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Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) OFFICE-BASED ANESTHESIA Mark D. Zajkowski, DDS, MD INTRODUCTION for years, offering safe, convenient care for millions of patients. Recent shifts in medicine toward this model of care have created controversies among many stakeholder groups, and our specialty thesia, the landscape of current practice is changing as more and more parties of interest come intertwined with dentistry and oral and maxillofacial surgery. This issue of Selected Readings in Oral and Maxillofacial Surgery from a “30,000 foot level”, exploring our deep history as a specialty with anesthesia, the evolution of us can do to improve patient care and how we view ourselves as part of the larger picture of medicine HISTORY Surgery today without modern anes cheap alternative to gin,5 and for its use at thrill. umented procedures were actually recorded in The Edwin Smith Surgical Papyrus. These Similarly, nitrous oxide was used for control were attempted, from nerve compres sion2 to hypnosis (referred to as mesmerism)3 and refrigeration, all in an attempt to alle preparation of nitrous oxide was completed and scientist. to study its effects on humans in great detail, ed with varying success, and some prominent agents were initially overlooked. Nitrous Oxide. Not coincidentally, Davy not ed the “transient relief of a severe headache, Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) 6 Sadly, known for coining the term “laughing gas” to success in his dental practice. Later in the nineteenth century, one for surgical pain control emerged, although much later than it had actually occurred. On ered ether anesthesia for removal of two neck tion and to perform a demonstration of his 7 “The patient continued to inhale ether dur ing the time of the operation; when informed it was over, seemed incredulous, until the tumor was shown to him.”7 was widely ridiculed, despite the fact that the patient did not recall having any pain during the tooth removal. this clinical setting, he did not claim credit practice in a rural environment and his lack of opportunity for a large series of proce Georgia, a series of events in New England thesia as we know it. to Morton in the delivery of nitrous oxide for dental procedures. Morton then later dentists, who saw this as a threat to their live fessor of chemistry. Morton had dropped his focus on nitrous oxide and narrowed his efforts to using chloric ether as an anesthetic. ether, this new agent. of nitrous oxide that he contacted Colton and Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) nitrous oxide, Morton provided ether anes physician. Keep was a mentor to the young procedure, the patient reported that while he enrolled in medical school. Some surmise that Keep may have introduced Morton to ren then proclaimed the famous line, “Gen Morton initially refused to tell his peers it “letheon”, and attempted to patent it for ing of Morton as the discoverer of ether. This controversy carried on for several years, cost ing Morton his entire wealth and personal insane asylum, distraught over the prolonged and understanding of ether as an anesthetic Boston Medical Surgical Journal es” documented the preparation, storage, and administration of ether in his own delivery apparatus. tion in his role with ether anesthesia. Eventually, all of these men were rewarded in the annals of history. Long was al reputation surely helped the use of ether with annual recognition of his accomplish as a method to remove pain from surgery. Dentistry Moves to Nitrous Oxide Morton, of course, is Medical Examiner moved on, a mixture of chloroform and ether gotten in this history, is Dr. Nathan Cooley Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) nitrous oxide. a Minneapolis dentist, worked extensively on perfecting his nitrous oxide delivery the opportunity for patients to have an tion under nitrous oxide general anesthesia. no fatalities. inducing anesthesia to unconsciousness, and effects of hypoxia on these patients. point, the mask was removed, and the proce record, Oth acceptance of nitrous oxide, including Thom as Evans, a prominent dental surgeon in Paris, used in inhalational anesthetics evolved. One tile anesthetics for dentistry was halothane, formulation and use of this method of anes thesia has continued to evolve, with the mod today. sia training was offered in dental schools, nor were there residencies for oral surgeons to practice and train in general anesthesia. nitrous oxide and oxygen in varying percent ages. training in hospitals that eventually led to separate anesthesia departments dedicated to the education of future practitioners, dentists Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) dentists to provide anesthesia. Over the years, making shoes. in hospital residencies for dentists interested in anesthesiology. dentists and oral surgeons were not allowed to participate in training at many of the other departments of anesthesia at the Mayo Clin ment of oral surgery training programs in the with their medical colleagues, and the rapid During that time, outpatients rarely if ever received general anesthesia. vinced of the ideal properties of the drug for outpatient dental extraction. Lundy con year residency in anesthesiology, and served administer anesthesia to any patient who was not admitted to the hospital overnight. dency and returned home to Southern Cali School as its Chair and also served as a pro fessor at the School of Medicine. demonstrating the superior anesthetic tech gery residents who had completed training in other hospitals. the teaching of anesthesia to dentists and oral surgeons, and served as one of the founders mixture of nitrous oxide and oxygen. One deliver the pentothal, which eliminated the need for multiple thiopental syringes and the increasing power of medical anesthesi Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) sively, omitting oxygen, nitrous oxide, local anesthesia, or monitors of any kind (other focus on the teaching of standards in pain and anxiety control was necessary for our profes sion to advance. courses on the delivery of thiopental anesthe sia all over the country. This sparked the gen eration of intravenous anesthetics delivered nationwide, with varying updates and addi ences on pain and anxiety control. This led to the “Guidelines for Teaching the Compre rate thiopental for outpatient general anes thesia in oral surgery, a dentist teaching at and anxiety control among dental students, accreditation of dental anesthesia programs of sedation. This generally consisted of tal specialty. period of sedation. pharmacologic methods for procedural seda the risk of general anesthesia in the dental ment. Despite these advances and relatively good outcomes, the typical preoperative workup for patients was seldom more than oral surgeons only delivered pentothal exclu alleviate anxiety for many patients without the inherent risk of a general anesthetic. titioners shifted the focus of their practice to a conscious sedation anesthesia, with excep Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ushered in a new era of oversight and regula deep sedation was more effective than mod A NEW ERA OF PUBLIC AWARENESS AND OVERSIGHT priate monitoring. ifornia Society of Oral Surgeons developed conference. The participants at the confer ence pointed out the critical need for greater research in dental anesthesia with regards to pharmacologic approaches, environmental risk assessment, new drugs, and the need for resources to conduct this research. The con clusion of the conference was, “The use of all effective drugs carries some degree of risk, however small. Available evidence suggests that use of sedative and anesthetic drugs in the of safety. However, even this record can anesthesia and emergency management for facial Surgeons adopted this program, and made it mandatory for all state component Several studies of the safety of anes thesia gave credence to oral and maxillofa Lytle and Stamper reported a mortality rate of vey of Southern California oral and maxillo 20 ate guidelines governing requirements patients, in a survey of Massachusetts oral One of the most recent prospective cohort studies of anesthesia in an oral surgery Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) 22 Encompassing the entire spectrum of anesthesia, they found to pursue his passion for outcomes and per formance measurements that he so strongly work, detailing 337 patient admissions and with all complications deemed minor and . Particularly with anesthesia safety, med icine has come full circle in the pursuit of in testing its one page of minimum standards 23 in The list of standards, now known as the Man, had grown This was a radical concept, and not each of his patients with meticulous detail with his “end result cards” that contained patient demographics, diagnosis, treatment, similar conditions. This also meant that treat patients. Most shockingly to his colleagues, he pushed to make the failures in treatment 25 ity conferences to openly discuss treatment Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) The “drift” of our specialty towards this tional facilities to its accreditation standards services, including psychiatric facilities, spotlight of an unforgiving press.27 more interested in how safe outpatient anes Board of Governors. Committee on Patient Safety and Risk Man premiums for anesthesiologists. of accredited facilities came a refocusing disciplines with an interest in patient safety performance processes. Currently, the focus of the accreditation process is the review of structured around functions central to patient care delivered to the patient,26 including Of particular importance to the oral and maxillofacial surgery community is the goal of conducting safety research and edu cation, providing patient safety programs and campaigns, and promoting the national and international exchange of information and patient safety, and continues to fund a num specialties have mandated accreditation or Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Standards, and the Statement on the Safe Use . ) based Anesthesia administration of and facility for providing the anesthetic, with recommendations on the facility. The document reviews clinical care guidelines that include patient and pro cedure selection, perioperative care, moni transfer procedures. These are in agreement can argue that the fundamental change is well underway, as you will read later in this review. anesthesia for medicine and dentistry are who practices within the standard of care in the adoption of the ASA Standards on Basic Monitoring Over the years, the produced many guidelines for anesthesiolo sources. Technologic advances in monitoring have also allowed for a greater safety margin. are continually updated. to review the good suggestions to improve clinical care ered. Some of the more relevant guidelines Guidelines for , The Anesthesia Care Team, Guidelines for Ambulatory Anesthesia and Surgery, Basic Anesthetic Monitoring tice. These new standards applied irrespec tive of whether the anesthetic was general, regional, or monitored anesthesia care. The recorded at least every 5 minutes the case Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) assess ventilation, the participants depending more on either a precordial stethoscope or nect monitor with alarm Many surgeons had resisted this moni low concentration alarm with oral surgery patients and a lack of con ment 2 grew, pulse oximetery and end tidal CO2 mandate the use of capnography. The guide 30 when either a pulse oximeter or capnograph was used. Medicine has continued in updating and general anesthesia the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical ed or invalidated by the nature of the initially used in operating rooms to prevent intraoperative awareness, these monitors facility.32 Nevertheless, these monitors have not yet reached universal acceptance and standard of care. the monitoring advances as well, rapidly incorporating state of the art technologies to Despite the long and consistent safety record of anesthesia in oral and maxillofacisl method persist. This is somewhat due to outpatient anesthesia, capnography had not Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) found on the package inserts in propofol con THE CULTURAL SHIFT TO OFFICE-BASED SURGERY The advancements mentioned previous tion of general anesthesia and not involved in the conduct of the surgical/diagnostic pro cedure.” thesiologists asserted that the insert was cor rect, offered its own statement on the safe use ditional settings, particularly among medical to have procedures performed in an outpatient setting has increased, so too has the increase procedures, resulting in the need for deeper sedation, analgesia, and general anesthesia.33 tists. The statement read, sedation/anesthesia, it should be adminadministration of general anesthesia, who are not simultaneously involved in insert, and failure to follow these rec- west of health care”. events occurred, they were reported in the Wall Street Journal article highlighted the “crackdown” on doctors performing unreg 35 The data gath 36 showed The controversy has waxed and waned, nurse anesthetists to provide itinerant anes thesia services independent of anesthesiolo most common respiratory events were air events were due to incorrect dosing or drug, allergic reaction, or malignant hyperther mia.33 surgery practitioners. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ulations with a wide spectrum, from a limited ments for the administration of anesthesia to nent neurologic damage or death occurred to hospitals.37 Study ASA Closed Claims ment or monitoring. Of particular note in this study was that the provider was often an oral surgeon, periodontist or nurse anesthe of this paper was that providers should have airway management training as well as the gists guidelines and the reporting of adverse events. put regulations in place or were considering doing so, with some granting exceptions to accredited facilities or mandating accredita Currently in the oral and maxillofacial sur or regulations) dental practitioners to undergo limiting.22 Despite this report and continu ing ongoing efforts of our specialty to edu Oral and maxillofacial surgery has anesthesia training, experience, and consis tent positive outcomes assessment, the tide in 2007, with the passage of legislation that cialty practices and more towards third party maxillofacial surgeons to have their practices serving the oral and maxillofacial sur gery community well for decades, is likely encroaching tide of state regulations on our in outpatient settings. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) oral and maxillofacial surgeons, as long as they practice within the scope of their dental license. Because the waiver took over two years York undertook the accreditation process, for and against outside regulation of oral and Journal of Oral and Maxillofacial Surgery. nario for the oral and maxillofacial surgeons three different experiences undergoing this Journal of Oral and Maxillofacial Surgery article. Nevada surgeons also were caught in the crosshairs of state regulations with the sive control of anxiety and pain control, the the AAOMS Parameters of Care as reasons The following year, he acknowledged the rapid trend of regulation of medical maxillofacial surgeons in practice to ensure facial surgeons were not directly involved in menting voluntary accreditation, we now future. with mandated reporting of complications, and stiff penalties for those not in compliance. gery societies and associations. These experiences should serve as a move out of the “cottage industry” and more into the current mainstream of transparent, like everything we do, is framed within our practice guidelines. Contemporary practices AAOMS Parameters of Care Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) permit or license to provide this care, and the practice within the anesthesia team model. Care, with material on emergency protocols and monitoring standards. The l is predi cated on a surgeon with at least two assis ties other than to monitor the patient during systemic diseases and evaluation of patients, and monitoring, and emergency manage WHAT AND WHY DO WE NEED TO sistants, oral and maxillofacial surgery will other specialties to emulate, as well as to gain some political capital in defending our treat ment model. AAOMS Parameters of Care So, you may ask, if the oral and maxil an exemplary record of safety over the years, has committed to maintaining standards that technology and science improve, what or why do we need to change? standards with regard to anesthesia contain anesthesia, general standards, criteria and considerations for anesthesia in outpatient facilities, special considerations for medi cally compromised patients, and outcomes assessment indices for deep sedation and general anesthesia. This document generally sia, with the exception of propofol delivery a companion to the AAOMS Parameters of maxillofacial surgery procedures are within regulations continue to increase, so too will seen all too often in the past, a reluctance to those outside of the specialty to set it for us. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) maxillofacial surgery stays complacent, with tion for accreditation. the New York and Nevada experiences, and facility include a clear demonstration to your patients that you offer the highest level of patient safety and care, a competitive edge in marketing your practice, attainment of a foolish arguments that will doom our spe cialty to the loss of autonomy that we have worked so hard to preserve. ensure safe and appropriate care is delivered. Currently, accreditation for an oral and es, with a premium added to payments due solely to the accredited status of our facility. ited facilities, and offer patient resources for the patient to partner with you in their care. care, and monitoring of outcomes. There are certain advantages and disadvantages within licity kit to promote the accredited status of downloaded for your media campaigns. _____________________________________________________________________________ TABLE 1: AREAS FOR WHICH THE JOINT COMMISSION OFFICE-BASED SURGERY PROGRAM SETS STANDARDS-BASED PERFORMANCE Environment of Care Emergency Management National Patient Safety Goals Provision of Care, Treatment & Services Records of Care, Treatment & Services Leadership Life Safety Medication Management Transplant Safety Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ______________________________________________________________________________ TABLE 2: SERVICES AND REPORTS AVAILABLE FROM CONSULTANT WEBSITES Audits Benchmark Studies sea and vomiting) Essential Internal Studies (cost of care/medical supplies, patient satisfaction, patient waiting times) High Risk Process Analysis (e.g., recovery room audit) policies and procedures tialing, policy and procedure review. perioperative checklists, links to specialty guidelines, emergency management drills, human resources forms, etc. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) process focuses on operational systems criti The survey process evaluates actual care pro tion to the patient tracer activity, the surveyor also reviews key operational systems that directly impact patient care. These surveyors are health care professionals who practice in experience in similar settings. Often, the sur veyor during site visits is a fellow oral and maxillofacial surgeon or dentist. time to make corrections if needed. Once creditation decision is made; maintenance of accreditation is fairly straightforward. Calendar. ____________________________________ varies among the agencies, the current direct Many accredited facilities retain a con cies and procedures updated, and keep prac tices informed of changing standards. One fees for multiple locations. There are also annual fees to remain accredited, currently offers monthly email that reports scores for your practice and reminders to keep records, stud hire a consultant for the initial evaluation, or for ongoing maintenance of your accredited consulting companies as well as among the correlates with your chance of success should you encounter an unannounced survey. Links to some of the various services and reports Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) align your practice with current accreditation standards, a calendar of studies is posted, our facilities review “near misses” that could have resulted in harm to a patient in a logical, progressive manner to ensure it never hap of data. oral and maxillofacial surgery practices give an accurate infection rate for their facilities medication errors in facilities if there is no formal medication management plan? an accredited facility has far more failsafe mechanisms in place to avoid adverse events Journal of Oral and Maxillofacial Surgery process improvements that an accredited ation may refresh a practicing oral and maxil lofacial surgeon in emergency drills every six years, it offers little in those areas of accredi Patient Safety Goals into practice. Surely, if modeling our practices along the practic to practice for so many years has room for the improvement that accreditation can offer. and risk prevention. and the potential role for accreditation in oral cialty to do the right thing and move in the of the accrediting agencies to tailor a program ______________________________________________________________________________ TABLE 3: APPLICABLE GOALS FOR A WELL-RUN OMS PRACTICE decision making Knowledge and skills management Development of effective teams Coordination of care across patient conditions, services and settings over time Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) research found “a health care system that fre knowledge into practice, and to apply new technology safely and appropriately.” One of the most salient points in the report was that medicine is using outdated systems to deliver care we will need to have “redesigned sys tems of care, including the use of information technology to support clinical and adminis trative processes”.52 largely aimed at chronic conditions in medi ____________________________________ thesia Evaluation as a central component, or run oral and maxillofacial surgery practice typically already incorporates, and others for the typical oral and maxillofacial surgery practice, with the goal of making the process addressed safety and human error.53 HOW DOES OMS FIT IN WITH THE NEW CULTURE OF SAFETY AND 50 was a landmark in a national reckoning to improve in their care, and hundreds of thousands suffer prevent. Medication errors alone, occurring either in or out of the hospital, are estimated to account for over 7,000 deaths annually. 52 “Crossing the approaches. The (which is all too common in medicine) focuses on attention, forgetfulness or moral weakness. The focuses more on the conditions that individuals work under, and or lessen their effects. This approach under that “error is not the monopoly of an unfor mishaps tend to occur in recurrent patterns, hence the need for the system approach. Rea Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) TABLE 4: FIVE KEY PRINCIPLES SHARED BY HROS does not allow a process to rely on a single person without redundancy. ______________________________________________________________________________ tem accidents shows how a series of weak result in an untoward event. tions and facing great potential for error and positive results. improvement (as in auto manufacturing with ing extracted, for example, a series of errors in the system could leave this potential error undetected until the adverse event happened. improvement to reduce the rate of defects). dency, stemming from our training in the sci 55 Two overriding principles Reason surmises that almost all adverse active failures and latent (system) conditions. surement tools to eliminate inappropriate variation (known in medicine as the “art” rationale) and to document the continuous improvement (via outcomes).56 57 (constant vigilance cognitive function, dynamic tasks, chang ing technologies, and time pressures while line) and (immediate actions taken to reduce further damage when an error industrial areas like this (such as an aircraft carrier, a nuclear power plant or air traf ciples. great effectiveness that are exceedingly reli Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) out where the weakness in the system resides tion, and act as powerful reminders of system 60 care system. This method of continual assess ment and improvement makes systems (such “Effective leadership of in the process of care to achieve maximum patient safety and satisfaction, delivered with Barach notes that several complex, approach for data collection, analysis and improvement. standard protocols for anesthesia delivery was for health care to adopt modeled on the crew resource management used in the aviation industry, lofacial surgery team can enhance the safety training. lature seeking to “do something”. This pro resource management are to produce positive Crew resource management incorporates team training sessions, simulation, group perfects this concept, they can potentially is exactly what has happened in aviation, and the parallels in anesthesia are easy to see. team can truly work together for the common goal of safe, effective care. Oral and maxillofacial surgeons have clearly heeded the call to improve skill sets and participate in team training. This is seen grams for residents and practitioners alike. cial surgeons have participated in some type referred to as a “failure mode analysis” Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ______________________________________________________________________________ on the input of the user, and now are the tinues to improve to the point that teams can train around surgical events and simulate the effects of an anesthetic. a wooden model of a soldier.62 Medical simu central venous and pulmonary artery pressure as well as allowing management of the air 62 simulation models have incorporated model internet.63 Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ______________________________________________________________________________ and were revised for training for responses and explosive incidents. The advantages of multiple users in remote locations and sive” experience show unlimited potential for training of health care and industrial profes sionals worldwide. convert to electronic medical records. These records, coupled with improvements in mon itoring systems can help us incorporate the to ensure a high level of care, and can help us mentioned previously. PUTTING IT ALL TOGETHER… Below, are some sample screen shots electronic medical record) to tie some con Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ______________________________________________________________________________ system approach to error reduction and the to ensure a completion of informed consent. lofacial surgeon. This anesthesia record is divided into different segments, following a logical se case (all images courtesy of Carestream Den incorporation of the team in the care process, and the provision of another opportunity for signed. The documentation of these key ele review of medical conditions and allergies, a Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) _____________________________________________________________________________ ing for the surgical “time out”, assurance of the correct patient and procedure, and mark ing of the operative site (performed on the of importing monitored data at the onset of the patient visit. This segment documents the cally imported from the monitors, and allows the preoperative evaluation, as well as the documentation of extremity positioning to catheter. These steps are critical to involve the entire surgical team, much like in the re view of crew resource management discussed earlier. The chronologic time details are automatically entered from the monitor at the completion of the case. Many of these Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) _____________________________________________________________________________ elements incorporate the National Patient the incorporation of a graphical user inter are easily and seamlessly incorporated into the patient record, and include the culture of safety in an oral and maxillofacial surgery facility. of the procedure and stored within the anes thetic record for review should the monitor show changes, allowing a comparison to the The times are either manually entered one of the most exciting portions of the elec medications are provided during the case, ing a “real time” recording of events. Typical Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) ______________________________________________________________________________ lection of data is later scanned into the an esthetic record after completion, and is used on the following day. This allows the patient another opportunity to review postoperative notations on any complications or anesthetic recovering as expected. later entered in the recovery room, as well as documentation of the escort and instructions provided for postoperative care. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) CONCLUSIONS is a graduate of Oral and maxillofacial surgeons have ways to the progress in anesthesia for well proud of our long track record of safety in our illofacial surgery at Massachusetts General doctor practice in South Portland, Maine that practices the full scope of the specialty, and pioned to improve patient care. Times, how ever, are changing, and with the increased having served on numerous committees and task forces. on how we provide care. the opportunity to again lead the way in this exploring the coast of Maine with the love of his life Michele and their two children. This issue of SROMS is dedicated to them. and safety of the care delivered, the devel our systems of care, and the modeling of our forward and preserve the autonomy that we have worked so hard to gain. should seriously consider the accreditation of for the right patients all of the time. To offer anything less to our patients undermines not of the pioneers in oral and maxillofacial sur Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) REFERENCES mitigating human suffering in surgical operations and acute diseases. Boston anesthetic in surgical operation. South and Oral surgery. Philadelphia, Lea & Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) thesia Survey of the Southern California Society of Oral and Maxillofacial Sur prevention in anesthesia and surgery. 2006. experience among Massachusetts oral Standards for patient monitoring during outcomes of clinical practice of oral and The End Result of a Life in Medicine. index monitoring allows faster emer gence and improved recovery from propofol, alfentanil, and nitrous oxide dation of patient safety. Perioperative Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) accrediting agencies and suggestions for changes in private practice oral and maxillofacial surgery facility evalua states crack down on doctors who per lessons learned from the closed claims Deja vu mission of accreditation of healthcare maxillofacial surgery. Oral Maxillofac 2000. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Crew resource management and team 2007. oral and maxillofacial surgery resi dents in general anesthesia and airway and Sutton R (eds) Research in Organizational Behavior, Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) RELATED ARTICLES IN SELECTED READINGS IN ORAL AND MAXILLOFACIAL SURGERY Risk Prevention for Oral and Maxillofacial Selected Readings in Oral and Maxillofacial Surgery . Sedation. Vasiliki Karlis, DMD, MD, Selected Readings in Oral and Maxillofacial Surgery . Vol. man, DMD, Selected Readings in Oral and Maxillofacial Surgery son, DMD. Selected Readings in Oral and Maxillofacial Surgery . Outpatient Orthognathic Surgery Performed and Douglas P. Sinn, DDS. Selected Readings in Oral and Maxillofacial Surgery . DMD, MD. Selected Readings in Oral and Maxillofacial Surgery . Selected Readings in Oral and Maxillofacial Surgery . Vol. Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com) Create PDF files without this message by purchasing novaPDF printer (http://www.novapdf.com)