oral surgery anesthesia pointers

[GTFOOMICT]

---

Members don't see this ad.

Statistically, we do a good and safe job, but you are claiming we aren't prepared. Why?

Because you're fighting a straw man. You're the one escalating this. From one OMS resident to another....you need to calm down, you're not defending us, you're embarrassing us. Anesthesiologists are our friends and allies in our training. You're acting like ENT and Plastics is defaming us. You'll see that the anesthesia board is full of very nice conversations on topics and this could have been one of them.

This provider model MAY be forced upon us despite good stats. Laws don't follow stats they follow emotions. The dental anesthesiologists could also turn on us. These are the kinds of things I'd be interested in though from an OMS standpoint:

1) How does the anesthesiologist anticipate navigating an extremely crowded region of the body. You'll have an OMS with precordial, surrounded by surgical motor cables, a surgical assistant sucking water and the 1cc of blood lost and retracting, a 'chinner' providing airway support all at the 9, 12, 3 oclock position of the patient. Point being, once you're setup, no one likes to move nor is their reason to move. All equipment is within reach, +pressure, nasal trumpets, intubation supplies, etc. In the current no-MDA (i don't like the term but it's gonna work here) model, the procedure can be stopped very quickly, airway adjusted, mandible thrust applied etc with zero shuffling. The threshold for stopping the procedure is so low because it is so easy to do so. If an office transitioned to your presented model, do you anticipate this same disruption of flow that I see in my mind? Most importantly, the OMS has his or her eyes within a few cm of the airway a majority of the time and is correlating what they see intraorally and hear precordial and the 'chinner' who is about 3 feet away is always spouting off the latest data from the monitors. How do you feel the communication will be between OMS team and anesthesiologist and how will you be able to effectively watch a non-secured airway? With ortho scopes, GI scopes, closed reduction, etc I don't see this same amount of turf battle for space near the airway.

2) Pre-Op evaluation. Who will be doing this? Are you based full time at this practice? The honest pre-sedation H&P for most OMS office based minor oral surgery is pretty limited and is part of the surgical workup/discussion. A quick review of systems, MH, and a heart and lungs check is usually all they get. But right now that is done at the consultation. Will you be there for that? Will you require a separate visit? An OMS would be concerned about canceling sedations the day of if you delay the H&P til procedure day and find something concerning. Where do you fit in? Pre-operative blood lab work is very limited in office based oral surgery. Do you think you'll be comfortable with only an INR or HIV viral load or CD4 count and vitals? That's all you're getting, other lab tests are rare. Referring dentists are finicky and if they find out their basic oral surgery patients are being put through the ringer for an extraction or implant under sedation, they'll send their patient elsewhere. In fact we OMS like to downplay the 'surgery' aspect of our office based procedures. Surgery scares the patients away.... The use of an anesthesiologist MAY paradoxically scare patients!

3) What Procedures? OMS practice a broad scope of procedures that have varying degrees of invasiveness. Will you be providing care only for wisdom teeth and dental implants? Or will you be providing anesthesia care for facelifts, le forts, trauma.....essentially stuff that can very quickly become surgically demanding where an anesthesia provider is necessary. Wisdom teeth and dental implant procedures can be stopped almost immediately and 100% attention spent towards airway management. Patients tend to be deep for the local anesthetic placement and quite superficial for the remainder of the procedure as our blocks are good. Just curious how your new job will be using you.

4) Threshold for intubation. This comes straight from an OMS' mouth who uses in office MDA anesthesia. He said he went through more than a few MDA before he found one that was comfortable with sedation. He said they had zero dental/oral surgery sedation experience, but lots of GI experience. These are different worlds per him. The threshold for intubation was orders of magnitude lower with the MDA vs the OMS himself. Poor utilization of LMAs. Maybe the OMS was wrong or exaggerating but that will kill referrals if patients get intubated. Yeah i know, killing referrals is better than killing patients.

5) Equipment. As suggested earlier, are you comfortable with no capnography?

6) General Dentistry groups get pissed off when MDA leave their practice. There is apparently a high turnover. All heresay... Credentialing is state specific and it can get challenging with the dental board and portability issues. But the dentists get angry because time and money is spent on one provider to get them approved and then they leave to better jobs in the hospital. As you move forward you might experience pushback while they assess if you're worth the effort. State specific though....

7) The surgeons in the hospital with CRNA-only anesthesia are complaining they are getting named as a greater % of liability because there is no longer a 2nd physician in the room. The ultimate outcomes of the cases don't seem to be impacted much by this but >50% of practicing OMS are non-physicians. Do you find this to be of greater exposure risk? Is this even an issue?

8) Money is important and we can't ignore it. Have you learned how your addition to the practice can actually increase cash flow to the practice?

Well my raisan bran is done....and therefore my post must be done.

 

[pgg]

In my office the gold standard is BP, pulse ox, EKG, end tidal CO2, O2 and nitrous on nasal hood, and a precordial stethoscope.

How quaint.

So when I am "concentrating" on my surgery I am also looking at my monitors and listening to that beep beep pulse ox.

I'm trying to picture you doing your procedure, tethered to your precordial stethoscope and molded earpiece, listening to the beep beep all at once. I have a pretty vivid imagination, but I'm just not getting it.

Everyone needs to get a grip.

The OMFS guys who rotated through my program for their anesthesia time were some of the brighest and most hardworking people in the hospital.


I'll tell you though, our standard is that the person monitoring the patient and providing sedation or anesthesia does not also do the procedure. All of the board certified anesthesiologists with subspecialty pain board certification that I know have a 2nd person do their moderate/deep sedations. The thought of OMFS'ers doing both with less training makes me uncomfortable.

Then again, most of us get uncomfortable when the EM docs do their etomidate "sedations" in the ER. They have literature showing low complication rates, too.

So I'll tell you what I tell them: It's not our place to tell you how to practice, on your turf, with your license, with your patients. Just don't come into the anesthesia forum and expect us to give you anything but an opinion grounded in OUR standard of care.

 

[sevoflurane]

Because you're fighting a straw man. You're the one escalating this. From one OMS resident to another....you need to calm down, you're not defending us, you're embarrassing us. Anesthesiologists are our friends and allies in our training. You're acting like ENT and Plastics is defaming us. You'll see that the anesthesia board is full of very nice conversations on topics and this could have been one of them.

This provider model MAY be forced upon us despite good stats. Laws don't follow stats they follow emotions. The dental anesthesiologists could also turn on us. These are the kinds of things I'd be interested in though from an OMS standpoint:

1) How does the anesthesiologist anticipate navigating an extremely crowded region of the body. You'll have an OMS with precordial, surrounded by surgical motor cables, a surgical assistant sucking water and the 1cc of blood lost and retracting, a 'chinner' providing airway support all at the 9, 12, 3 oclock position of the patient. Point being, once you're setup, no one likes to move nor is their reason to move. All equipment is within reach, +pressure, nasal trumpets, intubation supplies, etc. In the current no-MDA (i don't like the term but it's gonna work here) model, the procedure can be stopped very quickly, airway adjusted, mandible thrust applied etc with zero shuffling. The threshold for stopping the procedure is so low because it is so easy to do so. If an office transitioned to your presented model, do you anticipate this same disruption of flow that I see in my mind? Most importantly, the OMS has his or her eyes within a few cm of the airway a majority of the time and is correlating what they see intraorally and hear precordial and the 'chinner' who is about 3 feet away is always spouting off the latest data from the monitors. How do you feel the communication will be between OMS team and anesthesiologist and how will you be able to effectively watch a non-secured airway? With ortho scopes, GI scopes, closed reduction, etc I don't see this same amount of turf battle for space near the airway.

2) Pre-Op evaluation. Who will be doing this? Are you based full time at this practice? The honest pre-sedation H&P for most OMS office based minor oral surgery is pretty limited and is part of the surgical workup/discussion. A quick review of systems, MH, and a heart and lungs check is usually all they get. But right now that is done at the consultation. Will you be there for that? Will you require a separate visit? An OMS would be concerned about canceling sedations the day of if you delay the H&P til procedure day and find something concerning. Where do you fit in? Pre-operative blood lab work is very limited in office based oral surgery. Do you think you'll be comfortable with only an INR or HIV viral load or CD4 count and vitals? That's all you're getting, other lab tests are rare. Referring dentists are finicky and if they find out their basic oral surgery patients are being put through the ringer for an extraction or implant under sedation, they'll send their patient elsewhere. In fact we OMS like to downplay the 'surgery' aspect of our office based procedures. Surgery scares the patients away.... The use of an anesthesiologist MAY paradoxically scare patients!

3) What Procedures? OMS practice a broad scope of procedures that have varying degrees of invasiveness. Will you be providing care only for wisdom teeth and dental implants? Or will you be providing anesthesia care for facelifts, le forts, trauma.....essentially stuff that can very quickly become surgically demanding where an anesthesia provider is necessary. Wisdom teeth and dental implant procedures can be stopped almost immediately and 100% attention spent towards airway management. Patients tend to be deep for the local anesthetic placement and quite superficial for the remainder of the procedure as our blocks are good. Just curious how your new job will be using you.

4) Threshold for intubation. This comes straight from an OMS' mouth who uses in office MDA anesthesia. He said he went through more than a few MDA before he found one that was comfortable with sedation. He said they had zero dental/oral surgery sedation experience, but lots of GI experience. These are different worlds per him. The threshold for intubation was orders of magnitude lower with the MDA vs the OMS himself. Poor utilization of LMAs. Maybe the OMS was wrong or exaggerating but that will kill referrals if patients get intubated. Yeah i know, killing referrals is better than killing patients.

5) Equipment. As suggested earlier, are you comfortable with no capnography?

6) General Dentistry groups get pissed off when MDA leave their practice. There is apparently a high turnover. All heresay... Credentialing is state specific and it can get challenging with the dental board and portability issues. But the dentists get angry because time and money is spent on one provider to get them approved and then they leave to better jobs in the hospital. As you move forward you might experience pushback while they assess if you're worth the effort. State specific though....

7) The surgeons in the hospital with CRNA-only anesthesia are complaining they are getting named as a greater % of liability because there is no longer a 2nd physician in the room. The ultimate outcomes of the cases don't seem to be impacted much by this but >50% of practicing OMS are non-physicians. Do you find this to be of greater exposure risk? Is this even an issue?

8) Money is important and we can't ignore it. Have you learned how your addition to the practice can actually increase cash flow to the practice?

Well my raisan bran is done....and therefore my post must be done.

Great attitude. Thx for your courteous comments. 👍

 

[GreatOMFSHope]

Good post.

Please see my earlier posts at the beginning of this topic. I believe I was very respectful and humble about my knowledge of anesthesia and their role in the OR. My problem wasn't with anesthesiologists (I'm having an amazing experience learning from them), it was with a single person, who from my experience, believed what most anesthesiologists don't. The fact that OMFS are not prepared or capable of running efficient anesthesia using propofol for our cases.

I apologize if I came off aggressive. As a first year resident, I'll respect my elders and be a little calmer with my discussions.

 

[nap$ter]

Good post.

Please see my earlier posts at the beginning of this topic. I believe I was very respectful and humble about my knowledge of anesthesia and their role in the OR. My problem wasn't with anesthesiologists (I'm having an amazing experience learning from them), it was with a single person, who from my experience, believed what most anesthesiologists don't. The fact that OMFS are not prepared or capable of running efficient anesthesia using propofol for our cases.

I apologize if I came off aggressive. As a first year resident, I'll respect my elders and be a little calmer with my discussions.

inflammatory posts (from both sides) aside, i am another anesthesiologist that believes that OMFS should not use propofol in their office.

one of my friends is an OMFS and I have rotated with many of them during residency. as a group OMFS folks are some of the brightest and most capable of surgeons.

However, they should not use propofol in their offices.

just because they can doesn't mean they should. it is the wrong setting (the OMFS may be trained, but the staff in general is not), they are distracted by their procedure, and there are multiple alternative agents for sedation that are more appropriate. this subject has been treated ad nauseum on this forum elsewhere.

as so eloquently stated by pgg, it is however your license, your turf, and you will do what you like in that arena.

however, your statement that most anesthesiologists support the use of propofol by OMFS in the office (if I understand you correctly) is incorrect. you will be hard pressed to find blessings by board-certified anesthesiologists for that practice, because it is not safe.

 

[sfoksn]

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.

Oh boy

 

[armorshell]

However, they should not use propofol in their offices.

just because they can doesn't mean they should. it is the wrong setting (the OMFS may be trained, but the staff in general is not), they are distracted by their procedure, and there are multiple alternative agents for sedation that are more appropriate. this subject has been treated ad nauseum on this forum elsewhere.
.

I don't understand how I keep hearing this in the face of peer-reviewed research showing an excellent safety record. Can we at least address the research with an argument, instead of simply ignoring it?

 

[nap$ter]

I don't understand how I keep hearing this in the face of peer-reviewed research showing an excellent safety record. Can we at least address the research with an argument, instead of simply ignoring it?

sure. show me the study demonstrating that propofol is safe in the hands of an omfs surgeon/anesthetist in an outpt clinic. it's controversial, even within your specialty. my specialty thinks your practice is unsafe, but it is up to each individual specialty to determine its own standard of care.

oh, and that previous methohexital vs propofol study you popped up is invalid - it doesn't answer our question. it was retrospective, there were no doses or level of anesthesia given, there was no control (ie non-propofol group), and the safety margin they reported was far rosier than that given in multiple other (OMFS generated and reviewed) studies.

in this study (which is skewed and biased beyond belief) the (OMFS) authors concluded that propofol (and/or ketamine) is safe in the hands of OMFS surgeon/anesthetists in the outpt clinic despite the fact that the morbidity rate increased seven-fold when propofol (and/or ketamine) was added to the standard sedation regimen of fentanyl/versed.

Safety of deep sedation in an urban oral and maxillofacial surgery training program.
Braidy HF, Singh P, Ziccardi VB.
J Oral Maxillofac Surg. 2011 Aug;69(8):2112-9.


but, this is moot. do as you like with your license, on your turf. but, if anyone asks me...

 

[beavis]

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.

This reeks of knowing just enough to be dangerous.

 

[UNLV OMS GUNNABE]

sure. show me the study demonstrating that propofol is safe in the hands of an omfs surgeon/anesthetist in an outpt clinic. it's controversial, even within your specialty. my specialty thinks your practice is unsafe, but it is up to each individual specialty to determine its own standard of care.

oh, and that previous methohexital vs propofol study you popped up is invalid - it doesn't answer our question. it was retrospective, there were no doses or level of anesthesia given, there was no control (ie non-propofol group), and the safety margin they reported was far rosier than that given in multiple other (OMFS generated and reviewed) studies.

in this study (which is skewed and biased beyond belief) the (OMFS) authors concluded that propofol (and/or ketamine) is safe in the hands of OMFS surgeon/anesthetists in the outpt clinic despite the fact that the morbidity rate increased seven-fold when propofol (and/or ketamine) was added to the standard sedation regimen of fentanyl/versed.

Safety of deep sedation in an urban oral and maxillofacial surgery training program.
Braidy HF, Singh P, Ziccardi VB.
J Oral Maxillofac Surg. 2011 Aug;69(8):2112-9.


but, this is moot. do as you like with your license, on your turf. but, if anyone asks me...

Did you look at what the complications were? 8 complications of that magnitude in 4-5 years is safe if you ask me. I've seen much worse from regional blocks gone bad in a much shorter period of time.

 

[nap$ter]

Did you look at what the complications were? 8 complications of that magnitude in 4-5 years is safe if you ask me. I've seen much worse from regional blocks gone bad in a much shorter period of time.

yes, i looked at what the complications were. one of the patients desaturated enough to warrant 0.4 mg of narcan - and then they continued with the procedure. 3 patients were taken to the emergency room. if i sent 1/350 patients from the asc to the ER, i would get fired.

a - it's not the number of complications/time period that is important - it is the number of complications/number of patients treated.

b - nearly 1/100 patients given propofol and/or ketamine had a complication - compared to 1/700 given the standard regimen of fentanyl/versed - as I said, this is a seven fold increase in the rate of problems - and the putative benefits are not discussed.

c - your last sentence is irrelevant, ridiculous, and nonspecific. analogy - i am rear-ended at a stop sign by an OMFS student. I get out, tell him the accident is his fault, and ask for his insurance information. his reply - "oh yeah, well your tabs are expired!".

 

[UNLV OMS GUNNABE]

yes, i looked at what the complications were. one of the patients desaturated enough to warrant 0.4 mg of narcan - and then they continued with the procedure. 3 patients were taken to the emergency room. if i sent 1/350 patients from the asc to the ER, i would get fired.

a - it's not the number of complications/time period that is important - it is the number of complications/number of patients treated.

b - nearly 1/100 patients given propofol and/or ketamine had a complication - compared to 1/700 given the standard regimen of fentanyl/versed - as I said, this is a seven fold increase in the rate of problems - and the putative benefits are not discussed.

c - your last sentence is irrelevant, ridiculous, and nonspecific. analogy - i am rear-ended at a stop sign by an OMFS student. I get out, tell him the accident is his fault, and ask for his insurance information. his reply - "oh yeah, well your tabs are expired!".

Giving narcan is an absolute indication to stop the procedure? why?
At a large university hospital with an EC downstairs people are always more quick to pull the trigger to send people to the EC. It doesn't matter what clinic you are in. Did a pt need to be sent for tachycardia? probably not. I still don't see how this study shows it isn't safe. 1 syncopal episode, 1 episode of desating that was managed appropriately, N/V, 1 episode of tachycardia, 1 episode of transient hypertension, weird psych kid that freaks out, conversion syndrome...what isn't safe? Do I need an anesthesiologist to handle these complications? Are you saying that if an anesthesiologist had been there then this complication rate would be different? You know that isn't true. Everyone just needs to relax.

 

[nap$ter]

Giving narcan is an absolute indication to stop the procedure? why?
At a large university hospital with an EC downstairs people are always more quick to pull the trigger to send people to the EC. It doesn't matter what clinic you are in. Did a pt need to be sent for tachycardia? probably not. I still don't see how this study shows it isn't safe. 1 syncopal episode, 1 episode of desating that was managed appropriately, N/V, 1 episode of tachycardia, 1 episode of transient hypertension, weird psych kid that freaks out, conversion syndrome...what isn't safe? Do I need an anesthesiologist to handle these complications? Are you saying that if an anesthesiologist had been there then this complication rate would be different? You know that isn't true. Everyone just needs to relax.

oh boy.

have you done your anesthesia months yet?

the need to give narcan indicates the pt wasn't appropriately selected for the outpt setting, or was given too much opiate, or both, or the airway wasn't managed appropriately - not clear from the study. proceeding with surgery after 0.4mg of naloxone is inappropriate, as the opiate receptors are blocked and you have demonstrated potential for an airway disaster. trying to give more opiates soon after a large dose of naloxone is dangerous as the therapeutic window is extremely narrow. if you are able to proceed under local alone, opiates should not have been given in the first place. either way the judgment is faulty. but - i wasn't there; there may have been extenuating circumstances.

i AM saying that the complication rate would have been different if an MD anesthesiologist had been present. patient selection, preop workup, choice of technique, and management of complications are all different when the anesthesiologist is not the surgeon, and has completed a four year residency and a rigorous board-certification.

i AM NOT saying an anesthesiologist should have been present, however.

i am saying simply this - OMFS providers should not use propofol in the outpatient setting when they are also performing the procedure. as i said before, in this study there was no benefit demonstrated from the use of propofol and/or ketamine (and because they added that "and/or" ketamine, the data was skewed towards safety as ketamine may be a safer conscious sedation drug than propofol), but there was still a seven-fold increase in the rate of complications.

as i also said before, your license, your turf, your specialty defines its own standards of care.

my specialty does not agree.

end of story.

 

[hoyden]

This reeks of knowing just enough to be dangerous.

to be very dangerous, to the point of complete carelessness. Couldn't help but laugh on the ignorance streaming after a "4 month stint"

 

[UNLV OMS GUNNABE]

oh boy.

have you done your anesthesia months yet?

the need to give narcan indicates the pt wasn't appropriately selected for the outpt setting, or was given too much opiate, or both, or the airway wasn't managed appropriately - not clear from the study. proceeding with surgery after 0.4mg of naloxone is inappropriate, as the opiate receptors are blocked and you have demonstrated potential for an airway disaster. trying to give more opiates soon after a large dose of naloxone is dangerous as the therapeutic window is extremely narrow. if you are able to proceed under local alone, opiates should not have been given in the first place. either way the judgment is faulty. but - i wasn't there; there may have been extenuating circumstances.

i AM saying that the complication rate would have been different if an MD anesthesiologist had been present. patient selection, preop workup, choice of technique, and management of complications are all different when the anesthesiologist is not the surgeon, and has completed a four year residency and a rigorous board-certification.

i AM NOT saying an anesthesiologist should have been present, however.

i am saying simply this - OMFS providers should not use propofol in the outpatient setting when they are also performing the procedure. as i said before, in this study there was no benefit demonstrated from the use of propofol and/or ketamine (and because they added that "and/or" ketamine, the data was skewed towards safety as ketamine may be a safer conscious sedation drug than propofol), but there was still a seven-fold increase in the rate of complications.

as i also said before, your license, your turf, your specialty defines its own standards of care.

my specialty does not agree.

end of story.

So you would have been able to lower that complication rate? I take it back then. If you guys are able to avoid 1 tachycardic event, 1 syncopal episode etc with your superior assesment and anesthetic plan then you are right. I shouldn't push propofol...🙄 Hello healthy 19 or 20 year old with no comorbidities. You are healthier than a horse. You are going to have a 20 min procedure. You look like you might have isolated transient tachycardia or a syncopal episode so I am not going to give you any propofol like that ignorant oral surgeon would so I can decrease the complication rate. I give them props for even reporting these weak sauce complications in their paper. I'm glad all the anesthesiologists I know are more realistic and less defensive. That's what I get for coming back to student doctor.

 

[pgg]

So you would have been able to lower that complication rate? I take it back then. If you guys are able to avoid 1 tachycardic event, 1 syncopal episode etc with your superior assesment and anesthetic plan then you are right. I shouldn't push propofol...🙄 Hello healthy 19 or 20 year old with no comorbidities. You are healthier than a horse. You are going to have a 20 min procedure. You look like you might have isolated transient tachycardia or a syncopal episode so I am not going to give you any propofol like that ignorant oral surgeon would so I can decrease the complication rate. I give them props for even reporting these weak sauce complications in their paper. I'm glad all the anesthesiologists I know are more realistic and less defensive. That's what I get for coming back to student doctor.

You're missing the point.

Anesthesia hasn't made astounding leaps in patient safety over the last few decades because we (as a specialty) were cool with pretty low complication rates.

Anesthesia used to have one of the highest malpractice premium rates of any specialty, because anesthesia-related payouts : claims were disproportionately high compared to other specialties. As a direct result of anesthesiologists being picky and systematic about safety, those rates have come down dramatically, and faster than any other specialty.

From those efforts, mainly starting in the 1980s, we got monitoring standards, very specific equipment standardization, crisis protocols like the difficult airway algorithm, practice guidelines, on and on and on - and as a direct result today anesthesia is so safe that nurses and dentists think they can do it without our help.

All the while, I'm sure guys like you were saying the status quo was good enough, that the existing risk was acceptable.


So go ahead and blow off your rare problems and complications, and do what you want with your patients in your space, but don't come in here and tell us how to safely administer anesthesia, or get upset when we answer your questions in a way that reflects our standard of care.

In return, I won't to tell you which pair of pliers to use for the big teeth. You have my solemn promise.

 

[nap$ter]

So you would have been able to lower that complication rate? I take it back then. If you guys are able to avoid 1 tachycardic event, 1 syncopal episode etc with your superior assesment and anesthetic plan then you are right. I shouldn't push propofol...🙄 Hello healthy 19 or 20 year old with no comorbidities. You are healthier than a horse. You are going to have a 20 min procedure. You look like you might have isolated transient tachycardia or a syncopal episode so I am not going to give you any propofol like that ignorant oral surgeon would so I can decrease the complication rate. I give them props for even reporting these weak sauce complications in their paper. I'm glad all the anesthesiologists I know are more realistic and less defensive. That's what I get for coming back to student doctor.

you are missing all of the points; i am not sure you read any of the posts.

i am finished with this clown.

 

[UNLV OMS GUNNABE]

You're missing the point.

Anesthesia hasn't made astounding leaps in patient safety over the last few decades because we (as a specialty) were cool with pretty low complication rates.

Anesthesia used to have one of the highest malpractice premium rates of any specialty, because anesthesia-related payouts : claims were disproportionately high compared to other specialties. As a direct result of anesthesiologists being picky and systematic about safety, those rates have come down dramatically, and faster than any other specialty.

From those efforts, mainly starting in the 1980s, we got monitoring standards, very specific equipment standardization, crisis protocols like the difficult airway algorithm, practice guidelines, on and on and on - and as a direct result today anesthesia is so safe that nurses and dentists think they can do it without our help.

All the while, I'm sure guys like you were saying the status quo was good enough, that the existing risk was acceptable.


So go ahead and blow off your rare problems and complications, and do what you want with your patients in your space, but don't come in here and tell us how to safely administer anesthesia, or get upset when we answer your questions in a way that reflects our standard of care.

In return, I won't to tell you which pair of pliers to use for the big teeth. You have my solemn promise.

I have only adressed one point, the paper he decided to quote and the fact that he said his complication rate would be lower if he had performed those 1200 or whatever sedations. I'm not arguing anything else. I know that if you look at what those 8 complications were in those 1200 sedations you know in your heart of hearts that your complication rate would not have been lower. That study does not show that it is unsafe for OMS to administer propofol. We are going to have to agree to disagree on everything else and I will ignore the plier comment as a token of my good will. I really think the OMS/anesthesia relationship is one that shouldn't bicker this much. Lets leave that to the other specialties.

 

[GreatOMFSHope]

inflammatory posts (from both sides) aside, i am another anesthesiologist that believes that OMFS should not use propofol in their office.

one of my friends is an OMFS and I have rotated with many of them during residency. as a group OMFS folks are some of the brightest and most capable of surgeons.

However, they should not use propofol in their offices.

just because they can doesn't mean they should. it is the wrong setting (the OMFS may be trained, but the staff in general is not), they are distracted by their procedure, and there are multiple alternative agents for sedation that are more appropriate. this subject has been treated ad nauseum on this forum elsewhere.

as so eloquently stated by pgg, it is however your license, your turf, and you will do what you like in that arena.

however, your statement that most anesthesiologists support the use of propofol by OMFS in the office (if I understand you correctly) is incorrect. you will be hard pressed to find blessings by board-certified anesthesiologists for that practice, because it is not safe.

I made sure I put "based on my experience" in there for a reason with that statement. I very likely am more narrow-minded and blind to the differing opinions due to my very limited experience. The OMFS/Anesthesia relationship at my program is spectacular so I assumed most OMFS/anesthesia relationships were like that. I have felt like the attendings have worked and pushed/pimped me even harder than other CA-1's because honestly, it was VITAL that I caught up to speed for immediate patient safety. I will admit that. I think I had to work my ass off to catch up and prove myself worthy to gain their trust in the OR. And we should have to gain their trust, we come from a completely different training method/background.

Apparently, we may be hard-pressed to find blessings to use propofol from the anesthesia community. But is it fair to say because "it is not safe"? If it was not safe, I would think there would be more reported deaths and more uproar about OMFS using propofol. Or is it more because we are stepping into your territory? We do the same thing when different dental specialties try and do procedures geared more towards OMFS. Please don't take this as a slight or disrespect, I truly want to know why you think it's unsafe when we've had what seems to be a decent success rate with it.

I actually had this discussion with my attending today during a turn-over. He told me what I thought everyone believed (apparently not). He believed with the right patient, the right monitoring, the right dosage and the right surgeon, OMFS using propofol is safe (I'm not blind to the fact that he could have been lying to me, but he's usually a straight shooter). I strongly agree with him that if any one of those four things are poor, then the risk increases.

You're missing the point.

Anesthesia hasn't made astounding leaps in patient safety over the last few decades because we (as a specialty) were cool with pretty low complication rates.

Anesthesia used to have one of the highest malpractice premium rates of any specialty, because anesthesia-related payouts : claims were disproportionately high compared to other specialties. As a direct result of anesthesiologists being picky and systematic about safety, those rates have come down dramatically, and faster than any other specialty.

From those efforts, mainly starting in the 1980s, we got monitoring standards, very specific equipment standardization, crisis protocols like the difficult airway algorithm, practice guidelines, on and on and on - and as a direct result today anesthesia is so safe that nurses and dentists think they can do it without our help.

All the while, I'm sure guys like you were saying the status quo was good enough, that the existing risk was acceptable.


So go ahead and blow off your rare problems and complications, and do what you want with your patients in your space, but don't come in here and tell us how to safely administer anesthesia, or get upset when we answer your questions in a way that reflects our standard of care.

In return, I won't to tell you which pair of pliers to use for the big teeth. You have my solemn promise.

We really don't do it without your help...

Please don't flog me for asking the question. No hidden meanings, just curious. So how do you feel about your anesthesia attendings at various universities teaching us? If we aren't capable of running the anesthesia in our private practices, should we be getting the attention that could be used on anesthesia students? Again, I've had a great experience with not only the attendings, but with my co-residents as well, but I do wonder if they think it's ridiculous that I'm training with them. Thanks.

 

[nap$ter]

I made sure I put "based on my experience" in there for a reason with that statement. I very likely am more narrow-minded and blind to the differing opinions due to my very limited experience. The OMFS/Anesthesia relationship at my program is spectacular so I assumed most OMFS/anesthesia relationships were like that. I have felt like the attendings have worked and pushed/pimped me even harder than other CA-1's because honestly, it was VITAL that I caught up to speed for immediate patient safety. I will admit that. I think I had to work my ass off to catch up and prove myself worthy to gain their trust in the OR. And we should have to gain their trust, we come from a completely different training method/background.

Apparently, we may be hard-pressed to find blessings to use propofol from the anesthesia community. But is it fair to say because "it is not safe"? If it was not safe, I would think there would be more reported deaths and more uproar about OMFS using propofol. Or is it more because we are stepping into your territory? We do the same thing when different dental specialties try and do procedures geared more towards OMFS. Please don't take this as a slight or disrespect, I truly want to know why you think it's unsafe when we've had what seems to be a decent success rate with it.

I actually had this discussion with my attending today during a turn-over. He told me what I thought everyone believed (apparently not). He believed with the right patient, the right monitoring, the right dosage and the right surgeon, OMFS using propofol is safe (I'm not blind to the fact that he could have been lying to me, but he's usually a straight shooter). I strongly agree with him that if any one of those four things are poor, then the risk increases.



We really don't do it without your help...

Please don't flog me for asking the question. No hidden meanings, just curious. So how do you feel about your anesthesia attendings at various universities teaching us? If we aren't capable of running the anesthesia in our private practices, should we be getting the attention that could be used on anesthesia students? Again, I've had a great experience with not only the attendings, but with my co-residents as well, but I do wonder if they think it's ridiculous that I'm training with them. Thanks.

we have a great relationship with OMFS at my hospital - we chat about anesthesia, surgery, and airway toys during the cases. i enjoy teaching dental and OMFS residents - you folks are bright and enthusiastic.

the objectives of a 4 month OMFS resident rotation in anesthesia (in my hands) are to:

a) enable you to triage your patients to the correct setting and anesthestic technique depending on the procedure, medical history, airway exam, and resources available to you.
b) manage routine and emergent airways
c) provide conscious sedations with appropriate monitoring

the objective is not to tell you folks what you should and should not do in your practice - it is your specialty and you guys are plenty witty. the objective is to provide you with enough knowledge and familiarity for you to make informed decisions.

i guess you balk when we say propofol in your hands in the office while doing the procedure and anesthetic isn't "safe". it's relative really.

perhaps it would be more palatable to say that it is not optimal. (although this is just sugar-coated "not safe" in anesthesiaspeak)

i would suggest your attending meant that your practice with propofol would be safe if three of your four conditions were OPTIMIZED, not just right ie the right patient, the optimal monitoring, the optimal dose, and the optimal surgeon.

you might come close to the first 3 out of 4. however, the surgeon, no matter if he/she is the greatest OMFS genius to grace the earth, cannot be OPTIMAL so long as he/she is also DOING THE PROCEDURE.

during your anesthesia months have you ever tried to place an IV, aline, or central line in a patient under general when you are the only anesthesia provider in the room? it can be extremely difficult to maintain stability while scrubbed, distracted, and giving directions to personnel not trained in anesthesia. we do them, but these are extremely brief procedures (usually) and we sometimes have to break scrub to handle an issue.

propofol is a dangerous and beautiful drug. it's not however necessary for outpatient OMFS procedures - plenty of other agents are available. (and if those agents aren't sufficient the patient should be brought to the OR)

propofol administration for mac requires intensive and frequent evaluation, adjustment, and attention. my objection to your practice is that you are not able to give both surgery and anesthesia their due attention simultaneously.

perhaps this concession will pacify some - i do believe that propofol would be safer in the OMFS setting if one OMFS surgeon was doing the surgery, and one OMFS surgeon provided MAC c propofol, although still not quite optimal 😀

 

[UNLV OMS GUNNABE]

we have a great relationship with OMFS at my hospital - we chat about anesthesia, surgery, and airway toys during the cases. i enjoy teaching dental and OMFS residents - you folks are bright and enthusiastic.

the objectives of a 4 month OMFS resident rotation in anesthesia (in my hands) are to:

a) enable you to triage your patients to the correct setting and anesthestic technique depending on the procedure, medical history, airway exam, and resources available to you.
b) manage routine and emergent airways
c) provide conscious sedations with appropriate monitoring

the objective is not to tell you folks what you should and should not do in your practice - it is your specialty and you guys are plenty witty. the objective is to provide you with enough knowledge and familiarity for you to make informed decisions.

i guess you balk when we say propofol in your hands in the office while doing the procedure and anesthetic isn't "safe". it's relative really.

perhaps it would be more palatable to say that it is not optimal. (although this is just sugar-coated "not safe" in anesthesiaspeak)

i would suggest your attending meant that your practice with propofol would be safe if three of your four conditions were OPTIMIZED, not just right ie the right patient, the optimal monitoring, the optimal dose, and the optimal surgeon.

you might come close to the first 3 out of 4. however, the surgeon, no matter if he/she is the greatest OMFS genius to grace the earth, cannot be OPTIMAL so long as he/she is also DOING THE PROCEDURE.

during your anesthesia months have you ever tried to place an IV, aline, or central line in a patient under general when you are the only anesthesia provider in the room? it can be extremely difficult to maintain stability while scrubbed, distracted, and giving directions to personnel not trained in anesthesia. we do them, but these are extremely brief procedures (usually) and we sometimes have to break scrub to handle an issue.

propofol is a dangerous and beautiful drug. it's not however necessary for outpatient OMFS procedures - plenty of other agents are available. (and if those agents aren't sufficient the patient should be brought to the OR)

propofol administration for mac requires intensive and frequent evaluation, adjustment, and attention. my objection to your practice is that you are not able to give both surgery and anesthesia their due attention simultaneously.

perhaps this concession will pacify some - i do believe that propofol would be safer in the OMFS setting if one OMFS surgeon was doing the surgery, and one OMFS surgeon provided MAC c propofol, although still not quite optimal 😀

I think this may be the first time one of these threads hasn't ended in an ugly way. Just one more question out of curiosity...would any of you feel any differently if we used it on a pump instead of boluses?

 

[pgg]

I will ignore the plier comment as a token of my good will.

Good - I mean it about as seriously as when I hassle my ortho buddy about his hammers. He strong like bull. Or when I thank the EM docs for doing their part to save the world from having to see their primary care providers.

🙂

 

[armorshell]

during your anesthesia months have you ever tried to place an IV, aline, or central line in a patient under general when you are the only anesthesia provider in the room? it can be extremely difficult to maintain stability while scrubbed, distracted, and giving directions to personnel not trained in anesthesia. we do them, but these are extremely brief procedures (usually) and we sometimes have to break scrub to handle an issue.

Just wanted to make sure you realize that 99.9% of procedures OMS do single provider anesthesia/surgery for are non-sterile (no scrub)

 

[drpainfree]

propofol administration for mac requires intensive and frequent evaluation, adjustment, and attention. my objection to your practice is that you are not able to give both surgery and anesthesia their due attention simultaneously.



It's precisely the point.

 

[nap$ter]

Just wanted to make sure you realize that 99.9% of procedures OMS do single provider anesthesia/surgery for are non-sterile (no scrub)

thanks.

you miss the point; the scrub isn't the issue - it's the distraction and division of attention.

 

[GTFOOMICT]

I think this may be the first time one of these threads hasn't ended in an ugly way.

That's because it's anesthesia...almost always classy. Can't say the same about the wars with ENT and Plastics.