I'll start with a simple premise—the current IV anesthetic agents available for sedation and anesthesia in dentistry are quite good, even excellent. In fact, they are the best yet and only continue to improve as the march toward anesthesia nirvana, an instantaneous pharmacologic on/off switch, persists. The advent of remifentanil with its plasma esterase–based metabolism has blown the door open for a whole new generation of ultra–short-acting agents. Remimazolam, a similarly metabolized benzodiazepine, is the newest arrival. These drugs have extremely short clinical durations of action and context-sensitive half-times (≤8 minutes) attributed to lightning-fast terminal half-lives and lack of active byproducts. This type of pharmacologic profile engenders optimal and linear “steerability,” replicating the immediate and easy titration to a desired end point found with volatile anesthetics. These newer anesthetic agents, along with propofol, may very well kick off a new golden age for ambulatory and office-based anesthesia by providing a speedy induction, coupled with an extremely clean emergence and rapid recovery. Given the ample benefits of our current pharmacologic wonders, I ask a simple question: Are they too good?
The genesis of my question began during the “Great Propofol Shortage of 2009,” only to be distilled further while supervising oral surgery anesthetics as faculty. For those blissfully unaware, the lack of available propofol in 2009 was so sudden, so unexpected, and so universal that most anesthesia providers were forced to search elsewhere for viable short-acting sedative/hypnotic alternatives. Some elected to turn back the clock and use methohexital (Brevital), as was the case in my residency. The stark differences between the smoothness of propofol and the rockiness of methohexital were immediately apparent. Patients were considerably more prone to airway disturbances like hiccuping, coughing, and laryngospasms. With time, brief oral surgery anesthetic cases became more predictable and less bumpy after we learned to increase the baseline level of sedation (ie, more midazolam and fentanyl up front).
Although working with methohexital was challenging and at times stressful, I now consider it a blessing in disguise. The propofol shortage provided an overabundance of real-world experience in recognizing and appropriately managing common airway complications. Some may attribute the noted increase in intraoperative airway events to inexperience with methohexital or an inability to maintain a free and clear airway. There is no doubt those contributing factors were likely present. However, my supervising faculty and mentors, who all used methohexital prior to the release of propofol, reported similar historical trends. In fact, many described airway urgencies/emergencies being so frequent they became virtually mundane, which brings us back to the question at hand. Are our current drugs so good they may inadvertently foster a false sense of security, promoting a state where providers lose acuteness in recognizing and skillfully responding to airway events?
Complications, especially those involving the airway, are part and parcel of sedation and general anesthesia for dentistry. They can and will arise at any time throughout the perioperative period despite our best efforts. The responsibility to rapidly identify and deftly manage such problems rests squarely on the shoulders of the anesthesia provider. In the event of an intraoperative respiratory event, by far the most common complication, time is of the essence. Most of the time these events are relatively minor and effectively managed with minimal disruption. However, there are events when more significant deviations from the anesthetic plan are required, and accordingly, providers must intuitively know what to do and then almost reflexively perform the interventions flawlessly without delay. A classic example is a complete laryngospasm occurring in a child after induction that requires immediate paralysis to reestablish airway patency after failing the usual steps (repositioning, airway suctioning, and deepening the patient). An inattentive or poorly prepared provider may not properly recognize the issue and appropriately rescue the patient before permanent damage occurs. Someone who has never given an effective dose of succinylcholine emergently or has not done so after many years in practice may be equally hesitant. Although there are many factors at play for a successful outcome in such a scenario, 2 of the biggest are undoubtedly experience and training. An anesthesia provider not lacking in either is more likely to not only quickly assess the gravity of the situation and institute immediate treatment but also identify risk factors preemptively, possibly preventing the complication from even arising.
Today's anesthetics (propofol, fentanyl, and midazolam) and the newer arrivals (remifentanil, remimazolam) are phenomenal agents capable of routinely facilitating silky-smooth deep sedation and general anesthesia, especially compared with drugs of the past such as methohexital. However, one unintended consequence of such brilliance may be the lack of consistent exposure to airway complications requiring more significant interventions, like emergent paralysis, assisted ventilation, direct laryngoscopy, and intubation. This level of intervention may be rare; however, continued proficiency in maintaining advanced airway management skills is vital to patient safety. Furthermore, when clearly indicated, there is zero room for hesitation in deploying such measures simply because of lack of provider comfort. This could be likened to a dentist performing extractions and the occasional need to section a tooth. Most would consider proficiency and ease using a handpiece as crucial unless only extracting mobile periodontally involved teeth. Expertise in managing an airway should be considered in the same vein, so to speak.
Given that adverse respiratory events persist as the main contributing factors related to morbidity and mortality outside of the OR, this remains an issue for all providers of sedation and anesthesia for dentistry. The adage that practice makes perfect rings ever true. Training programs must ensure residents become competent managing all type of airway complications. Assumptions that newer practitioners have had ample practice managing events like laryngospasms requiring succinylcholine are probably unfounded. Their experiences likely pale in contrast to those who trained with methohexital and the like. Today's drugs are simply too good, and opportunities are too few and far between. Advanced airway management techniques should be utilized with regularity in the office-based environment to build confidence and expertise beyond the operating room and to ensure proficiency in responding to an untoward event. Unless these techniques are used routinely, seasoned practitioners should refreshen their clinical skills more frequently than every 2-year advanced cardiovascular life support recertification cycle. Planned intubation could be incorporated into clinical repertoires as a regular alternative for nonintubated cases when indicated. Those working in hospitals or ambulatory surgery centers with other anesthesia providers should ask to practice bag-mask ventilations and intubations when appropriate. As with all skills, performance during a crisis depends heavily on regular practice.
The remarkable anesthetic drugs and techniques currently available may have substantially reduced the frequency of significant respiratory complications. However, it is likely that your next adverse airway event is out there waiting. Will you be ready to address that challenge? With a little imagination and some ingenuity, opportunities to hone your clinical skills are endless. Your patients deserve nothing less than your very best.
Plans for the 2021 International Dental Congress on Anesthesia, Sedation, and Pain Control hosted by the International Federation of Dental Anesthesiology Societies (IFDAS) in Moscow, Russia, this September, have been revised due to the ongoing COVID-19 pandemic. The IFDAS Executive Council has adopted the following policy:
The 16th IFDAS Triennial Congress, which earlier had been scheduled to take place from the 17th to the 19th of September, 2021, in Moscow, Russia, shall be postponed to a date to be determined by the IFDAS Executive Council;
the 16th IFDAS General Assembly, which earlier had been scheduled to take place on September 18, 2021, shall be postponed to a date to be determined by the IFDAS Executive Council;
the officers of IFDAS, whose terms are ordinarily about 3 years, shall remain in their offices until the 16th IFDAS General Assembly is convened; and
the meeting, now in its advanced planning stage, that was intended to be the 16th Triennial IFDAS Congress shall be held in Moscow on the dates originally scheduled (September 17–19, 2021) and shall be a cooperative international scientific IFDAS conference to exchange ideas, techniques, case studies, and other information in the fields of dentistry, anesthesia, sedation, pain control, patient safety, and related fields; this meeting shall be in a “hybrid” format in which some attendees will be present at the meeting site and other attendees will be connected to the proceedings remotely through Internet teleconferencing linkages; this meeting shall be promoted through announcements displayed at the IFDAS website.
All members of IFDAS component societies are encouraged to attend the 2021 International Dental Conference on Anesthesia, Sedation, and Pain Control. If it is safe and convenient to travel to Moscow, attend in person and enjoy direct interpersonal communication with colleagues and new friends while also taking in the eye-catching architecture and other sights of Moscow. If staying at home at this time is better, virtually attend the oral presentations, view the posters, interact with the poster presenters, and participate in the symposia by registering as a virtual participant! The videoconferencing technology will provide high-quality audio and video to remote participants linked through the Internet, who will be able to participate in sessions in real time.
Please watch for announcements and updates at the IFDAS website, https://www.ifdas.org/meetings.