|Year : 2017 | Volume
| Issue : 11 | Page : 1497-1500
Is age a determinant for nausea and vomiting in disabled patients after dental treatment under sedation?
Hüseyin Cihad Turgut1, Metin Alkan2, Gülay KİP3, Mustafa Sancar ATAÇ1, Sevil Kahraman Altundağ1, Süleyman Bozkaya1, Berrin IŞIK2, Mustafa Arslan2
1 Faculty of Dentistry, Department of Oral Maxilla-Facial Surgery, Gazi University, Ankara, Turkey
2 Faculty of Medicine, Department of Anesthesiology and Reanimation, Gazi University, Ankara, Turkey
3 Faculty of Dentistry, Department of Paediatric Dentistry, Gazi University, Ankara, Turkey
|Date of Acceptance||24-Jun-2016|
|Date of Web Publication||05-Jan-2018|
Dr. Hüseyin Cihad Turgut
Faculty of Dentistry, Department of Oral Maxilla-Facial Surgery, (Anesthesiology and Reanimation Specialist). Gazi University, Ankara
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Keywords: Nonintubated general anesthesia, patients with special needs, postoperative nausea and vomiting, sedation
|How to cite this article:|
Turgut HC, Alkan M, KİP G, ATAÇ MS, Altundağ SK, Bozkaya S, IŞIK B, Arslan M. Is age a determinant for nausea and vomiting in disabled patients after dental treatment under sedation?. Niger J Clin Pract 2017;20:1497-500
|How to cite this URL:|
Turgut HC, Alkan M, KİP G, ATAÇ MS, Altundağ SK, Bozkaya S, IŞIK B, Arslan M. Is age a determinant for nausea and vomiting in disabled patients after dental treatment under sedation?. Niger J Clin Pract [serial online] 2017 [cited 2020 Feb 17];20:1497-500. Available from: http://www.njcponline.com/text.asp?2017/20/11/1497/222296
| Introduction|| |
Patients with motor dysfunctions such as cerebral palsy, Parkinsonism More Details, hereditary familial tremor, or mental disorders, such as Down syndrome, autism, seizure disorders, mental retardation, or both of mental and motor dysfunctions classified as patients with disabilities or special needs. All over the world approximately 785 million (15.6%) persons 15 years and older live with a disability. In Turkey, percentage of people with mental and/or motor dysfunctions (0–70 years) to overall population was 2.58%.
Higher incidence of dental caries and other dental problems in patients with special needs have been reported because of inadequate plaque removal, malocclusion, uncontrolled high carbohydrate diet also receiving not enough regular dental care for dental conditions because of unawareness of general health care and dental condition.,
Sedation either conscious or unconscious often facilitates dental procedures in patients with anxiety and fear, cognitive impairment, or motor dysfunction. A safe and successful dental intervention frequently becomes possible when performed under sedation in this group of patients.
Postoperative nausea and vomiting (PONV) is one of the most frequently reported complications of sedation protocols and PONV is the main cause of unplanned hospital admission after day care surgery in children. Also in adults 30% of surgical patients are affected by PONV every year.
In this study, we aimed to investigate and compare the PONV incidence in patients with disabilities aged under 18 years with patients are equal or greater than 18 years received different dental procedures under deep (unconscious) sedation. Also, we investigated overall complication rates related with anesthesia protocols.
| Materials and Methods|| |
After obtaining approval of Ethics Committee of Gazi University Faculty of Medicine, we performed a retrospective analysis of clinical and anesthesia reports of 664 cases of 494 different patients (286 males, 208 females) with special needs who underwent different dental procedures under deep sedation. Reports of patients with Down syndrome, mental retardation, cerebral palsy, seizure disorders, motor function disorders, schizophrenia, Parkinsonism were investigated for purpose of study. Age, sex, duration of procedure, dose of administered anesthetic agent, postoperative complications include nausea vomiting, hypoxia, and hemodynamic disturbances were recorded. Two study groups regarded to age limit of <18 (Group 1 patients <18 years old, Group 2 ≥18 years) were created.
The statistical analysis was performed using Statistical Package for Social Sciences 20.0 software and P < 0.05 was considered statistically significant. The results were analyzed using independent t-test, Wilcoxon, Mann–Whitney, and Pearson's chi-square tests as appropriated. Data were expressed as mean ± standard deviation, (minimum-maximum), n (%).
| Results|| |
Data from 664 cases were evaluated; demographical data and total anesthesia time are presented in [Table 1]. Number of female patients in Group 2 was significantly higher than in Group 1 (0.043). Various anesthetic agents include midazolam, ketamine, propofol, fentanyl, sevoflurane, and N2O were used alone or combined with each other. The most frequently used agent was midazolam, while ketamine had second place [Table 2]. Mean amounts of intravenous agents are presented in [Table 3]. Nausea was observed in 36 (5.4%) patients, while vomiting was in 31 (4.7%) patients. Only two respiratory or cardiac complications (hypoxia (defined as SpO2<90%) and bradycardia (heart rate <50/minute) were observed [Table 4].
|Table 1: Demographical data and duration of anesthesia in groups [mean ± SD (minimum-maximum), n]|
Click here to view
|Table 3: Mean amount of administered anesthetic drugs in groups [mean±SD (minimum-maximum)]|
Click here to view
Mean anesthesia time was significantly longer in Group 2 than that in Group 1 (37.72 ± 14.89 vs 40.53 ± 16.51, P = 0.046). Administered mean midazolam dose was significantly higher in Group 2 than recorded in Group 1 (P = 0.017). Mean doses of other administered agents were found similar between groups [Table 3]. In terms of postoperative complications, only one patient suffered from hypoxia and again only one patient suffered from bradycardia that did not required additional anticholinergic/sympathomimetic drug therapy. We found significantly higher nausea rates in Group 1 than that in Group 2 [9.3% (n = 17) vs 3.9% (n = 19), P = 0.006]. Similarly postoperative vomiting rates were higher in Group 1 than that in Group 2 [7.7% (n = 14) vs 3.5% (n = 17), P = 0.023].
| Discussion|| |
Safe, successful, and effective dental treatment (extraction, restorative, endodontic, periodontal treatment) of patients with special needs often requires sedation or general anesthesia due to lack of cooperation, involuntary movements of head, tongue or another parts of body, high levels of anxiety that does not respond regular medical therapy of patients.,,, Different levels of sedation can be used during dental procedures; however, we usually prefer deep sedation using intravenous or—with less frequency—inhalation anesthetics in patients with special needs because of higher incidence of uncontrolled movements and resistance to both anesthesiologist and dentist during session. During deep sedation patient is asleep, difficult to arouse, or unarousable [Table 5]. Also, we ensure an effective and sufficient local anesthesia because previous reports showed that more satisfied sedation without pain can be possible with an effectively provided local anesthesia.
PONV is one of the most common adverse events seen at early postoperative period that affects 30% surgical patients every year. Although clinically PONV is often self-limiting and resolves spontaneously with/without any medication, Macario et al. reported that patients rated PONV as more distressing than postoperative pain. Another two studies also reported significantly improved patient satisfaction rates following successful prevention of postoperative nausea., In patients at high risk (female, nonsmoking status, history of PONV or motion sickness, anxiety, general anesthesia using volatile anesthetics or nitrous oxide, the use of opioids, longer surgical as well as anesthesia periods, children 3 years or older) incidence of PONV can be as high as 80%. In our study, overall nausea and vomiting rates are 5.4% and 4.7%, respectively. When we made a comparison between two study groups we clearly noted that PONV incidence in patients younger than 18 years was significantly higher than those at 18 years or older (9.3% vs 3.9% and 7.7% and 3.5%, respectively, P = 0.006 and P = 0.023, respectively). Whenever we investigate used anesthetics in two groups—because opioids, inhalational agents, such as N2O and sevoflurane are all accepted as risk factors for PONV—we found significant differences in only mean midazolam doses (1.59 ± 0.69 vs 1.80 ± 0.97, P = 0.017) between two groups. Also number of female patients and duration of procedure—both of two are accepted as risk factors for PONV —were significantly higher in Group 2 (P = 0.043 and P = 0.046, respectively). These findings strongly indicate that disabled patients younger than 18 years are at high risk for PONV even without risk factors, such as female gender, longer anesthesia time. Results of this study are compatible with findings of previous studies indicating the average incidence of PONV in childhood of between 33.2% and 82% can be twice as high compared with adults.,,, As mentioned previously patients with any disabilities are not accepted as high-risk patients for PONV and several investigations showed similar PONV rates in patients with special needs compared to phobic and anxious patients., As a result, we can suggest that the age of patients undergoing dental treatments under deep sedation using various anesthetic drugs even emetogenic agents include opioids and inhalation agents can be accepted as risk factor for PONV but not the special status of disabled patients.
In deep sedation it's essential to secure the airway clear from rinsing water, secretions, and debris. Although any complications (mainly mild or moderate) related with anesthesia administration were reported at approximately 20%, we found only two postoperative complications (hypoxia and bradycardia without any medical treatment) except PONV in our study records. This finding is similar with results of various studies conducted in this patient group. Perrott et al. reported no mortality in 34,391 procedures involving deep sedation/general anesthesia (71.9%), conscious sedation (15.5%), and local anesthesia only (12.6%) over a 1-year period and only two complications (an allergic reaction to antibiotic treatment and aspiration) that required hospitalization occurred. In another study, Enever et al. retrospectively investigated postoperative complications in children with or without any disabilities and found no life-threatening complications [nausea/vomiting (20%), unexpected drowsiness (13%) and the need for pain relief at home (13%)].
| Conclusion|| |
We suggest that the low incidence of morbidity found in our study and studies cited previously is related to careful patient selection, perioperative management include close monitoring, usage of anesthetic drugs with improved side effect and faster recovery profile, finally and most importantly excellent cooperation between the anesthesiologist and dentist. Finally, according to our results we can conclude that PONV rates encountered during dental treatments under deep sedation of patients with special needs younger than 18 years are higher than those found in older patients. Additionally PONV rates in both of two age groups may not differ from those seen in normal population—data from previous studies that have been cited above.
Retrospective and uncontrolled design of this study is the main limitation of study that does not allow further and more accurate evaluation of risk factors related with PONV and other complications in this special population. However, results of this study conducted on a large number of patients with special needs may lead future studies and encourage anesthesiologists and dentists in their practice on disabled patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The global burden of disease: 2004 update. Geneva WHO 2008;2004:8.
Turkish Statistical Institute Statistics. The proportion of disability. 2002;2002.
Wang YC, Lin IH, Huang CH, Fan SZ. Dental anesthesia for patients with special needs. Acta Anaesthesiol Taiwanz 2012;50:122-5.
Caputo AC Providing deep sedation and general anesthesia for patients with special needs in the dental office-based setting. Spec Care Dentist 2009;29:26-30.
Blacoe DA, Cunning E, Bell G. Paediatric day-case surgery: An audit of unplanned hospital admission Royal Hospital for Sick Children, Glasgow. Anaesthesia 2008;63:610-5.
Fero KE, Jalota L, Hornuss C, Apfel CC. Pharmacologic management of postoperative nausea and vomiting. Expert Opin Pharmacother 2011;12:2283-96.
Lalwani K, Kitchin J, Lax P. Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model. J Oral Maxillofac Surg 2007;65:427-33.
Chaushu S, Gozal D, Becker A. Intravenous sedation: An adjunct to enable orthodontic treatment for children with disabilities. Eur J Orthod 2002;24:81-9.
Enever GR, Nunn JH, Sheehan JK. A comparison of post-operative morbidity following outpatient dental care under general anaesthesia in paediatric patients with and without disabilities. Int J Paediatr Dent 2000;10:120-5.
Messieha Z. Risks of general anesthesia for the special needs dental patient. Spec Care Dentist 2009;29:21-5.
Becker DE. Pharmacodynamic considerations for moderate and deep sedation. Anesth Prog 2012;59:28-42.
Macario A, Weinger M, Truong P, Lee M. Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg 1999;88:1085-91.
Darkow T, Gora-Harper ML, Goulson DT. Record KE, Impact of antiemetic selection on postoperative nausea and vomiting and patient satisfaction. Pharmacotherapy 2001;21:540-8.
van den Bosch JE, Bonsel GJ, Moons KG, Kalkman CJ. Effect of postoperative experiences on willingness to pay to avoid postoperative pain, nausea, and vomiting. Anesthesiology 2006;104:1033-9.
Elgueta MF, Echevarria GC, De la Fuente N, Cabrera F, Valderrama A. Cabezon R, Effect of intravenous fluid therapy on postoperative vomiting in children undergoing tonsillectomy. Br J Anaesth 2013;110:607-14.
Apfel CC, Kranke P, Piper S, Rusch D, Kerger H, Steinfath M. [Nausea and vomiting in the postoperative phase. Expert- and evidence-based recommendations for prophylaxis and therapy]. Anaesthesist 2007;56:1170-80.
Eberhart LH, Morin AM, Guber D, Kretz FJ, Schauffelen A, Treiber H.Applicability of risk scores for postoperative nausea and vomiting in adults to paediatric patients. Br J Anaesth 2004;93:386-92.
Hamid SK, Selby IR, Sikich N, Lerman J. Vomiting after adenotonsillectomy in children: A comparison of ondansetron, dimenhydrinate, and placebo. Anesth Analg 1998;86:496-500.
Holt RD, Chidiac RH, Rule DC Dental treatment for children under general anaesthesia in day care facilities at a London dental hospital. Br Dent J 1991;170:262-6.
Miyazawa H, Namba H, Seiki K, Karasawa S, Kaneko H, Imanishi T. [Dental treatment for children under general anesthesia]. Shoni Shikagaku Zasshi 1990;28:1117-24.
Perrott DH, Yuen JP, Andresen RV, Dodson TB. Office-based ambulatory anesthesia: Outcomes of clinical practice of oral and maxillofacial surgeons. J Oral Maxillofac Surg 2003;61:983-95
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]