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deleted307836
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No one should perform a surgical procedure while administering or supervising anesthesia... period!
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I think some of this stems from the dentists ability to bill/charge for the sedation. This can add $400 to the bill.
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deleted171991
I doubt this was patient-related. I would rather bet on local anesthetic plus epi overdose, possibly injected without aspirating first. Hypertension and arrhythmia from unknown cardiac condition... sure. Was this before or after Santa Claus came down the chimney? I am surprised nobody ordered an autopsy, not even the state.
I have seen something similar once when a "wise" orthopod injected local around a closed forearm fracture before incision. Patient went from 90/60 to 250/120 in 30 seconds. And that was an adult.
I have seen something similar once when a "wise" orthopod injected local around a closed forearm fracture before incision. Patient went from 90/60 to 250/120 in 30 seconds. And that was an adult.
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I made sure I had an anesthesiologist for my procedure- complicated, 4 tooth, bony extraction. Unfortunately, most of the public isn't aware of how much their life is in danger when undergoing anesthesia for "minor" procedures, they just think anesthesia is anesthesia and trust that things will be okay. Someone should do a retrospective study on outpatient anesthesia complication rates with and without an anesthesiologist present.
I had a patient who was having a colonoscopy a few months back, booked with anesthesia because she was "difficult to sedate." While chatting with her, she said she recently had a dental procedure under sedation, and her dentist had reiterated that she was difficult to sedate, and wrote down what he had given her. Mind you, this was in a dentist's office, with the dentist himself administering the sedation. It read something to the effect of "Midazolam 10 mg, Fentanyl 500 mcg, Propofol 100 mg, Ketamine 50 mg."
Knowing nothing else about the case, my hunch is that this case was due to oversedation, the dentist not recognizing it, and the inability to properly manage an airway. Not sure where and how they get credentialed to administer anesthesia themselves, but these cases make me think a lot of them attend a weekend course in sedation, and they come away feeling like they can handle any situation.
Sad case, feel terrible for the parents of this child, and for future unsuspecting patients who don't know any better.
Knowing nothing else about the case, my hunch is that this case was due to oversedation, the dentist not recognizing it, and the inability to properly manage an airway. Not sure where and how they get credentialed to administer anesthesia themselves, but these cases make me think a lot of them attend a weekend course in sedation, and they come away feeling like they can handle any situation.
Sad case, feel terrible for the parents of this child, and for future unsuspecting patients who don't know any better.
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At our large academic training center, OMFS residents do I believe 4 months of adult anesthesia and 1 month of peds. Months 3 and 4 of adults they get their own room albeit with simple cases and a close attending eye. I still don't believe they should be administering their own anesthesia once they get into the real world.
We had a "dental anesthesiologist" pedi dentist where I trained. She did dental exams and restorations but wasn't allowed to administer anesthesia in the hospital setting. She had an office down that street tucked in some corner of the campus. I think we got about three calls for pedi codes coming from that office before someone finally told her to cut the **** and stick to dentistry. A friend responded to one case where the kid was blue and clearly in laryngospasm with an oversized LMA in his mouth.
I also heard of a local OMFS who apparently had a patient death in his office because he didn't know what he was doing. Over sedated the girl, didn't monitor properly, patient became hypoxic and coded. I feel it's more common than we hear about.
I also heard of a local OMFS who apparently had a patient death in his office because he didn't know what he was doing. Over sedated the girl, didn't monitor properly, patient became hypoxic and coded. I feel it's more common than we hear about.
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Don't worry. I am here to get roasted!!!!! I lurk here from time to time because I do think you guys provide great education regardless of whether you mean to or not.
While everyone is entitled to their opinion, please know this is a horrible disaster for the family. It's also a horrible issue for the dentist, who I hope is at least trained as an OMS. While there will be multiple theories (guesses), please know that there are many in the dental community who don't take these things lightly and see this as one too many. It turns my stomach and is truly my worst nightmare. We will be watching, just like you, for more details.
Just wanted to make sure we wait until the facts come out until we talk about epi overdose (1:100k epi in a 1.8mL cartridge of 2% lidocaine, usually 4-6 cartridges for a set of third molars) or other possible zebras. Correct me if I'm wrong, but the other case they refer to with the Maryland teen (in 2011 I think) had anesthesia administered by an MD. We will all be watching, but try not to blast the dental community too much just yet. I was following your Joan Rivers thread too. All the best.
Proceed with the roast.
While everyone is entitled to their opinion, please know this is a horrible disaster for the family. It's also a horrible issue for the dentist, who I hope is at least trained as an OMS. While there will be multiple theories (guesses), please know that there are many in the dental community who don't take these things lightly and see this as one too many. It turns my stomach and is truly my worst nightmare. We will be watching, just like you, for more details.
Just wanted to make sure we wait until the facts come out until we talk about epi overdose (1:100k epi in a 1.8mL cartridge of 2% lidocaine, usually 4-6 cartridges for a set of third molars) or other possible zebras. Correct me if I'm wrong, but the other case they refer to with the Maryland teen (in 2011 I think) had anesthesia administered by an MD. We will all be watching, but try not to blast the dental community too much just yet. I was following your Joan Rivers thread too. All the best.
Proceed with the roast.
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deleted171991
A 1:100,000 epi solution has 10 mcg/ml of epi, so 18 mcg/cartridge. If one injects a few of those at the same time, intravascularly, in a 45 kg kid...
It might be a zebra, but kids don't get hypertension from unknown cardiac problems. Especially bradycardia with hypertension (although the latter goes against the epi theory, unless lidocaine toxicity or hypoxia also had a contribution there).
Another bet would be on some form of pre-existing secondary hypertension that turned into an emergency for some reason. But that's really a zebra.
Regardless of OMFS training, no physician should supervise an anesthetic (including "sedation") and perform surgery at the same time.
It might be a zebra, but kids don't get hypertension from unknown cardiac problems. Especially bradycardia with hypertension (although the latter goes against the epi theory, unless lidocaine toxicity or hypoxia also had a contribution there).
Another bet would be on some form of pre-existing secondary hypertension that turned into an emergency for some reason. But that's really a zebra.
Regardless of OMFS training, no physician should supervise an anesthetic (including "sedation") and perform surgery at the same time.
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Having several relatives that are dentists I will assume those are total possible doses for the duration of the procedure, not all at once. They usually aren't injecting more than 0.5 ml to 1 ml at a time. Very small area they are working in. Even a direct vascular injection would tend not to cause more than the brief old "i'm allergic to novocaine because my heart raced at the dentist" sort of reaction.
I do however, have problems with people providing anesthesia during a procedure that they are performing. I'm not sure how you focus on the technical procedure you are doing for a prolonged period of time while also being responsible for their anesthetic care. When I'm doing a TEE or central line on a patient, I appreciate having the anesthetist being able to monitor the patient and treat them as needed while I'm focusing on something technical.
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deleted171991
That's what I would assume, too. I am just trying to figure out a cause for hypertension followed by bradycardia. Hypoxia, either initially or after a bolus of sedative pushed for hypertension and pain?
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deleted171991
There can be post-arrest cerebral edema, due to all those dead little gray cells, I guess. Again, why not an autopsy? It was an unexpected death.
And I guess they did a CT for the seizures, so they would have had an explanation in case of a mass.
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deleted171991
Very likely. Some blood aspiration by an oversedated patient followed by laryngospasm and hypoxia, who knows? I just don't buy the heart disease story.
Anyway, it must be very sad for everybody involved. I'll stop turning the knife.
Obviously airway is the most likely cause of a downward spiral leading to a bad outcome and probably would account for 95% likelihood of being the root cause. For such a minor procedure, that's almost always the #1 threat.
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My guess is they were blaming it in hypertrophic cardiomyopathy.
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Htn and bradycardia should help a patient with hocm, not result in cardiac arrest ... Doesn't add up.
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deleted59964
phaeo?
Not sure if in actuality the BP went up and HR went down. To me this is lost airway until proven otherwise. Possibility of local going intravascular with the seizures? Unless that was response to anoxic brain injury.
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Hundreds of thousands of dentists each day give anywhere from 5-20 blocks a day I would guesstimate. I'm sure that more go intravascular than we like to admit. Just don't see 18 mcg causing this kind of issue.
I agree with you. Respiratory issue caused the CV incident until proven otherwise.
I agree with you. Respiratory issue caused the CV incident until proven otherwise.
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They tend to fibrillate very easily. I don't think it is the low cardiac output that gets them.
There is no indication of sedation in the news article. Any respiratory etiology is just speculation.
Cardiac arrest on a young skinny athlete while getting epi makes me think hocm.
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Reports in my world coming in that it wasn't an oral and maxillofacial surgeon, just a general dentist with no sedation and local only. Honestly though, I would be amazed if a general dentist had a pulse ox/BP on during the procedure if local only. Will keep you guys updated.
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deleted171991
One really has to inject intravascularly for that epi to matter.
Plus the skinny athlete probably had tons of workouts where her HR and BP were high (as in intravascular epi), while also sweating profusely, and I assume she didn't pass out. Undiagnosed HOCM should be less probable in an athlete than in the general population.
In this case, the patient is NOT the culprit, until proven otherwise.
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Could he have accidentally injected a small amount of local into the internal carotid artery? I know it's not very close to where this guy was supposed to inject but it takes less than 0.25 cc to cause seizures. And if you can't manage the airway during seizures then it's a bad situation.
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Never reported to my knowledge. Most needles wouldn't have the length to get to the ICA.
I should remember this, but wasn't there some study that says how many mcg of epi is released during stress? I'll look it up when I get home tonight if not. Just wondering in relation to the mcg in a dental cartridge.
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deleted171991
I am not saying it doesn't happen. I am only saying that the likelihood of crashing in a dentist's chair should be much higher for the general population, and yet it almost never happens.
The fact that she was an athlete should decrease, not increase, our suspicion for congenital heart disease. Sick athletes usually die during training or some other athletic event.
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Why do we have to reduce everything to airway? Even looking for zebras to make it into an airway complication.
There is no report about seizures.
All we know is that someone who took care of the girl told the family about a possible cardiac etiology.
That's all the information there is.
Unless you are thinking along those lines, you are probably way off.
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deleted171991
That actually might be the case. Those guys stress their hearts much more, on the field, which explains why we rarely hear of sudden cardiac death in non-athlete teens.
That might be the reason why one needs a medical clearance for most competitive sports, while the same does not apply for regular phys ed classes.
From the original article...
"Once at the University of Minnesota Masonic Children’s Hospital, she was stabilized but continued to have seizures, Diane Galleger wrote."
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You got a point. I was thinking seizures in dental office. I doubt those late seizures are related to the local anesthetic.
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Why would there be signs of LA toxicity with an intravascular injection?
Agree with your other statement that pulse ox would not be on patient unless some sort of sedation.
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These are the same people that tell their patients they have an allergy to epinephrine.
Obviously that would cause seizures, but the quote was that the seizures continued in the ICU. Leaves the door open to seizures happening prior to any primary brain damage. Obviously none of us are sure, just taking a stab at possibility etiologies for an unexpected death.
Airway is obviously the cause until proven otherwise in an otherwise healthy person having minor procedure under some form of sedation.
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Ahhh... Dentists?
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deleted171991
Those who don't know how little they know.
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Generally people who think that an allergy to epinephrine is a thing.
Which dentists? If dentists are saying this to their patients than they are clearly deficient in their knowledge. However, sometimes things get said to a patient e.g. 'You had a reaction to the epinephrine in the local. That's why you are getting palpitations...' The patient than interprets this as an allergy. Sometimes its the patient who misunderstands something. I have heard many patients say they have an allergy to something when in fact it is not the case. Also it is possible to have an allergy to sulfite which as you know is contained in local anesthetics with epi.
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Awkward..........Don't mind me, I just lurk here.
And dentists tell patients they are allergic to epinephrine just like anesthesiologists sleep at the anesthesia machine. Might have happened before, but we both know it's not a common occurrence in real life.
But hey, I know, it's your forum. Trust me, not picking a fight here. I might be outnumbered.
