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Virginia Commonwealth UniversityVCU Scholars Compass
Theses and Dissertations Graduate School
2007
Adverse Anesthesia Outcomes: A RetrospectiveStudy of an Ambulatory Surgical Center versus aDental Office SettingGaurav AgarwalVirginia Commonwealth University
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In the post-operative phase the adverse events noted were respiratory difficulty (1 event,
0.5%), pain (3 events, 1.6%) and nausea/vomiting (4 events, 2.1%). Pain was defined as
discomfort in the post-anesthesia care unit requiring the administration of pain
medication for relief.
Adverse Events in the Hospital-based Ambulatory Surgical Setting
During the induction phase the adverse events noted were bronchospasm in one
patient (0.4%), desaturation < 90% in 7 patients (3.1%), heart rate below 60 in four
patients (1.7%), and vomiting in one patient (0.4%). During the intubation phase, the
only adverse event noted was difficult intubation in seven patients (3.1%). During the
maintenance phase the adverse events were; bronchospasm in one patient (0.4%), blood
pressure drop of greater than 20% below base in 37 patients (16.2%), heart rate below 60
in two patients (0.9%), and light anesthesia in 37 patients (16.2%). During the
emergence phase, the only adverse events noted were a drop in SpO2 < 90% in 22
patients (9.6%) and delayed wakeup (> 9 minutes) in 172 patients (76.1%). In the post-
operative phase, the adverse events noted were respiratory difficulty in two patients
(0.9%), wheezing in three patients (1.4%), pain observed by 43 patients (19.7%) and
nausea/vomiting in four patients (1.8%).
Comparison of Adverse Events in the two Settings
Table 2 summarizes the comparisons between surgical settings for adverse events
in each of the five phases of general anesthesia. A logistic regression of these adverse
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events tested for a difference in surgical setting (ASC versus dental clinic) adjusting for
gender, ASA classification, and age. Additionally, an exact p-value for the surgical
setting difference within this logistic regression model was provided.
During the induction phase, the only significant relationship was between age
(older patients) and a heart rate drop below 60 (p-value=0.0315) (Figure 1). During the
intubation phase, there were no differences between the two surgical settings or with
demographic factors (Figure 2). There were a couple of differences during the
maintenance phase (Figure 3). The ASC has significantly more instances of a blood
pressure drop greater than 20% below baseline and documentation of light anesthesia
compared to the dental clinic setting (p-value < .0001). There was a significant
relationship between a child’s age and a heart rate drop below 60 (p-value =0.0186). The
two instances of low heart rate were in older patients (10 and 16 years).
During the emergence phase, there were two significant differences between
surgical settings (Figure 4). The ASC had an increased number of desaturations SpO2 <
90% (p-value=0.0011) and delayed wake-up times of greater than 9 minutes (p-value
<0.0001). The median emergence time in the ASC was 12 minutes and in the dental
clinic it was 9 minutes (ASC mean = 12.8, SD = 4.8 versus dental clinic mean = 9.6, SD
= 5.68). The two groups had significantly different emergence times (Kaplan Meier
survival analysis, Wilcoxon p-value < .0001). ASA classification was also significantly
related to delayed wake up times with less healthy patients having longer wake-up times.
In the post-anesthesia phase, the ASC had significantly higher instances of pain recorded
than in the dental clinic setting (p-value < .0001) (Figure 5). Child’s age (older patients)
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was also significantly associated with nausea/vomiting in the post-operative phase (p-
value=0.0044).
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Discussion
Safety concerns about pediatric sedation have moved many national
organizations to produce statements and guidelines regarding the delivery of care. The
Joint Commission on Accreditation of Hospitals, the American Society of
Anesthesiologists, the American Academy of Pediatrics, the American College of
Emergency Physicians, and the American Academy of Pediatric Dentistry have all
published some form of guidelines concerning sedation of children7,8,10,12,19. These
recommendations have been made on the limited studies available and are not based on
actual incidence of complications in pediatric sedation. Furthermore, there are limited
studies that have examined the practice of general anesthesia for dental rehabilitation in
pediatric patients in the various surgical settings.19 The incidence of adverse events in
these settings is largely unknown.
To compound the problem even more, the trend has moved to performing
sedation procedures in non-hospital-based facilities. To date, there have been no studies
that have examined general anesthesia for pediatric dental rehabilitation procedures in the
dental clinic setting. Cote et al highlighted the fact that adverse events during sedation do
occur and are largely predictable. A limitation of that study was that it only looked at
injury in the broadest sense (severe hypoxia, neurologic injury, death, etc) and did not
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look at the frequency of more common adverse events.13 Other studies have looked at
individual events such as mortality, anxiety, and postoperative morbidity but have not
compared adverse events between various surgical settings16-18.
This investigation specifically sought to compare and analyze the occurrence of
adverse events between the dental clinic setting and the hospital-based ambulatory
surgical setting. Adverse events in each phase (induction, intubation, maintenance,
emergence, and PACU) of general anesthesia were observed. The results showed that
more adverse events occurred in the hospital-based ambulatory surgical center (ASC)
than in the dental clinic setting. This rejects our null hypothesis that there is equal
prevalence of adverse events in both settings. Although, during the induction and
intubation phase there were no differences between settings, all other settings had
significant differences. During the maintenance phase, the occurrence of blood pressure
drop of greater than 20% of baseline and light anesthesia were higher in the hospital-
based ASC. During the emergence phase, the occurrence of delayed wakeup was also
higher in the hospital-based ASC. Finally in the post-operative phase, the occurrence of
pain was also greater in the hospital-based ASC.
A limitation of the study is that it was a retrospective chart review which means
pre-existing data was used to make comparisons between the two surgical settings.
Differences in patient selection, charting, the possibility of artifacts, and a lack of a
standardized anesthesia monitoring record were all factors which may have contributed to
the study biases.
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The hospital-based ASC used a computerized charting system. All times,
medications, personnel, vital signs, adverse occurrences and materials used are recorded
electronically in real-time through the hospital computer system. The dental clinic
setting uses a handwritten method of anesthesia monitoring charted on paper. This means
that the anesthesia provider records all of the above mentioned information by hand.
This may have biased the studies results in recording adverse events. To compound the
issue of differences in charting between the two settings, with electronic charting there is
also the occurrence of artifacts. Artifacts are the mechanical disruptions during
monitoring of vital signs that create incorrect readings, but are still picked up by the
computerized system in real-time. Interference from the surgeon leaning on the blood
pressure cuff, or the pulse oximeter slipping off the finger, for instance, requires
documentation that the vital sign recorded is in error due to artifact. If artifacts are not
noted, then in review of the charts these erroneous values are recorded as adverse events
showing a false positive for an adverse event that did not occur. Conversely, in the dental
clinic setting, the anesthetist, who is recording by hand may be busy solving the problem
at hand, whether it is a real desaturation or the displacement of a sensor, and then does
not go back and chart the actual drop in vital signs.
Hospitals are considered a highly monitored environment and capable of
providing the ultimate safety net and definitive care that is needed for patients with
complex co-morbid conditions. For this reason, the treatment of patients who have a
significant medical history and co-morbidities has historically been in a hospital setting.
This study found a similar trend. Patients in the ASA category I and II were treated in
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the dental clinic setting whereas in the hospital-based ASC setting, the population was
younger and had a higher proportion of medically compromised patients in addition to
the ASA I patients (ASA I, II, and III). Patients that had any respiratory issues such as
poorly controlled asthma and were set up for their surgeries in the ASC setting, while
well controlled asthmatics were considered suitable for treatment in the dental clinic
setting.
For future studies, there is a need to create a more uniform and standardized
method of data collection for anesthesia charting. A prospective study with standardized
data collection procedures would allow for less biased results. We propose the use of a
data collection sheet to remind the anesthesia provider to chart specific critical events. It
would serve as a check off sheet and a better means to note the incidence of adverse
events. Future research may consist of a prospective study with standardized anesthesia
monitoring and data collection using the same inclusion criteria as the present study in
order to better examine the safety of anesthesia comparing the dental clinic and hospital-
based settings.
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Conclusions
1. This study showed a higher prevalence of adverse events in a hospital-based
ambulatory surgical center (ASC) setting as compared to a dental office setting.
2. Demographic differences showed that the patients treated in the dental office
setting were older and healthier than those treated in the ambulatory surgical
center.
3. Controlling for demographic differences, the phases of anesthesia that showed
a significantly higher occurrence of adverse events in the hospital-based ASC
included maintenance, emergence, and post anesthesia.
4. The higher occurrence of adverse events in the hospital-based ASC may be
due to the false positives that resulted from artifacts.
5. Further study is required with standardized anesthesia monitoring methods in
order to better assess the safety of general anesthesia comparing the dental clinic
and hospital-based settings.
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Literature Cited
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Literature Cited
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and Anesthesia. Guidelines on the Elective Use of Minimal, Moderate, and Deep Sedation and General Anesthesia for Pediatric Dental Patients. Chicago, IL. Available at: www.aapd.org/media/Policies_Guidelines/G_Sedation.pdf. Pediatric Dent 2006; 27:7, 110-118. Accessed February 7, 2006.
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monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: addendum. Pediatrics. 2002;110:836-838.
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15. Collins LM, Padda J, Vaghadia H. Mini-audits facilitate quality assurance in
outpatient units. Canadian Journal of Anesthesia. 2001;48:737-741. 16. D’eramo EM, Bookless SJ, Howard JB. Adverse events with outpatient anesthesia in
Massachusetts. Journal of Oral and Maxillofacial Surgery. 2003;61(7):793-800 17. Twersky R, Fishman D, Homel P. What happens after discharge? Return hospital
visits after ambulatory surgery. Anesthesia & Analgesia. 1997;84: 319-324. 18. Lee JY, Roberts MW. Mortality risks associated with pediatric dental care using
general anesthesia in a hospital setting. The Journal of Clinical Pediatric Dentistry. 2003;27(4):381-383.
19. Cravero JP et al. Incidence and nature of adverse events during pediatric
sedation/anesthesia for procedures outside the operating room: report from the pediatric sedation research consortium. Pediatrics. 2006;118(3):1087-1096.
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21. Chye EP, Young IG, Osborne GA, Rudkin GE. Outcomes after same-day oral surgery: a review of 1,180 cases at a major teaching hospital. Journal of Oral and Maxillofacial Surgery. 1993;51(8):846-849.
22. Fancourt-Smith PF, Hornstein J and Jenkins LC. Hospital admissions from the
Surgical Day Care Centre of Vancouver General Hospital 1977-1987. Canadian Journal of Anesthesia. 1990;37:699-704.
Phases of Anesthesia: I: Induction, In: Intubation, M: Maintenance, E: Emergence, P: Post Anesthesia.
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Figure 1. Adverse Events During the Induction Phase
Induction Comparing ASC to Clinic
00.5
11.5
22.5
33.5
Laryn
ospa
sm
Brocho
spas
m
SpO2 <
90
HR < 60
Vomitin
g
Adverse Event
Perc
enta
ge o
f Occ
uren
ce
ASCClinic
25
Figure 2. Adverse Events During the Intubation Phase
Intubation Comparing ASC to Clinic
00.5
11.5
22.5
33.5
DifficultyVentilating
DifficultyIntubating
RightMainstem
EsophagealIntubation
Adverse Event
Perc
enta
ge o
f Occ
uren
ce
ASCClinic
26
Figure 3. Adverse Events During the Maintenance Phase
Maintenance Comparing ASC to Clinic
02468
1012141618
Bronch
ospasm
BP drop
>20 %
HR < 60
Light A
nesth
esia
Adverse Event
Per
cent
of O
ccur
ence
ASCClinic
27
Figure 4. Adverse Events During the Emergence Phase
Emergence Comparing ASC to Clinic
0
10
20
30
40
50
60
70
80
Bronch
ospasm
Laryn
gosp
asm
SpO2 <
90%
Vomitin
g
Delayed W
akeup
Adverse Events
Per
cent
age
of O
ccur
ence
ASCClinic
28
Figure 5. Adverse Events In the Post Anesthesia Care Unit
PACU Comparing ASC to Clinic
05
10152025
Res
pira
tory
Diff
icul
ty
Whe
ezin
g
Pai
n
Nau
sea/
Vom
itin
g
Adverse Events
Perc
ent o
f Occ
uren
ce
ASCClinic
29
APPENDIX A
Description of Adverse Events
Phase of Anesthesia Adverse Event Description
Induction Laryngospasm The forceful closure of the vocal cords caused by stimulation of the superior laryngeal nerve causing the inability to ventilate; can be partial or complete.
Bronchospasm Difficulty breathing caused by the constriction of the muscles in the walls of the bronchioles
SpO2<90 Desaturation below 90 percent HR < 60 Heart rate drop below 60 beats per minute Vomiting Emesis Intubation Difficulty Ventilating Difficulty moving air into patients lungs Difficult Intubation Failing to intubate in two attempts or less by an
experienced provider Right Mainstem Intubation The endotracheal tube placed into the right
bronchial trunk Esophageal Intubation The endotracheal tube placed into the esophagus Maintenance Bronchospasm Difficulty breathing caused by the constriction of
the muscles in the walls of the bronchioles BP Drop >20% Blood pressure drop of greater than 20% of
baseline BP HR < 60 Heart rate drop below 60 beats per minute Light Anesthesia Patient stimulated during treatment; “bucking” Emergence Bronchospasm Difficulty breathing caused by the constriction of
the muscles in the walls of the bronchioles Laryngospasm The forceful closure of the vocal cords caused by
stimulation of the superior laryngeal nerve causing the inability to ventilate; can be partial or complete.
SpO2 < 90 Desaturation below 90 percent Vomiting Emesis Delayed Wakeup Emergence time of greater than 9 minutes after
anesthesia gas discontinued. PACU Respiratory Difficulty Difficulty breathing Wheezing Continuous course whistling sound during
respiration Pain Discomfort experienced by patient in the PACU
requiring medication Nausea/Vomiting Sensation of needing to throw-up/emesis
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VITA
Gaurav Agarwal was born on September 15, 1977 in Utter Pradesh, India. He
graduated from Lake Braddock High School, Burke, Virginia 1995. He attended James
Madison University in Harrisonburg, Virginia, where he received his Bachelor of Science
in 1999 in Health Sciences. Dr. Agarwal received his Doctor of Dental Surgery from The
Medical College of Virginia at Virginia Commonwealth University, Richmond, Virginia