J. Dent. 1986; 14: 247-250 Printed in Great Britain 247

General anaesthesia, parenteral sedation, and emergency drugs and equipment in general dental practice

P. J. Shirlaw, C. Scully, M. J. Griffiths, B. G. H. Levers and R. T. M. Woodwards University Department of Oral Medicine and Oral Surgery, Bristol Dental Hospital and School

J. Dent. 1986; 14: 247-250 (Received 27 May 1986; accepted 3 July 1986)

ABSTRACT General dental practitioners were surveyed with respect to their use of general anaesthesia, parenteral sedation, and possession of emergency drugs and equipment.

Over 50 per cent of respondents used some form of general anaesthetic or parenteral sedation technique. Most of these respondents used inhalational general anaesthesia, and about 50 per cent used relative analgesia (RA) and/or intravenous sedation techniques: however, the number of administrations of relative analgesia far exceeded that of any other technique.

Over 80 per cent of respondents possessed a source of oxygen, and some 30 per cent had corticosteroids and adrenaline available for use in an emergency. The level of emergency drugs and equipment was higher for those using general anaesthesia or parenteral sedation.

General dental practitioners expressed a keen desire for the provision of advice on both the management of emergencies in the dental surgery and appropriate equipment and drugs.

INTRODUCTION There were 120 deaths associated with dentistry reported in the UK during 1970-79. One hundred of these deaths were associated with general anaesthesia and related techniques such as parenteral sedation (Coplans and Curson, 1982). Over 9 million administrations of general anaesthesia were authorized by the Dental Estimates Board in that period, but the number administered in the private sector of general dental practice was unknown. Forty-nine of the deaths associated with general anaesthesia occurred in general dental practice (Coplans and Curson, 1982), but none of these during the use of intravenous sedation or anaesthesia. There is, therefore, a low mortality rate in relation to general anaesthesia in dental practice, but of course any fatalities are unacceptable (Goldman, 1958; Green and Coplans, 1973; Tomlin, 1974; Coplans and Curson, 1982).

Sudden cardiovascular collapse or respiratory obstruction in otherwise apparently healthy patients appear to be the major factors contributing to deaths in relation to anaesthesia in dental practice (Coplans and Curson, 1982; Lunn and Mushin, 1982). Other factors contributing to deaths associated with general anaesthesia,

at least in relation to inpatients, are diverse and include particularly errors of judgement, expertise and lack of experience (Lunn and Mushin, 1982). Lack of equipment is only a minor factor in deaths in hospital dental practice (Lunn and Mushin, 1982), but it is a widely held belief that the facilities which exist in dental practice may sometimes fall short of the ideal.

There may be controversy as to what emergency equipment and drugs should be carried, but irrespective of whether general anaesthetic or sedation techniques are used, oxygen, adrenaline, corticosteroids, an effective aspirator, and a laryngoscope are needed (Scully and Cawson, 1982).

The aim of this study was to determine the pattern of use of general anaesthesia and parenteral sedation, and the type of emergency equipment and drugs kept in general dental practice in the UK.

MATERIALS AND METHODS Questionnaires were sent to all 1200 general dental practitioners (GDPs) in the South West Region of Britain in 1983 requesting details of the emergency equipment

248 J. Dent. 1986; 14: No. 6

and drugs available and the use of inhalational anaesthesia, relative analgesia, intravenous anaesthesia and intravenous sedation. Some 40 per cent of the GDPs responded. The information obtained was transferred to a computer database for analysis.

RESULTS

Table I shows the pattern of use of general anaesthesia and parenteral sedation in general dental practice. Nearly 60 per cent of practitioners used some form of general anaesthesia at some time in their practice; 24 per cent gave relative analgesia; 17 per cent used intravenous anaesthesia, and 22 per cent gave intravenous sedation. The total number of inhalational anaesthetics given by all respondents in one month was 1484. Each month 525 intravenous anaesthetics and 536 intravenous sedations were given. By far the most popular technique, however, was relative analgesia at 3444 administrations per month (Table II).

The items of emergency equipment and drugs held most frequently by all respondents were oxygen (80.4 per cent), airway (37.8 per cent), adrenaline (30.5 per cent), hydrocortisone (29.6 per cent), glucose (14.0 per cent), antihistamine (11.8 per cent) and Ambu bag (1 l-8 per cent). The most popular means of artificial ventilation were via an anaesthetic machine (48.8 per cent), an oxygen cylinder (24 per cent), Brook’s airway (18.4 per cent), relative analgesia machine (15.5 per cent), Ambu bag ( 10 per cent) and Air Viva Resuscitator (7.3 per cent). However, 20 per cent of all the respondents had no specific means of giving oxygen in an emergency and,

Table I. Patterns of use of general anaesthesia and parenteral sedation in general dental practice

Technique % GDPs using

technique

Any form of general anaesthesidsedation 56.1 lnhalational general anaesthesia 354 Relative analgesia 24.4 Intravenous anaesthesia 17.1 Intravenous sedation 22.4

furthermore, only one-quarter of those felt a need to carry oxygen.

The equipment held is indicated more fully in Table III which compares the levels of equipment and drugs held by GDPs who gave some form of general anaesthesia or parenteral sedation with the levels held by those who did not use any of these techniques. Those using general anaesthesia or sedation were more likely to hold an emergency kit then those not using these techniques.

Table IK which gives an analysis of the same equipment and drugs held by the groups giving inhalational or intravenous anaesthesia, relative analgesia and intravenous sedation, shows that even those using relative analgesia, the most innocuous of the forms of sedation, had similar patterns of drugs and equipment to those using full anaesthesia.

Some 68 per cent of GDPs expressed content with their emergency equipment, but in response to the suggestion of a regionally organized training seminar in the diagnosis and management of emergencies in dental practice, 96 per cent of all GDPs requested the course. Some 94 per cent of the GDPs felt that it would improve the efficiency of their staff in handling emergencies (Table V), and 9 1 per cent gave a positive response to the suggestion that a regionally organized emergency kit might be made available (Table V).

DISCUSSION

This study examined the use of general anaesthesia, parenteral sedation and emergency drugs and equipment in general dental practice. The response rate of 40 per cent, although not unexpected and comparable with most postal surveys, may, of course, introduce a bias. However, it is reasonable to assume that the respondents would include the more interested, enthusiastic and caring GDPs. The results are therefore likely to show the better side of the situation. Nevertheless, this study indicates that the level of emergency equipment and drugs currently held in dental practices where general anaesthesia or parenteral sedation techniques are used is undesirably low, although most possess oxygen. Nearly two-thirds of practitioners may not have adrenaline or corticosteroids, but the majority of GDPs appear keen to receive further

Table Il. Extent of use of general anaesthesia and parenteral sedation in general dental practice

Technique

General anaesthesia Relative analgesia Intravenous anaesthesia Intravenous sedation

Average number Estimated number of adminstrations of administrations per GDP using

per month technique per month

1484 3444 3;

525 7 536 5

Shirlaw et al.: Drugs and equipment in general dental practice 249

Table Ill. Percentage of GDPs possessing emergency equipment and drugs, in relation to the use of general anaesthesia or parenteral sedation

Equipment/drugs

GDPs giving any GDPs not giving any form of general form of general

anaesthesia or sedation anaesthesia or sedation (%I W

Basic equipment Oxygen Adrenaline Steroids Airway Laryngoscope Emergency drug box

Other equipment Anaesthetist’s kit Intravenous infusion

set Endotracheal tubes Tracheotomy

equipment Other drugs

Atropine Glucose Chlorpheniramine

96.8 59.3 36.5 22.8 38.8 22.8 51.1 43.1 11.1 3.0 20.2 5.0

11.9 5.9

9.1 3.0

9.1 2.0 14.2 13.7 1 7.4 4.5

0.0 2.0

2.0 I.0

Table IV: Patterns of emergency equipment and drugs possessed by GDPs who use general anaesthesia or parenteral sedation techniques

Equipment/drugs

Inhalational or intravenous

anaesthesia VW

Relative analgesia

w

Intravenous sedation

l”/ol

Basic equipment / drugs Oxygen Adrenaline Steroids Airway Laryngoscope Emergency drug box

Other equipment Anaesthetist’s kit Intravenous infusion set Endotracheal tubes Tracheotomy equipment

Other drugs Atropine Glucose Chlorpheniramine

100.0 100.0 92.0 35.2 42.5 44.5 34.5 47.2 54.4 52.2 44.4 63.3 13.8 13.8 16.8 22.6 18.5 21.7

18.2 4.6 8.9 6.9 10.1 12.8

11.9 12.0 14.8 4.4 4.6 2.9

10.0 11.1 16.8 13.8 12.0 18.8 15.7 22.2 31.6

Table V. Emergency items requested by GDPs

hem % of GDPs requesting

Means of administering oxygen 26.3 Emergency drug box 90.8 Training seminar 95.9

training in the management of emergencies, and would welcome an ‘official’ emergency kit.

Nearly 60 per cent of the respondents were practising general anaesthetic or sedation techniques (Table I), but the information given by GDPs regarding the numbers of anaesthetics given in their practices (Table II) cannot be

250 J. Dent. 1986; 14: No. 6

Table Vi. Other potent drugs kept by a few GDPs

Alpha and beta blockers Respiratory stimulants Pethidine Morphine Aminophylline Promethazine

Nitrates/nitrites Chlorpromazine Frusemide Pentazocine Antiemetics

regarded as completely accurate since not all kept full records and the numbers of anaesthetics given may have been overestimated. The anaesthetics which were given in general dental practice in the South West Region in the survey period (GDS Special Area Analyses, 1983) were lower than the estimate from the GDP figures. Undoubtedly, practice outside the General Dental Services may account for some of this discrepancy.

Although a larger number of practitioners were giving inhalational anaesthesia than relative analgesia, the numbers of patients receiving relative analgesia were more than double those having general anaesthesia. The administrations of relative analgesia varied widely between practitioners, from 2 to 200 per month. Intravenous anaesthesia and intravenous sedation were less frequently used by GDPs than was general anaesthesia-only about one-fifth of practitioners having used one or other of these techniques.

Over 80 per cent of all GDPs possessed oxygen, but only one-half had an airway or specific means of administering oxygen. Only about one-third had adrenaline and corticosteroids available for systemic use in an emergency, but we have no data as to whether these drugs were within the expiry date for use. How GDPs who did not possess these agents could hope to cope with an anaphylactic reaction is quite unclear, and a cause for some concern.

GDPs providing a general anaesthetic or parenteral sedation service had better equipment and drugs, and were four times more likely to hold an emergency kit than those not offering this type of service, but some 80 per cent of the former group still had no kit.

The particular anaesthetic or sedation technique favoured by the GDP appeared to have relatively little influence on the emergency equipment or drugs possessed, apart from those using inhalational anaesthesia who more frequently possessed an anaesthetics kit, and those giving intravenous sedation who were more likely to have an infusion set.

Many items kept by the GDPs are not noted here, but controlled drugs were kept by some GDPs as were alpha and beta blockers and respiratory stimulants (Table VZ). Many GDPs expressed concern as to the advisability of

keeping large numbers of drugs with which they were unfamiliar, a view with which the authors concur. Several GDPs openly admitted to lack of confidence in their intravenous techniques. Many were also concerned about the shelf-life of drugs that were unlikely to be used very often, and the cost of replacement of such items. It is also clear that most GDPs (95 per cent) would welcome further training on the management of emergencies in dental practice.

Coplans and Curson (1982) recorded that 100 of the 120 deaths associated with dentistry in the UK (1970- 79) were associated with general anaesthesia. Of these, about one-half (n = 49) occurred in general dental practice. Two main types of collapse were identified, one associated with respiratory obstruction usually during the course of the anaesthetic, the second occurring most frequently in the recovery period and cardiovascular in origin. Clearly, general anaesthesia is the main cause of avoidable death in a dental practice and cardiopulmonary complications are usually involved.

In a dental practice where techniques which potentially depress respiration and protective reflexes and are able to induce unconsciouness are used, expertise in the mainten- ance of the airway and in cardiopulmonary resuscitation is essential.

It would seem reasonable for all GDPs, whether or not using general anaesthetic or sedation techniques, to carry an emergency kit which includes oxygen, 1 in 1000 adrenaline and corticosteroids (hydrocortisone sodium succinate or methylprednisolone). The kit should be accessible for ready use and be easy to keep updated. Clearly, an effective method of aspiration is needed.

Acknowledgement

We wish to acknowledge Rosalind Howarth who first suggested such a study.

References

Coplans M. P. and Curson I. (1982) Deaths associated with dentistry. Br. Dent. J. 153,357-362.

GDS Special Area Analyses (1983) DHSS. London, HMSO

Goldman V. (1958) Deaths under anaesthesia in the dental surgery. Br. Dent. J. IO5, 160.

Green R. A. and Coplans M. P. (1973) Anaesthesiu in Dentistry. London, H. K. Lewis.

Lunn J. N. and Mushin W. W. (1982) Mortality Associated with Anaesthesiu. London, Nuffield Provincial Hospitals Trust, London, pp. 55-86.

Scully C. and Cawson R. A. (1982) Medical Problems in Dentistry. Bristol, Wright PSG.

Tomlin P. J. (1974) Deaths in out-patients dental anaesthetic practice. Anaesthesia 29, 55 1.

Correspondence should be addressed to: Professor C. Scully, University Department of Oral Medicine and Oral Surgery, Bristol Dental Hospital and School, Lower Maudlin Street, Bristol BSI 2LY.