Indications For General Anesthesia Research Articles

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity. To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity. In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023. Cesarean delivery. The rate of general anesthesia for cesarean delivery by race and ethnicity. Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity. Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Stifling the sneeze in ACHOO syndrome-What the anesthesiologist should know.

Dear Editor, A 32-year-old male, a known patient of ocular amyloidosis, was posted for superficial keratectomy (removal of the corneal epithelium up to Bowman membrane) of the right eye under topical anesthesia. This patient had a history of photic sneeze reflex (PSR) since 12 years of age and was a diagnosed case of autosomal dominant compelling helio-ophthalmic outburst (ACHOO) syndrome. This condition is characterized by uncontrollable sneezing episodes on exposure to bright light or periocular injection including peribulbar block or eyelid infiltration. He suffered from continuous sneezing episodes lasting around 5 min even in response to slit-lamp examination. This was usually followed by a refractory period during which the ophthalmic examination was conducted. He had no other systemic illness. On the day of the procedure, he developed an irrepressible sneezing reflex after cleaning and draping of the right eye in the operating room. The ambient light had stimulated the PSR. The anesthesiologist was called for help. On clinical examination, the patient’s vitals were stable with a heart rate of 62/min, SpO2 98%, and blood pressure 100/70 mmHg. His sneezing fit had ceased but the patient was extremely anxious. An intravenous line was secured and he was administered midazolam 1 mg and fentanyl 50 μg intravenously. He became calm and allowed the gentle insertion of a wire speculum but still could not look at the light of the operating microscope though there were no more sneezing episodes. He was given another 50 μg fentanyl intravenously and reassured. The procedure was completed smoothly in 10 min. No further drugs were administered nor were there any sneezing episodes. A syringe filled with injection pheniramine maleate 22.75 mg was kept ready but was not required. Five days later, he was posted for superficial keratectomy of the other eye under monitored anesthesia care. The same anesthetic technique was followed and he was administered midazolam 1 mg and fentanyl 100 μg in small aliquots even before skin preparation. The procedure was completed uneventfully under topical anesthesia without a single sneezing episode. Sneezing fit after exposure to bright light or “sun sneezing” has been reported in about 25% of the population. These patients are also prone to a sternutatory reflex after local anesthetic injection under sedation.[1] Unexpected or sudden head movement during peribulbar block or eye surgery can cause globe perforation or vascular injury and retrobulbar hemorrhage.[2] PSR is a primitive brainstem reflex, sometimes considered a variant of the trigemino-cardiac reflex with the center in the trigeminal nucleus and adjacent reticular formation. The afferent arc is from the first (ophthalmic) and second (maxillary) division of the trigeminal nerve (VN) and the efferent is the vagus nerve. A cross-talk between the optic nerve (IIN) and VN has also been hypothesized.[3] No known treatment exists except avoidance. Few authors have found deep sedation, eyelid infiltration, midazolam, and propofol to increase the risk while opioids, dexmedetomidine, and antihistamines have been found to reduce the risk.[2,4] Some have even suggested PSR as an indication for general anesthesia in ophthalmic surgery.[5] It is important for anesthesiologists routinely caring for patients for ophthalmic surgery to be aware of this reflex as it can have severe sight-threatening consequences. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Scoline apnoea and pregnancy: SICU experiences

Background: Suxamethonium chloride (scoline) is a short acting depolarizing muscle relaxant; it was discovered early in the nineteenth century but not used in clinical practice until 1951.1 Scoline became a popular muscle relaxant due to its rapid onset of action, quick metabolism and hence shorter duration of action. It is metabolized by cholinesterase. Scoline apnoea was described within a few years of clinical use of Suxamethonium due to inherited or acquired deficiency of the cholinesterase enzyme resulting in prolonged muscle relaxation.2 Now scoline is used in prehospital and emergency intubating conditions, in pregnancy fetal distress or cord prolapse due to obvious advantages in these circumstances.3,4,5 The aim of our study was to investigate the trends and incidence of scoline apnoea in pregnant patients. Patients and methods: All patients admitted with scoline apnoea during pregnancy in the surgical intensive care unit of a tertiary healthcare facility were included retrospectively in our study. Patients demographic data, duration of apnoea and intubation, intensive care unit stay and trends of scoline apnoea were recorded. Results: A total of 32 pregnant patients post-lower segment caesarean section were admitted to the surgical intensive care unit during the study period. The indications for general anaesthesia in the majority of patients were obstetrical emergencies (n = 23, 71.87%), refused regional anaesthesia (n = 7, 21.87%), and required general anaesthesia after the regional anaesthesia (n = 2, 6.25%) patients. Twenty-nine (90.62%) patients received premedication with metoclopramide and sodium citrate (Table 1a). Thirty (93.75%) patients received reversal combination of neostigmine and atropine. Four (12.50%) patients received fresh frozen plasma (Table 1a). The mean age of the patients was 31.7 ± 6.4 years old (minimal age was 25 years), all patients belonged to ASA class 1 and the mean duration of apnoea time was 4 ± 2.5 hours. The duration of intubation was 6 ± 4.5 hours and the length of surgical intensive care stay was 1.2 ± 0.7 days (Table 1b).As shown in Figure 1a, the majority of patients were found to belong to the age group of 31 to 35 years (n = 12, 37.5%), followed by 9 (28.12%) patients in the age group of 26 to 30 years. It was also found that the Qatari locals and Egyptians formed the majority nationality (n = 12, 37.5% and n = 7, 21.87%) of patients (Figure 1b). The overall Arab patient population had a higher incidence of scoline apnoea compared to the Asian group of patients.All patients were found to have cholinesterase levels below 3500 units/litre (normal range varies from 5400 to 13,200 units/litres), which is less than 70% of the normal value (Figure 2a).There was a decreasing trend of scoline apnoea patients in recent years. From 2013 to 2016, there were no patients admitted to SICU with scoline apnoea and in 2017, only one patient with scoline apnoea was admitted (Figure 2b). Conclusion: Scoline apnoea incidence and trend in our parturient population is decreasing. The majority of our patients received premedication and reversal medication which decreases the cholinesterase levels. The decreasing trend may be attributable to increased regional anaesthesia practice and frequent use of rocuronium.

Dental Trauma

The article by Neuhauser et al focuses on recommendations for administering analgesia-sedation in painful procedures in children and adolescents. One serious and common item needs to be added to the list of indications (Box 2 in the article): dental treatment in anxious patients—in particular, in uncooperative children. Most dental and dental-surgical procedures (for example, tooth extractions) can be performed without any problems under local anesthesia. However, this is usually insufficient in patients with exaggerated phobias of dental treatment (dental phobia, oral phobia) or children. Anxiety is usually caused by several coinciding factors—such as particularly traumatic childhood experiences at the dentist’s (“dental trauma”). Further, mere reports of dentist’s visits may trigger phobias (1). The more experienced the dentist and the practice team are in dealing with (young) anxious patients, the better the patient will feel (2). Analgesia-sedation provides an additional, gentle instrument for administering diagnostic measures or necessary dental treatment in a calm and relaxed state (3). However, in some children, or in patients with extreme phobias, a general anesthetic will be required so as not to endanger the treatment result by overly strong phobic reactions or having to interrupt the treatment session. The indication for general anesthesia and how it should be administered will need to be discussed with the parents, the pediatrician or primary care physician, and the anesthesiologist. Whereas analgesia-sedation or general anesthesia should be given in order to enable successful local treatment in dental procedures, causative treatment of chronic phobias additionally requires psychological and psychosomatic approaches.

Not Coordinated

It is regrettable that the opportunity for an interdisciplinary statement in coordination with the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft fur Anasthesiologie und lntensivmedizin, DGAI), the Professional Association of German Anaesthesiologists (Berufsverband Deutscher Anasthesisten, BDA), and the German Society of Pediatrics and Adolescent Medicine (Deutsche Gesellschaft fur Kinder- und Jugendmedizin, DGKJ) was not used, and we wish to contradict the authors’ statement that specially trained non-anesthesiologists (analgesia-sedation team) will ensure a standard of patient safety in patients of ASA classes I and II during the administration of analgesia-sedation that is comparable to that provided by anesthesiologists (even when propofol is used). To write that problems are unlikely to occur in children of ASA classes I and II is to play down reality and risk danger. No compromise is possible with regard to the qualifications of the sedation team: every child requires a fully trained and experienced anesthesiologist. Deep analgesia-sedation is a variant of general anesthesia, and unexpected incidents with life-threatening consequences may occur at any stage, even in completely healthy children. The boundaries between the stages of sedation are fluid, and moderate sedation can turn into deep sedation at any stage. For this reason, the German Society of Anaesthesiology and Intensive Care Medicine and the Professional Association of German Anaesthesiologists have unequivocally explained in a recent statement: “Planned deep analgesia-sedation or analgesia-sedation in patients at risk (which includes children) should be administered by anesthesiologists. Other doctors should be consulted only if they have the required qualifications (additional qualifications in emergency medicine or intensive care medicine), if they have mastered the procedures, and if they are able to identify life threatening events early and deal with these according to the specialty standard for anesthesiology” (1, 2). Further, the indications listed in Box 2 of the article are really indications for general anesthesia with endotracheal intubation.

The Frequency of and Indications for General Anaesthesia in Children in Western Australia 2002–2003

We conducted a retrospective database search of the Hospital Morbidity Data System at the Health Department of Western Australia to determine the number of anaesthetics given to children aged 16 years or less in Western Australia over a twelve-month period. Information was also collected to assess the types of surgery for which anaesthesia was being provided, and the categories of hospital in which children were being anaesthetized. We found that 28,522 anaesthetics were given to 24,981 children, and 2,462 (9.9%) children had more than one anaesthetic. Five and a half percent of the children in Western Australia had an anaesthetic during the twelve months studied. The most common types of surgery were ear nose and throat (28% of anaesthetics), general (21%), dental/oral procedures (17%) and orthopaedic (15%). There was a bimodal distribution in the incidence of anaesthesia versus age, with peaks at 4 years and at 16 years. The most common category of hospital that children were anaesthetized in was private metropolitan (40%) followed by tertiary (38%), rural (14%) and public metropolitan (8%). One thousand, seven hundred and seven children aged less than one year were given an anaesthetic. These anaesthetics were most frequently given to children in tertiary hospitals (62%) followed by private metropolitan (30%), public metropolitan (6%) and rural hospitals (2%).

General anaesthesia for dentistry

Although general anaesthesia is used to reduce the pain and anxiety associated with dental treatment, most dental procedures can be managed with good local anaesthesia, with or without conscious sedation. Since the 1960s there has been a progressive fall in the use of general anaesthesia for dentistry and in the mortality associated with it. However, between 1996 and 1999, eight people died as a result of dental anaesthesia, five of them were children. Investigations and inquiries into these deaths were critical of the standard of care provided in areas such as preoperative assessment, perioperative monitoring, resuscitation and transfer to a critical care facility. In response to these concerns, the General Dental Council (GDC), the Royal College of Anaesthetists (RCA) and the Department of Health (DOH) have issued closely linked guidelines for standards of care in dental general anaesthesia. Since 1 January 2002, general anaesthesia for dentistry has been confined to a hospital setting with critical care facilities. This article summarizes the guidelines, with particular reference to the status of the anaesthetist, the indications for general anaesthesia, patient referral and assessment, the definition of a hospital setting, peroperative monitoring and resuscitation, and management of the emergency; it also reviews the technique of dental anaesthesia in current use.

The Role of Anesthesiology During the Performance of Endoscopic Retrograde Cholangiopancreatography: Indications and Outcomes at a Tertiary Care Center

Background: Adequate sedation and amnesia are important in the performance of ERCP's. In the ill or uncooperative patient the decision to involve anesthesiology for administrating monitored anesthesia care (MAC) or general anesthesia (GA) is often important for patient safety and procedural success. We evaluated characteristics, indications, and complications in patients undergoing ERCP with anesthesiology assistance at our tertiary referral center. Results: From 7/1/02 to 6/30/04 2077 ERCP's were performed. A total of 192 procedures were performed in 111 patients with anesthesiology assistance. One hundred eighty-nine patients received GA and 3 received MAC. Sixty patients were female. The average procedural age was 43.9 years. Indications for GA or MAC included age of 18 or less (34%), ASA class IV (10.4 %), inability to sedate during an earlier procedure (11.4 %), chronic narcotic use (14.1 %), age 85 or greater (6 %), and sepsis (4.6 %). Thirty-four percent were ASA II and 40.6 % were ASA class III. Eight had PSC, 11 had choledochoceles, and 2 were pregnant. Ninety-one percent of procedures were therapeutic. Findings: 6 normal exams, pancreatic duct dilation in 75, common bile duct (CBD) dilation in 57, CDB stone in 30, benign CBD stricture in 35, benign pancreatic duct stricture 39, malignant biliary stricture in 11, pseudocyst 16, anastomotic stricture after liver transplantation in 9, pancreatic divisum in 5, and pancreatic mass in 5 patients. Procedural success was 98%. Anesthesia complications occurred in 2 patients (1%) (prolonged paralysis and uncomplicated ventricular tachycardia). Thirty- four patients were discharged the same day. Seventy-two were discharged within 24 hours of the procedure. Thirty-six of the 72 had sphincterotomies necessitating a 24 hour observational stay at our institution. Fifteen patients were discharged within 48 hours. Eight patients were admitted for an average of 6.9 days. The remaining 57 procedures were performed on hospitalized patients. Conclusion: Anesthesia support is employed in a variety of conditions and not limited to those with multiple comorbidities. The involvement of anesthesiology increases the procedural success and can be accomplished with low morbidity.

Prospective multidisciplinary audit of obstetric general anaesthesia in a District General Hospital

In the 3 years leading up to March 2001, the general anaesthesia rate for emergency and elective caesarean sections at our hospital was higher than that recommended by the Royal College of Anaesthetists. There were also concerns regarding the quality of communication between surgeon and anaesthetist prior to emergency caesarean section. A multidisciplinary audit was undertaken on both the indications for obstetric general anaesthesia and quality of communication between staff members during the perioperative period between January and August 2002. The results of the audit highlighted potential serious shortfalls in communication and teamworking; however, there was insufficient information to assess the appropriateness of the indication for general anaesthesia. Following this audit recommendations were made to improve communication channels between the personnel on labour ward and this coincided with a reduction in the use of general anaesthesia.

Evaluation of Endoscopic Retrograde Cholangiopancreatography Under Conscious Sedation and General Anesthesia

In adults, general anesthesia is usually only provided during endoscopic retrograde cholangiopancreatography (ERCP) when prior attempts using conscious sedation have failed. It was hypothesized that in our hospital, other factors might be associated with general anesthesia for ERCP. The aim of this study was therefore to assess the indications for ERCP under general anesthesia, and to evaluate the underlying diseases, type, and efficacy of ERCP under general anesthesia in comparison with conscious sedation. We retrospectively analyzed 1,056 ERCPs that had been carried out with the patients under general anesthesia or conscious sedation. The indications for general anesthesia were recorded, and the underlying diseases, the type and success of the interventions, and the causes of premature ERCP termination in both groups were assessed. Eighteen percent of the ERCPs were performed under general anesthesia and 82% under conscious sedation. The indications for general anesthesia were related to the type of procedure planned (46%), premature termination of ERCP under conscious sedation (28%), and other reasons. Patients with primary sclerosing cholangitis and liver transplant recipients received general anesthesia more frequently (general anesthesia vs. conscious sedation, 36% vs. 16%, P < 0.0001 and 22% vs. 13%, P = 0.003). Conscious sedation was provided more frequently in patients with neoplasms and cholelithiasis (21% vs. 12%, P = 0.004 and 13% vs. 3%, P < 0.001). Painful dilations were performed more frequently with the patients under general anesthesia (60% vs. 19%, P < 0.001), whereas major papillotomies were preferably performed with conscious sedation (34% vs. 21%, P = 0.006). More interventions per ERCP were performed with the patient under general anesthesia compared to conscious sedation (P < 0.001), during the same time (51 +/- 28 min vs. 52 +/- 26 min, P = 0.39). With conscious sedation, the ERCP failure rate was double that with general anesthesia (7% vs. 14%, P = 0.012), mainly due to inadequate conscious sedation (61%). The frequent use of general anesthesia for ERCP at our institution is related to the underlying diseases, which are frequently treated with complex and painful ERCP procedures. The efficacy of ERCP with general anesthesia supports a continued preference for general anesthesia rather than conscious sedation when complex and painful interventional ERCP procedures are planned.

7041 Is ercp under general anesthesia more complicated compared to ercp under conscious sedation?

ERCP is usally performed under intravenous analgosedation (AS). In particular cases examinations or planned interventions have to be terminated prematurely due to inadequate sedation. In cases of difficult anatomy supine position is useful. Supine position requires intubation for airway protection. Methods: In the present study we compared the extent and efficacy of examinations performed under general anesthesia (GA)and AS. 20 ERPCs under AS and GA (10m, 10f) were analyzed. ERCPs under AS were carried out in left position, ERCPs under GA in supine position. Results: Patients who received GA were younger compared to patients who received AS (40 vs. 51 years mean). The underlying diseases were distributed similary. In the GA group interventions were more extensive. Indications for GA were: prematurely terminated ERCP under AS due to inadequate sedation (n=10), intubation for airway protection and achievment of ideal examination conditions (n=10). To identify risk factors, the ASA-(American Society of Anesthesiologists) classification was used. Both groups showed the mean ASA-grade 2. All patients were recovered from GA without incidents with postoperative extubation at a mean time of 8.7 min after termination of ERCP. The recovery time until PARS (post anesthesia recovery score) >9 achieved did not differ between the groups examined (AS vs. GA: 12.1 vs. 13.0 min, p=0.20). In comparison to AS, more interventions were performed under GA (2.4 vs. 1.7). The duration of ERCP under GA was 25 min prolonged (GA vs. AS: 59 vs. 34 min). All ERCP performed under GA were successful, whereas 2 examinations under AS had to be terminated prematuraly due to inadequate sedation. The endoscopic procedure was not impaired by monitoring, oral intubation, mechanical ventilation and supine position. Discussion: Although more extensive ERCP interventions were performed, and the duration of ERCP under GA requieres more time compared to AS, recovery time did not differ. There were no complications due to the anesthetic procedure. GA allows a successful and safe completion of difficult ERCPs.

REGIONAL ANESTHESIA SHOULD BE THE FIRST CHOICE OF ANESTHESIA IN EMERGENT CESAREAN SECTIONS WHENEVER POSSIBLE

S260 INTRODUCTION: There is considerable evidence demonstrating that neither regional nor general anesthesia will cause harm to the fetus if the anesthetics are administered properly, however maternal morbidity and mortality for cesarean section (CS) under general anesthesia (GA) is considerably higher than with regional anesthesia (RA). Despite the potential benefit of RA, many obstetricians and anesthesiologist hesitate to undertake a RA for an emergent C/S because of concern about an inadequate block, or delay in onset of induction of anesthesia as compared to a GA. Indeed some studies show that a RA can slightly delay the start of a C/S. No study has examined fetal and maternal outcome when a RA is attempted and then converted to GA because of a failed or inadequate block. This study was undertaken to determine whether the additional time taken for induction of RA and subsequent conversion to GA because of failed or inadequacy of block, adversely affects neonatal or maternal outcome, as compared to cases where the initial anesthetic choice was GA. METHODS: Parturients who underwent emergency cesarean section under GA between 12/1996-12/1997 were identified from a prospectively collected computerized obstetric anesthesia data bank. Data were extracted regarding maternal age, weight, ASA status, gestational age, indication for C/S, indication for GA, Apgar scores, cord blood gases, neonatal birth weight, OR entry /anesthesia start times, delivery times, and uterine incision to delivery times. Since in most clinical situations the anesthesia start times begins once the patient enters the operating room (OR), we calculated OR entry/anesthesia start to delivery times. The data obtained was divided into two groups: A= patients who received GA, B= patients who initially received RA which was subsequently converted to GA. Chi-square analysis and the Mann Whitney U test were used to compare the groups. RESULTS: A total of 661 C/S were performed, 68 of which received GA (10.14%). Of these 68, 35 had GA without failed RA and 33 patients had GA after failed regional. The rate of RA's subsequently converting to GA was 5.27%. There was no significant difference between the two groups with regards to patient age, weight, gestational age, and uterine incision to delivery times, Apgar scores at 1 and 5 minutes, cord blood gases, or indications for C/S despite the longer anesthesia start to delivery time in group B. Indications for emergency C/S did not differ between groups and were fetal distress (46%), malpresentation (13%), abruptio placenta (6%), failure to progress (3%), placenta previa (6%), and other (26%). (Table 1)Table 1CONCLUSION: Our data support the use of regional anesthetic as a first choice for emergent C/S when the patient is hemodynamically stable, and without coagulopathy, since it provides for a safer anesthetic which puts the mother at less risk for morbidity and mortality. This study also suggests that despite the additional time often required for regional anesthesia induction, even in the face of a failed regional which is subsequently converted to GA, neonatal outcome is not significantly affected.

General anesthesia for cesarean section at a tertiary care hospital 1990–1995: indications and implications

Complications of general anesthesia for cesarean section remain the leading cause of anesthesia-related maternal mortality. General anesthesia, however, is becoming less popular for obstetric anesthesia, and thus fewer cesarean sections are conducted using this technique. As the number of general anesthesia cases decrease, the number of difficult intubations witnessed and managed by residents decreases. In addition, patients who undergo general anesthesia may have co-morbidities which, while not contraindicating regional anesthesia, may increase the risk of providing anesthesia. We reviewed the medical records of 6 calendar years (1990–1995) at our busy tertiary center, to determine patient demographics, indications for cesarean section, indications for general anesthesia, time of day, and complications related to airway management. From 1990 through 1995, cesarean sections under general anesthesia decreased from 7.2% to 3.6% ( P = 0.0001), however, they were performed on parturients with more maternal diseases (17.2% to 35.8%; P = 0.0034). Although the incidence of difficult intubations in those years ranged from 16.3% to 1.3%, only one failed intubation with resultant maternal mortality occurred. Few residency programs offer instruction on the difficult airway in the parturient population. Organized airway management programs specifically for the obstetric population may assist efforts to decrease the morbidity and mortality associated with the provision of general anesthesia for cesarean section.

A Study of Arterial Oxygenation as an Additional Indication for General Anesthesia in Endoscopy

A Study of Arterial Oxygenation as an Additional Indication for General Anesthesia in Endoscopy

Indications for General Anesthesia in the Extraction of Deciduous Teeth*

Indications for General Anesthesia in the Extraction of Deciduous Teeth*