WILL YOU HAVE AN ANESTHESIOLOGIST FOR YOUR WISDOM TEETH EXTRACTION SURGERY?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

In the United States, will you have an anesthesiologist for your wisdom teeth extraction surgery?Probably not.

In the United States, oral surgeons perform most wisdom teeth extraction surgeries.  This is a very common surgery, with the operation performed on up to five million times in the United States each year. Most patients are healthy teenagers.  Wisdom teeth can be extracted under local anesthesia alone, but most patients and oral surgeons do not prefer this option. Oral surgeons perform wisdom teeth surgeries in their office operating rooms, and most oral surgeons manage the intravenous sedation anesthesia themselves, without the aid of an anesthesiologist.

Oral surgeons are trained in the airway management and general anesthesia skills necessary to accomplish this safely, and a nurse assists the oral surgeon in delivering sedative medications.  Oral surgeons must earn a license to perform general anesthesia in their office. To administer general anesthesia in an office, most oral surgeons complete at least three months of hospital-based anesthesia training. In most states, oral surgeons then undergo an in-office evaluation by a state dental-board-appointed examiner, who observes an actual surgical procedure during which general anesthesia is administered to a patient. It’s the examiner’s job to inspect all monitoring devices and emergency equipment, and to test the doctor and the surgical staff on anesthesia-related emergencies. If the examinee successfully completes the evaluation process, the state dental board issues the doctor a license to perform general anesthesia.  Note that even though the oral surgeon has a license to direct anesthesia, the sedating drugs he or she orders are often administered by a nurse who has no license or training in anesthesia.

In an oral surgeon’s office, general anesthesia for wisdom teeth extraction typically includes intravenous sedation with several drugs:  a benzodiazepine such as midazolam, a narcotic such as fentanyl or Demerol, and a hypnotic drug such as propofol, ketamine, and/or methohexital.  After the patient is asleep, the oral surgeon injects a local anesthetic such as lidocaine to block the superior and inferior alveolar nerves.  These local anesthetic injections render the mouth numb, so the surgeon can operate without inflicting pain.  Typically, no breathing tube is used and no potent anesthetic vapor such as sevoflurane is used.  The oral surgeon may supplement intravenous sedation with inhaled nitrous oxide.

The oral surgeon has all emergency airway equipment, breathing tubes, and emergency drugs available, but these are rarely used.

The safety record for oral surgeons using these methods seems excellent.  My review of the National Institutes of Health website PubMed reveals very few instances of death related to wisdom teeth extraction.  Recent reports include one patient who died in Germany due to a heart attack after his surgery (Kunkel M, J Oral Maxillofac Surg. 2007 Sep;65(9):1700-6.  Severe third molar complications including death-lessons from 100 cases requiring hospitalization).  A second patient died in Japan because of a major bleed in his throat occluding trachea, one day after his surgery (Kawashima W, Forensic Sci Int. 2013 May 10;228(1-3):e47-9. doi: 10.1016/j.forsciint.2013.02.019. Epub 2013 Mar 26. Asphyxial death related to postextraction hematoma in an elderly man).

Most oral surgeons have no interest in publishing their mishaps or complications, so the medical literature is not the place to search for data on oral surgery deaths. Deaths that occur during or after wisdom teeth extraction are sometimes reported in the lay press.  In April 2013, a 24-year-old healthy man began coughing during his wisdom teeth extraction in Southern California, and went into cardiac arrest.  He was transferred to a hospital, where he died several days later.

In 2011, a Baltimore-area teen died during wisdom teeth extraction. The family’s malpractice claim was settled out of court in 2013.

Every general anesthetic carries a small risk, even when the patient is young and healthy, such as these two cases of death following wisdom teeth extractions.  All acute medical care involves attending to the A – B – C ‘s of Airway, Breathing, and Circulation.  During surgery for wisdom teeth extraction, the oral surgeon is operating in the patient’s mouth. Surgery in the mouth increases the chances that the operation will interfere with the patient’s Airway or Breathing.  The surgeon’s fingers, surgical instruments, retractors, and gauze pads crowd into the airway, and may influence breathing.  If the patient’s breathing becomes obstructed, altering the position of the jaw, the tongue, or the neck is more challenging than when surgery does not involve the airway.

I’ve attended to hundreds of patients for dental surgeries.  For dental surgery in a hospital setting, anesthesiologists commonly insert a breathing tube into the trachea after the induction of general anesthesia.  A properly positioned tracheal tube can assure the Airway and Breathing for the duration of the surgery.  Because an anesthesiologist is not involved with performing the surgery, his or her attention can be 100% focused on the patient’s vital signs and medical condition.  When anesthesiologists are called on to perform general anesthesia for wisdom teeth extraction in a surgeon’s office, we typically use a different anesthetic technique. Usually there is no anesthesia machine to deliver potent inhaled anesthetics, therefore intravenous sedation is the technique of choice.  Usually no airway tube is inserted.  A typical technique is a combination of intravenous midazolam, fentanyl, propofol, and/or ketamine.  Oxygen is administered via the patient’s nostrils throughout the surgery. The adequacy of breathing is continuously monitored by both pulse oximetry and end-tidal carbon dioxide monitoring.  The current American Society of Anesthesiologist Standards for Basic Anesthetic Monitoring (July 1, 2011) state that “Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. … Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment.”

The motto of the American Society of Anesthesiologists is “Vigilance.”  If the patient’s oxygen saturation and/or end-tidal carbon dioxide numbers begin to decline, an anesthesiologist will act immediately to improve the A – B – C ‘s of Airway, Breathing, and Circulation.

Let’s return to our opening question: Will you have an anesthesiologist for your wisdom teeth extraction surgery?  I cannot show you any data that an anesthesiologist provides safer care for wisdom teeth surgery than if an oral surgeon performs the anesthesia. The majority of wisdom teeth extractions in the United States are performed without an anesthesiologist, and reported complications are rare.  If you want an anesthesiologist, you need to make this clear to your oral surgeon, and ask him to make the necessary arrangements.  If you do choose to enlist a board-certified anesthesiologist for your wisdom teeth extractions, know that your anesthesia professional has completed a three or four year training program in his field, and is expert in all types of anesthesia emergencies.  As a downside, you will be responsible for an extra bill for the professional fee of this anesthesiologist.

Whether an anesthesiologist or an oral surgeon attends to your anesthesia, the objectives are the same:  Each will monitor the A – B – C ‘s of your Airway, Breathing, and Circulation to keep you oxygenated and ventilated, so you can wake up and leave that dental office an hour or so after your wisdom teeth extraction surgery has concluded.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

WHAT IF THE TRACHEAL TUBE FALLS OUT WHEN THE ANESTHESIOLOGIST AND THE ANESTHESIA MACHINE ARE AT THE PATIENT’S FEET?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Clinical Case for Discussion: It is the conclusion of a craniotomy for a tumor resection on a 50-year-old, 80 kg woman.  The operating room table is turned 180 degrees, you are the sole anesthesiologist. and you are at the patient’s feet.   The nurse and scrub tech are applying the head dressing.  The patient coughs, turns her head, and the endotracheal tube comes out above the vocal cords.  What do you do?

Discussion:    You have been peering intently at the monitors and the patient for the past 4 uneventful hours, seeking the perfect anesthetic, but now you have some urgent work to do.

The approach to acute medical care is always:  Airway, Breathing, and Circulation.

In this case, the airway is distant from you and your equipment, because the surgeon needed full access to the head for the surgery.  Your first move is to go to the head of the table, and attempt to push the endotracheal tube (ETT)  back into the trachea.  This is not successful.  The oxygen saturation is 100%, so the patient is in no immediate danger.  You unlock the OR table, and and rotate it back so that the patient’s head is next to the anesthesia equipment again.  You  remove the ETT, apply a mask to the patient, and manage the airway as the patient awakens from anesthesia.

What if the oxygen saturation had dropped below 90% when the ETT fell out?

The answer is the same.  You take the time to turn the table so that the patient’s head is back adjacent to your airway equipment and anesthesia machine, and then you use mask ventilation to return the patient’s oxygenation to a safe level.  To deliver continuous positive airway pressure (CPAP) or positive pressure ventilation to your patient, you need to be able to reach both the ventilation bag and hold the mask over the patient’s face.  You can not do this if the table is turned 180 degrees.  If the patient develops laryngospasm that you can not break with CPAP, a small dose of succinylcholine (10 – 20 mg) is recommended.

Any attempt to manage the airway problem with the table still turned 180 degrees, but relying on the surgeon or the circulating nurse to hand you drugs and equipment, or to squeeze the bag on the circle system, is not recommended by this author.  Their skill level may not be what you were used to in  your residency training, when you were sharing the responsibility with a second anesthesiologist.

What if, in a parallel universe, at the onset of this same scenario a different anesthesia provider inserted the laryngoscope into the patient’s mouth to attempt to replace the ETT.    The patient bit down on the blade, and the anesthesiologist wrestled with a forceful laryngoscopy.  The oxygen saturation dropped below 90%.  He decided to inject succinylcholine to paralyze the patient, but his drugs and syringes were at the foot of the operating room table, six feet away and out of reach.  He instructed the nurse to draw up and inject the drug for him, but this took over 60 seconds of valuable time, during which the patient was hypoxic.  He finally inserted the ETT into the trachea, and was able to ventilate the lungs to increase the oxygen saturation to 100% again. But the blood pressure was now 180/110, the heart rate was 140 beats per minute, and the intracranial pressure was higher than the surgeon’s temper at this point.

Make a different choice:  turn the head end of the operating room table back to where your equipment is.

Regarding the possibility of the ETT coming out during surgery, I anticipate comments like:   “How could this happen?  Why didn’t you use Benzoin to hold the ETT tape to the skin overlying the maxilla?  Why did you tape the tube to the mandible instead of the mandible? You should hold the ETT yourself when you are awakening a patient and they are applying a head dressing.  You should keep the patient anesthetized until the dressing is done,” etc.

Alas, despite experience and planning, unexpected events do occur.  Your worth as a clinician will be proven and tested by how you handle the unexpected.

In sum:  If you are working alone, and an airway problem occurs with the airway six feet away from your anesthesia equipment, I advise you to bring the airway back to your equipment.

*
*
*
*

Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited