Is it safer to do one longer anesthetic than several shorter ones?
Myron Yaster MD, Lynne G. Maxwell MD, and Kyle J. Kramer DDS MS
I’m sure you’ve faced this question regularly. Is it safer to bundle several procedures into one longer anesthetic or do them separately as shorter anesthetics on different days? Indeed, it used to really bother me when the only thing that wasn’t added on to an anesthetic with multiple specialties and procedures was a haircut. Today’s PAAD by Berens et al.1 investigates this question by reviewing the experience of pediatric dental patients undergoing general anesthesia at Children’s Wisconsin in Milwaukee Wisconsin.
I must admit that I didn’t do many dental cases during my time at Johns Hopkins and was stunned by the enormous volume of dental cases I saw at Colorado (I was assured that the water was fluoridated!). My recent experience at the American Society of Dentist Anesthesiologists 2024 Scientific Session confirmed that Colorado was actually the norm and reinforced just how common anesthesia services are for both healthy and medically complex patients with dental needs ranging from a simple cleaning to significant restorations and extractions.
I’ve asked Dr. Kyle Kramer, a leader in dental anesthesiology and a member of the PAAD’s executive council, to assist Lynne and me in today’s PAAD. Myron Yaster MD
Original article
Berens RJ, Greene CC, Frahm CE, McCormick ME, Hoffman GM. Does anesthesia duration or number of cases per patient predict safety events? Paediatr Anaesth. 2024 Jun;34(6):568-574. doi: 10.1111/pan.14861. Epub 2024 Feb 21. PMID: 38379426.
Dental procedures under general anesthesia can be long and are often combined with other procedures to facilitate ease of scheduling for both the family and operating services. “The primary aim of this study was to test the null hypothesis that there is no difference in the incidence of perioperative quality and safety events between patients who receive complete dental care under one anesthetic (anesthesia start time to anesthesia stop for single encounter) versus those patients who receive multiple anesthetics for dental care. A secondary aim was to explore the risk associated with patient age, ASA category, anesthesia case time, and number of cases per patient.”1
“Since June 2015, the Children's Wisconsin Anesthesiology Department, coincident with the initiation of the quality process included in the American College of Surgeons Children's Surgical Verification Program (ACS CSVP),2,3 instituted a mandatory quality assessment performed by the responsible anesthesiologist for each anesthetic prior to closure of the anesthesia encounter. In addition, any other events identified through hospital quality and safety teams, resuscitation or rapid response, or death within 48 h of anesthetic completion are reviewed. Collectively these will be referred to as ACS/ASA/Safety events. These perioperative events were reviewed by one Children's Wisconsin anesthesiologist (R.J.B.) to ensure the validity of the perioperative event and to categorize each event into one of nine domains: neurologic; airway; respiratory; cardiac; other; human factors (communication, equipment, experience, judgment, mechanical, vigilance, technical); hospital-acquired conditions (central line infections, ventilator associated pneumonias, pressure ulcers, peripheral IV infiltrates and catheter related urinary tract infections); metabolic; and never events.”1 The data for this study were obtained from EPIC.
OK, what did they find? The incidence of severe, life-threatening events for pediatric dental patients undergoing general anesthesia was quite rare. However, when adverse perioperative events did occur, the most significant factors in safety complications were ASA PS > 2 and anesthesia duration > 4 hours. “Interestingly, the risk of 7 h of anesthesia time approximates the same risk as an ASA-PS of 4. We believe this is the first time a comparison of multiple anesthetics versus prolonged anesthesia time has been studied.”1 Are these findings generalizable to other procedures that produce more physiologic perturbations than dental procedures? Maybe, maybe not.
Furthermore, we have several concerns with the author’s basic conclusions. If you look closely at the supplemental figure 3 in the article you will see that most of the cases >4 hours were in ASA 3 and especially ASA 4 patients. Although they state multivariable logistic regression was done, they don’t comment on the interaction between anesthesia duration and ASA status. Similarly there may be an interaction between ASA status and multispecialty encounters. It also concerns us that they don’t specify the nature of the added specialty procedures or identify the anesthesia time associated with the prolonged dental only encounters vs multispecialty encounters. It would have been cleaner to have compared only prolonged dental encounters to multi-encounter anesthetics for dental only. Additionally, we wonder whether the author’s conclusion can be justified when there is such a huge disparity between the number of patients who underwent a single dental procedure (7765) and those who had multiple procedures (317) and the number who had anesthesia for <4 hours (8233) and those who had > 4 hrs (235). In addition, the table in the supplemental materials which stratifies a selection of adverse events by case duration < or > 4 hours, reveals that the sole significantly different safety event between the < and >4 hrs groups was HAI and this difference appears to be solely responsible for the reported significant difference in safety events overall. This detail seems important and diminishes the import of their conclusion. In general, the fact that the adverse events that were tallied were not identified in the paper is of concern.
Nevertheless, based on today’s PAAD, bundling many procedures or doing very extensive dental work and taking more than 4 hours appears to increase the risk of adverse perioperative adverse events. In the absence of other concerns (i.e., concurrent airway, cardiovascular, or other complicating factors), it is probably a good idea to consider breaking up the dental care into multiple sessions < 4 h in duration. Finally, bundling many procedures is not unique to dental cases. Hopefully, this study can be repeated in other settings to confirm or refute these findings.
What do you think? Send your responses to Myron who will post in a Friday reader response.
References
1. Berens RJ, Greene CC, Frahm CE, McCormick ME, Hoffman GM. Does anesthesia duration or number of cases per patient predict safety events? Pediatric Anesthesia 2024;34(6):568-574. DOI: https://doi.org/10.1111/pan.14861.
2. Barnhart DC, Fallat ME, Grant CA, et al. Evolution of the American College of Surgeons Children's Surgery Verification Program: Implications for optimizing multidisciplinary surgical care of the pediatric patient. Semin Pediatr Surg 2023;32(2):151276. (In eng). DOI: 10.1016/j.sempedsurg.2023.151276.
3. Wang KS, Cummings J, Stark A, et al. Optimizing Resources in Children's Surgical Care: An Update on the American College of Surgeons' Verification Program. Pediatrics 2020;145(5) (In eng). DOI: 10.1542/peds.2020-0708.