Martin L. Gonzalez

Comparison of methohexital and propofol use in ambulatory procedures in oral and maxillofacial surgery.

PURPOSE Short-acting anesthetic agents, such as propofol and methohexital, are commonly used for ambulatory procedures in the practices of oral and maxillofacial surgeons (OMS). This study compares the safety and anesthetic outcomes of propofol and methohexital. In addition, the study compares the safety and outcomes of these agents when administered either by an OMS who simultaneously provides anesthesia and performs the procedure (anesthetist/surgeon), or by a non-OMS provider of anesthesia (anesthesiologist or certified registered nurse anesthetist; CRNA) whose sole obligation is to provide anesthesia. MATERIALS AND METHODS This is a prospective study of anesthesia techniques used in an office-based ambulatory setting by OMS throughout the United States, in which either propofol or methohexital was used for sedation/anesthesia. The study variables included demographic information, anesthetic agent, adverse outcomes related to anesthesia, operative procedure, and provider of anesthesia. These variables were compared with the patient group that received a benzodiazepine/narcotics regimen for sedation (control group). Bivariate (contingency tables) and multivariate (logistic regression) analyses were conducted. P < or = .05 was considered statistically significant. RESULTS The study included 47,710 patients who met the inclusion criteria: 26,147 (54.8%) patients were in the propofol group, 15,859 (33.2%) were in the methohexital group, and 5,704 (12.0%) were in the benzodiazepine group. Among all study patients, 333 (0.7%) had an adverse event. The most common complication was nausea and vomiting without aspiration. Of the patients in the propofol group, methohexital group, or benzodiazepine group, 0.4%, 1.1%, and 0.8% had an adverse event, respectively. The higher number of complications among patients in the methohexital group compared with patients in the other 2 groups was statistically significant. Of 26,147 patients in the propofol group, 23,799 (91.0%) received anesthesia from an anesthetist/surgeon (OMS), and 2,368 (9.1%) from an anesthesiologist or nurse anesthetist (non-OMS). A total of 109 patients (0.4%) had an adverse event. The majority of patients who received anesthesia from a non-OMS were in the propofol group (2,368 of 2,404 patients; 98.5%). There was no statistically significant difference in the occurrence of adverse outcomes when comparing patients in the propofol group who received anesthesia from an OMS with those who received anesthesia from a non-OMS (P = .24, bivariate analysis; P = .33, multivariate analysis). CONCLUSIONS There is a statistically significant increase in adverse events related to methohexital compared with propofol or benzodiazepine/narcotics for anesthesia. Propofol appears to have the lowest risk for adverse events. There is no statistically significant difference in the number of adverse outcomes between the administration of propofol for ambulatory surgery by OMS as an anesthetist/surgeon and anesthesiologist/nurse anesthetist. It remains critical that our specialty maintains the highest standards, to provide safe anesthesia and to reduce adverse anesthetic events.

Complications of Moderate Sedation Versus Deep Sedation/General Anesthesia for Adolescent Patients Undergoing Third Molar Extraction

PURPOSE To examine the complications resulting from moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction and determine whether any differences in complication risks exist between the 2 levels of sedation. MATERIALS AND METHODS We performed a prospective study of the Oral and Maxillofacial Surgery Outcomes System from January 2001 to December 2010. The primary predictor variable was the level of sedation, divided into 2 groups: moderate sedation versus deep sedation/general anesthesia. The primary outcome was the incidence of adverse complications resulting from the sedation level. Differences in the cohort characteristics were analyzed using the independent samples t test, χ(2) test, and analysis of variance, as appropriate. Multivariable logistic regression was used to measure the effect the level of sedation had on the adverse complication rate. RESULTS Patients in the moderate sedation group had a complication rate of 0.5%, and patients in the deep sedation/general anesthesia group had a complication rate of 0.9%. Compared with moderate sedation, deep sedation/general anesthesia did not pose a significantly increased risk of adverse anesthesia complications (adjusted odds ratio 1.63, 95% confidence interval 0.95 to 2.81; P = .077). CONCLUSIONS The results of our study have shown that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction.

American Association of Oral and Maxillofacial Surgeons' Anesthesia and Third Molar Extraction Benchmark Study: Rationale, Methods, and Initial Findings

PURPOSE Benchmark statistics are used in quality assurance/quality improvement processes. The purposes of the present report are to 1) review the rationale for a new specialty-specific benchmark study, 2) summarize the methods to create a practice-based research collaborative (P-BRC) designed for collecting data to create benchmarks, and 3) describe the characteristics of the P-BRC surgeon participants. MATERIALS AND METHODS The study was designed as a prospective cohort study. We created a P-BRC composed of randomly selected American Association of Oral and Maxillofacial Surgeons (AAOMS) members in private practice in the United States, who agreed to enroll patients scheduled to receive anesthesia of any type in the office-based ambulatory setting. The study variables included clinician demographics and their P-BRC status, grouped as 1) invited, active participants, 2) invited, inactive participants, and 3) uninvited AAOMS members. The P-BRC participants collected data for dozens of variables from their patients related to anesthesia. If the procedure was third molar (M3) surgery, additional M3 procedure-specific data were collected. Data analyses were composed of computing descriptive and bivariate statistics. Preliminary sample size estimates suggested that the P-BRC should include 300 surgeons to produce estimates with a ±5% error. RESULTS During the 1-year study interval, 642 surgeons (11.8%) were invited to join the P-BRC from a population of 5,455 eligible AAOMS members. The 124 active participants in the P-BRC contributed 6,344 subjects to the anesthesia data set and 2,978 subjects who had had 9,207 M3s removed to the M3 data set. The active participants in the P-BRC were younger and more likely to be board-certified than were the inactive participants (P < .05). Details of the anesthesia and M3 variables will follow in future reports. CONCLUSIONS Despite vigorous efforts, we did not achieve our stated goal of creating a P-BRC composed of a random sample of 300 AAOMS members. With the current P-BRC sample, variables with very high (>93%) or very low (<7%) frequency estimates will produce estimates with the desired range of ±5% error. The P-BRC includes a sample of self-selected, not random, participants and is well-characterized in terms of age, gender, board-certification status, academic degrees, and geographic distribution.