A healthy 18-year-old female with no known health conditions
is complaining of tooth pain. The dentist diagnoses her with a cavity and
schedules her for a root canal. During the root canal procedure, the patient
continues to stop the procedure due to pain. The dentist decides to give an additional
1.8mL dose of 0.5% Marcaine, to effectively numb the area being operated on.
The additional dose of Marcaine was ineffective and the encountered
complications resulted in the procedure running longer than anticipated. At this
point in the surgery the roots of the tooth are fully exposed and the patient is
still not receiving proper pain relief to allow the procedure to continue. The
dentist is now behind schedule and determines that another 1.8mL dose of 0.5% Marcaine
is necessary to stabilize the tooth until she can return to complete the
procedure. Immediately after the third dose the patient begins to complain of
an excruciating head ache, nausea, and light sensitivity. The dentist believes
the symptoms are a result of experiencing pain during the operation and he
decides to shut off the lights and let the patient rest while they call a
designated driver to come pick her up. Shortly after, the patient begins
exhibiting loss of consciousness, muscle convulsions, and becomes incontinent.
The patient is rushed to the emergency room and based on clinical symptoms, is diagnosed
with a Marcaine overdose.
Based on FDA regulations the recommended concentration and
dose of Marcaine for a dental block is 0.5% Marcaine at 1.8-3.6mL per site not
to exceed 3mg/kg. The patient weights 54kg and has received a total of 5.4mL (27mg)
of 0.5% Marcaine. The FDA also states injections should be made slowly and with
frequent aspirations. These recommendations are for local anesthetic use in the
maxillary and mandibular areas only.
A study assessed the
incidence of intravascular needle entrance in mandibular nerve block injections
and found that 15% of injections resulted in needle entrance into the vessel confirmed
by a positive aspiration test (Taghavi Zenouz et al.,
2008). These results stress the importance of aspiration prior to injection
and only 60% of dentists declared that they often perform aspiration before
inferior alveolar (mandibular) nerve block (Taghavi Zenouz et al., 2008).
https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/018692s015lbl.pdf
Taghavi Zenouz A,
Ebrahimi H, Mahdipour M, Pourshahidi S, Amini P, Vatankhah M. The Incidence of
Intravascular Needle Entrance during Inferior Alveolar Nerve Block Injection. J
Dent Res Dent Clin Dent Prospects. 2008 Winter;2(1):38-41. doi:
10.5681/joddd.2008.008. Epub 2008 May 15. PMID: 23285329; PMCID: PMC3533637
This was interesting to read, I wonder what ended up happening to the Doctor who administered the shots. It is important to know, especially for anyone pursuing any type of career in health that there are limits to what can be done to a patient. I am pretty sure the dentist in that position must have been in a stressful spot having to weigh the decision of either administering more anesthesia to finish the job or just stop the procedure before things got worse. Either way it seems that all of this could have been avoided if the anesthesia was administered properly. It seems that anesthesia can be more dangerous than I originally thought and it can even cause toxicity (Dickerson & Apfelbaum, 2014). At the end of the day there more benefits than cons to using local anesthesia if it is given the right way.
ReplyDeleteDickerson, D. M., & Apfelbaum, J. L. (2014). Local anesthetic systemic toxicity. Aesthetic surgery journal, 34(7), 1111–1119. https://doi.org/10.1177/1090820X14543102
Hi Shelbi!
ReplyDeleteThis was a very interesting case study to read and it brought up quite a few questions regarding how medicine is practiced and developed. I read a book over the summer, Complications by Atul Gawande that discussed the challenges those in the medical field face with having to learn medicine through practice—something that’s very frightening when the practice is being done on people. The book mentions that we learn, grow, and adapt through both good and bad experiences when practicing medicine, however it’s still important to take very careful considerations in making decisions on the spot (especially when there’s a patient being actively “worked” on). In this study however, it seemed as the dentist was not practicing their knowledge/understanding of medicine in an ethical way in that it appears these decisions were being made without considering proper dosage nor consequences that could occur in the alteration of these dosages. I think this is a struggle in all fields of medicine where too much practice might get into practitioners heads and drastic consequences may being to be overlooked. Now you didn’t mention necessarily how experienced this particular dentist was, but I think it made a statement that too much confidence in the medical field can have some very ugly side effects and its important, no matter how much experience a practitioner has, to keep questioning decision making when there are peoples lives and wellbeing at stake.