oral surgery anesthesia pointers

[drpainfree]

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mostly MAC (versed, fentanyl, propofol) for wisdom teeth extraction...anything to watch out for?

 

[Oggg]

capnograph?

 

[Idiopathic]

capnograph?

theyll be mouthbreathing anyway but its always nice to consider ASA standard monitors.

watch out for apnea and asystole, but that holds true for most anything

 

[GreatOMFSHope]

I'm an OMFS resident doing my five months of anesthesia. I have been reading this board for some pointers and have learned a tremendous amount just from all your experiences.

Are you taking the wisdom teeth extraction to the OR? If so, the biggest thing you should watch out for usually has nothing to do with OMFS. The main reason we do dental extractions in the OR is because the patients are sick (ASA III or greater) and we don't feel comfortable with the MAC in our office setting. We know the limitations of what we are comfortable with and prepared to handle. If there's a chance something could go wrong, we want to be in the OR and have you guys concentrating on the patient the entire time. So really, I would assume the biggest reason for taking an extraction case to the OR is the patient's history.

 

[epidural man]

capnograph?

 

[drpainfree]

thanks for all the input.

No, I'm actually talking about MAC cases in oral surgeon's office. I've done enough ASA III (down syndrome, non-cooperative kids, etc) in OR. Here I'm referring to wisdom teeth extraction in office under MAC.

Capnography is nice, but no, it's not available at this time.

 

[nap$ter]

mostly MAC (versed, fentanyl, propofol) for wisdom teeth extraction...anything to watch out for?

avoid hypoxia, hypercarbia, and hemodynamic instability.

oh, and judging from the presentation of your question, you should not be using propofol.

 

[GreatOMFSHope]

If these kids are ASA I and II, there shouldn't be too many surprises. I'm not sure I understand everything though. Are you doing this for an oral and maxillofacial surgeon or just a general dentist doing oral surgery? Most OMFS guys push their own meds so I'm not sure what the issue is. Not questioning your worth at all (it would be awesome to focus just on the surgical procedure), but usually it doesn't make sense for us financially to hire a doc to solely run our 15-20 minute cases on healthy 16-21 year olds.

And slavin, why no propofol?

 

[OB1🤙]

And slavin, why no propofol?

He's saying that if the OP needs to even ask the question, propofol should be disqualified from his arsenal.

 

[IlDestriero]

.

 

[OB1🤙]

Upon further review, OP appears to be an anesthesia-trained pain doc. I assumed he was OMFS based on an oddly worded post.

 

[Monty Python]

thanks for all the input.

No, I'm actually talking about MAC cases in oral surgeon's office. I've done enough ASA III (down syndrome, non-cooperative kids, etc) in OR. Here I'm referring to wisdom teeth extraction in office under MAC.

Capnography is nice, but no, it's not available at this time.

Do sedation cases in the dental office fall under ASA guidelines? If so, capnography became a standard on July 1, 2011.

 

[pgg]

Do sedation cases in the dental office fall under ASA guidelines? If so, capnography became a standard on July 1, 2011.

Applying ASA standards apply to other professionals doing their thing in their spaces on their licenses isn't really appropriate. I'm not interested in scouring the professional standards for other specialties looking for bits that might conceivably apply to what we do in anesthesia.

I think this issue isn't quite 100% straightforward though, because JC requires anesthesia to have a hand in monitoring sedation services within a hospital.

We've had a couple recent threads on this, here's one.

 

[drpainfree]

yes, slavin, I'm well qualified to run propofol (boarded in both anesthesia and pain) and have done sedation for 1 year old to 86 years old, from 10 pounder to 400# pre-gastric bypass patient.

the reason you questioned my "question" shows your ignorance what oral facial surgery involves. without exactly clarifying what type of patients and what kind of cases they are doing, you assumed you know everything about everything.

does asking for suggestion from your colleagues ever come to your mind during your practice? have you ever talk to your partners and learn from them how they provide safe yet different anesthesia?

i don't have any personal issue with you or have ever read your posts before, but really, talk with your brain not with your tongue,

 

[drpainfree]

greatOMFhope, you have a legitimate question, here I will answer for you: yes a lot of OMFs do their own sedation. It's the reason I asked about propofol. Unless you're very quick with your procedure (10-20 minutes), your fentanyl, versed and initial bolus of propofol for sure to wear off. you'd have to titrate in propofol very very carefully, to both maintain spontaneous breathing, and yet not lose gag reflex.

I'll tell you even as an experienced anesthesiologist, it's not an easy task. Now you have to focus on your work, why do you want to take on the risks of losing the airway or patient going into laryngospasm, or asthma attack?

It absolutely makes no sense to me why OMFS takes on this much of risks in their office.

And this is why I've been asked to work in OMFS office to provide this type of anesthesia.

 

[nap$ter]

yes, slavin, I'm well qualified to run propofol (boarded in both anesthesia and pain) and have done sedation for 1 year old to 86 years old, from 10 pounder to 400# pre-gastric bypass patient.

the reason you questioned my "question" shows your ignorance what oral facial surgery involves. without exactly clarifying what type of patients and what kind of cases they are doing, you assumed you know everything about everything.

does asking for suggestion from your colleagues ever come to your mind during your practice? have you ever talk to your partners and learn from them how they provide safe yet different anesthesia?

i don't have any personal issue with you or have ever read your posts before, but really, talk with your brain not with your tongue,

whoa there, slick.

reread your OP. you totally sound like an OMFS asking about doing your own sedations. thus my reply.

you're down with anesthesia? cool. more power to you. ask a question with specifics. your question was extremely general and oddly phrased - "what should I watch out for in oral surgery cases?" just didn't sound like it was coming from a board-certified anesthesiologist, that's all.

my reply wasn't a personal attack - just gave some safe advice for someone who sounded like a beginner.

believe me - i ask for advice all the time - which is why i like this forum.

and by the way, i do lots and lots and lots of dental - much of which is preop for cardiac patients. if you have a specific question, would be happy to discuss.

 

[GreatOMFSHope]

greatOMFhope, you have a legitimate question, here I will answer for you: yes a lot of OMFs do their own sedation. It's the reason I asked about propofol. Unless you're very quick with your procedure (10-20 minutes), your fentanyl, versed and initial bolus of propofol for sure to wear off. you'd have to titrate in propofol very very carefully, to both maintain spontaneous breathing, and yet not lose gag reflex.

I'll tell you even as an experienced anesthesiologist, it's not an easy task. Now you have to focus on your work, why do you want to take on the risks of losing the airway or patient going into laryngospasm, or asthma attack?

It absolutely makes no sense to me why OMFS takes on this much of risks in their office.

And this is why I've been asked to work in OMFS office to provide this type of anesthesia.

Fair enough. I understand, but we do differ in opinions on some points. You said "a lot of OMFs do their own sedation" which is not really true. I would estimate 95% of surgeons do their own case. In my very limited anesthesia experience, I do know that anesthesia isn't easy. I have a profound respect for you guys that most surgeons probably don't. At the same time, our guys have been doing it this way for years. We are trained by you guys how to handle an airway, a laryngospasm, and an asthma attack. In an emergency, would I rather have a licensed anesthesiologist there...ABSOLUTELY! I would love to have one of you guys in my office running every case. The problem is that it doesn't make enough sense for us financially to have you around for the 20-30 minute typical healthy ASA I 16 year old kid. When we have that ASA III-IV person with COPD and/or a recent MI, we will see you in the OR. I do not pretend to have the anesthestic ability that you guys possess, but what we do, we do it well.

And I have to agree with slavin on your OP (although he may have been taking a cheap shot at OMFS). For someone who has done a tremendous amount of cases, you didn't sound too confident in the initial questioning. Although, didn't you just post a topic on SDN dental yesterday asking where to find jobs for dental anesthesiology positions? Must have been a quick job search.

 

[drpainfree]

i intentionally left my questions broad so that anyone can jump in with specifics. i did quite a lot of MAC cases for all kinds of situations and patients. i also did a lot of dental cases in OR. what i was asking is more about MAC/sedation cases in office. i guess i was looking for some insider tips without leading your answers.

actually, if you look at the other way, if you are able to offer MAC sedation to all your patients in office, your cases could flow much quicker and more patients would probably enjoy (at least wouldn't be traumatized) by the experience. i had 4 wisdom teeth extraction done a couple of years ago. i postponed year after year after suffering from frequent molar infection because my mom had 2 extracted under local only, and it was very very traumatizing for her. As it turned out, it was such an easy process with my 4 molar extraction that i didn't feel a bit, and was eating and resumed normal activities the following day.

i would never recommend anyone doing oral facial surgery without IV sedation.

now if i had known the OMF surgeon was going to use propofol on me, i'd rethink otherwise and insist on an anesthesiologist though.

it's a balance between increased cases volume, better patient experience, reduced liability risks and payment to trained specialist for these benefits.

 

[GreatOMFSHope]

i intentionally left my questions broad so that anyone can jump in with specifics. i did quite a lot of MAC cases for all kinds of situations and patients. i also did a lot of dental cases in OR. what i was asking is more about MAC/sedation cases in office. i guess i was looking for some insider tips without leading your answers.

actually, if you look at the other way, if you are able to offer MAC sedation to all your patients in office, your cases could flow much quicker and more patients would probably enjoy (at least wouldn't be traumatized) by the experience. i had 4 wisdom teeth extraction done a couple of years ago. i postponed year after year after suffering from frequent molar infection because my mom had 2 extracted under local only, and it was very very traumatizing for her. As it turned out, it was such an easy process with my 4 molar extraction that i didn't feel a bit, and was eating and resumed normal activities the following day.

i would never recommend anyone doing oral facial surgery without IV sedation.

now if i had known the OMF surgeon was going to use propofol on me, i'd rethink otherwise and insist on an anesthesiologist though.

it's a balance between increased cases volume, better patient experience, reduced liability risks and payment to trained specialist for these benefits.

I have trouble believing that you didn't know the OMFS was going to use propofol or you didn't ask what he/she would be using. I just can't imagine that you didn't know that OMFS use propofol since you do many dental cases. What did you think they would use when they said you would get IV sedation?

And glad to hear your experience went well. We do offer MAC anesthesia to all our patients that we feel it is beneficial to and we feel comfortable doing it. Most people, like your mother, that only require 2 teeth extracted do not need IV sedation. There are those cases that surprise you when you get in there and you wish you would have sedated them.

You're absolutely right, it is a balance that is tough and could easily be questioned if something goes wrong. I don't think that every patient under local is "traumatized", but it even makes our job easier when they are getting IV sedation. Again, I'm not questioning your value in an OMFS office, just don't know if it will ever transition to a team approach in most private practice offices. Good discussion to think about though.

 

[drpainfree]

no, he didn't disclose he would use propofol. i thought he would use only fentanyl and versed. GI doc routinely use fentanyl and versed for their endoscopy and colonoscopy. Most of them know if they ever require propofol, they'd ask for anesthesiologist to monitor (therefore changing from IV sedation to MAC). Somehow OMF surgeons don't know about that while they are working in a more risky area for more prolonged period of time.

anybody can push propofol in, even able to titrate the infusion, too with enough cases. but when the case goes south, your vigilance on monitoring and reacting quickly enough to emergency are the most important benefits a dedicated anesthesiologist can bring in.

if an OFM surgeon only uses fentanyl and versed in office, I think it's relatively debatable to have an anesthesiologist. but the moment he/she uses propofol, he/she steps into the gray area. I wouldn't be surprised if ever a case goes south, there would be more than enough expert witness lined up to testify.

Think about it. Is it really worth it?

 

[GreatOMFSHope]

no, he didn't disclose he would use propofol. i thought he would use only fentanyl and versed. GI doc routinely use fentanyl and versed for their endoscopy and colonoscopy. Most of them know if they ever require propofol, they'd ask for anesthesiologist to monitor (therefore changing from IV sedation to MAC). Somehow OMF surgeons don't know about that while they are working in a more risky area for more prolonged period of time.

anybody can push propofol in, even able to titrate the infusion, too with enough cases. but when the case goes south, your vigilance on monitoring and reacting quickly enough to emergency are the most important benefits a dedicated anesthesiologist can bring in.

if an OFM surgeon only uses fentanyl and versed in office, I think it's relatively debatable to have an anesthesiologist. but the moment he/she uses propofol, he/she steps into the gray area. I wouldn't be surprised if ever a case goes south, there would be more than enough expert witness lined up to testify.

Think about it. Is it really worth it?

I don't think GI docs get the anesthesia training we get either, which is probably why they bring in anesthesiologists when propofol is used. We do 5-6 months of anesthesia as a CA-1, not an anesthesia rotation like a surgery intern. I have been the lone provider of anesthesia (with an attending), just like a CA-1, for the last 2 months. Again, I don't pretend that makes me an anesthesiologist, but I think it prepares me to perform IV sedation/MAC in a private practice, just like every other OMFS guy has done for so many years.

There's no "gray area", we use propofol every day in private practice without the help of an anesthesiologist and rarely have complications. It's healthcare, when a case goes south, there's always "expert witnesses" to testify. That's why we are vigilant, we pick the right patients, and we get trained by anesthesiologists for the bad situations that will arise.

 

[drpainfree]

see, you didn't get my point. you might be very comfortable pushing propofol, even titrating it after doing it for a while. but what about airway emergency? are you going to be able to react quick enough to salvage the situation when you are focused on your work? OMF surgery is only subspecialty where surgeons are performing fairly complicated and risky (from anesthesia perspective) procedures and acting as the anesthesiologist.

GI doc could (have tried) make the same argument as you did. All it took is a few cases of malpractice they know it's not worth it. Another reason GI doc couldn't push propofol is because most of them still do their cases in hospitals and surgery centers where they are forced to have an anesthesiologist if they lose common sense for financial reason. Fortunately, most of GI docs I worked in the past are not careless like that.

As for expert witness, you've already provide perfect testimony, "doc xxx, do you think a few months of rotation as a first year anesthesiology resident prepare you well to give propofol AND deal with airway emergency WHILE you are focusing on your surgery"?

I don't think GI docs get the anesthesia training we get either, which is probably why they bring in anesthesiologists when propofol is used. We do 5-6 months of anesthesia as a CA-1, not an anesthesia rotation like a surgery intern. I have been the lone provider of anesthesia (with an attending), just like a CA-1, for the last 2 months. Again, I don't pretend that makes me an anesthesiologist, but I think it prepares me to perform IV sedation/MAC in a private practice, just like every other OMFS guy has done for so many years.

There's no "gray area", we use propofol every day in private practice without the help of an anesthesiologist and rarely have complications. It's healthcare, when a case goes south, there's always "expert witnesses" to testify. That's why we are vigilant, we pick the right patients, and we get trained by anesthesiologists for the bad situations that will arise.

 

[GreatOMFSHope]

see, you didn't get my point. you might be very comfortable pushing propofol, even titrating it after doing it for a while. but what about airway emergency? are you going to be able to react quick enough to salvage the situation when you are focused on your work? OMF surgery is only subspecialty where surgeons are performing fairly complicated and risky (from anesthesia perspective) procedures and acting as the anesthesiologist.

GI doc could (have tried) make the same argument as you did. All it took is a few cases of malpractice they know it's not worth it. Another reason GI doc couldn't push propofol is because most of them still do their cases in hospitals and surgery centers where they are forced to have an anesthesiologist if they lose common sense for financial reason. Fortunately, most of GI docs I worked in the past are not careless like that.

As for expert witness, you've already provide perfect testimony, "doc xxx, do you think a few months of rotation as a first year anesthesiology resident prepare you well to give propofol AND deal with airway emergency WHILE you are focusing on your surgery"?

Doc XXX: "Yes, they even let nurses do it." (Sorry, that's my one cheap shot, I swear)

The last study done in 2008 for OMFS anesthesia-related deaths had a mortality rate of 1/1.7 million cases. Thousands and thousands of patients undergo anesthesia in a private practice OMFS office daily and have great outcomes, including yourself. There are thousands and thousands of Oral and Maxillofacial Surgeons who continue to use propofol in their office without an anesthesiologist.

Your argument in like wiping your @$$ before you take a deuce, it just doesn't matter. We will continue to do things exactly how we are doing them because we do them very damn well. That's what great about OMFS for me.

By your argument, a patient could have a heart attack in the dental chair, so each dentist should have a cardiologist on staff as well, correct?

 

[drpainfree]

yes, again, your argument shows the lack of respect for the risk you put the patient under when you start using propofol.

yes, if the patient has cardiac issues, and you don't know much about (history of MI, stents, even stable CAD), and you start to titrate your propofol and patient code in your office, you are pretty sure gonna be sued and have no defense. if you brought the patient to hospital, very likely the anesthesiologist will ask for cardiologist input. On the other hand, if you did this patient in the office, and you have an anesthesiologist there and he didn't hesitate and recommend cardiology consult or at least to avoid using propofol, then it's his liability on the line.

Besides there are other medications an anesthesiologist is trained and comfortable to use for patients with different comorbidities. One thing for sure, just because OFM surgeons have been giving sedation in office for years doesn't mean it's safe for every patient. All it takes is one patient to scare you off and rethink about the practice. For that one patient, it's something sad and avoidable completely.

Doc XXX: "Yes, they even let nurses do it." (Sorry, that's my one cheap shot, I swear)

The last study done in 2008 for OMFS anesthesia-related deaths had a mortality rate of 1/1.7 million cases. Thousands and thousands of patients undergo anesthesia in a private practice OMFS office daily and have great outcomes, including yourself. There are thousands and thousands of Oral and Maxillofacial Surgeons who continue to use propofol in their office without an anesthesiologist.

Your argument in like wiping your @$$ before you take a deuce, it just doesn't matter. We will continue to do things exactly how we are doing them because we do them very damn well. That's what great about OMFS for me.

By your argument, a patient could have a heart attack in the dental chair, so each dentist should have a cardiologist on staff as well, correct?

 

[Arch Guillotti]

yes, if the patient has cardiac issues, and you don't know much about (history of MI, stents, even stable CAD), and you start to titrate your propofol and patient code in your office, you are pretty sure gonna be sued and have no defense. if you brought the patient to hospital, very likely the anesthesiologist will ask for cardiologist input. On the other hand, if you did this patient in the office, and you have an anesthesiologist there and he didn't hesitate and recommend cardiology consult or at least to avoid using propofol, then it's his liability on the line.

I almost never ask for a cardiologists input.

If propofol is used carefully, it is very safe in the vast majority of patients with cardiac disease.

 

[drpainfree]

define "carefully"...and what's "very safe"...

I've seen a cardiac patient (with CAGB) code with 50mg of propofol...

Do you do cardiac anesthesia? What do you use for induction? If you say 200mg of propofol, I'd be surprised. Ask any cardiac anesthesiologist, they'll tell you otherwise.

The fact is, it takes about average 30 minutes for a typical routine OMF procedure in office. You won't be able to really control how much propofol you use for the whole procedure. At what level of plasma concentration of propofol will cause enough cardiac depression for what kind of cardiac patient is really unknown. This is aside from all the respiratory depression propofol will cause.

All in all, the key point here is, does the patient patient deserve a dedicated specialist to monitor and more importantly to respond to emergency when the surgeon is busy at working in an area where airway could be compromised?

As a patient, I would say yes. As a physician, I say absolutely.

I almost never ask for a cardiologists input.

If propofol is used carefully, it is very safe in the vast majority of patients with cardiac disease.

 

[GreatOMFSHope]

define "carefully"...and what's "very safe"...

I've seen a cardiac patient (with CAGB) code with 50mg of propofol...

Do you do cardiac anesthesia? What do you use for induction? If you say 200mg of propofol, I'd be surprised. Ask any cardiac anesthesiologist, they'll tell you otherwise.

The fact is, it takes about average 30 minutes for a typical routine OMF procedure in office. You won't be able to really control how much propofol you use for the whole procedure. At what level of plasma concentration of propofol will cause enough cardiac depression for what kind of cardiac patient is really unknown. This is aside from all the respiratory depression propofol will cause.

All in all, the key point here is, does the patient patient deserve a dedicated specialist to monitor and more importantly to respond to emergency when the surgeon is busy at working in an area.

As a patient, I would say yes. As a physician, I say absolutely.

Remember what I said about wiping before you deuce? In the words of the great philosopher, Dewayne "The Rock" Johnson, "It doesn't matter what you think." If a patient has any cardiac issues at all, we take them to the OR so you are debating a "what-if" scenario that doesnt happen. One of the reasons our mortality rate is very low is because patient selection is KEY!

I would rather use things called statistics to determine if an OMFS is prepared and educated enough to use propofol instead of one attending questioning the intelligence and attention span of thousands of surgeons. Protect your own specialty from CRNAs and don't try to slide your way into ours.

Congrats on getting the job in an OMFS practice (even though you posted on the SDN dental looking for jobs the same day). And if you truly want information on how to run good anesthesia for OMFS cases, feel free to venture to SDN dental and ask someone who's been doing it for 30-40 years......an OMFS. I'm done running in circles with you, I should be reading Baby Miller instead.

 

[drpainfree]

that's right, patient selection is the key, but not all of them. once again, it shows your lack of respect for someone going under anesthesia and you massing around near the airway.

you're obviously trying to protect your turf with financial reason in sight. i don't blame you. on the other hand, there are very experienced OMF surgeons who have come to realize they can not only do more cases and improve the patient safety with an assistance of an experienced anesthesiologist, it says a lot about what you need to learn from your own.

the post was started to ask for inputs from anesthesiologists and I stayed on the actual anesthesia topics. to talk about protection from CRNA on an anesthesia forum and flaming the issue shows the lack of maturity. so please go back to your book and focus on learning your anesthesia.

 

[hoyden]

GreatOMFSHope,

what monitors do you guys use in the office when running propofol? and who is watching them when the surgeon's attention is elsewhere?

 

[GreatOMFSHope]

GreatOMFSHope,

what monitors do you guys use in the office when running propofol? and who is watching them when the surgeon's attention is elsewhere?

Hi Hoyden. I have asked for help from the OMFS guys on the dental forum to come over here and answer your question. I know how my private practice OMFS does his office, but I don't know what is the standards and norm in all offices. Im only a first year resident and i realize there are guys in the dental forum who have been doing this for quite some time. I just dont want to give you false information. Hopefully, these guys will provide you with an answer. Thanks.

 

[hoyden]

Hi Hoyden. I have asked for help from the OMFS guys on the dental forum to come over here and answer your question. I know how my private practice OMFS does his office, but I don't know what is the standards and norm in all offices. Im only a first year resident and i realize there are guys in the dental forum who have been doing this for quite some time. I just dont want to give you false information. Hopefully, these guys will provide you with an answer. Thanks.

Thanks.

 

[Arch Guillotti]

Friend, I think you are misinterpreting what I am saying.

I am a board-certified anesthesiologist. I am well aware of how propofol works and how to use it.

Propofol is safe if you know how to use it (skilled anesthesiologist).

define "carefully"...and what's "very safe"...

I've seen a cardiac patient (with CAGB) code with 50mg of propofol...

Do you do cardiac anesthesia? What do you use for induction? If you say 200mg of propofol, I'd be surprised. Ask any cardiac anesthesiologist, they'll tell you otherwise.

The fact is, it takes about average 30 minutes for a typical routine OMF procedure in office. You won't be able to really control how much propofol you use for the whole procedure. At what level of plasma concentration of propofol will cause enough cardiac depression for what kind of cardiac patient is really unknown. This is aside from all the respiratory depression propofol will cause.

All in all, the key point here is, does the patient patient deserve a dedicated specialist to monitor and more importantly to respond to emergency when the surgeon is busy at working in an area where airway could be compromised?

As a patient, I would say yes. As a physician, I say absolutely.

 

[armorshell]

that's right, patient selection is the key, but not all of them. once again, it shows your lack of respect for someone going under anesthesia and you massing around near the airway.

you're obviously trying to protect your turf with financial reason in sight. i don't blame you. on the other hand, there are very experienced OMF surgeons who have come to realize they can not only do more cases and improve the patient safety with an assistance of an experienced anesthesiologist, it says a lot about what you need to learn from your own.

the post was started to ask for inputs from anesthesiologists and I stayed on the actual anesthesia topics. to talk about protection from CRNA on an anesthesia forum and flaming the issue shows the lack of maturity. so please go back to your book and focus on learning your anesthesia.

Is 1:1,700,000 a serious complication rate that deserves this sort of language in an argument? Do you disagree with what these statistics are saying?

At this low level of complications, it's going to be hard to argue from a real financial and statistical standpoint that a two provider model is worth it. How much additional cost are we willing to burden the system with?

Even if a universal two-provider model reduced the serious complication rate by a factor of 5 (wildly high exaggeration), and the per-case cost for an anesthesiologist was $50 (wildly low exaggeration), you're going to charge $21,250,000 for each life saved. Assuming 50 years of life expectancy for the average patient in an OMS office, even with these generous numbers you're off on cost effectiveness by a factor of 3-8 per year of life saved (My standards ranged from $50,000-120,000 YLS and with these numbers the calculated cost per YLS is $425,000)

Even if this makes sense from a patient safety perspective (Which I don't believe it does), for it to be worth it for the healthcare system, you have to be able to prove you can prevent complications around 15-40x better than oral surgeons while billing out $50 per patient.

 

[sevoflurane]

Is 1:1,700,000

Really? Are talking 'bout OMFS and anesthesia in this number? Care to provide a link? I thought it was closer to 1:400k. Still safe, but I think 1.7mil is stretching a little.

We are talking 'bout allergic reactions, Intravascular injections, can't ventilate/intubate scenarios, oversedation and apnea, bleeding issues, etc.


http://blog.teethremoval.com/six-year-old-dies-after-dentist-visit/

http://www.dailymail.co.uk/news/art...routine-teeth-extraction-dental-practice.html

http://www.teethremoval.com/dental_deaths.html

 

[senpai]

Really? Are talking 'bout OMFS and anesthesia in this number? Care to provide a link? I thought it was closer to 1:400k. Still safe, but I think 1.7mil is stretching a little.

We are talking 'bout allergic reactions, Intravascular injections, can't ventilate/intubate scenarios, oversedation and apnea, bleeding issues, etc.


http://blog.teethremoval.com/six-year-old-dies-after-dentist-visit/

http://www.dailymail.co.uk/news/art...routine-teeth-extraction-dental-practice.html

http://www.teethremoval.com/dental_deaths.html

Did you seriousely just quote a statistic from a blog? lol There is something called an academic journal. All of the publications are approved by an IRB and peer-reviewed. I highly reccommend reading one.

 

[sevoflurane]

Did you seriousely just quote a statistic from a blog? lol There is something called an academic journal. All of the publications are approved by an IRB and peer-reviewed. I highly reccommend reading one.

Dude... chill out and stop crying. 👎poke:

I don't read dental journals. Just like you don't read journals on regional anesthesia, cardiac anesthesia or pediatric anesthesia. Thanks for telling me about them though... I had no idea they were peer reviewed and approved by IRB. Thanks. You are a genius. 👎slap:


Dental deaths do happen. I encourage you to site the 1:1.7mil death rate while using anesthesia in the office. It doesn't seem likely, but I don't know. Hence the question.

Yes, I do google things on the fly. Of which 3 sources sited 1:350-1:450k. I'm sure they are all wrong...

Go troll some place else my dear dental student.

 

[IlDestriero]

Did you seriousely just quote a statistic from a blog? lol There is something called an academic journal. All of the publications are approved by an IRB and peer-reviewed. I highly reccommend reading one.

If you have access to one, how about posting a link.
BTW, armorshell, it's naive to think the Dentists and OMFS folks are not already charging for the sedation services they are providing. Perhaps more than we could bill for the same 30 minute procedure. So your cost savings argument is questionable.
I don't care either way. I dislike dental anesthesia and generally try to avoid it.

 

[sevoflurane]

http://www.ncbi.nlm.nih.gov/pubmed/9195616

1.4 deaths per 1,000,000

or

1 death per 714,285

 

[armorshell]

If you have access to one, how about posting a link.
BTW, armorshell, it's naive to think the Dentists and OMFS folks are not already charging for the sedation services they are providing. Perhaps more than we could bill for the same 30 minute procedure. So your cost savings argument is questionable.
I don't care either way. I dislike dental anesthesia and generally try to avoid it.

I don't think its questionable to assume that doubling the number of physician-level providers across the board is going to cost more, no.

 

[IlDestriero]

I don't think its questionable to assume that doubling the number of physician-level providers across the board is going to cost more, no.

Not if they're already billing $250 or $500 for "sedation services".
Or are you taking the CRNA approach to "cost" and including the cost of training people, etc.

 

[armorshell]

Not if they're already billing $250 or $500 for "sedation services".
Or are you taking the CRNA approach to "cost" and including the cost of training people, etc.

Overhead is fixed, and you're adding an additional student loan payment, malpractice insurance, high-income disability, health insurance and salary expectation.

My random Googling shows the average anesthesiologist makes around $300,000 a year, do you realize how many sedations you'd have to do at OMS cost to keep up with that without raising costs? I calculated around around 80 a week (At $350 a pop and a generous 40% of production which is likely no profit to the OMS), and again that's with generous numbers.

How many OMS practices have the patient load to support that? Not to mention this is as an IC, so you're paying your own malpractice, soc. sec. tax, insurances, uniforms, etc...

 

[armorshell]

Some more reading:

http://www.ncbi.nlm.nih.gov/pubmed/18848094

 

[drpainfree]

armorshell, you have effectively turn this forum from a pure anesthesia question to financial/healthcare cost issue, great, congratulation! Are you in med school? you'll be hard-pressed when you come out and practice 6 years from now you'll be barely paid enough to make a reasonable living!

why do i sound like talking to obamacare? because you're talking like one.

you obviously don't have any idea how dentistry/OMFS work. OMFS charges anywhere from 300 to 500 per case for IV sedation, regardless whether or not they contract an anesthesiologist. so as a patient (or healthcare cost in general), the cost is already included. besides, it's mostly optional from patient's perspective whether or not he/she wants to spend extra 300 to 500 bucks.

how much does an anesthesiologist get if the OMFS think the risk is too much for him/her to handle? Typically less than how much patient pays to the OMFS.

do you see it's a win-win situation for the patient, OMFS and anesthesiologist? Without assuming any sedation/monitoring/resuscitation risks, the OMFS can offer the procedures to more patients, and do more cases in a day (therefore more income), then receive margin on the anesthesia charge.

 

[drpainfree]

http://blog.cleveland.com/metro/2011/01/elyria_girl_13_dies_after_oral.html

 

[IlDestriero]

Overhead is fixed, and you're adding an additional student loan payment, malpractice insurance, high-income disability, health insurance and salary expectation.

My random Googling shows the average anesthesiologist makes around $300,000 a year, do you realize how many sedations you'd have to do at OMS cost to keep up with that without raising costs? I calculated around around 80 a week (At $350 a pop and a generous 40% of production which is likely no profit to the OMS), and again that's with generous numbers.

How many OMS practices have the patient load to support that? Not to mention this is as an IC, so you're paying your own malpractice, soc. sec. tax, insurances, uniforms, etc...

If you're a 1099 person, overhead for anesthesia services is billing costs and the same drug/equipment costs that already exist to the practice. As private practice OMFS folks are not likely to be providing large medicaid and uninsured volume in their offices, unless they're coming cash in hand, it should be easy to bill for anesthesia services. I have no idea about what is involved in billing or getting approval from insurance for anesthesia services for dental/OMFS work, however we do it at the hospital every day for healthy (and unhealthy) kids. We don't do any at the ASCs and there may be reason for this? When my father had plastic surgery he paid the anesthesiologist ~$1k upfront for his unbillable services.
I'm not sure how you're generating your numbers, or how these services are usually paid/billed.

 

[GreatOMFSHope]

http://blog.cleveland.com/metro/2011/01/elyria_girl_13_dies_after_oral.html

It's ridiculous and a little classless to use blogs and local news reports to make the case that OMFS shouldn't be doing their own anesthesia. I respect your right to have an opinion, but I'm sure a quick google search will let me find someone that died from throwing a tube down the goose and not realizing it or similar anesthesia complications. We don't argue that complications never happen. We argue that they are rare and we do a good job taking care of our patients. I appreciate sevoflurane using a credible source for statistics.

My apologies for the cheap shots earlier as well. It just felt like you were getting dangerously close to claiming OMFS aren't competent to do what we feel like is our jobs, financial gain or not.

If you have access to one, how about posting a link.

I can't post the link because the site is password protected from the Journal of Oral and Maxillofacial Surgery, but below is where I got my information for the 1/1.7 million mortality rate. It is one study in one state, but it's the most recent I could find. I'm sure there is a middle ground between the rate sevoflurane found and this one.

 

[GreatOMFSHope]

Anesthesia Morbidity and Mortality Experience Among Massachusetts Oral
and Maxillofacial Surgeons
Edward M. D’Eramo, DMD,* William J. Bontempi, DMD, MD,†
and Joanne B. Howard‡
Purpose: To document the incidence of specific complications and the mortality rate for office anesthesia administered by fully qualified oral and maxillofacial surgeons in the state of Massachusetts.
Materials and Methods: A survey questionnaire was mailed to the 169 active members of the Massachusetts Society of Oral and Maxilofacial Surgeons. Using a specific method for follow-up, a 100%
response was obtained.
Results: The frequency of office anesthetic complications occurring in 2004 were consistent with our previous studies. There was 1 office death, for a mortality rate of 1/1,733,055.
Conclusion: From the data presented here, we conclude that outpatient anesthesia in the oral and maxillofacial surgery office continues to be a safe therapeutic modality.
© 2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:2421-2433, 2008

 

[ObviousGuy]

OKAY Big Dicks.

#1 Resorting to calling people dental or medical students is ridiculous. ArmorShell is one smart cookie. He is currently working on his MD while doing his OMFS residency at the same time. Some of you guys would have diarrhea for a month just thinking about how brutal OMS residency can be. While ACGME is cracking down on hours OMS keeps working brutal shifts, post call? Never heard of it. Anesthesia was a vacation when I was a resident. In other words, the "stuff" we know about anesthesia is drilled into us just like it is for you from day one.

#2 Some (Just a few) OMS guys DO get anesthesiologists to run their sedations. They do a good job and don't want the headache of the sedation. I see nothing wrong with this, it is one guys way of handling his office affairs.

#3 The majority of OMS do do their own MAC sedations in their private practice office. In my office the gold standard is BP, pulse ox, EKG, end tidal CO2, O2 and nitrous on nasal hood, and a precordial stethoscope. I use versed, ketamine, fentanyl, and propofol. Because I trained in this stuff for four years, as well as a 4 month anesthesia stint (during which I performed >400 intubations, LMA's, MACS, spinals, fiber optic intubations and ran my own room for everything from ophtho cases to major trauma), guess what?!?! I FEEL COMFORTABLE RUNNING MACS IN MY OFFICE - GASP!
This peeing match between specialties is stupid and arrogant.

I know how to treat complications, I know how to manage the airway, I know reversal agents, I know exactly, EXACTLY how to manage complications. Heaven forbid, if it does come to that, I know how to cric someone if needs be. So when I am "concentrating" on my surgery I am also looking at my monitors and listening to that beep beep pulse ox. If I need to , my surgery waits (15 minutes to get those 3rd molars out, or 35-45 minutes to wire someone down and put on a plate, ec) and I manage the airway. Nothing like pulling out the tongue or slamming in a lubed up nasal trumpet. I use LMA's every week if I have to. NBD. Laryngospasms are rare.

Anesthesia has it's place for me though. The ASA III pt that I want to do in the OR, gets done at the hospital. Me and my anesthesia colleagues laugh and have a good time, each doing what we love. Since the anesthesia docs at my local hospital respect me and I them, we don't have these stupid 'wars' about pushing propofol in my office. I push a **** load of it too. It does make me money, but that is not the reason OMS push it. We push it because if done right, it is done safely, is a great convenience for the patient, and has low mortality rates in the right hands.

Everyone needs to get a grip.

 

[drpainfree]

OKAY Big Dicks.

#1 Resorting to calling people dental or medical students is ridiculous. ArmorShell is one smart cookie. He is currently working on his MD while doing his OMFS residency at the same time. Some of you guys would have diarrhea for a month just thinking about how brutal OMS residency can be. While ACGME is cracking down on hours OMS keeps working brutal shifts, post call? Never heard of it. Anesthesia was a vacation when I was a resident. In other words, the "stuff" we know about anesthesia is drilled into us just like it is for you from day one.

Yes, if you're not practicing medicine, or anesthesia, don't make a mis-informed comment on something you have no idea and pretend you care about the cost of healthcare or any other grand idea. This was meant to be a discussion on oral dental case sedation, the risk involved and the management, not about the cost, or the financial of it.

And don't talk about your hours of residency vs. other medical specialty (including anesthesia). I don't even have any interest to even entertain your comments here because it just sounds immature.


#2 Some (Just a few) OMS guys DO get anesthesiologists to run their sedations. They do a good job and don't want the headache of the sedation. I see nothing wrong with this, it is one guys way of handling his office affairs.

Yes, this WAS the reason of Original Post. Nobody was telling the rest of OMF surgeons to hire anesthesiologists to do their sedation in office.

#3 The majority of OMS do do their own MAC sedations in their private practice office. In my office the gold standard is BP, pulse ox, EKG, end tidal CO2, O2 and nitrous on nasal hood, and a precordial stethoscope. I use versed, ketamine, fentanyl, and propofol. Because I trained in this stuff for four years, as well as a 4 month anesthesia stint (during which I performed >400 intubations, LMA's, MACS, spinals, fiber optic intubations and ran my own room for everything from ophtho cases to major trauma), guess what?!?! I FEEL COMFORTABLE RUNNING MACS IN MY OFFICE - GASP!
This peeing match between specialties is stupid and arrogant.

Let's see, 400 intubations in 4 months, that's 100 per month, or about 4-5 intubations a day, and you did LMA, MACS, spinal , FOB intubation, run your room from ophtho to major trauma! Even if I believe what you said (which I don't, I was trained and trained residents in major level one trauma center, and I know for sure a CA-1 don't get 400 intubations in 4 months with spinal, FOB and let him/her run their trauma room), I'd have congratulate how much you have learn about anesthesia in the 4 months to make you say something as arrogant as the following.


I know how to treat complications, I know how to manage the airway, I know reversal agents, I know exactly, EXACTLY how to manage complications. Heaven forbid, if it does come to that, I know how to cric someone if needs be. So when I am "concentrating" on my surgery I am also looking at my monitors and listening to that beep beep pulse ox. If I need to , my surgery waits (15 minutes to get those 3rd molars out, or 35-45 minutes to wire someone down and put on a plate, ec) and I manage the airway. Nothing like pulling out the tongue or slamming in a lubed up nasal trumpet. I use LMA's every week if I have to. NBD. Laryngospasms are rare.

Really? do you really know how to manage airway emergency? Is putting a LMA in the throat of someone who's bleeding and choking the right way to salvage an airway? Laryngospasm is rare? Do you know how rare? As an anesthesiologist, we don't talk about how rare an event is, we talk about how to manage the
complication.

Do you really, really know EXACTLY how to manage a complication? EXACTLY? If you answer the word "EXACTLY" on anesthesia oral board, you will most likely be cornered to utterly speechless

Anesthesia has it's place for me though. The ASA III pt that I want to do in the OR, gets done at the hospital. Me and my anesthesia colleagues laugh and have a good time, each doing what we love. Since the anesthesia docs at my local hospital respect me and I them, we don't have these stupid 'wars' about pushing propofol in my office. I push a **** load of it too. It does make me money, but that is not the reason OMS push it. We push it because if done right, it is done safely, is a great convenience for the patient, and has low mortality rates in the right hands.

I've done cases in hospitals and in office, for both peds and adult. I'd have to tell you it's much less stressful if I was doing the case in hospital as opposed to in office. As a matter of fact, my liability insurance carrier mandates a separate waiver application be covered for giving MAC (which can easily go into general) in office. Again, you are not an anesthesiologist, you don't know what's involved. And it's the scary part of the whole thing. You don't know what you don't know, and you think you know it all.

Everyone needs to get a grip.

Yes, you do need to get a grip before coming onto an anesthesia discussion topic and flame about how much you know about anesthesia with 4 months of intensive anesthesia "stint"...it's not only disrespectful, but also ignorant. You can do whatever you want in your office because you're governed by the dental board, not by medical board. No other physicians are able to get away with what you do in office even with 4 months of anesthesia "stint" (GI doc would love to get 4 months of "vacation" in anesthesia and be able to "push" propofol, but can they do it? no, because it's generally recognized in medical community that it's not safe).

What if an ENT doc claims he know exactly how to management a le fort fracture and boast his arrogance in front of OMF surgeons? Doesn't it sound ridiculous? Well, that's exactly what you're doing on anesthesia topic.

On the other hand, all it takes is one case to bring down your arrogance because they'll be plenty of expert witness in the field of anesthesia to tell the juror how risky what you're doing in the office in terms of anesthesia and how much vigilance you need to monitor and prepare to treat in the case of complication.

And guess what, based on your arrogance and lack of true understanding of anesthesia risk, it just made one more anesthesiologists willing to testify.

Good luck, and keep your fingers crossed!

.

 

[GreatOMFSHope]

My apologies for the cheap shots earlier as well. It just felt like you were getting dangerously close to claiming OMFS aren't competent to do what we feel like is our jobs, financial gain or not.

Apology redacted. It didn't sound like you were getting close, you are screaming it. Why do you ignore the posts about the statistics? Statistically, we do a good and safe job, but you are claiming we aren't prepared. Why?