Administration of alternative drugs patient monitoring airway management

Abstract

Propofol has emerged as a leading sedative hypnotic in oral and maxillofacial surgery due to production problems with methohexital. Despite its popularity and advantages, propofol requires a learning curve that was not nearly as predictable as methohexital. Propofol has been a mainstay among anesthesiologists for almost fifteen years. Early in its clinical use, additional important uses were discovered for its administration. Alternative hypnotic medications include parenterally administered drugs such as ketamine, midazolam, as well as a host of rapidly acting opiates such as alfentanil and remifentanil. Sevoflurane, due to its favorable profile in both adults and children, warrants consideration as an alternative to propofol and methohexital. More effective medication choices have emerged for the prevention and treatment of postoperative nausea and vomiting including serotonin antagonists and dexamethasone. Combination therapy has improved their effectiveness in high-risk patients. Unfortunately, a most cost-effective medication, droperidol received a black box warning several years ago. Many clinicians have stopped administering this medication. Airway management has undergone revolutionary changes within the last 15 years. The American Society of Anesthesiologists promulgated an algorithm to manage the difficult airway in 1993 with a thoughtful update in 2003. The algorithm not only implied the technical use of the different devices but the more important evidence-based decision pathways. Most notably, rescue devices such as the LMA have become far more important in the nonsurgical arm of the decision making process. Awake management of the difficult airway has been stressed by many airway experts whenever possible. In oral and maxillofacial surgery, the nasotracheal route of airway management has been the mainstay for years. Recent uses of the LMA, including the flexible LMA and the intubating LMA, have garnered importance in oral and maxillofacial surgery. Monitoring of the patient undergoing oral and maxillofacial surgery has been revolutionized by the use of capnography and pulse oximetry in the past 15 years. Patient safety came only be enhanced by the use of these devices. However, public demands for the assurance that awareness is eliminated during anesthesia have lead to the use of bispectral index devices such as the BIS. These devices do not guarantee elimination of recall, however, they give the clinician a better indication of the level of consciousness. References American Society of Anesthesiologists: Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology 98:1269, 2003 Borgeat A, Wilder-Smith OHG, Suter PM: The nonhypnotic therapeutic applications of propofol. Anesthesiology 80:642, 1994 Jellish WS, Lien CA, Fontenot HJ, et al: The comparative effects of sevoflurane versus propofol.