Prevention and Treatment of Selected Complications
with Local Anesthesia Alone-and with the Adjuvants
Frank M. McCarthy, M.D., D.D.S.t
INTRODUCTION can also cause serious complications or can even be
Complications from local anesthesia alone and from My choice of complications for review is purely
the sedation modalities are obviously best prevented, pragmatic and makes no attempt to be comprehensive.
both with respect to the patient's welfare and in your I have chosen topics which I feel are especially relevant
own self-interest, particularly with regard to malprac- to contemporary practice.
tice claims. Some of the complications to be reviewed
here are potentially serious or even lethal. Wrongful
death lawsuits are the leading cause of big-dollar LOCAL ANESTHESIA ALONE
awards, averaging at least one case per month in
California alone of a judgment or settlement of one Local Complications
million dollars or more. Wrongful death claims can also This topic will be confined to a single concern, the
result in the loss of your license, felony manslaughter disposable needle. The disposable needle is responsi-
charges, and possible imprisonment. ble for a vast increase in post-injection trismus, pain,
In the area of mortality and serious morbidity, two hematoma, and paresthesia of the lingual nerve and
groups may be categorized according to cause. First, inferior alveolar nerve. Added to this is the use of fine
the patient whose time to die coincides closely with gauge needles for deep injections, which adds to the
dental treatment. The average practitioner will ex- complication rate. And add to this the use of short
perience 1-2 patient deaths during his or her practice needles for deep injections, which increases the break-
lifetime occurring within 24 hours of treatment.1 age rate.
These deaths occur solely at random and are unrelated The long, pointed bevel of the present disposable
to dental therapy. Second are serious illnesses or death needle is responsible for an enormous increase of
directly related to dental therapy - i. e., related to the hematomas. For a 10-year period at Loma Linda Uni-
physical or emotional stresses of treatment, or to versity School of Dentistry when conical reusable
specific actions or inactions, or to local anesthetic and needles were used, one post-injection hematoma was
sedative drugs or techniques used or not used. In observed. When 23-gauge disposable needles were
dentistry the contemporary dental doctor who pro- introduced at the School, seven hematomas occurred
vides comprehensive care has learned to prevent most during the first 500 injections.3 The long bevel acts as a
complications by adequate pretreatment physical knife blade.
evaluation, comprehensive pain/anxiety control, and The long bevel is also difficult to position and gives
emergency preparedness. the doctor little "feel" of injection as compared to the
In the arena of malpractice, one of the three R's for old conical reusable needle with a short bevel. Fur-
prevention stands for reason* - knowledge of drugs ther, if you use a needle size finer than 23-25 gauge,
and techniques, knowledge of physical evaluation and the needle bends severely during deep injections and
the principles of basic life support, knowledge of our you have little control ofwhere the tip actually is. A 27
own skills and limitations, and good judgment always.2 gauge needle is far too flexible for deep injections.
As contemporary health practitioners, we use local For deep injections a 1%-1% inch 23-25 gauge nee-
anesthetic agents by the quart, nitrous oxide by the dle is recommended. There is no -difference in pain
gallon, and sedative drugs by the pound. Familiarity perception between the insertion of a heavier gauge
and daily use without problems may give us a false versus the 27 gauge. By using a 25 rather than a 27
sense of security and omnipotence - and then Mur- gauge, you gain greater rigidity and control, as well as
phy's Law strikes - if anything can go wrong, it will, gaining 20 percent in inside diameter, thus enhancing
and at the worst time. All of our remarkable pain/ the opportunity for positive aspiration.
anxiety control agents and techniques are extremely The disposable needle, especially the fine gauge, is
safe, and in fict prevent complications in the anxious, responsible for a marked increase in injuries to the
fearful, and medically compromised patient. Yet all lingual nerve. The long, sharp bevel acts as a knife
blade if the nerve trunk is inadvertently transfixed.
tProfessor and Chairman, Anesthesia and Medicine Section, Uni- Similar injury to the inferior alveolar nerve is increas-
versity of Southern California School of Dentistry. ing, although not to the extent of the lingual nerve.
Presented, in part, at the annual scientific session of the American Needles still break, especially the fine gauge, flexi-
Dental Association, Anaheim CA, October 22, 1978. ble type, and particularly if you are using a short nee-
*The other R's are rapport and records. dle for a deep injection. If a needle breaks and is not
MARCH-APRIL, 1979 37
immediately recovered, the patient should be referred inadequate anesthesia is the increasing use of local
to an oral/maxillofacial surgeon for evaluation, not anesthetic agents without a vasoconstrictor. This al-
necessarily for surgical removal. Suggestions for pre- most doubles the risk of toxic overdose, and, if anes-
venting needle breakage follow: thesia is inadequate, greatly increases the risks of emo-
1. Never use a long needle finer than 25 gauge. tional stress in the medically compromised patient.
2. Do not insert to the hub. Due to malpractice concerns, local anesthesia without
3. Never re-direct the needle without almost fully vasoconstriction may be arbitrarily chosen. This de-
withdrawing it. spite the fact that clear guidelines for the cardiac pa-
tient from the New York Heart Association and now
Systemic Complications the American Heart Association have existed for al-
Allergic reactions to local anesthetic agents are ex- most 30 years. The AHA states that there is no hazard
tremely uncommon. While serious anaphylaxis with for a cardiac patient without cardiac arrhythmias if not
procaine and related esters has been reported very more than 0.04 mg ofepinephrine is utilized at a single
rarely, I am not aware of a single documented case of appointment. With epinephrine 1:100,000, that is two
anaphylaxis with lidocaine or the other amides. cartridges; at 1:200,000, four cartridges.
Allergy to the amides such as lidocaine is uncom- Another potentially serious problem with respect to
monly seen as angioedema - a localized glassy swell- toxic overdose has surfaced during the past several
ing of the upper lip perhaps, or the eyelid, or tongue. years. That is reverse arterial flow from a forceful injec-
When the glottis is involved, asphyxiation can occur. tion of a local anesthetic agent into the lingual artery or
This is one of those uncommon life-threatening inferior alveolar artery.5 A very high concentration of
emergencies where injectable epinephrine is essen- anesthetic agent may thus be rapidly introduced into
tial, e.g., 0.3-0.5 ml of 1:1000 epinephrine 1M. the brain, and immediate and possibly lethal toxic
Toxic overdose, with occasional fatal results, is be- overdose results. The rapid injection of a single car-
coming more common with local anesthetic agents. tridge into the lingual artery can be fatal. This can be
The most common reason for this is carelessness or prevented by proper instrumentation and technique
complacence on the part of the practitioner - not 25 gauge or larger needle, aspiration, and slow
remaining familiar with the maximum recommended injection.
drug dosages - and not following proper technique. While the most common systemic reaction as-
The incidence of toxic overdose is increasing due to the sociated with local anesthesia is vasodepressor syncope
lengthening duration of dental treatments and the or the common faint, I have left it to the last. The
need for larger amounts of drug. This applies particu- reader does not need this problem reviewed, but I
larly to children, whose tolerance is far less than the would like to make one point. Unconsciousness must
adult. I am aware of several dead children from toxic be assumed to be cardiac arrest until proved otherwise.
overdose in the Los Angeles area during the last couple You must immediately determine in the unconscious
of years. How many nonlethal toxic reactions occur is patient if there is a patent airway and if there is spon-
anyone's guess; the number is probably quite large. taneous breathing. The obvious first sign of common
Let me present a hypothetical case of a fatal toxic faint and cardiac arrest is identical unconsciousness.
overdose occuring in a child, which I have created from Follow the ABC's of basic life support A for airway,
several cases in litigation at present. A 5-year old child B for breathing, C for circulation. Do not take a com-
is given 8 cartridges of local anesthetic by infiltration mon faint lightly until you determine that it is indeed a
with a 27-gauge short needle. Total injection time is no common faint.
more than 2 minutes. The child convulses intermit-
tently over a period of several minutes, hypotension Nitrous Oxide-Oxygen Alone
and pulmonary edema occur, oxygen is given,
diazepam is given IV by paramedics, and cardiac arrest Local Complications
occurs. The child suffers irreversible CNS damage and Local complications with nitrous oxide/oxygen seda-
dies 10 days later. Eighteen restorations were re- tion alone are limited to the irritating and drying effect
quired. The practitioner had planned to complete all of the gases on nasal membranes when a nasal cannula
treatment during one appointment because "the wel- is used. The use of a cannula is very wasteful of gases
fare fees were so low that it was economically unfeasi- and does not permit the reservoir bag to function, an
ble to accomplish treatment over several appoint- omission which compromises the technique. Further,
ments." possible dangers to operating personnel exist from
This hypothetical case illustrates the necessity of waste gases. This question will not be fully answered
absolute understanding of maximum dose of the local until the present ADA-ASA study of dental personnel
anesthetic agent you normally use related to the has been completed and analyzed. Some patients are
weight ofthe patient.4 Become re-acquainted with the frightened of a nasal mask, and sometimes treatment of
package insert, and review your books on toxic over- the anterior maxilla is very difficult without using a
dose. Also, use proper instrumentation and injection nasal cannula, but this should be kept to an absolute
technique -25 gauge or larger needle, aspiration, and minimum until we know more about the possible rela-
slow administration. tionship of trace amounts of nitrous oxide and the
Another factor related to both toxic overdose and to incidence of teratogenicity and spontaneous abortion.
38 ANESTHESIA PROGRESS
Systemic Complications type individual who has little insight and who feels
Systemic complications related to nitrous oxide in- threatened by being out of control.
clude one other area of danger to operating personnel, The psychotic is not a candidate for dental sedation
and that is what is euphemistically called the recrea- of any kind, as his or her grasp of reality is already
tional use of nitrous oxide. A number of cases have tenuous at best.
been observed where the frequent use of nitrous oxide The alcoholic is a poor candidate for inhalation seda-
by health professionals and auxiliaries has caused cen- tion, and the drug abuser can be a serious problem.
tral nervous system damage similar to multiple sclero- Heavy marijuana use can produce extreme excitement
sis, with peripheral numbness and loss of coordination. and even belligerance with nitrous oxide; the
As this syndrome becomes more widely recognized, technique is contraindicated if marijuana is used more
more cases are surfacing. While it is too early to tell as than once weekly. This same is also true for hallucino-
yet, some of the CNS damage may be irreversible. gens such as acid (LSD) and angel dust (PCP), and for
Under no circumstances should the dental prac- frequent abuse of minor tranquilizers, barbiturates,
titioner use nitrous oxide personally as a sedative, amphetamines, cocaine, and other hard narcotics.
mood elevator, or hypnotic. The inhalation sedation Further with regard to serious mental illness
machine should be considered as being professional (psychosis, past or present), and drug abuse (including
equipment only, and not be used for fun and games by alcohol), a psychic "high" produced by sedation of any
the office staff. Each assistant should experience ni- kind may adversely effect such a patient's recovery.
trous oxide once, but never again for other than dental Systemic Complications and Existing Disease.
treatment reasons. Some people have addictive per- With respect to nitrous oxide/oxygen sedation and
sonalities, i.e., anything pleasurable causes immediate the systemic complications of existing disease, the field
addiction or habituation. The assistant or professional is virtually limitless, and I will confine my comments to
with a nitrous oxide abuse problem should stop treat- several areas directly related to sedation.
ing patients and seek professional help. Meniere's disease is caused by degeneration of the
Systemic complications of the patient include some cochlea, and is progressive and irreversible. The dis-
rather mundane areas such as expectoration during ease is evident at age 40-60, and is marked by dizzi-
sedation, which can be discouraged by vigorous aspira- ness, tinnitus, nausea, and perhaps vomiting. Sedation
tion; and nausea, which is quite uncommon with ni- of any kind would be contraindicated for this patient
trous oxide, especially if oxygen delivery is not under when he or she is symptomatic.
50 percent - further, a heavy meal before inhalation With respect to bronchopulmonary diseases, the
sedation should be discouraged - an excellent substi- patient with bronchial asthma, bronchiectasis, or
tute is a light high carbohydrate meal about 3-4 hours moderately advanced emphysema benefits from the
before dental treatment (such as dry cereal and milk) oxygen enrichment ofinhalation sedation. The patient
- this also eliminates the possibility of weakness from with advanced pulmonary emphysema (respiratory
hypoglycemia, especially in children and in the debili- cripple) who displays shortness of breath at rest may
tated geriatric patient; the possibility of vomiting is stop breathing when given oxygen in high concentra-
nearly eliminated by not carrying nitrous oxide deliv- tion.1 Inhalation sedation is not indicated for this
ery beyond 50 percent and by the light high carbohy- patient.
drate meal. When .we consider occlusive cerebrovascular dis-
Patients who become too deeply sedated may de- ease, we think first of stroke or CVA, probably repre-
velop mental dissociation, with disturbing dreams and senting either cerebral hemorrhage or cerebral
mental distortions. Since the dreams may be erotic, thrombosis. Yet the first signs and symptoms ofocclu-
under no circumstances should the practitioner ad- sive cerebrovascular disease are dizziness, visual de-
minister nitrous oxide/oxygen to a patient of either sex fects, memory loss, and behavioral problems. These
or any age without an assistant present at all times. The patients usually do well with inhalation sedation, but
mentally disturbed adult or fantasizing teenager or every effort is made to keep the patient light and
child can make extremely damaging claims of sexual rational.
impropriety. Inhalation sedation is of value in all the anemias and
The bottom line regarding behavioral problems and diseases of the white blood cells and reticulo-
systemic complications associated with nitrous oxide endothelial system because of oxygen enrichment.
sedation, as far as I am concerned, is this - if light, Never should oxygen delivery be below 30 percent.
effective, pleasant conscious-patient sedation cannot This is particularly important with polycythemia vera
be achieved with nitrous oxide concentration of up to and sickle cell anemia where a minimum of50 percent
50 percent, discontinue and seek another remedy. oxygen would be preferred. In sickle cell anemia re-
Don't push the technique, and don't deliver less than duced oxygen tension can produce a crisis which can be
30 percent oxygen under any circumstance. lethal.
With respect to mental illness, neurotic individuals Patients with convulsive disorders, especially grand
usually do quite well with nitrous oxide, although mal epilepsy, usually benefit greatly from inhalation
acute anxiety states should be treated with caution. sedation. Some few of these patients are heavily
This warning is also true ofthe very uptight, migraine- habituated to sedatives such as barbiturates and chloral
MARCH-APRIL, 1979 39
hydrate and deliberately seek a "high" or actual obliv- tective reflexes or depression of respirations. The
ion, thus bizarre behavior or demands may be noted. manufacturer recommends a maximum of 5 mg per
Caution and good judgment are in order, as always. minute, slowly administered. Most healthy adults can
be readily managed with a total dose of 10-20 mg. Yet
Accidents an elderly or debilitated patient may suffer respiratory
On balance, the use of inhalation sedation is ex- arrest from 2.5 mg of diazepam, and have to be artifi-
tremely beneficial. Nitrous oxide/oxygen allows cially ventilated. Slow administration is the watch-
comprehensive and preventive dental care for word, carefully titrating to the proper sedative end-
many millions who formerly sought only emergency point of that particular patient. Do not inject an initial
care because of fear or anxiety. The modality allows bolus of 5-10 mg, because Murphy's Law is waiting to
the treatment of medically compromised patients strike.
in comparative safety. Yet, as we have seen, there are Those doctors using multiple drugs for IV sedation
contraindications to its use. must remember the additive and synergistic effects of
Further, inaccurate sedation machines can be narcotics. If meperidine follows diazepam, the dose
hazardous. Demnand-flow machines can be extremely must be carefully tailored to that particular patient's
inaccurate and are not recommended. Continuous- requirements.
flow machines are generally accurate +5 percent. In a recent office death, 150 mg of pentobarbital was
They should be examined periodically for leaks and followed by 10 mg of diazepam, followed by 100 mg, or
malfunctioning valves and flowtubes. perhaps more, of meperidine. Sedation technique is
Nitrous oxide and oxygen cylinders are pin-indexed not a part of my paper, but I implore you to follow
so that they cannot be reversed. Yet damnage to the pins proper standards of care. The IV route is the most
occasionally allows transposition of cylinders. The controllable and safest route for sedation when used
practitioner is responsible for seeing that this does not properly, and is the most unsafe when used im-
We all hear horror stories about the transposition of Vasodepressor syncope or common faint is far less
nitrous oxide and oxygen lines in new office or hospital commonly associated with IV sedation now that we are
installations, and this does occur, sometimes with le- using the supine position. If it is observed during
thal results. Again Murphy's Law applies - if some- induction, sedation should be discontinued, oxygen
thing can go wrong, it will. Follow the old anesthesia administered and the legs elevated further, while vital
axiom - "If a patient deteriorates on 100 percent signs are checked. If momentary faintness without loss
oxygen, switch to room air." of consciousness occurs, and vital signs are normal,
The practitioner is responsible for seeing that any dental treatment may continue. This is a judgment
central supply system is installed by an experienced decision. If unconsciousness occurs, under no cir-
licensed contractor, that it conforms to NFPA specifi- cumstances should treatment continue. It takes the
cations, and that it is inspected by a fire marshal. Have cardiovascular system 6-8 hours to recover under that
nothing to do with bootleg systems or the use of plastic circumstance.
piping. Nausea with IV sedation is uncommon, and may
Recovery precautions with nitrous oxide will be usually be prevented by a light high carbohydrate meal
reviewed under IV sedation. several hours before treatment.
Your goal with the IV route is to produce light seda-
tion, a patient who will respond knowledgeably to
Intravenous Sedation Alone question or command. The deeply sedated patient can
Local Complications develop mental dissociation, or even become belliger-
Phlebitis from diazepam occurs occasionally, and is ent and unmanageable. The next mistaken step in
treated by hot wet compresses. If progression occurs, control could be surgical depth general anesthesia,
an antibiotic and antiinflammatory agent may be re- followed by respiratory paralysis and death.
quired. If one uses large veins and injects slowly, there As is true with inhalation sedation, psychotics, al-
is rarely a problem of consequence. coholics, and drug abusers are not good candidates for
Systemic Complications IV sedation. A psychic "high" from sedation for the
Allergic reactions to diazepam are extremely rare. former drug abuser may adversely effect recovery.
They usually are cutaneous, with itching and hives, but Further, venipuncture alone in the former narcotic
may be of the angioedema variety. Glottic swelling and mainliner may produce a "high". It is my routine to
asphyxia could occur, and injectable epinephrine withhold the IV route from the present drug abuser
should be available. and from the former abuser who has been off the IV
Overdose with diazepam may occur, with resultant route for less than one year.
respiratory depression or arrest. The practitioner
utilizing the IV route must be equipped to provide Systemic Complications and Existing Disease
positive-pressure oxygen and artificial ventilation. Comments regarding the IV route and existing dis-
Diazepam IV must be carefully titrated to reach the ease will be limited to several important areas. The
proper sedative endpoint without depression of pro- patient with symptomatic Meniere's disease is not a
40 ANESTHESIA PROGRESS
good candidate. Bronchial asthma and bronchiectasis vehicle or dangerous machinery for the balance of the
make excellent candidates for light sedation, while the calendar day. If treatment has occurred in the evening,
emphysematous patient with rest dyspnea is not a the end of the calendar day may be 4 hours away.
candidate for sedation of any kind, as the respiratory Should we say 12 hours or 24 hours? The half-life of
apparatus is already marginal. diazepam averages 32 hours, and 5 half-lives are re-
The geriatric patient with early occlusive cere- quired to totally eliminate the drug.7 Due to the fact
brovascular disease marked by dizziness, memory loss, that it is stored in bile, it is reabsorbed at the next meal
and management concerns will usually do well with IV and may cause significant return of sedation.
sedation. Light sedation is a must in order to avoid
behaviorial problems, and in order to avoid depression Combination of Inhalation and IV Routes
of cerebral circulation and possible thrombosis. For a combination of the inhalation and IV routes,
Light IV sedation is not contraindicated in the we simply combine local and systemic complications of
anemias and diseases of the white blood cells and re- both modalities, and the same contraindications apply.
ticuloendothelial system. The same precautions men- The combining of inhalation and IV modalities re-
tioned for inhalation sedation apply. quires discussion of the practitioner's training, and I
With respect to severe grand mal epilepsy where am unable to take a firm stand as yet. Let me share my
heavy dependence on sedative drugs has developed, thoughts with you.
light IV sedation may not be satisfactory due to be- We teach both inhalation and IV sedation to predoc-
havioral problems and demands for complete oblivion. toral students at USC. Teaching of anesthesia,
If IV sedation is unsatisfactory, hospitalization must be medicine, sedation, and emergency medicine far sur-
considered. passes the ADA Commission on Accreditation
Recovery Precautions, Inhalation and IV Routes guidelines for teaching of comprehensive pain/anxiety
control and comprehensive physical evaluation. We
Special attention must be given to adequate recov- teach our students that the two techniques are not to
ery time following sedation of any kind, with particular be combined under any circumstances at School or in
emphasis upon operation of a vehicle or dangerous practice. That is constantly re-emphasized. On rare
machinery, and the return of business or health profes- occasions we will combine both modalities for special
sionals to matters requiring fine judgment. Unfortu- management problems at School, but only with the
nately, I don't have all the answers to the moral and constant, direct supervision of a Faculty member who
legal fine points, and I may introduce more questions fully meets all ADA general anesthesia training re-
than solutions. quirements, and who is competent in advanced life
With respect to recovery from nitrous oxide/oxygen support.
sedation alone, various investigators have demon- I do not believe that ADA-pproved training in the
strated complete psychomotor recovery in 5-6 inhalation and IV routes qualifies the dental prac-
minutes. These studies have used the Bender Motor titioner to combine the modalities, unless the doctor
Gestalt Test popularized by Trieger,6 and the Flicker takes additional training. How much additional train-
Fusion Test, and other tests for cerebral function and ing? And where? Combining ofsedative modalities can
motor response. But what about patients who do criti- cause serious aberrant behavior and cardiorespiratory
cal "cerebral work," such as accountants, dental and depression, and even death. Filed malpractice suits
medical doctors, attorneys, bankers, etc. Should they reinforce this warning. It would seem that comprehen-
return to these functions on the same day after lengthy sive advanced conscious-patient sedation should be
nitrous oxide sedation? both dental school and hospital based. Experience in
As an example, let us take a dental practitioner who basic life support physical diagnosis, airway manage-
has just completed a 3-hour nap with the assistance of ment, laryngoscopy, and emergency medicine may
nitrous oxide/oxygen. Would you allow this person to readily be obtained in the hospital, while clinical ex-
perform dental therapy requiring fine judgment and perience and basic sciences review may logically be
superb motor skills for you 6 minutes later? By the supplied in the dental school. Should the training be
same token, do you feel that, after 30-120 minutes of the present one-year full-time minimum required by
nitrous oxide sedation, your accountant or banker the ADA for general anesthesia competence? I rather
should give you investment advice, your surgeon think that 3-6 months would be sufficient. The ques-
should remove your appendix, or your attorney pre- tion must be addressed, because many practitioners
pare your will? qualified in the inhalation route are becoming qualified
I would personally be uncomfortable as a patient or a in the IV route.
client under those circumstances. Certainly there has When the routes are combined by the inadequately
been gross measurable recovery from nitrous oxide, trained or experienced practitioner, the possibility of
but has there been complete recovery from the psychic complications increases a hundred-fold - overdose,
and physical experience? respiratory depression and arrest, cardiac arrest -
We have the same problem, though magnified, with airway management problems with hypoxia and car-
IV sedation. From the standpoint of diazepam and diac arrest - vomiting, aspiration pneumonitis, and
other drugs, we forbid the patient to operate a motor death - etc., ad nauseam.
MARCH-APRIL, 1979 41
When the routes are combined, you accept some of REFERENCES
the same complications faced with general anesthesia, 1. McCarthy F M Emergencies in Dental Practice, ed. 3 Philadel-
and you must therefore accept the responsibilities of phia W B Saunders Co in press 1979.
training and experience as well.8 2. McCarthy F M Prevention of emergencies and malpractice
claims by in-office peer review in Middleton R A (ed.), Current
Summary Therapy in Dentistry vol 7 St Louis C V Mosby Co in press 1979.
Various selected complications of local anesthesia 3. Jorgensen N B and Hayden J Jr Sedation Local and General
Anesthesia in Dentistry ed 2 Philadelphia Lea and Febiger 1972.
alone, and with the adjuvants, have been presented.
Special concerns regarding the disposable local 4. Malamed S F Handbook of Medical Emergencies in the Dental
Office St Louis C V Mosby Co 1978.
anesthetic needle were expressed, as were possible 5. Aldrete J A et al Reverse arterial blood flow as a pathway for
training guidelines for the practitioner utilizing a com- central nervous system toxic responses following injection of local
bination of the inhalation and intravenous routes. anesthetics Anesth Analg 57:428-433 1978.
6. Trieger N Pain Control Chicago Die Quintessenz 1974.
7. HoyumpaA M Jr et al The disposition and effects ofsedatives and
Grateful acknowledgment is made to Drs. T. J. analgesics in liver disease Ann Rev Med 29:205-218 1978.
Pallasch and S. F. Malamed for their critique of the 8. Driscoll E J Dental anesthesiology: its history and continuing
manuscript. education Anes Prog 25:143-151 1978.
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42 ANESTHESIA PROGRESS