PRACTICE MAKES PERFECT

 

We all saw it coming; the protocol improvements in CPR are official. Next time that you and your staff re-certify you will encounter these changes.

 

Based on clinical research it was found that while 5 percent of cardiac arrest victims survived without CPR, only 6 percent of those who received standard CPR survived, what a frustrating, low yield technique! However, when bystanders performed chest compressions without mouth-to-mouth breathing, the survival rate jumped to 11 percent, quite a substantial improvement! Gone for now is the old CPR dogma of the ABC’s of CPR (Airway, Breathing, and Circulation).

 

The new courses will teach you the change to CAB (Circulation, Airway, and Breathing). Can’t we all remember the endless fumbling around to open the airway before giving the first breath? How could this change make sense? Think of the residual capacity of the lungs. What a great reservoir of life giving Oxygen!

 

What about the changes in the compression: breathing ratios for almost all scenarios? The compression: breath ratio has been changed to 30:2. Think of the bathroom soap dispenser, how many pumps does it take to get the viscous soap moving, and if you stop, how many more to get it started again?

 

The only thing with survival improvement in this league was the arrival of the AED. The NJDSA executive committee will continue their successful AED rebate program for the next three years with the following requirements:

1. The AED rebate program is available only to regular NJDSA members who have paid full membership dues for the year prior to their request.

2. Documentation will need to be provided from the ADSA’s web site to show the active member status of the rebate applicant.

3. A copy of a paid receipt for a new AED will need to be provided, not for reprogramming of an older model or a supplies purchased.

4. A photograph or photocopy of the back of the new AED needs to be provided showing the unit’s serial number to be verified on the purchase receipt.

5. One AED rebate per member per year.

 

Martin Kaminker, DMD

 

OH FENTANYL! OH FENTANYL! WHERE ART THOU, MY FENTANYL???

 

(With appreciation to William Shakespeare for inspiration to write)

Seems like there is another shortage of the anesthesia drugs we need and use every day. This time it’s Fentanyl. Just a few weeks ago a colleague called me all worried and anxious. He was running out of Fentanyl and he wasn’t able to get any. “Backordered” all over. “What can I do?” “What can I use instead of Fentanyl?” Add to this: midazolam, diazepam (that old stuff), alfentanil, and odansetron, dexamethasone, and atropine. Every week it’s something else on backorder or “we won’t get that in until the end of next month, maybe!”

 

I know you all know how to use narcotics and opioids; you did it once upon a time. Let’s go into the Way Back Machine with Mr. Peabody and Sherman and see what is on the menu. Some substitutes for Fentanyl: of course you can use Demerol (meperidine); most of us had the chance to use during residency and training, relatively inexpensive, easy to get, still available. Of course morphine (MS) will do in a pinch. Just remember a longer time to onset and longer time of duration. You can try Dilaudid (hydromorphone) for your longer cases. (Read & review any drug first before using it)

 

What about remifentanil? (‘Ultiva’) It has to be diluted and must be used with a pump. (If you don’t have a pump, don’t buy it. The infusion rates are in micrograms per kilogram per minute. It is not for the “bump along” bump the syringe plunger technique many use for propofol or methohexital.)

 

For short acting opioids there are alfenta and sufentanil. (I use alfenta with my propofol via pump. In a similar way I use remi and propofol mixtures.)

 

What to use in addition to the regular midazolam? (Or when there is none left in the cabinet?) Remember diazepam (‘Valium’) was used very successfully for decades. Keep in mind it is not in an aqueous carrier (propylene glycol) like midazolam. So use a larger vein, inject slowly, with fast running IV fluid.

For postoperative pain management try ketorolac (‘Toradol’) or ibuprofen (‘Caldolor’). To provide smoothness to your sedation technique, use your propofol on the pump. What if you want a pinch more analgesia during the rougher aspects of a particular case? Sometimes ketamine provides the perfect answer. Use of a small amount (10 mg) with its fast action and limited duration provides a synergistic addition to sedation techniques.

 

If you have the vaporizer in your treatment room, use the sevoflurane or isoflurane to enhance your anesthesia. I use “sub MAC” doses of inhalation agents to balance my anesthetics all the time. I visited a beautiful office with a surgical suite. I was impressed that there was a full anesthesia machine with two vaporizers. When I inquired when they were used, the answer, “not for a long time.” I was heartbroken!!! – Two magnificent vaporizers strung up on the deck , just as functional as attractive bookends to my old “Hardy Boys” collection on the bookcase somewhere. To find the doses, look up in your anesthesia text, go online, and only in the last resort, call me.

 

And don’t forget the nitrous oxide & oxygen! It’s our birthright to use it. If the patient can breathe through their nose and exchange easily, nitrous is a great helper. With the cost rising and availability of all my other choices in question these days, how fortunate our oldest dental anesthetic is still around.

“Oh Nitrous! Oh Nitrous! Where art thou, my Nitrous Oxide???”

 

Lee M. Lichtenstein, DMD