate the anesthesia provider in providing effective sedation of dental procedures performed in the nonoperating room setting. RECENT FINDINGS: Specific indications for dental anesthesia improve the patient selection process. Airway assessment and strategies to secure the difficult airway are paramount because of the nature of the procedures and the patients on whom they are performed. Pediatric patients and those with special needs present specific preanesthetic assessment, induction, and management challenges. Emergence delirium is disruptive, possibly dangerous, prolongs recovery time, and may necessitate hospitalization. Simplified techniques and objective recovery criteria are necessary to ensure a safe and smooth discharge to home. Airway fire precautions should not be overlooked given the rare but potential risk of airway fire during dental treatment. SUMMARY: This article reviews the indications, facility and equipment needs, monitoring requirements, treatment methods, and recovery protocols necessary for the safe administration of off-floor anesthesia for dentistry.

Alpha-2 adrenergic receptor agonists: a review of current clinical applications.

The α-2 adrenergic receptor agonists have been used for decades to treat common medical conditions such as hypertension; attention-deficit/hyperactivity disorder; various pain and panic disorders; symptoms of opioid, benzodiazepine, and alcohol withdrawal; and cigarette craving. (1) However, in more recent years, these drugs have been used as adjuncts for sedation and to reduce anesthetic requirements. This review will provide an historical perspective of this drug class, an understanding of pharmacological mechanisms, and an insight into current applications in clinical anesthesiology.

Adult airway evaluation in oral surgery.

Patients with a history of difficult intubation or with conditions associated with difficult airway should be approached with organized primary and secondary plans for airway management. When these potential problems are detected, patient safety may be improved with use of advanced airway management techniques and equipment. Additionally, patient referral for consultation and/or management at facilities where advanced airway management practitioners and equipment are available may be beneficial in some cases.

Management of allergy and anaphylaxis during oral surgery.

Minor and major allergic reactions occur during oral and maxillofacial treatment. Immediate diagnosis and pharmacologic intervention are imperative. Signs and symptoms may be variable. The early administration of epinephrine is critical.

Pharmacology of intravenous sedative/anesthetic medications used in oral surgery.

This article provides an overview of historical and current sedative agents available to the dentist anesthetist. The surgeon is given rational choices for sedation and the individualization of drug selection for each patient. Total intravenous anesthesia is becoming increasingly popular for dental sedation because of the availability of ultra-short-acting drugs and computerized infusion technology. Levels of sedation are more easily achieved and maintained, and recovery is enhanced, which gives the operator extreme, moment-to-moment control of the anesthetic experience and improves patient outcomes.

Pharmacology of local anesthetics used in oral surgery.

This article provides a comprehensive review of the pharmacology of local anesthetics as a class, and provides details of the individual drugs available in dental cartridges. Maximum recommended doses of local anesthetics and vasoconstrictors are presented for healthy adult and pediatric patients, and for patients with cardiovascular system impairments. Various complications and reasons for failure of local anesthesia effectiveness are discussed, and current and future trends in local anesthesia are presented to provide an overview of current research in local anesthesia.

Needle phobia: etiology, adverse consequences, and patient management.

Needle phobia has profound health, dental, societal, and legal implications, and severe psychological, social, and physiologic consequences. There is genetic evidence for the physiologic response to needle puncture, and a significant familial psychological component, showing evidence of inheritance. Needle phobia is also a learned behavior. The dental practitioner must recognize patients with needle phobia before the administration of local anesthetics to identify patients who are potentially reactive and to prevent untoward sequelae. Needle phobia is highly associated with avoidance behavior, and the dentist must exhibit compassion and respect. To avoid bradycardia, hypotension, unconsciousness, convulsions, and possibly asystole, oral premedication with benzodiazepines or other antianxiety agents must be considered for patients who are needle phobic. Management of needle phobiaeinduced syncope includes perioperative monitoring, oxygen administration, positioning, atropine, and vasopressors.