Inhalation Anesthetic Agents in Oral and Maxillofacial Office Practice

Abstract

Summary All four agents have many of the characteristics that describe the ideal office anesthetic agent. Each represents substantial advances over the agents of Morton, Wells, and Long. The agent that the individual clinician chooses to include in his or her office practice depends on its intended use in that office. For the oral and maxillofacial surgeon who intends to use the anesthetic agent for inhalation inductions only, the nonpungent agents halothane and sevoflurane are the most rational choices. For short cases with pediatric patients, both agents perform well, but halothane causes more arrhythmias if epinephrine is also used. Both agents are appropriate for maintenance as well as induction in the pediatric patient. Halothane's only advantage in this situation is cost. It is the most economical of all agents and is the choice for those practitioners whose objective is to provide the lowest cost anesthesia for the pediatric patient. For the inhalation induction of adult patients, the most reasonable choice is sevoflurane because the risk of hepatitis usually precludes the use of the only other nonpungent agent, halothane, in the adult. For maintenance of anesthesia in the adult patient, isoflurane, desflurane, or sevoflurane is acceptable; in this situation the most significant differentiating characteristic is speed of emergence. Desflurane is clearly the fastest, followed by sevoflurane and then isoflurane. As is the practice with many anesthesiologists, it may be reasonable for the oral and maxillofacial surgeon to include more than one agent in office anesthetic practice, but this usually adds to the overall cost and complexity. The most versatile single agent available currently that closely approaches the ideal inhalation anesthetic agent for oral and maxillofacial surgery office practice is sevoflurane. This one agent is appropriate for both induction and maintenance of adult and pediatric patients, provides the second fastest emergence, has acceptable hemodynamics and respiratory function, and is not arrhythmogenic. Other than cost, the only potential deterrent to use of this agent is the theoretical concern for renal toxicity that currently has not been totally resolved. As the body of clinical experience with this new agent grows in North America, there will be continual reassessment for toxicity. After approximately 35 million administered sevoflurane anesthetics world wide, there have been no reports of renal toxicity causally related to sevoflurane,“ Current opinion among most experts in the anesthesia community is that this agent is safe and unlikely to become associated with toxicity. It is a substantial step closer to the ideal inhalation anesthetic and probably represents the best choice for oral and maxillofacial surgery office practice.