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Emerging evidence suggests that many conventional anticonvulsants, such as carbamazepine, phenytoin, and valproic acid, could cause cross-resistance to nondepolarizing muscle relaxants. However, there are few reports describing the interactions between levetiracetam and rocuronium. This case report describes the delayed onset of rocuronium in an adult patient with intractable epilepsy on long-term levetiracetam therapy. A 33-year-old man was scheduled for extraction of third molars and restorative dental treatment. His daily levetiracetam was continued preoperatively, and after a slow mask induction, rocuronium (20 mg; 0.66 mg/kg) was administered. Muscle relaxation was monitored by train-of-four (TOF) stimulation using the adductor muscle of the thumb. However, it took more than 9 minutes to finally obtain a TOF count of 0. This case report highlights that patients with intractable epilepsy taking levetiracetam may have resistance to rocuronium and should be carefully monitored to avoid harm triggered by prematurely initiated intubation maneuvers.
Objective
This study aimed to establish which anesthetic agents are associated with minimized adverse outcomes during laryngeal mask airway (LMA) insertion.
Methods
Databases were searched for randomized controlled trials (RCTs) with American Society of Anesthesiologists I or II adult patients (≥15 years of age) receiving general anesthesia (GA) with an LMA. Propofol only was the comparator to other anesthetics used during LMA insertion. The primary outcome was prolonged apnea, and secondary outcomes were adverse airway events, LMA insertion failure, inadequate depth of anesthesia, and hemodynamic events. A network meta-analysis was conducted to estimate the treatment effects (odds ratios, 95% credible intervals, and surface under the cumulative ranking curve [SUCRA]).
Results
A total of 28 anesthetic combinations used on 4695 patients for GA induction and LMA insertion were examined across 53 RCTs. Overall, there was an apnea incidence rate of 33.3% (849 of 2548) with a mean time of 3.74 ± 3.56 minutes (n = 3091). Propofol + dexmedetomidine had the highest overall summed score of SUCRA ranks in reducing adverse outcomes (apnea incidence: SUCRA = 37%, apnea time: SUCRA = 66%, airway adverse event: SUCRA = 67%, insertion failure: SUCRA = 73%, inadequate depth of anesthesia: SUCRA = 84%). In comparison among all propofol combinations, propofol alone ranked lowest for overall summed score of SUCRA in reducing adverse outcomes (apnea incidence: SUCRA = 47%, apnea time: SUCRA = 71%, airway adverse event: SUCRA = 9%, insertion failure: SUCRA = 20%, inadequate depth of anesthesia: SUCRA = 9%).
Conclusion
All anesthetic combinations, other than those with thiopental, reduced adverse outcomes as compared with propofol alone. The combination of propofol and dexmedetomidine infused over 10 minutes ranked as the most effective for reducing adverse outcomes during LMA insertion.
This past January officially marked the start of my sixth year serving as editor of Anesthesia Progress, a journey that has been both enjoyable and challenging. The journal has seen several changes throughout my tenure, and this year appears to be no different. Along with its editorial board, the journal is undergoing some noteworthy updates, of which some are exciting and others quite bittersweet.
With the recent passing of Stuart E. Lieblich, DMD, the journal lost a significant long-standing editorial board member. Among his multitude of achievements, Dr Lieblich was a past president of the American Dental Society
In conjunction with the 2024 Annual Session of the American Dental Society of Anesthesiology (ADSA), the International Federation of Dental Anesthesiology Societies (IFDAS) held its 17th International Dental Congress on Anesthesia, Sedation, and Pain Control from March 15 to 16, 2024, at the Aria Resort and Casino in Las Vegas. Held every 3 years in various locations around the globe, IFDAS meetings are exciting opportunities for members of international dental anesthesia societies to present cutting-edge research and initiatives and exchange clinical advances in the areas of anesthesia, sedation, and pain control for dentistry.
With a diverse array of presenters from
Comparison of Circulatory Dynamics During Induction of General Anesthesia Between Propofol and Remimazolam: Clinical Research
Kanoko Hirata, DDS; Yozo Manabe, DDS, PhD; Akina Toya, DDS; Shigeru Iwamoto, DDS; and Yoshihiro Momota, DDS, PhD
Department of Dental Anesthesiology, Osaka Dental University, Osaka, Japan
Objective: Propofol is characterized by its relatively strong circulatory depressant effects. Basic studies have shown that remimazolam has less potent effects on circulatory dynamics than propofol. The purpose of this study was to clarify the cardiovascular effects of propofol and remimazolam in clinical practice.
Methods: Sixty patients aged 18 years to 39 years undergoing surgery under
The American Society of Dental Anesthesiology (ADSA) is deeply saddened to report the passing of one of its most highly regarded members, Stuart E. Lieblich, DMD, after a 6-month battle with esophageal cancer. Dr Lieblich’s extensive curriculum vitae places him among the brightest luminaries in many academic and clinical disciplines. As he was to receive the 2024 Heidbrink Award, the ADSA’s highest honor, it was posthumously awarded on March 16, 2024, during the ADSA Annual Session in Las Vegas, NV.
Dr Lieblich was an accomplished surgeon from Avon, CT, spending more than 40 years in the private practice of oral
Most invasive dental procedures elicit some degree of bleeding which ultimately leads to clotting and eventual hemostasis. However, patients with inherited coagulation disorders may exhibit prolonged or, in some cases, excessive bleeding requiring multiple perioperative interventions. Von Willebrand disease is the most common inherited coagulopathy and often manifests via easy bruising, epistaxis, or prolonged bleeding. Hemophilia A (factor VII) and B (factor IX) are factor deficiencies that are clinically indistinguishable and managed according to severity and the required dental treatment. Other coagulopathies are rare (ie, inheritance is autosomal recessive) and may only become evident in homozygotes or compound heterozygotes. Current lab values and medical consultation with the patient’s hematologist are imperative prior to rendering invasive dental treatment. There are a myriad of sedation and general anesthesia considerations, including risks for epistaxis with nasal instrumentation and bruising with improper patient positioning. Preoperative treatment with desmopressin or factor replacement may be required and generally should facilitate normal hemostasis. Additional therapies should be considered to help ensure adequate postoperative hemostasis, including pressure dressings, resorbable clotting materials, laser therapy, and oral rinses.
Muscle relaxants and their reverse drugs should be carefully administered to patients with acute polymyositis and/or dermatomyositis. However, the use of these drugs in controlled polymyositis and/or dermatomyositis is controversial. This case report describes the use of rocuronium and sugammadex in a 27-year-old female patient with controlled polymyositis who was scheduled for minor oral surgery under general anesthesia. General anesthesia was induced rapidly, and 0.66 mg/kg of rocuronium was administered prior to nasotracheal intubation. No additional muscle relaxants were administered during the surgery. At the end of surgery, approximately 2 hours after the rocuronium was administered, her train-of-four (TOF) ratio was still 49%. A dose of 3.3 mg/kg of sugammadex was administered, and it took 12 minutes for the TOF ratio to exceed 90%. The prolonged duration of muscle relaxation in patients with polymyositis may be due to a decrease in skeletal muscle and capillary volume. The slow onset of sugammadex may be caused by slow diffusion of rocuronium from the neuromuscular junction. Patients with polymyositis require close perioperative neuromuscular function monitoring, regardless of their disease control status.
We report a case in which tracheal stenosis was discovered during endotracheal intubation. A 19-year-old woman with Down syndrome was scheduled to undergo treatment of multiple dental caries under intubated general anesthesia. During the first general anesthetic, we felt some resistance while advancing the endotracheal tube through the trachea. Prior to a second general anesthetic 2 years later, we performed 3-dimensional computed tomography to evaluate the tracheal stenosis and devised a strategy that established an airway without advancing the endotracheal tube over the stenotic lesion. Careful attention is required when performing endotracheal intubation because patients with Down syndrome sometimes have tracheal stenosis.
Chhabada S, Skinner C, et al. Association between age- and sex-specific body mass index percentile and multiple intubation attempts: a retrospective cohort analysis. Anesth Analg. 2024;138(4):821–828. doi:10.1213/ANE.0000000000006400
Obesity distorts airways and has been shown to slightly complicate intubation in adults, but whether obesity complicates pediatric intubations remains unclear. The authors tested the primary hypothesis that increasing age- and sex-specific body mass index (BMI) percentile is associated with difficult intubation, defined as more than 1 intubation attempt. A retrospective analysis of pediatric patients between 2 and 18 years of age undergoing noncardiac surgery with oral endotracheal intubation was conducted.