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Prizefighter Mike Tyson, once the heavyweight boxing champion of the world, has amassed a bevy of memorable quotes throughout his life. Perhaps most well-known was his response to a reporter asking whether he was worried about Evander Holyfield’s fight plan in preparation for their upcoming match. Tyson quipped “Everyone has a plan until they get punched in the mouth.” Although many in history have shared similar comments about plans crumbling under pressure, Tyson’s quote was the one that came to mind while recently reading the court documents detailing an ill-fated dental sedation case with an exceptionally poor outcome.
The case
Sprung J, Deljou A, Schroeder D, Warner D, Weingarten T. Effect of propofol infusion on need for rescue antiemetics in postanesthesia care unit after volatile anesthesia: a retrospective cohort study. Anesth Analg. 2024;139(1):26–34. doi:10.1213/ANE.0000000000006906
This retrospective analysis examined the anesthetic records of 47,847 patients undergoing procedures with volatile agents, with or without propofol infusion, at a single institution from May 2018 through December 2020. The study tested the hypothesis that adding a propofol infusion to a volatile-based anesthetic would be associated with a dose-dependent decrease in the use of rescue antiemetic drugs in the postanesthesia care unit (PACU).
We herein report a case in which an automatic cuff pressure controller (SmartCuff, Murata Manufacturing Co, Ltd) enabled detection of endotracheal tube (ETT) cuff damage. A 23-year-old woman underwent nasally intubated general anesthesia, and several minutes after securing the airway, the device alarm suddenly sounded in response to a drop in cuff pressure. This alerted us to the damaged cuff despite the noted absence of decreased ventilatory volumes or abnormal capnographic waveforms. The damaged ETT was successfully exchanged, and the case proceeded without any further incidents. This case report suggests that an automatic cuff pressure controller is a useful device
Hepatic compromise poses significant impacts upon the care of patients undergoing routine dental treatment. When sedation or general anesthesia is planned for dental treatment or oral and maxillofacial surgery, an understanding of basic liver function and clinical evaluation can assist in adapting treatment modifications for patients with limited function due to previous disease and resultant organ transplantation efforts. Beginning with a basic overview of hepatic physiology, this review will outline the specific functions of digestion, metabolism, synthesis, and detoxification involving the liver. Specific clinical considerations will be reviewed regarding comorbidities that develop prior to and after liver transplantation that often impact a patient’s suitability for ambulatory and office-based care. Lastly, choices in both local anesthetics, sedative medications, general anesthetics, and postoperative analgesics utilized in dental treatment will be discussed.
Recently, intranasal dexmedetomidine (DEX) has been reported to be effective as a preanesthetic medication, mostly in healthy pediatric patients. We attempted to administer intranasal DEX premedication in this case to an adult patient with intellectual disability who previously had difficulty tolerating premedication with oral midazolam. Using an intranasal atomization delivery device (MAD Nasal, Teleflex), we administered 1.5 µg/kg of DEX intranasally and were able to achieve adequate sedation, which facilitated a smooth mask induction of general anesthesia with sevoflurane. Premedication with intranasal DEX may be a useful method for enabling induction of general anesthesia in adult patients with intellectual disabilities.
Nasotracheal intubation can reveal unexpected findings like a foreign body in the airway. In such instances, expeditious decision-making is crucial to achieve ideal outcomes. This case report describes a petroleum jelly–based foreign body discovered in the nasopharynx during nasotracheal intubation and the subsequent airway management. A 64-year-old man with no prior history of adverse anesthetic events presented to an oral surgery office for extraction of teeth and placement of implants. While video laryngoscopy for nasotracheal intubation was performed, a blue foreign body was discovered inside the tip of the nasal endotracheal tube. Subsequent attempts to locate the source of the foreign body revealed in the nasopharynx a strip of blue gelatinous foreign body which was removed with suction. Due to the persistent presence of foreign body residues in the nasopharynx, orotracheal intubation was performed. Nasopharyngeal foreign bodies may elude even the most thorough preoperative medical history review and airway assessment. Therefore, it is reasonable for practitioners to ask explicitly about any foreign bodies in the nasal passages. Practitioners should become familiar with cognitive aids for relevant airway emergency management techniques and equipment for expeditious decision-making when unexpected foreign bodies are found.
Pfeiffer syndrome (PS) is a rare inherited disorder that affects the craniofacial and extremity bones but can also include anomalies of the upper and lower airways. Among the 3 subtypes, PS types 2 and 3 are the most severe. We describe the anesthetic management of a 10-year-old boy with PS type 2 scheduled for dental treatment under general anesthesia. Because of his history of Chiari malformation, avoiding neck hyperextension was recommended to prevent worsening of his neurologic function. Preoperative computed tomography revealed significant nasal stenosis but no tracheal anomalies. Considering the difficulty of nasotracheal intubation, we planned for an oral intubation. General anesthesia was induced using sevoflurane, nitrous oxide, and oxygen along with an oropharyngeal airway. After lidocaine was topically applied to the oropharynx, fiber-optic orotracheal intubation was performed under spontaneous ventilation to minimize head and neck movement. Anesthesia was maintained using desflurane and remifentanil, and no postoperative complications were observed. General anesthesia for patients with PS requires careful planning, which should include preoperative assessment of the airway to determine the feasibility of nasotracheal intubation and identify airway irregularities.
In complex maxillofacial fractures in which orotracheal and nasotracheal intubation are otherwise contraindicated, alternatives for airway management include tracheostomy and submental intubation (SMI). In this case, SMI was used successfully, although it did result in accidental endobronchial intubation intraoperatively that was quickly recognized and managed appropriately. SMI can be a useful method for securing a patient’s airway, but like all surgical approaches, it does carry the potential for complications. We report a case involving the use of SMI during which an unintended endobronchial intubation occurred.
Objective
Dilution of concentrated epinephrine prior to intravenous use during clinical emergencies can delay urgent interventions. The objective of this study was to determine whether diluted epinephrine remains stable and sterile over time in common hospital settings.
Methods
Epinephrine samples were prepared by clinically relevant double dilution techniques. Samples were stored in 10-mL syringes and incubated under 1 of 4 simulated hospital environments with a mixture of lighting and temperature settings: 4°C/20°C, with or without fluorescent lighting. Samples were incubated for 0, 15, 30, 60, or 90 days. Capillary zonal electrophoresis was used to quantify the concentration of epinephrine and/or presence of any degradation products. All samples were tested for the presence of bacterial growth using blood agar cultures.
Results
Diluted epinephrine samples remained stable for up to 90 days in all 4 simulated clinical storage conditions. No bacterial colony-forming units were detected in any of the environmental samples regardless of incubation duration, light, or temperature conditions.
Conclusion
Diluted epinephrine for anticipated clinical emergencies may remain clinically useful for up to 90 days, thus improving patient safety, access to medications, and overhead costs by reducing waste.
Objective
To evaluate the anesthetic efficacy of 4% articaine with 1:100,000 epinephrine via primary intraosseous (IO) injection with the QuickSleeper device vs inferior alveolar nerve block (IANB) for mandibular first molars diagnosed with symptomatic irreversible pulpitis (SIP).
Methods
Sixty-four patients with a first mandibular molar with SIP were randomly divided into 2 groups: IO (n = 32) and IANB (n = 32). Each received either an IO injection with the 5th generation QuickSleeper device or a conventional IANB with 1.7 mL 4% articaine with 1:100,000 epinephrine. Success was defined as no/mild pain upon the access cavity preparation and initial filing. Injection pain, anesthetic onset, heart rate (HR) change, HR recovery time, and duration of anesthesia were also recorded and analyzed.
Results
The success rates were 40.6% for IANB and 81.2% for IO (P < .001). IO exhibited a significantly lower injection pain (P = .027), a shorter onset of action (P < .001), a greater heart rate increase (P < .001), a faster heart rate recovery time (P < .001), and a shorter duration of action (P < .001) vs IANB.
Conclusion
Primary IO anesthesia using the fifth generation of the QuickSleeper device was more successful than IANB when using 4% articaine with 1:100,000 epinephrine to anesthetize mandibular first molars with SIP. The QuickSleeper device appeared to be a viable alternative to IANB for mandibular anesthesia.