Complications of Intravenous Sedation Versus General Anesthesia for Adolescent Patients Receiving Third-Molar Extraction

The American Association of Oral and Maxillofacial Surgeons (AAOMS) established the Oral and Maxillofacial Surgery Outcomes System (OMSOS) with the goal of “tracking national practice trends, estimating risk-adjusted outcomes of care, and determining associations between alternative processes of care and outcomes of care”.  While previous literature has focused on reporting anesthesia practices of oral surgeons in the ambulatory setting, studies are yet to risk-stratify adverse anesthesia complications for adolescent patients.  Therefore, the purpose of this study was to examine the complications resulting from intravenous sedation versus deep sedation/general anesthesia for adolescent patients receiving third-molar extraction, and whether any differences in complication risk exist between the two methods of anesthesia.  Our aims were to 1) document the type and frequency of anesthetics use, 2) calculate the anesthesia complication rate, and 3) model the risk of adverse complication for each of the methods of anesthesia.

A prospective cohort study was conducted on adolescent patients (defined as < 21 years of age) who underwent third-molar extraction procedures and were enrolled in OMSOS between January 2001 and December 2010.  The primary predictor variable was method of anesthesia used and divided by subjects receiving intravenous sedation and subjects receiving deep sedation/general anesthesia.  The primary outcome was adverse complication(s) resulting from anesthesia.  Multivariable logistic regression applied to measure the effect anesthetic technique had on adverse complication rate and adjusted for patient demographics, as well as preoperative anxiety level.

Overall, 29,548 subjects met inclusion criteria for the study cohort.  The most common narcotic used was fentanyl, followed by meperidine in both the intravenous sedation group (68.4% and 11.4%, respectively) and deep sedation/general anesthesia group (38.7% and 16.5%, respectively).  For subjects in both the intravenous and deep sedation/general anesthesia group, the most common benzodiazepine administered was midazolam (68.4% and 44.3%, respectively). 

Subjects receiving intravenous sedation were less likely to experience a complication from anesthesia in comparison to subjects receiving deep sedation/general anesthesia (99.5% and 99.2%, respectively; P = 0.032).  Subjects in the intravenous sedation group had an anesthesia complication rate of 0.5% and commonly experienced vomiting without aspiration during recovery (0.2%), prolonged emergence from anesthesia (0.1%), and new cardiac arrhythmia (0.1%).  Subjects receiving deep sedation/general anesthesia had an anesthesia complication rate of 0.9% and commonly experienced vomiting during aspiration during recovery (0.2%), prolonged emergence from anesthesia (0.1%), and peripheral vascular injury (0.1%). 

Multivariable logistic regression analysis revealed that ASA physical status was associated with a 72% increase of adverse complication per level increase (Adjusted Odds Ratio [AOR] 1.72 (CI 1.24- 2.38); P = 0.001).  Increase in preoperative anxiety score was also found to increase the risk of adverse anesthesia complication by 23% per level increase (AOR 1.23 (CI 1.06- 1.43); P = 0.005).  In comparison to intravenous sedation, administration of deep sedation/general anesthesia did not pose a significant increased risk of adverse anesthesia complication (AOR 1.63 (CI 0.95-2.81); P = 0.08).

In conclusion, this study demonstrates that there is no increased risk in adverse anesthesia complication when choosing between intravenous sedation versus deep sedation/general anesthesia for adolescent patients receiving third-molar extraction.  Future studies should evaluate anesthesia methods for extraction of teeth in other vulnerable populations such as the elderly to evaluate if any differences in risk of adverse anesthesia complications exist.

References

1. Perrott DH, Yuen JP, Andresen RV, et al: Office-based ambulatory anesthesia: Outcomes of clinical practice of oral and maxillofacial surgeons. J Oral Maxillofac Surg 61:983, 2003

2. American Society of Anesthesiologist: Manual for Anesthesia Department Organization and Management. American Society of Anesthesiologists, Park Ridge, IL, 2003