Office Based Anesthesia (Pediatric Dental)

[WDP05]

My group is looking into expanding our practice to include office based anesthesia. Mostly the impetus for this is that the pediatric dentists in the area have expressed concern that the provider currently providing "sedation" in the office may not be well suited to their needs. I wanted to get input from those who have set up such a practice and how they have set things up.
I think we would be likely to nasally intubate most patients and run a propofol TIVA. I know others include Remi, but my concern is the complexity of accounting for this in terms of narcotics, etc. Many have also said they bring a nurse along as well (or an EMT). Do most just let the nurse recover patients, are they starting IVs after we induce? What equipment do you bring with you? A portable machine and an EMT bag for the obvious supplies (drugs, syringes, tubes, etc.) Does anyone bring a portable "ranger" glidescope? Do offices typically have oxygen/nitrous supply lines? Defibrillator?
Any guidance is appreciated. Clinical stuff is easy, but the logistics are what concerns us.

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[aneftp]

My group is looking into expanding our practice to include office based anesthesia. Mostly the impetus for this is that the pediatric dentists in the area have expressed concern that the provider currently providing "sedation" in the office may not be well suited to their needs. I wanted to get input from those who have set up such a practice and how they have set things up.
I think we would be likely to nasally intubate most patients and run a propofol TIVA. I know others include Remi, but my concern is the complexity of accounting for this in terms of narcotics, etc. Many have also said they bring a nurse along as well (or an EMT). Do most just let the nurse recover patients, are they starting IVs after we induce? What equipment do you bring with you? A portable machine and an EMT bag for the obvious supplies (drugs, syringes, tubes, etc.) Does anyone bring a portable "ranger" glidescope? Do offices typically have oxygen/nitrous supply lines? Defibrillator?
Any guidance is appreciated. Clinical stuff is easy, but the logistics are what concerns us.

My buddy is peds fellowship (and cardiac echo boarded). Basically jack of all trades.

He does tons of office base anesthesia these days.

He says,

"Yes. We intubate all the kids. Age 2 is the cutoff. We bring anesthesia cart and anesthesia machine. Kids recover in the parents lap.


No nurses at dentist office

Duffel bag with defibrillator and cardiac meds and dantrolene. "

I make dentist offices get their own narcotics , but I don't use them. No narcotics are needed for Peds dental. Toradol.

Stopped doing nasal tubes for dental years ago. The official policy I wrote says no nasal tubes for kids under 8. Good Peds dentists don't need a nasal tube. If they demand a nasal tube, they can come to the hospital. "

 

[propadope]

My group is looking into expanding our practice to include office based anesthesia. Mostly the impetus for this is that the pediatric dentists in the area have expressed concern that the provider currently providing "sedation" in the office may not be well suited to their needs. I wanted to get input from those who have set up such a practice and how they have set things up.
I think we would be likely to nasally intubate most patients and run a propofol TIVA. I know others include Remi, but my concern is the complexity of accounting for this in terms of narcotics, etc. Many have also said they bring a nurse along as well (or an EMT). Do most just let the nurse recover patients, are they starting IVs after we induce? What equipment do you bring with you? A portable machine and an EMT bag for the obvious supplies (drugs, syringes, tubes, etc.) Does anyone bring a portable "ranger" glidescope? Do offices typically have oxygen/nitrous supply lines? Defibrillator?
Any guidance is appreciated. Clinical stuff is easy, but the logistics are what concerns us.

My advice is to find out what the state requirements are for GA in terms of equipment, drugs, standard of care, guidelines etc... thats the bare minimum and make a list of additional stuff you want. Find out if any of the offices have any of the equipment/ armamentarium on site. This makes things more convenient for you but you have to make sure the equipment is properly maintained. Offices vary greatly so you will need to check each one out.


I think propofol alone as a TIVA is not great. Remifentanil makes things a lot smoother. Precedex as well.

I carry a McGrath MAC. Portable and you can do nasal intubations with a Magill forecep. Not so easy with a Glidescope

Bottom line:its easy to take things for granted in a hospital/surgicentre environment. Office based anesthesia takes a lot of logistics and planning

 

[Mman]

Stopped doing nasal tubes for dental years ago. The official policy I wrote says no nasal tubes for kids under 8. Good Peds dentists don't need a nasal tube. If they demand a nasal tube, they can come to the hospital. "

What about a nasal tube dictates going to the hospital if I may ask as opposed to an oral tube? Who cares?

 

[propadope]

What about a nasal tube dictates going to the hospital if I may ask as opposed to an oral tube? Who cares?

I'm assuming more risk involved. But there is also risk with a dentist working around an oral tube.

 

[Mman]

I'm assuming more risk involved. But there is also risk with a dentist working around an oral tube.

I guess I'm wondering what the "more risk" is? I've put in hundreds (thousands?) of nasal tubes in kids from ages 2-10 in outpatient settings and haven't had any complication that kept a kid from going home that same day.

 

[aneftp]

I guess I'm wondering what the "more risk" is? I've put in hundreds (thousands?) of nasal tubes in kids from ages 2-10 in outpatient settings and haven't had any complication that kept a kid from going home that same day.

You've put thousands of kids asleep with nasal intubation in an office based setting?

Outpatient real surgical AAAHC/Jhaco compliant setting vs wild Wild West office base settings with limited support staff are different ballgames

 

[Mman]

You've put thousands of kids asleep with nasal intubation in an office based setting?

Outpatient real surgical AAAHC/Jhaco compliant setting vs wild Wild West office base settings with limited support staff are different ballgames

I said hundreds or thousands, I can't keep track of that many, but I also said outpatient, not office. But I'm kinda curious what added risk a nasal tube has over an oral tube that would make you say yes to one in the office but no to the other. I think I probably did 10 or 12 last week in the outpatient center.

What is your concern with a nasal tube? Bloody nose? I'm pretty conservative and don't push hard, but nasal tubes in kids are infinitely easier than most adults. Babies are nose breathers anyway and kids haven't lived long enough to get major pathology that makes it tougher.

 

[aneftp]

I said hundreds or thousands, I can't keep track of that many, but I also said outpatient, not office. But I'm kinda curious what added risk a nasal tube has over an oral tube that would make you say yes to one in the office but no to the other. I think I probably did 10 or 12 last week in the outpatient center.

What is your concern with a nasal tube? Bloody nose? I'm pretty conservative and don't push hard, but nasal tubes in kids are infinitely easier than most adults. Babies are nose breathers anyway and kids haven't lived long enough to get major pathology that makes it tougher.

I personally don't do office base. Like u. Just don't outpatient kids dental. Different settings between office based anesthesia and real outpatient surgical settings in terms of comfort level and staffing.

My friend who has done it for well 13 years says this,

"Lots of nosebleeds, especially in winter. You are in an office with no support. The dentists don't actually need it, but they have been spoiled by their residency training. "

U got to draw the line somewhere. Office based anesthesia is where dentists/gi docs/plastic surgeons try to get away with as little money expenditures as possible. Plus add in pediatric population for dental cases in an office. Do what's in your comfort level.

Even a few of my friends who done just adult office based general anesthesia including dental cases have had a few close calls (huge desats in those 5 foot 7 290 pound airways male patients. We all know those type of airways can get risky. (especially the days before video largyscopes availability

 

[WDP05]

Thanks for the replies. The logistics are so foreign compared to everything else we do in our group. There's a big expense up front and certainly no guarantee we could find enough work to make it worthwhile.
I think we'd probably opt for the nasal tube just to keep the dentist's happy since that's what they are used to. Agree with some that the risk isn't much greater as long as you aren't being too aggressive with placement.

 

[WDP05]

My advice is to find out what the state requirements are for GA in terms of equipment, drugs, standard of care, guidelines etc... thats the bare minimum and make a list of additional stuff you want. Find out if any of the offices have any of the equipment/ armamentarium on site. This makes things more convenient for you but you have to make sure the equipment is properly maintained. Offices vary greatly so you will need to check each one out.


I think propofol alone as a TIVA is not great. Remifentanil makes things a lot smoother. Precedex as well.

I carry a McGrath MAC. Portable and you can do nasal intubations with a Magill forecep. Not so easy with a Glidescope

Bottom line:its easy to take things for granted in a hospital/surgicentre environment. Office based anesthesia takes a lot of logistics and planning

Propadope, do you have any other staff come with you, or are you taking the kids to the parents and just letting them wake up a little bit before sending them out?

 

[propadope]

Propadope, do you have any other staff come with you, or are you taking the kids to the parents and just letting them wake up a little bit before sending them out?

A nurse depending on the day. I train the dental assistants to hold the mask, pass me the Magill foreceps, give BURP, and to hold the tube and circuit as I'm taping etc...

 

[deleted59964]

What is the reluctance to place a nasal tube? and why the video scope?
i've only done kids in a hospital setting ... but I always do a nasal tube for them and have never had an issue.
kids airways can be very difficult ... but you can see them a mile away - unanticipated difficult airways in kids are unbelievably rare.

 

[propadope]

What is the reluctance to place a nasal tube? and why the video scope?
i've only done kids in a hospital setting ... but I always do a nasal tube for them and have never had an issue.
kids airways can be very difficult ... but you can see them a mile away - unanticipated difficult airways in kids are unbelievably rare.

I carry a videoscope because I also see adults. Yes unanticipated difficult airways in kids are rare but I have used it the odd time on a child. In my opinion its nice to have just in case.

 

[deleted697535]

Tiva in kids be tricky wouldn't it? Aside from the fact none of the algorithms are licensed (isn't that right?) Getting a drip up on every awake kid would wreck your head! And the freq fliers would kick the face off you...

Nasal tubes on n2o/sevo only with the McGrath be the way I learned do it. Rarely if ever opiates or relaxants needed. Any decent dentist can block everything they operate on basically.

If you wanna get fancy don't even use the McGrath for nasals and just follow the air. Cheap set up...
McGrath's are way cheaper than standard blades if you factor cssd. Prob not much more than disposable macs

 

[propadope]

Tiva in kids be tricky wouldn't it? Aside from the fact none of the algorithms are licensed (isn't that right?) Getting a drip up on every awake kid would wreck your head! And the freq fliers would kick the face off you...

Nasal tubes on n2o/sevo only with the McGrath be the way I learned do it. Rarely if ever opiates or relaxants needed. Any decent dentist can block everything they operate on basically.

If you wanna get fancy don't even use the McGrath for nasals and just follow the air. Cheap set up...
McGrath's are way cheaper than standard blades if you factor cssd. Prob not much more than disposable macs

I think you are getting TCI and TIVA mixed up... I'm assuming a mask induction or a premed before placement of the IV. Obviously makes things a lot easier.

The problem with giving local for a whole mouth of treatment on a small child is that you can get into LAST territory. Also kids hate feeling numb when they wake up. Local is usually given sparingly for extractions only.

 

[aneftp]

What is the reluctance to place a nasal tube? and why the video scope?
i've only done kids in a hospital setting ... but I always do a nasal tube for them and have never had an issue.
kids airways can be very difficult ... but you can see them a mile away - unanticipated difficult airways in kids are unbelievably rare.

Risks/rewards with office based anesthesia.

I personally do not do kids in office base. M

My friend does. But if "the man" is taking a 30-40% cut of ur money. And office setting means very little staffing support.

Proceed with caution with office based pediatric cases.

U don't want to be on the front page of the newspaper with dental death in office.

 

[deleted697535]

I think you are getting TCI and TIVA mixed up... I'm assuming a mask induction or a premed before placement of the IV. Obviously makes things a lot easier.

The problem with giving local for a whole mouth of treatment on a small child is that you can get into LAST territory. Also kids hate feeling numb when they wake up. Local is usually given sparingly for extractions only.

Well you are right I did mix them up. But mainly because I can't see why anyone would ever use tiva without a target controlled infusion. How do you know what you are giving?

Just bolus them when they move?

And to be fair you are also mixed up because total intravenous anaesthesia cannot be give by a mask unless I'm very much mistaken!

Agreed on the LAST point. Hadn't thought of that

 

[nimbus]

Risks/rewards with office based anesthesia.

I personally do not do kids in office base. M

My friend does. But if "the man" is taking a 30-40% cut of ur money. And office setting means very little staffing support.

Proceed with caution with office based pediatric cases.

U don't want to be on the front page of the newspaper with dental death in office.

Aren't these usually very well compensated cash pay gigs?

 

[aneftp]

Aren't these usually very well compensated cash pay gigs?

Adult dental is lucrative cash pay. Especially restorative dental where dentist charges $20k plus. Usually $2-4K anesthesia depending on hours worked.

But with kids. And Obamacare mandates paying for "pediatric dental" general anesthesia. Many Or most kids dental go through insurance.

 

[Mman]

Well you are right I did mix them up. But mainly because I can't see why anyone would ever use tiva without a target controlled infusion. How do you know what you are giving?

Well you use a pump to monitor the infusion rate so that's how you know "what you are giving". I've heard rumors of TCI from colleagues that trained in Europe, but have never been in a location that had one and have done thousands of TIVAs without difficulty. It isn't that hard. Give them a bolus, turn the pump on at estimated rate you will need and then titrate to signs of light or deep anesthesia. If the case drags on for a long time, you can back of your rate a little bit.

 

[Arch Guillotti]

Well you are right I did mix them up. But mainly because I can't see why anyone would ever use tiva without a target controlled infusion.

My guess is that hardly anybody on this board uses anything other than a regular old pump.

 

[Mman]

My guess is that hardly anybody on this board uses anything other than a regular old pump.

as far as I know there still aren't any TCI pumps that are FDA approved

 

[deleted59964]

as far as I know there still aren't any TCI pumps that are FDA approved

wow - it's great to hear of the regional differences in our field.

TCI propofol (marsh model mostly) is routine here for propofol infusions ... for all but the shortest cases (scopes).
minto model less so for remi as mcg/kg/min or just ml/hr works just as well.

I'm sure titrating ml/hr of propofol to physiological variables works fine, but TCIs make TIVA MUCH easier and less titration is required.

 

[propadope]

Well you are right I did mix them up. But mainly because I can't see why anyone would ever use tiva without a target controlled infusion. How do you know what you are giving?

Just bolus them when they move?

And to be fair you are also mixed up because total intravenous anaesthesia cannot be give by a mask unless I'm very much mistaken!

Agreed on the LAST point. Hadn't thought of that

I did not mix up TIVA with anything. You can induce however you want but maintain with TIVA. TCI is available in Canada and I use it, however, it merely estimates plasma and effect site concentrations based on pharmacokinetics from a small study population. There are a lot of assumptions made. You still have to titrate to vital signs and the clinical situation. Hopefully the models will improve over time and there will be a way to actually measure plasma concentrations (directly or indirectly).

 

[Libertas]

Do people using tci's for all their tiva typically use bis or any type of depth monitoring ? Just curious.

 

[deleted59964]

Do people using tci's for all their tiva typically use bis or any type of depth monitoring ? Just curious.

I use bis if I'm using tiva with nmb drugs ... for whatever it's worth

 

[deleted697535]

I did not mix up TIVA with anything. You can induce however you want but maintain with TIVA.

Seriously? Total intravenous anaesthesia actually means totally mixed inhalational and iv anaesthesia?

And what will measuring plasma concentrations tell you? Still an estimate to effect site

Lots of our measurements are based on some form of an estimate

 

[deleted697535]

My guess is that hardly anybody on this board uses anything other than a regular old pump.

That is really jaw dropping

 

[Mman]

That is really jaw dropping

why? it's done all over the US on a daily basis. Brits I've worked with in the US mention TCI pumps are nice, but it's the exact same anesthetic when you run it on an infusion pump.

 

[propadope]

Seriously? Total intravenous anaesthesia actually means totally mixed inhalational and iv anaesthesia?

And what will measuring plasma concentrations tell you? Still an estimate to effect site

Lots of our measurements are based on some form of an estimate

The OP said he was going to use TIVA. He didn't say how he was going to get the IV in. There are lots of ways to approach this. Thats why I clarified TIVA maintenance if an inhalational induction is done. No need to get into semantics...

Measuring is better than estimating no? The PK models used in TCI make assumptions. Much more room for error and deviations

 

[propadope]

why? it's done all over the US on a daily basis. Brits I've worked with in the US mention TCI pumps are nice, but it's the exact same anesthetic when you run it on an infusion pump.

Exactly. One should know how to run a TIVA without TCI. It might not be the usual technique you would use but there are procedures and patients that favour or even dictate it.

 

[deleted162650]

Eh, TCI is kind of a nurse tool isn't it?

 

[propadope]

Eh, TCI is kind of a nurse tool isn't it?

Just like anything that make things easier and more convenient

 

[WDP05]

The OP said he was going to use TIVA. He didn't say how he was going to get the IV in. There are lots of ways to approach this. Thats why I clarified TIVA maintenance if an inhalational induction is done. No need to get into semantics...



Measuring is better than estimating no? The PK models used in TCI make assumptions. Much more room for error and deviations

Yes my intention was to start an IV following a mask induction then convert to straight TIVA. No TCI. Sorry for the confusion and resulting argument on semantics.

 

[deleted697535]

No need to get into semantics...

Lol were you not the first grammar tyrant?

I don't really care mate loads of ways to do it...

It's interesting I suppose to hear other approaches

 

[Swamp Gas]

"Lots of nosebleeds, especially in winter. You are in an office with no support. The dentists don't actually need it, but they have been spoiled by their residency training. "

U got to draw the line somewhere. Office based anesthesia is where dentists/gi docs/plastic surgeons try to get away with as little money expenditures as possible. Plus add in pediatric population for dental cases in an office. Do what's in your comfort level.

Had a brisk nose bleed on a nasal intubation yesterday for routine dental rehab. I was thankful that I was in the OR and not in a dentist's office with limited resources......I could see where this scenario could get real dicey.

 

[propadope]

Had a brisk nose bleed on a nasal intubation yesterday for routine dental rehab. I was thankful that I was in the OR and not in a dentist's office with limited resources......I could see where this scenario could get real dicey.

Sometimes a bleed can happen even if the tube passes easily. There is always a risk involved no matter how small. Did it happen right away or on extubation?

 

[aneftp]

Sometimes a bleed can happen even if the tube passes easily. There is always a risk involved no matter how small. Did it happen right away or on extubation?

The issue is DO U WANT to take the risk in a highly unregulated office anesthesia environment?

I guess if u are doing ur own billing and no one is taking money off the top. It may be worth it if u guaranteed $3000-4000 per 6 hours of work.

Office base anesthesia ain't worth it to be if I'm getting $1500/6 hours when I know someone if milking another $1500-2000 off the top and I'm taking all the risks and they sit back and collect profits with no risk involved.

 

[Swamp Gas]

Sometimes a bleed can happen even if the tube passes easily. There is always a risk involved no matter how small. Did it happen right away or on extubation?

Happened on intubation despite generous Afrin and lube. Red rubber passed easily.