Reader response

Myron Yaster MD

From Ralph Epstein, DDS, Dentist Anesthesiologist, Chief, Division of Dental Anesthesiology and Program Director of the Dental Anesthesiology Residency program at Stony Brook Medicine and Stony Brook School of Dental Medicine

My remarks below are my personal opinion after 45 years of providing clinical anesthesia care and teaching at the predoctoral and residency level. I have also been privileged to be Chair of the New York State Board for Dentistry, and Chair of its Anesthesia Committee. In addition, I have been president of the American Society of Dentist Anesthesiologists and President of the American Dental Board of Anesthesiology. My positions in the ADA and CODA have been as a member of the Council on Ethics, Bylaws and Judicial Affairs, member of the Anesthesia Committee (Committee H) and a member of the Residency Review Committee for GPR and Anesthesiology. I mentioned the above to show that my views are not just from being a clinical provider but from someone who accepted positions where I was responsible for the safety of New York State Citizens and other positions where I helped lead the profession of dental anesthesiology.

During my years of clinical experience, I practiced as a single provider (operator/anesthetist) and as someone who was the anesthesia provider for general dentists and dental specialists. My opinions are not new to me. I have had them for many years. I am very fortunate to have lived through the evolution of newer sedative and general anesthetic medications, medications that work faster and have significant life altering effects in an incredibly short period of time. More impressive is the evolution of monitors we use. For at least 4 years following my anesthesia training I treated patients without pulse oximetry (the monitor was not yet available) a little longer without capnography and much longer without brain monitoring (BIS or SedLine). Today, I routinely use all these monitors. The essence of this paragraph is our medications and monitors have evolved and so have I. I have not provided care as an operator/anesthetist in decades.

I am writing this to comment on the proposed guidelines here, specifically, lines 583-609. In this section, two models of care for pediatric patients relating to personnel are proposed. Model 1 is what we have called for decades the Operator/Anesthetist or the single provider model. Model 2 is the separate provider Model with an official licensed anesthesia provider be present along with the dentist or oral & maxillofacial surgeon who is providing the dental/surgical care. Just as our medications & Monitors have evolved, it is time that our guidelines and regulations for treating children evolve. All the monitors I mentioned require a degree of interpretation to recognize some irregularity, diagnose the cause of the irregularity and treat the problem. This takes a certain amount of time, and experience. When a doctor is focused on the surgery he/she cannot readily refocus on the status of the patient including vital signs and determine the best treatment to correct the problem. Even as an independent anesthesia provider I have had the surgeon/dentist say I just need 30 seconds, a minute more to finish rather than just allowing me to correct the problem. We all know and have experienced how quickly a child can decompensate in 30 seconds or a minute. One question we must answer, is it more likely for the surgeon/dentist to stop when the independent anesthesia provider says stop, the saturation is too low or when the dental assistant says the saturation is “88” and the dentist/surgeon says I just need a few more seconds.

My conclusion is that we need to evolve and provide the safer treatment model, that being the separate anesthesia provider. In this case Model 2.

From Rich Berkowitz, MD, FAAP, Department of Anesthesiology, Pain ,and Perioperative Medicine, Powers Health, Munster, Indiana

To this day I advocate that children not get their dental procedures requiring anesthesia done in offices. I covered this many years ago in my chapter in Smith’s that Peter Davis edited. While the latter is not always possible due to cost constraints, I totally concur with Randy and Charlie’s assessments here, and referenced Charlie’s initial work in the book chapter

The second time I wrote the chapter was with a colleague who owned an office -based anesthesia practice utilizing ONLY physician or dental anesthesiologists... in fact, his practice was certified by one of OP/ ambulatory certifying bodies which mitigated the need for the dental and cosmetic offices to go through certification. Furthermore, I lobbied the DOI several times in Indiana to make insurance companies cover anesthesia services, based on safety issues, in our surgery center under the family’s medical plan. Most of the time I was successful. Each state has their own laws on what must be covered and what doesn’t have to be.

I feel like we are going backwards... and not until there is a catastrophe will things change... again.... If one is a dentist or pediatric dentist, why in the world would you not want qualified staff there monitoring the child and use quality data to improve practice.

From Dr Gareth Kantor, MBChB | Diplomate, American Board of Anesthesiology, Honorary Lecturer, University of Cape Town, Assistant Professor, Case Western Reserve University, Faculty, Institute for Healthcare Improvement commenting on TIVA in pediatric practice here

I’m surprised that processed EEG monitoring didn’t feature in this motivation for switching to TIVA. In the 2006 ASA Practice Advisory for Intraoperative Awareness and Brain Function Monitoring, consultants agreed that a brain electrical activity monitor should be used for patients undergoing TIVA; ASA members were equivocal.[1]

The POQI-6 Joint Consensus Statement (2020) from the American Society for Enhanced Recovery and Perioperative Quality Initiative recommended that EEG monitoring be considered as part of monitoring to guide anesthetic management.[2], The UK’s 2018 NICE guidelines (Cochrane Library) proposed that depth of anesthesia should be monitored using EEG-based devices during TIVA.[3]

There are no formal society guidelines mandating EEG monitoring specifically during pediatric TIVA, but expert consensus and recent reviews advocate for its use in this population:

• TIVA dosing in children is less predictable than in adults. Traditional pharmacokinetic-based dosing using age and weight frequently leads to oversedation, and there is no end-tidal measurement equivalent to confirm drug delivery.[4][5][6]

• EEG monitoring is considered especially important in children receiving TIVA with neuromuscular blockers, as well as in neonates, infants, children with atypical neurodevelopment, altered consciousness, or limited cardiorespiratory reserves.[4][7]

• A 2019 review in Anesthesiology stated that processed EEG monitoring is helpful in pediatric TIVA and target-controlled infusion anesthesia, particularly in the presence of neuromuscular blockade.[5]

• Quality improvement initiatives at major pediatric centers have set goals of EEG use in ≥80% of TIVA cases.[11][12]

• A 2026 review summarizing recent advances in pediatric TIVA notes that EEG-guided and combined pharmacokinetic-EEG strategies enhance safety in infants and represent a key direction for the field.[6]

An important caveat is that processed EEG (pEEG) indices such as BIS and PSI were developed and validated in adults and may not reliably indicate hypnotic state in neonates and young infants. Expert reviews therefore recommend learning to interpret non-proprietary EEG parameters (raw EEG waveform, spectral-edge frequency, density spectral array) rather than relying on index values.[4][8][9]

References

1. Practice Advisory for Intraoperative Awareness and Brain Function Monitoring: A Report by the American Society of Anesthesiologists Task Force on Intraoperative Awareness. Anesthesiology. 2006;104(4):847-64. doi:10.1097/00000542-200604000-00031.

2. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on the Role of Neuromonitoring in Perioperative Outcomes: Electroencephalography. Chan MTV, Hedrick TL, Egan TD, et al. Anesthesia and Analgesia. 2020;130(5):1278-1291. doi:10.1213/ANE.0000000000004502.

3. Intravenous Versus Inhalational Maintenance of Anaesthesia for Postoperative Cognitive Outcomes in Elderly People Undergoing Non-Cardiac Surgery. Miller D, Lewis SR, Pritchard MW, et al. The Cochrane Database of Systematic Reviews. 2018;8:CD012317. doi:10.1002/14651858.CD012317.pub2.

4. The Utility of Electroencephalography in Guiding General Anesthesia in Children. Bong CL, Yuan I. Anesthesia and Analgesia. 2026;142(6):1155-1168. doi:10.1213/ANE.0000000000007230.

5. Practicalities of Total Intravenous Anesthesia and Target-Controlled Infusion in Children. Anderson BJ, Bagshaw O. Anesthesiology. 2019;131(1):164-185. doi:10.1097/ALN.0000000000002657.

6. Update on Total Intravenous Anesthesia in Children. Quintão VC, Carlos RV, von Ungern-Sternberg BS. Current Opinion in Anaesthesiology. 2026;39(3):304-316. doi:10.1097/ACO.0000000000001635.

7. A Narrative Review Illustrating the Clinical Utility of Electroencephalogram-Guided Anesthesia Care in Children. Bong CL, Balanza GA, Khoo CE, et al. Anesthesia and Analgesia. 2023;137(1):108-123. doi:10.1213/ANE.0000000000006267.

8. Intraoperative Pediatric Electroencephalography Monitoring: An Updated Review. Yuan I, Bong CL, Chao JY. Korean Journal of Anesthesiology. 2024;77(3):289-305. doi:10.4097/kja.23843.

9. Electroencephalographic Density Spectral Array Monitoring in Pediatric Anesthesia: Clinical Background and Practical Applications. de Heer IJ, Weber F. Minerva Anestesiologica. 2023;89(4):351-358. doi:10.23736/S0375-9393.23.16999-9.

10. Implementation of an electroencephalogram‐guided propofol anesthesia education program in an academic pediatric anesthesia practice. Yuan I, Missett RM, Jones-Oguh S, et al. Paediatric Anaesthesia. 2022;32(11):1252-1261. doi:10.1111/pan.14520.

11. Implementation of an electroencephalogram‐guided propofol anesthesia practice in a large academic pediatric hospital: A quality improvement project. Jones Oguh S, Iyer RS, Yuan I, et al. Paediatric Anaesthesia. 2024;34(2):160-166. doi:10.1111/pan.14791.

12. Effect of age on Narcotrend Index monitoring during sevoflurane anesthesia in children below 2 years of age. Dennhardt N, Arndt S, Beck C, et al. Paediatric Anaesthesia. 2018;28(2):112-119. doi:10.1111/pan.13306.

From Dheeraj Nagpal MD

I read with interest the PAAD Pediatric Total Intravenous Anesthesia (TIVA): Is this the next great evolution in the practice of pediatric anesthesia.?

I have used propofol with and without other intravenous medications in both peds and adult patients. Four concerns come to my mind;

1) Are we concerned about propofol’s context sensitive half life, especially if higher dose is used.

2) Propofol if used repeatedly does cause tolerance/tachyphylaxis.

3) Propofol Infusion syndrome (PRIS) has to be kept in mind

4) We are discarding unused propofol in the regular trash, what are the implications of it seeping in ground water and contaminating it. I understand that some centers discard it in sharps containers and possibly incinerate it.

From anonymous

I have to say that I am tired of the “Inhaled anesthetics are potent greenhouse gasses and contribute to healthcare associated emissions” kabuki theater. Attached is an editorial that calls out this easy, politically correct but risk-free approach to climate change. We are figuratively pissing in the ocean and not dealing with the real problems in medicine that promote climate change.

Editorial

Weinberg L, Keane M, Barach P, Edward R. The 0.00015 degree problem: learning from the environmental debates around desflurane. Anaesthesia. 2026 Aug;81(8):1043-1046. doi: 10.1111/anae.70201. Epub 2026 Mar 12. PMID: 41816960; PMCID: PMC13352580.

I am not a denier; I have a 5 year-old grandson and I dread the world he is inheriting. But pretending this matters is frankly insulting. Tell me, if there was no climate issue, what propellant would you rather have in a metered dose inhaler? I think dry powder inhalers have patient compliance issues that we aren’t talking about. My point is why do we think we should potentially compromise patient care in order to fulfill some climate “goal”? Why is it OK that the oil and gas industry continues to “flare” megatons of CO2 into the atmosphere, but my patient has to choose an inferior medication delivery device? Or needs these medications at all thanks to the toxic air we breathe?

Or we stop using desflurance despite it having some niche indications, but the top 0.1% fly around in their private jets and create 12% of total CO2 emissions? Or thousands of anesthesiologists flying to the ASA meeting in San Diego in October. Don’t say it’s because it’s something we can control. It is a waste of our effort to do something meaningful, like reducing the plastic pollution we create or the hydrocarbon supply chain that provides our TIVA syringes. Or not flying to San Diego but pressing ASA for a virtual meeting. Whoops, how much money does ASA make on the Annual Meeting? The irony of flying to San Diego to hear a talk on Anesthesia and Climate Change is thick, isn’t it?