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INTRODUCTION Deliberate hypotension is an important tool for anesthetics provided for orthognathic surgery. 1 The maxilla is a highly vascularized area of the human body. 2 Since orthognathic surgery in the form of the LeFort I osteotomy involves the separation and repositioning of the maxilla, significant surgical blood loss is a risk. 2 One method of avoiding excessive hemorrhage is through the utilization of deliberate hypotension induced and maintained by the anesthesiologist. The target pressures for deliberate hypotension can vary

reduction of zygomatic arch fractures and manipulation of midface fractures. Asystole has been reported during downfracture of the maxilla during a Le Fort I osteotomy. Repositioning of the maxilla showed a return to sinus rhythm. Treatment with both atropine and glycopyrrolate allowed the downfracture to continue without further occurrence of a dysrhythmia. 2 The reflex has also been induced by a displaced zygomatic fracture and resolved when the fracture was reduced. 3 The case presented is a unique example of the trigeminovagal reflex where the afferent impulses are

to minutes) following a triggering stimulus. VVS often does not require treatment with medications (eg, atropine), as placing the patient in the Trendelenburg position is usually sufficient. However, administration of atropine may be needed if the VVS episode is severe or unresponsive to patient repositioning. Bradycardia is one of the typical signs noted with VVS, but modest tachycardia may be noted during the prelude to the actual syncopal event. Differentiating between VVS and anaphylaxis may be difficult given that some of the common signs and symptoms may

% lidocaine containing 1:80,000 epinephrine was then administered, after which restorative procedures were performed for the mandibular first and second premolar teeth on the right. Slight body movement was observed at 5 and 30 minutes intraoperatively; intravenous midazolam 0.25 mg was administered on both occasions. There were no intraoperative episodes of upper airway obstruction requiring manual repositioning of the airway. Dexmedetomidine was administered intraoperatively at a dose of 0.5–0.7 μg/kg/h and discontinued upon completion of surgery. His intraoperative OAA

occurring in a child after induction that requires immediate paralysis to reestablish airway patency after failing the usual steps (repositioning, airway suctioning, and deepening the patient). An inattentive or poorly prepared provider may not properly recognize the issue and appropriately rescue the patient before permanent damage occurs. Someone who has never given an effective dose of succinylcholine emergently or has not done so after many years in practice may be equally hesitant. Although there are many factors at play for a successful outcome in such a scenario, 2

boluses of fentanyl (0.2 mg). Rocuronium for neuromuscular blockade was not readministered. Volume-controlled ventilation was obtained with a 500-mL tidal volume and 40% fraction of inspired oxygen. The expiratory tidal volume (V TE ) and the peak airway pressure were 470 mL and 16 hPa (∼12 mm Hg), respectively. Thirty minutes into the sagittal split osteotomy, the V TE abruptly decreased from 470 to 100–300 mL. The surgeon did not think the ETT had been damaged at this time. However, after repositioning the patient's head and neck, the ETT cuff was presumed to have