Do Patients With Mental Illness Undergoing Office-Based Sedation Require an Increased Propofol Dosage?

BACKGROUND: Providers report needing higher sedative doses to achieve adequate sedation in patients with mental illnesses. These claims, however, have not been thoroughly assessed. PURPOSE: The purpose of the study was to measure the association between mental illness and the propofol dosage necessary to achieve a satisfactory level of anesthesia. STUDY DESIGN, SETTING, SAMPLE: The study consisted of a single-center, retrospective cohort consisting of patients treated by oral and maxillofacial surgery at the University of Cincinnati Medical Center in 2020. The study was comprised of subjects 15 or older who were American Society of Anesthesiologists (ASA) classification I or II. Subjects under 15 or ASA III or higher were excluded from the study. PREDICTOR VARIABLE: The predictor variable was the presence or absence of mental illness. MAIN OUTCOME VARIABLE(S): The primary outcome was the total dose of propofol, measured as the total amount of propofol administered divided by the patient's weight in kilograms divided by the length of the procedure in minutes (mg/kg/min). The secondary outcome was the Richmond Agitation-Sedation Scale (RASS) score achieved during sedation. COVARIATES: Sex, race, ethnicity, age, weight, body mass index, ASA score, prior tobacco use, marijuana use, use of adjunct midazolam, fentanyl, and ketamine during the procedure, and type of procedure served as covariates. ANALYSES: Test statistics were calculated using the Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, and χ2 test for bivariate analyses. Linear and logistic regression models were used to estimate association while controlling for confounding. P values ≤ .05 were considered statistically significant. RESULTS: The study sample was 409 subjects (36.92% male, mean age 28.27 ± 12.20 years). In bivariate analysis, mental illness did not show any association with propofol dose (mean dose with mental illness 150.85 ± 143.97 mg/kg/min, mean dose without mental illness 116.54 ± 104.16, P = .08) or RASS score (sufficiently sedated with mental illness 63.38%, sufficiently sedated without mental illness 58.80%, P = .36). After adjusting for all previously mentioned covariates, mental illness was statistically associated with propofol dose (P < .01). Adjusting for covariates, only sex had a statistically significant association with the RASS score (P < .05). CONCLUSION AND RELEVANCE: The findings suggest that a patient's mental illness may influence the amount of sedative required to achieve satisfactory anesthesia.

What Is the Incidence of Anesthesia-Related Adverse Events in Oral and Maxillofacial Surgery Offices? A Review of 61,237 Sedation Cases From a Large Private Practice Consortium.

BACKGROUND: The safety of the anesthesia team model performed in oral and maxillofacial surgery (OMS) offices has been criticized by professional and mainstream media. PURPOSE: This study aims to assess the incidence of adverse anesthetic events (AEs) associated with the OMS anesthesia team model and identify risk factors associated with AEs. STUDY DESIGN, SETTING, SAMPLE: This was a retrospective cohort study utilizing a patient database from Paradigm Oral Health, Lincoln, Nebraska, a managed service organization (MSO). Subjects included were 14 and older, undergoing open-airway intravenous anesthesia for ambulatory OMS procedures using the OMS anesthesia team model at multiple private practices in the MSO network between June 30, 2010, and September 30, 2022. Exclusion criteria included patients younger than 14 or patients with incomplete medical records. PREDICTOR VARIABLE: Primary predictor variables were age, sex, American Society of Anesthesiologists physical status classification system (ASA) score, type of surgical procedure performed, and the types of medications administered during sedation. MAIN OUTCOME VARIABLE(S): The presence of an AE. The definition of an AE was modeled on the World Society of Intravenous Anesthesia definition. All AEs were identified through surrogate markers, which were identified through chart review. One example of an AE is ventricular fibrillation, which necessitates the application of medications; here the medication is the surrogate marker. COVARIATES: None. ANALYSES: The data were analyzed using t-tests and χ2 tests. P values ≤ .05 were considered statistically significant. RESULTS: Included in the study were 61,237 sedation cases (53.87% female and 46.13% male), for 56,076 unique patients ranging from 14 to 98 years of age (mean 33.26 ± 18.35). An AE incidence of 3 per 100,000 per year (25 total events) was observed. Neither age, sex, ASA score, nor type of surgical procedure exhibited statistically significant associations with AEs. A statistically significant association was found between AEs and fentanyl (P = .0008). CONCLUSION AND RELEVANCE: This investigation shows a smaller incidence of AEs than previous studies of the OMS anesthesia team model.

Assessing the Efficacy of Buffered Versus Nonbuffered Lidocaine in Dental Extractions: A Double-Blinded Randomized Controlled Trial.

BACKGROUND: Injections using buffered lidocaine may decrease discomfort, have a quicker onset, and be a more efficacious local anesthetic. Previous studies have been inconclusive in the oral context. PURPOSE: To address if bicarbonate buffered 2% lidocaine can decrease pain from the use of local anesthesia, has a quicker onset time, and is more efficacious. STUDY DESIGN: The design was a single-center double-blinded randomized control trial, set in an outpatient oral and maxillofacial clinic housed in the University of Cincinnati Medical Center. Inclusion criteria for the study were patients requiring a single tooth extraction due either to caries or periodontal disease. PREDICTOR VARIABLE: The predictor variable was the local anesthetic used either nonbuffered 2% lidocaine with 1:100,000 epinephrine (control) or bicarbonate buffered 2% lidocaine with 1:100,000 epinephrine (study) was randomly assigned. MAIN OUTCOME VARIABLES: Primary outcome variables were injection pain score, and postoperative pain, time to anesthetic onset, and the number of rounds of injections required to achieve adequate anesthesia. COVARIATES: The covariates were jaw involved, age, sex, and race, American Society of Anesthesiologists score, body mass index, current tobacco use, history of psychiatric illness, chronic pain, and preoperative pain score. ANALYSES: Test statistics were calculated using Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, χ2 test for bivariate analyses, and Fisher's exact test. P values ≤ .05 were considered statistically significant. RESULTS: The final sample was 114 subjects. The mean age of the sample was 42.97 years, standard deviation ±13.43 years. The sample was 39.47% male. The racial demographics were Caucasian (62.28%) and African American (33.33%). Buffered lidocaine did not have a statistically significant relationship with any of the outcomes. The jaw involved had a statistically significant association to the injection pain score (P value = .006), and the number of rounds of anesthetic required (P value = .047). Age showed a statistically significant association to injection pain score (P value = .032), and the number of rounds of anesthetic required (P value = .027). Finally, preoperative pain had a statistically significant relationship with injection pain score (P value = < .001). CONCLUSION AND RELEVANCE: In this study, bicarbonate buffered lidocaine did not exhibit any discernible advantages over nonbuffered lidocaine for any study outcomes.

Is Psychiatric Illness Associated With Risk for Postoperative Complications in the Outpatient Setting?

PURPOSE: Little is known about the association between psychiatric illness and the risk for postoperative complications following outpatient oral and maxillofacial surgery treatment. The purpose of this study was to examine the significance of the presence of psychiatric illness on postoperative complications. MATERIALS/METHODS: This was a retrospective cohort study conducted in 2018 that identified patients by searching through the University of Cincinnati's electronic health records. The predictor variable in this study is the presence of psychiatric illness and the outcome variable is the presence or absence of postoperative complications. Additional covariates such as age, race, location, procedure type, and anesthesia type were also included. Results of appropriate descriptive statistics and multivariate logistic regression were presented. Statistical significance was set at P value < .05. RESULTS: The total number of patients who underwent procedures involving local anesthetic and intravenous sedition in clinic in 2018 were 3,874, of which 1,588 were males (40.99%) and 2,286 were females (59.01%) with a mean age of 36.14 and 35.08 years, respectively. The sample consisted of White (45.87%), Black (35.34%), Hispanic/Latino (2.27%), Asians (1.60%), other races (3.33%), and 11.59% patients have missing data on race. A psychiatric diagnosis was found in 21.37% patients (n = 828). The percentage of patients with 2 or more psychiatric diagnoses was 5.78% (n = 224). The rate of postoperative was reported as 11.33%. A bivariate logistic regression analysis of postoperative complications as an outcome variable found that postoperative complications were not associated with psychiatric history (Odds ratio = 1.049, 95% confidence interval: 0.825 to 1.333, P value = .695). However, sex (P value = < .0001), surgical procedure (P value = < .0001), and anesthetic technique (P value = < .0001) had statistically significant associations with postoperative complications. Other covariates like race (P value = .5943), American Society of Anesthesiologists score (P value = .2539), location (P value = .5323), and multiple psychiatric diagnoses (P value = .7256) were not found to be significantly associated with postoperative complications. CONCLUSION: Although our study did show a higher prevalence of psychiatric illnesses in our patient population, it did not show any statistically significant correlation between psychiatric illness and postoperative complications. In addition, there were no statistically significant differences in postoperative complications between different Diagnostic and Statistical Manual of Mental Disorders classes.

Facial Appearance as Core Expression Scale: Benchmarks and Properties.

Objective: Patients presenting for corrective facial surgery may have ideals that are not congruent with their surgeon's expectations for surgical outcomes. To identify and reduce disparities in expectations, the Facial Appearance as Core Expression Scale (FACES) was developed to assess the extent to which individuals identify their own faces as representing their ideal self. Method: In Study 1, 504 healthy young adult participants answered online questions about their own faces. In Study 2, 165 participants rated their own faces, digitally manipulated images of four patients before and after surgery, and two digitally averaged benchmark images. Results: In Study 1, the final FACES instrument had seven items and was highly reliable across genders and races. Study 2 replicated reliability findings. The before surgery and after surgery pictures yielded significant improvements in ratings, suggesting scale validity. Conclusions: The FACES consists of 14 items including a benchmark image to detect unusual responding. Results indicate the measure is reliable and sensitive to perceptions of surgical changes to faces. While the scale needs to be validated in a clinical sample, the measure may help identify patients with atypical ideal expectations for their face and may be used to quantify surgical outcomes.