Editorial Type: Departments
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Online Publication Date: 01 Jan 2009

JDSA Journal Abstracts

Article Category: Research Article
Page Range: 23 – 32
DOI: 10.2344/0003-3006-56.1.23
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Combination of Dexmedetomidine and Lidocaine Enhances Inhibitory Action Potential in The Rat Sciatic Nerve

YukakoTsutsui and Katsuhisa Sunada 2008;36(3):257–262.

Local vasoconstrictive drugs are commonly used in dental anesthesia. Recent reports indicated that α2-adrenoceptor agonist enhanced local anesthetic effect of lidocaine in the peripheral nerve. In addition, lidocaine with α2-adrenoceptor agonist decreased conduction velocity and amplitude of action potential (AP) of peripheral nerve. Furthermore, α2-adrenoceptor mRNA was expressed in rat peripheral nerve. Dexmedetomidine (Dex), a selective α2-adrenoceptor agonist, has been used in general anesthesia for sedation. DEX also has been known to have vasodepressor effect. We hypothesized that lidocaine with DEX might enhance the local anesthetic effect without cardiovascular side effect. We therefore investigated and determined the local anesthetic effect of DEX when combined with lidocaine on the rat peripheral nerve.

The sciatic nerve of Wistar rat was stimulated and recorded via two platinum electrodes. The stimulus duration was set at 0.5 msec and repetitive stimulation at 1 Hz. We measured AP and duration of depolarization phase (DDP) after lidocaine, DEX and lidocaine with DEX added to isolated rat sciatic nerve (Fig. 1). EC50 of lidocaine was 100 µM (Fig. 2). Lidocaine had no effect on DDP (Table 1). DEX decreased AP and EC50 was 10 µM (Fig. 3). DEX also decreased DDP significantly (Table 2). Addition of 10 µM DEX with 100 µM lidocaine decreased AP to 18.3±8.0% of control after 10 min. It was recovered to the same value of control by rinsing with 10 µM DEX + 100 µM lidocaine (Fig. 4a). In addition, we examined the percent change of DDP. Although DDP was shorter than control from 2 min after addition of lidocaine with DEX, it was recovered to the same value of control 2 min after rinse (Fig. 4b). Changes in DDP by 10 µM DEX with 100 µM lidocaine may have resulted from potassium channels, as observed in other local anesthetics.

These results suggest that the combination of DEX and lidocaine was more effective in increasing the pain threshold action potential and may have a potential for a new local anesthetic drug.

Department of Dental Anesthesiology, The Nippon Dental University, School of Life Dentistry at Tokyo

Figure 1. Typical tracing of AP and DDP. Method for measurement of AP and DDP.Figure 1. Typical tracing of AP and DDP. Method for measurement of AP and DDP.Figure 1. Typical tracing of AP and DDP. Method for measurement of AP and DDP.
Figure 1. Typical tracing of AP and DDP. Method for measurement of AP and DDP.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Table 1 % Change of AP and DDP for Lidocaine
Table 1
Table 2 % Change of AP and DDP for DEX
Table 2
Figure 2. Dose response curve of lidocaine. This graph showed dose response curve of lidocaine. Lidocaine EC50 was almost 100 µM.Figure 2. Dose response curve of lidocaine. This graph showed dose response curve of lidocaine. Lidocaine EC50 was almost 100 µM.Figure 2. Dose response curve of lidocaine. This graph showed dose response curve of lidocaine. Lidocaine EC50 was almost 100 µM.
Figure 2. Dose response curve of lidocaine. This graph showed dose response curve of lidocaine. Lidocaine EC50 was almost 100 µM.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Figure 3. Dose response curve of DEX. This graph showed dose response curve of DEX. DEX EC50 was almost 10 µM.Figure 3. Dose response curve of DEX. This graph showed dose response curve of DEX. DEX EC50 was almost 10 µM.Figure 3. Dose response curve of DEX. This graph showed dose response curve of DEX. DEX EC50 was almost 10 µM.
Figure 3. Dose response curve of DEX. This graph showed dose response curve of DEX. DEX EC50 was almost 10 µM.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Figure 4a. % change of AP for DEX 10 µM + lidocaine 100 µM.Figure 4a. % change of AP for DEX 10 µM + lidocaine 100 µM.Figure 4a. % change of AP for DEX 10 µM + lidocaine 100 µM.
Figure 4a. % change of AP for DEX 10 µM + lidocaine 100 µM.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Figure 4b. % change of DDP for DEX 10 µM + lidocaine 100 µM. When DEX 10 µM + Lidocaine 100 µM administered to the sciatic nerve, AP was significantly decreased from the control. When DEX 10 µM + Lidocaine 100 µM was rinsed by saline, AP recovered to the control value. When AP decreased, DDP also decreased significantly. / Mean values ± SD were shown for n = 9.Figure 4b. % change of DDP for DEX 10 µM + lidocaine 100 µM. When DEX 10 µM + Lidocaine 100 µM administered to the sciatic nerve, AP was significantly decreased from the control. When DEX 10 µM + Lidocaine 100 µM was rinsed by saline, AP recovered to the control value. When AP decreased, DDP also decreased significantly. / Mean values ± SD were shown for n = 9.Figure 4b. % change of DDP for DEX 10 µM + lidocaine 100 µM. When DEX 10 µM + Lidocaine 100 µM administered to the sciatic nerve, AP was significantly decreased from the control. When DEX 10 µM + Lidocaine 100 µM was rinsed by saline, AP recovered to the control value. When AP decreased, DDP also decreased significantly. / Mean values ± SD were shown for n = 9.
Figure 4b. % change of DDP for DEX 10 µM + lidocaine 100 µM. When DEX 10 µM + Lidocaine 100 µM administered to the sciatic nerve, AP was significantly decreased from the control. When DEX 10 µM + Lidocaine 100 µM was rinsed by saline, AP recovered to the control value. When AP decreased, DDP also decreased significantly. Mean values ± SD were shown for n = 9.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Randomized Controlled Study of Felypressin-Propitocaine And Mepivacaine for Inferior Alveolar Nerve Block

Kentaro Ouchi and Katsuhisa Sunada 2008;36(3):263–268.

Felypressin-propitocaine (FP) and mepivacaine (M) are marketed as local anesthetics that do not contain adrenaline. These anesthetics are frequently used for patients with circulatory diseases. However, differences of these anesthetics are not clear when used for inferior alveolar nerve block. The present randomized controlled trial sought to compare the effects of FP and M for inferior alveolar nerve blocks.

The studied group consisted of 19 healthy volunteers. Using blocked randomization, the following two anesthetics was randomly assigned to perform inferior alveolar nerve blocks: FP group (1.6 ml) and M group (1.6 ml). The subjects were asked to assess anesthesia success rate (occurrence of lower lip anesthesia in less than 20 minutes), anesthetic onset, duration of anesthetic effect and the degree of discomfort associated with inferior alveolar nerve blocks. An electric pulp tester was used to evaluate the anesthetic effects on each tooth. Dental pulp was judged as being anesthetized if no response was observed after application of the maximum stimulus for up to 60 minutes after the drug was administered. Chronological changes in success rate of pulp anesthesia (cases of pulp anesthesia/total cases) were examined. The data obtained between the two groups were analyzed as follows. Anesthesia success rate, anesthetic onset and duration of anesthetic effect were analyzed by unpaired-t test. Chronological changes in success rate of pulp anesthesia were analyzed by chi-square test. The number of discomfort were analyzed by Mann-Whitney test. Statistical significance was considered when P values for the respective test were <0.05.

Anesthesia success rate was not significantly different. Chronological changes in success rate of pulp anesthesia for FP group was significantly higher than M group by multiple points in time. They were 5–30 minutes value in lateral incisor, 5–10 minutes value in premolar, and 5, 15 and 30–50 minutes value in molar. However on other points in time, both groups had similar results (Fig. 1). Anesthesia onset was not significantly different between FP group and M group (Table 1). Duration of anesthetic effect in FP group was significantly longer than in the M group (Table 2). The number of discomfort with inferior alveolar nerve block was not significantly different (Table 3).

These findings suggest that FP can be a potential candidate for a drug of choice when quick onset and long lasting anesthesia is desired.

Department of Dental Anesthesiology, The Nippon Dental University, School of Life Dentistry at Tokyo

Table 1 Onset of Anesthesia
Table 1
Table 2 Duration of Anesthetic Effect
Table 2
Figure 1. Chronological changes in success rate of pulp anesthesia. Success rate of pulp anesthesia was determined by assessing the responses to electrical pulp stimulation at each post-injection time.Figure 1. Chronological changes in success rate of pulp anesthesia. Success rate of pulp anesthesia was determined by assessing the responses to electrical pulp stimulation at each post-injection time.Figure 1. Chronological changes in success rate of pulp anesthesia. Success rate of pulp anesthesia was determined by assessing the responses to electrical pulp stimulation at each post-injection time.
Figure 1. Chronological changes in success rate of pulp anesthesia. Success rate of pulp anesthesia was determined by assessing the responses to electrical pulp stimulation at each post-injection time.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Table 3 The Number of Discomfort
Table 3

Dexmedetomidine for Postoperative Management After Sevoflurane Anesthesia in Children

Hiroyoshi Kawaai, Jun Sato, MasahiroWatanabe, Hiroshi Ito, Sachie Ogawa, Kazuhiro Shimamura*, Yasuo Suzuki* and ShinyaYamazaki 2008;36(3):269–277.

Sevoflurane is widely used in pediatric anesthesia because of its advantages including quick induction and rapid emergence from anesthesia. However, agitation and/or delirium is a common phenomenon observed in emergence from sevoflurane anesthesia, which are difficult conditions to manage. Dexmedetomidine (Dex), an α2 agonist, has some unique properties, and has been used for conscious sedation. We studied the effects of Dex on circulation and respiration in children postoperatively undergoing sevoflurane anesthesia. We also investigated whether sedation with Dex could control the undesired behavior after sevoflurane anesthesia in pediatric cases.

Twenty healthy children were studied (Table 1). They were induced with 5% sevoflurane in 4 l/min nitrous oxide and 2 l/min oxygen without premedication. General anesthesia was maintained with 1.5–3% sevoflurane during the operation. Dex infusion (0.4 µg/kg/h) was started at approximately 30 minutes before the end of the operation and continued until 120 minutes (2 hours) after the end of the operation (Fig. 1). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), respiratory rate (f), percutaneous arterial saturated oxygen (Spo2), Ramsey score (RS) (Table 2) and Richmond Agitation-Sedation Scale (RAS) (Table 3) were monitored at admission to the hospital and every 30 minutes after the end of the operation for over 90 minutes after Dex infusion, and at 180 minutes after Dex infusion. On the next day, a questionnaire about the postoperative behavior was taken from their guardians (Fig. 5). Anesthetic duration and total dosage of Dex were 204±104 min and 24.5±7.4 µg (Table 4). SBP, DBP, HR and f showed no significant changes. However, Spo2 decreased significantly at 30 minutes after the end of Dex infusion (Fig. 2, 3). The results indicate that Dex had no influence on the circulation but oxygen administration was required for more than 30 minutes after the end of Dex infusion. It is advised that Dex should start from at least 90 minutes before the end of surgery, because agitation and/or delirium was still observed at 30 minutes after the end of the operation during Dex infusion (Fig. 4). Based on a questionnaire of postoperative sedation with Dex (Fig. 5), 90% of the guardians showed satisfaction and indicated that their children seemed to be sleeping comfortably without pain. All guardians stated that they would recommend Dex if their children required to be anesthetized again. The results indicate that sedation with Dex appeared to be useful for postoperative management after sevoflurane anesthesia in children.

Department of Dental Anesthesiology, Ohu University School of Dentistry

*Department of PediatricDentistry,Ohu University School of Dentistry

Table 1 Patient Characteristics
Table 1
Figure 1. Time course in this study. Dex (0.4 µg/kg/hr) was started at approximately 30 minutes before the end of the operation and continued until 120 minutes (2 hours) after the end of the operation. SBP, DBP, HR, f, Spo2, RS and RAS were monitored at hospitalization (cont) and every 30 minutes after the end of the operation until 90 minutes (A90) and at 180 minutes (A180) after the end of Dex infusion.Figure 1. Time course in this study. Dex (0.4 µg/kg/hr) was started at approximately 30 minutes before the end of the operation and continued until 120 minutes (2 hours) after the end of the operation. SBP, DBP, HR, f, Spo2, RS and RAS were monitored at hospitalization (cont) and every 30 minutes after the end of the operation until 90 minutes (A90) and at 180 minutes (A180) after the end of Dex infusion.Figure 1. Time course in this study. Dex (0.4 µg/kg/hr) was started at approximately 30 minutes before the end of the operation and continued until 120 minutes (2 hours) after the end of the operation. SBP, DBP, HR, f, Spo2, RS and RAS were monitored at hospitalization (cont) and every 30 minutes after the end of the operation until 90 minutes (A90) and at 180 minutes (A180) after the end of Dex infusion.
Figure 1. Time course in this study. Dex (0.4 µg/kg/hr) was started at approximately 30 minutes before the end of the operation and continued until 120 minutes (2 hours) after the end of the operation. SBP, DBP, HR, f, Spo2, RS and RAS were monitored at hospitalization (cont) and every 30 minutes after the end of the operation until 90 minutes (A90) and at 180 minutes (A180) after the end of Dex infusion.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Table 2 Ramsay Score
Table 2
Table 3 Richmond Agitation-Sedation Scale
Table 3
Table 4 Details in This Study
Table 4
Figure 2. Change in SBP, DBP and HR. There were no significant differences in SBP, DBP and HR.Figure 2. Change in SBP, DBP and HR. There were no significant differences in SBP, DBP and HR.Figure 2. Change in SBP, DBP and HR. There were no significant differences in SBP, DBP and HR.
Figure 2. Change in SBP, DBP and HR. There were no significant differences in SBP, DBP and HR.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Figure 3. Change in f and Spo2. f did not show significant changes, however, Spo2 showed a significant decrease at 30 minutes after the end of Dex administration.Figure 3. Change in f and Spo2. f did not show significant changes, however, Spo2 showed a significant decrease at 30 minutes after the end of Dex administration.Figure 3. Change in f and Spo2. f did not show significant changes, however, Spo2 showed a significant decrease at 30 minutes after the end of Dex administration.
Figure 3. Change in f and Spo2. f did not show significant changes, however, Spo2 showed a significant decrease at 30 minutes after the end of Dex administration.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Figure 4. Change in RS and RAS. RS and RAS showed significant changes from 30 minutes after the end of the operation to 30 minutes after the end of Dex infusion.Figure 4. Change in RS and RAS. RS and RAS showed significant changes from 30 minutes after the end of the operation to 30 minutes after the end of Dex infusion.Figure 4. Change in RS and RAS. RS and RAS showed significant changes from 30 minutes after the end of the operation to 30 minutes after the end of Dex infusion.
Figure 4. Change in RS and RAS. RS and RAS showed significant changes from 30 minutes after the end of the operation to 30 minutes after the end of Dex infusion.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Figure 5. Guardians responses to a questionnaire of postoperative sedation with Dexmedetomidine.Figure 5. Guardians responses to a questionnaire of postoperative sedation with Dexmedetomidine.Figure 5. Guardians responses to a questionnaire of postoperative sedation with Dexmedetomidine.
Figure 5. Guardians responses to a questionnaire of postoperative sedation with Dexmedetomidine.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Influences of Sevoflurane and Isoflurane on Body Temperature and Skin Blood Flow During General Anesthesia

Ken-Ichi Satoh, Junko Ikeda,Yuko Kashima, Ken Nishi, Ken-Ichi Nabeshima, Nozomu Sakamoto, Masahito Satoh, Kazuna Sugiyama* and Shigeharu Joh

To investigate influences of sevoflurane and isoflurane on body temperature and skin blood flow during general anesthesia, we measured rectal temperature, finger-tip skin temperature and finger-tip skin blood flow using Thermistor temperature gage (Nihon Kohden co. Ltd.), Therumofiner (Therumo co. Ltd.) and laser blood flow meter (Alf 21™; Advance co. Ltd.).

The subjects were 16 patients, ASA physical status I, who underwent oral surgery. They were divided into two groups: sevoflurane-nitrous oxide (GOS group, n = 8) and isoflurane-nitrous oxide (GOI group, n = 8). Patients were premedicated with 0.5 mg scopolamine and 15 mg of pentazocine administered IM 30 min before they were taken to the operating room. Anesthesia was induced with intravenous (IV) thiopental (4–5 mg/kg) and vecuronium (0.1 mg/kg). After endotracheal intubation, anesthesia was maintained with oxygen, nitrous oxide, and sevoflurane (1.5–2.0%) or isoflurane (1.0–1.5%). The lungs were mechanically ventilated using the F circuit system with a fresh gas flow of 6 l/min, which was adjusted to maintain end tidal Pco2 between 35–40 mmHg. Intravenous fluid was administered at a basal rate of 4 to 8 ml/kg/h and 4 ml of crystalloid was given to compensate for each estimated 1 ml of blood loss. Rectal temperature was measuered at 30, 45, 60, 75, 90, 105, 120 min after induction, end of operation and immediately after extubation. Finger-tip skin temperature and blood flow were measured at before induction, 30, 45, 60, 75, 90, 105, 120 min after induction, end of operation and immediately after extubation. There were no significant differences between the GOI group and GOS group regarding age, weight, room temperature, or duration of anesthesia (Table 1).

Results (Table 2, Fig. 1): 1. Rectal temperature decreased by 0.20°C in GOI group and 0.29°C in GOS group after induction and increased by 0.19°C in GOI group and by 0.12°C in GOS group respectively, immediately after extubation when compared with the control value. There was no significant difference in the two groups; 2. Finger-tip skin temperature increased by 1.4°C in GOI group and by 2.1°C in GOS group at 30 min after intubation, and decreased to the control value immediately after extubation; 3. Finger-tip skin blood flow increased by 17.6 ml/min/100 g in GOI group and by 21.8 ml/min/100 g in GOS group, and decreased immediately after extubation.

It is suggested that changes in rectal temperature and finger-tip skin temperature depend on the changes in the finger-tip skin blood flow.

Department of Dental Anesthesiology, School of Dentistry, Iwate Medical University

*Department of Anesthesiology, Kagoshima University Graduate School of Medical and Dental Sciences

Table 1 Demographic data
Table 1
Table 2 Changes in rectal temperature, finger-tip skin temperature and finger-tip skin blood flow during anesthesia
Table 2
Figure 1. Differences between each value for (a) rectal, (b) finger-tip skin temperature and (c) finger-tip skin blood flow at the measurement point and the control value. The values are expressed as means ± SEMs. The values of stroke index are as follows: (1)before induction, (2)30 min after induction, (3)45 min, (4)60 min, (5)75 min, (6)90 min, (7)105 min, (8)120 min, (9)the end of operation, (10)immediately after extubation.Figure 1. Differences between each value for (a) rectal, (b) finger-tip skin temperature and (c) finger-tip skin blood flow at the measurement point and the control value. The values are expressed as means ± SEMs. The values of stroke index are as follows: (1)before induction, (2)30 min after induction, (3)45 min, (4)60 min, (5)75 min, (6)90 min, (7)105 min, (8)120 min, (9)the end of operation, (10)immediately after extubation.Figure 1. Differences between each value for (a) rectal, (b) finger-tip skin temperature and (c) finger-tip skin blood flow at the measurement point and the control value. The values are expressed as means ± SEMs. The values of stroke index are as follows: (1)before induction, (2)30 min after induction, (3)45 min, (4)60 min, (5)75 min, (6)90 min, (7)105 min, (8)120 min, (9)the end of operation, (10)immediately after extubation.
Figure 1. Differences between each value for (a) rectal, (b) finger-tip skin temperature and (c) finger-tip skin blood flow at the measurement point and the control value. The values are expressed as means ± SEMs. The values of stroke index are as follows: (1)before induction, (2)30 min after induction, (3)45 min, (4)60 min, (5)75 min, (6)90 min, (7)105 min, (8)120 min, (9)the end of operation, (10)immediately after extubation.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Anesthetic Management for Palatoplasty in a Patient With Freeman-Sheldon Syndrome

Makiko Shibuya,Toshiaki Fujisawa,Yukifumi Kimura, Nobuhito Kamekura and Kazuaki Fukushima 2008;36(3):283–288.

Freeman-Sheldon Syndrome (FSS) is a congenital disorder defined by multiple abnormalities of the head, face, and skeleton. It is also called “whistling face syndrome” because of the characteristic appearance of the patient who has a small mouth and long philtrum. We performed general anesthesia for a patient with FSS.

A 2-year-old male was scheduled to undergo palatoplasty. He had micrognathia, a short neck, ventricular septal defect, a past history of aspiration pneumonia and mental retardation (Fig. 1). Because he had fever and wheezing on the day of admission to our hospital, the operation was postponed. Two months later when he had no symptoms of a common cold, we conducted anesthesia. No premedication was done. Anesthesia was gradually induced with nitrous oxide, oxygen and sevoflurane. Because of thick subcutaneous tissue, it was difficult to establish a venous route which took a long time. After the establishment of the venous route, 0.1 mg/kg vecuronium bromide was given. Mask ventilation was possible when his face was turned sideways. The Cormack sign was grade III on laryngoscopy at first. With external cricoid pressure, the bottom of the vocal cord could be seen, and intubation with a 4.5 tracheal tube size could be done on the first attempt. Since a micro-defect of the interventricular septum could be suspected, prophylactic ampicillin was administered 30 minutes before the operation. His temperature rose to 38.2°C during anesthesia, but there were no other symptoms of malignant hyperthermia such as abnormal tachycardia, arrhythmia, muscle rigidity, elevation of Etco2 or portwine-colored urine. After rectal acetaminophen administration, the temperature went down. As we judged that the airway could be sufficiently maintained after extubation and reintubation could be done, the endotracheal tube was removed in the operating room. There was no obstruction of the upper airway after the extubation. After he was moved back to his room, his respiratory condition was good until the 3rd postoperative day. However, on the 4th day, his temperature rose to 39.2°C and upper respiratory inflammation was diagnosed.

Patients with FSS have various abnormalities as shown in Table 1. Table 2 shows the problems of general anesthesia in patients with FSS. Patients with FSS who undergo palatoplasty need careful care and attention because the operating area overlaps the airway and the operation may adversely affect postoperative airway management.

Department of Dental Anesthesiology, Graduate School of Dental Medicine, Hokkaido University

Figure 1. Facial appearance of this patient shows slight degree of micrognathia and mandibular retraction, blepharodiastasis, short neck and hypoplastic nose wings.Figure 1. Facial appearance of this patient shows slight degree of micrognathia and mandibular retraction, blepharodiastasis, short neck and hypoplastic nose wings.Figure 1. Facial appearance of this patient shows slight degree of micrognathia and mandibular retraction, blepharodiastasis, short neck and hypoplastic nose wings.
Figure 1. Facial appearance of this patient shows slight degree of micrognathia and mandibular retraction, blepharodiastasis, short neck and hypoplastic nose wings.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Table 1 Findings of Freeman-Sheldon Syndrome
Table 1
Table 2 Problems of General Anesthesia in Patients with Freeman-Sheldon Syndrome
Table 2

Postoperative Shivering After Prolonged Remifentanil Infusion: A Case Report

Hideharu Agata and Toshiya Koitabashi 2008;36(3):289–293.

We present a case of a patient who exhibited marked shivering after a prolonged infusion of remifentanil. A 56-year-old male was scheduled for mandibular reconstruction with rib-latissimus dorsi musculocutaneous flap. There were no specific findings on the preoperative examination. The patient was anesthetized with combined thoracic epidural and general anesthesia (sevoflurane and remifentanil). Continuous epidural infusion of both fentanyl and 0.2% ropivacaine were started immediately after the conclusion of the flap. Duration of anesthesia lasted for 12 hours and 45 minutes. The continuous remifentanil infusion rate during the operation was 0.1–0.5 µg/kg/min and the cumulative dose was 13.5 mg. The minimum core temperature during operation was 35.5°C, and was 36.8°C at extubation. The patient received 100 µg fentanyl intravenuously 7 minutes before the end of surgery and the endotracheal tube was removed 5 minutes after the end of surgery. However, approximately one minute following extubation, the patient started shivering without signs of hypothermia or postoperative pain. Although we tried to treat shivering by administering intravenous fentanyl, nicardipine, flurbiprofen and epidural ropivacaine (0.2%), the shivering lasted for 45 minutes. As a result, the core temperature rose to 39.7°C. Since the core temperature was maintained at normothermia during the operation, we considered that this shivering has not been occured as a thermoregulatory response. We postulated that an acute development of withdrawal symptom caused by rapid offset of remifentanil may have been accountable for the shivering in the early postoperative period in this case. Therefore, when remifentanil is administered for a prolonged time, some strategies to prevent shivering such as the use of regional analgesia and/or use of transitional opioids may be necessary.

Department of Anesthesiology,Tokyo Dental College, Ichikawa General Hospital

Figure 1. Anesthesia record. (1) A-line, CV, (2) Infiltration anesthesia: 1% lidocaine (1/100,000 E) 20 ml, (3) Flurbiprofen 50 mg iv, (4) Epidural catheter, Th3/4, depth: 7.5 cm, length: 3.5 cm ↑, (5) Epidural continuous infusion: 4 ml/h (300 ml = 0.2% ropivacaine 280 ml+Fentanyl 1,000 µg), (6) Nicardipine 1 mg iv, (7) Epidural: 0.2% ropivacaine 6 ml, (8) Flurbiprofen 50 mg iv.Figure 1. Anesthesia record. (1) A-line, CV, (2) Infiltration anesthesia: 1% lidocaine (1/100,000 E) 20 ml, (3) Flurbiprofen 50 mg iv, (4) Epidural catheter, Th3/4, depth: 7.5 cm, length: 3.5 cm ↑, (5) Epidural continuous infusion: 4 ml/h (300 ml = 0.2% ropivacaine 280 ml+Fentanyl 1,000 µg), (6) Nicardipine 1 mg iv, (7) Epidural: 0.2% ropivacaine 6 ml, (8) Flurbiprofen 50 mg iv.Figure 1. Anesthesia record. (1) A-line, CV, (2) Infiltration anesthesia: 1% lidocaine (1/100,000 E) 20 ml, (3) Flurbiprofen 50 mg iv, (4) Epidural catheter, Th3/4, depth: 7.5 cm, length: 3.5 cm ↑, (5) Epidural continuous infusion: 4 ml/h (300 ml = 0.2% ropivacaine 280 ml+Fentanyl 1,000 µg), (6) Nicardipine 1 mg iv, (7) Epidural: 0.2% ropivacaine 6 ml, (8) Flurbiprofen 50 mg iv.
Figure 1. Anesthesia record. (1) A-line, CV, (2) Infiltration anesthesia: 1% lidocaine (1/100,000 E) 20 ml, (3) Flurbiprofen 50 mg iv, (4) Epidural catheter, Th3/4, depth: 7.5 cm, length: 3.5 cm ↑, (5) Epidural continuous infusion: 4 ml/h (300 ml = 0.2% ropivacaine 280 ml+Fentanyl 1,000 µg), (6) Nicardipine 1 mg iv, (7) Epidural: 0.2% ropivacaine 6 ml, (8) Flurbiprofen 50 mg iv.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

A Nasotracheal Tube Introducer That Minimizes Damage on Nasopharyngeal Membranes

Tomoe Iwabuchi,Toshiyuki Saito,Toshiyasu Kitayama, Takashi Hitosugi, Sono Suzuki and Yoshiyuki Oi 2008;36(3):294–297.

We usually choose nasal intubation in oral surgical procedures to provide sufficient oral cavity space for the surgeon. During nasal intubation procedure, the tip of the nasotracheal tube is advanced in the nasal cavity blindly. There are a number of reports of epistaxis, palatal perforation, perforation of cervical esophagus, obstruction by bleeding and dislocation of middle turbinate into the nasopharynx. We therefore developed a new nasotracheal tube with a balloon-tip introducer to decrease the complications and trauma to the nasopharyngeal membranes (Fig. 1).

Five anesthetists participated to test this device using the Laerdal Airway Management Trainer®. The process of nasotracheal intubation was as follows: Insertion of the inflatable balloon introducer into the nasotracheal tube was done. Let one fourth of the balloon protrude from the distal tip of the nasotracheal tube. After advancing the nasotracheal tube blindly through the nasopharynx until its tip is in the midpharyngeal cavity behind the fauces, the balloon is deflated and then, the balloon introducer is pulled out from the tube. The nasotracheal tube is further advanced and placed into the trachea using Magill forceps.

We obtained satisfactory results using our new device on the Laerdal Model Trainer®. There was less resistance during insertion of the nasotracheal tube (Mallinckrodt®) when compared with that of the conventional tracheal tube. We believe that it is crucial to perform smooth insertion of the nasotracheal tube to minimize trauma on the nasopharyngeal membranes.

Department of Anesthesia, School of Dentistry, Nihon University

Figure 1. New balloon tip nasotracheal tube introducer. A: rectangularly cut tube tip (non-bevel). B: balloon introducer.Figure 1. New balloon tip nasotracheal tube introducer. A: rectangularly cut tube tip (non-bevel). B: balloon introducer.Figure 1. New balloon tip nasotracheal tube introducer. A: rectangularly cut tube tip (non-bevel). B: balloon introducer.
Figure 1. New balloon tip nasotracheal tube introducer. A: rectangularly cut tube tip (non-bevel). B: balloon introducer.

Citation: Anesthesia Progress 56, 1; 10.2344/0003-3006-56.1.23

Table 1 The Values are Determined by the Feeling of the Anesthetists
Table 1
Copyright: 2009 by the American Dental Society of Anesthesiology 2009
Figure 1.
Figure 1.

Typical tracing of AP and DDP. Method for measurement of AP and DDP.

Figure 2.
Figure 2.

Dose response curve of lidocaine. This graph showed dose response curve of lidocaine. Lidocaine EC50 was almost 100 µM.

Figure 3.
Figure 3.

Dose response curve of DEX. This graph showed dose response curve of DEX. DEX EC50 was almost 10 µM.

Figure 4a.
Figure 4a.

% change of AP for DEX 10 µM + lidocaine 100 µM.

Figure 4b.
Figure 4b.

% change of DDP for DEX 10 µM + lidocaine 100 µM. When DEX 10 µM + Lidocaine 100 µM administered to the sciatic nerve, AP was significantly decreased from the control. When DEX 10 µM + Lidocaine 100 µM was rinsed by saline, AP recovered to the control value. When AP decreased, DDP also decreased significantly.

Mean values ± SD were shown for n = 9.

Figure 1.
Figure 1.

Chronological changes in success rate of pulp anesthesia. Success rate of pulp anesthesia was determined by assessing the responses to electrical pulp stimulation at each post-injection time.

Figure 1.
Figure 1.

Time course in this study. Dex (0.4 µg/kg/hr) was started at approximately 30 minutes before the end of the operation and continued until 120 minutes (2 hours) after the end of the operation. SBP, DBP, HR, f, Spo2, RS and RAS were monitored at hospitalization (cont) and every 30 minutes after the end of the operation until 90 minutes (A90) and at 180 minutes (A180) after the end of Dex infusion.

Figure 2.
Figure 2.

Change in SBP, DBP and HR. There were no significant differences in SBP, DBP and HR.

Figure 3.
Figure 3.

Change in f and Spo2. f did not show significant changes, however, Spo2 showed a significant decrease at 30 minutes after the end of Dex administration.

Figure 4.
Figure 4.

Change in RS and RAS. RS and RAS showed significant changes from 30 minutes after the end of the operation to 30 minutes after the end of Dex infusion.

Figure 5.
Figure 5.

Guardians responses to a questionnaire of postoperative sedation with Dexmedetomidine.

Figure 1.
Figure 1.

Differences between each value for (a) rectal, (b) finger-tip skin temperature and (c) finger-tip skin blood flow at the measurement point and the control value. The values are expressed as means ± SEMs. The values of stroke index are as follows: (1)before induction, (2)30 min after induction, (3)45 min, (4)60 min, (5)75 min, (6)90 min, (7)105 min, (8)120 min, (9)the end of operation, (10)immediately after extubation.

Figure 1.
Figure 1.

Facial appearance of this patient shows slight degree of micrognathia and mandibular retraction, blepharodiastasis, short neck and hypoplastic nose wings.

Figure 1.
Figure 1.

Anesthesia record. (1) A-line, CV, (2) Infiltration anesthesia: 1% lidocaine (1/100,000 E) 20 ml, (3) Flurbiprofen 50 mg iv, (4) Epidural catheter, Th3/4, depth: 7.5 cm, length: 3.5 cm ↑, (5) Epidural continuous infusion: 4 ml/h (300 ml = 0.2% ropivacaine 280 ml+Fentanyl 1,000 µg), (6) Nicardipine 1 mg iv, (7) Epidural: 0.2% ropivacaine 6 ml, (8) Flurbiprofen 50 mg iv.

Figure 1.
Figure 1.

New balloon tip nasotracheal tube introducer. A: rectangularly cut tube tip (non-bevel). B: balloon introducer.

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