When I think back to the drugs I used when I started anesthesia practice, most are totally different from what I use on a daily basis currently. In many ways, these newer drugs were the major factor in the tremendous growth of office-based surgery and anesthesia. By allowing clear and rapid recovery from even deeper levels of anesthesia, patients could be safely discharged in a relatively short time period. There was a time, before the early 1970s, when general anesthesia for medical procedures outside the hospital was almost unheard of. Nearly all hospital patients were admitted the day before surgery
The purpose of this study was to determine which anesthetic was preferable for ambulatory anesthesia: propofol alone or sevoflurane alone. A crossover study was performed to compare the recovery profile and patient satisfaction after 2 anesthesia methods. Twenty healthy patients with severe anxiety toward dental treatment undergoing 2 sessions of day-case dental treatment received either propofol or sevoflurane anesthesia. The order of these methods was randomized. The depths of anesthesia were kept constant using bispectral index (BIS) monitoring. Observations on recovery profiles were performed in the emergence phase, in the recovery phase, and 24 hours after discharge. Patient satisfaction and preference were obtained by a questionnaire. Most of the recovery profiles in the emergence phase such as time to eye opening to respond to verbal command, time to BIS ≥ 75, and time to extubation were shorter in the sevoflurane group than in the propofol group. All recovery profiles in the recovery phase showed no differences between the 2 groups. Based on the subject's satisfaction and preference, propofol was evaluated as a better anesthetic for ambulatory anesthesia than sevoflurane. Higher patient satisfaction and a greater preference for future dental treatment were revealed for propofol anesthesia. Propofol may be more suitable for ambulatory anesthesia for dental treatment.
The purpose of this study was to compare the effectiveness of various concentrations of N2O/O2 on obtunding a hypersensitive gag reflex. We hypothesized that the administration of nitrous oxide and oxygen would obtund a hypersensitive gag reflex enough to allow a patient to tolerate the placement and holding of a digital x-ray sensor long enough to obtain a dental radiograph. Volunteers claiming to have a hypersensitive gag reflex were first screened to validate their claim and then tested by placing a size 2 digital x-ray sensor in the position for a periapical radiograph of the right mandibular molar area and holding it in place for 10 seconds. Subjects were first tested using room air only, then 30%, 50%, or 70% nitrous oxide until they were able to tolerate the sensor without gagging or discomfort. A visual analog scale was used for subjective responses, and other statistical tests were used to analyze the results. We found that for some subjects, 30% nitrous oxide was sufficient; for others, 50% was needed; and for the remainder of the subjects, 70% was sufficient to tolerate the test. Using a combination of 70% nitrous oxide and 30% oxygen allowed all patients claiming to have a hypersensitive gag reflex to tolerate the placement and holding of a digital x-ray sensor long enough to take a periapical radiograph.
During dental sedation, control of the cough reflex is crucial for a safe and smooth procedure. Accumulated saliva is one of the predisposing factors for coughing. Body movements during dental sedation appear to enhance salivation. Therefore, the aim of this study was to investigate the difference in salivary secretion between the with-movements state and the without-movements state during sedation. Salivary weight for 1 min was measured 3 times in 27 patients with intellectual disability during dental treatment under deep sedation with midazolam and propofol. The observed variables were body movements, bispectral index (BIS), and predicted propofol effect-site concentration. A total of 81 measurements were classified into the with-movements state (n = 39; ie, measurements during which body movements were observed) or the without-movements state (n = 42; ie, measurements during which no body movements were observed). The median salivary weight was significantly smaller in the without-movements state compared with the with-movements state (0.03 vs 0.11 g, P < .0001). The BIS was significantly lower in the without-movements state. There was no significant difference in the predicted propofol effect-site concentration between the 2 states. Significant correlation was observed between salivary weight and BIS in the with-movements state (r = 0.44, P = .004). The findings indicate that salivary secretion decreased according to deep sedation. Furthermore, immobility also reduced salivary secretion. We concluded that one reason that immobility is beneficial is because of the resulting decreased salivary secretion during dental treatment under deep sedation.
A modified retraction technique was introduced into the DDS degree preclinical anesthesia course in 2011 with the goal of reducing needlestick exposure incidents. In numerous studies of dental exposures, injuries from dental anesthetic needles account for the highest proportion of all exposures. The purpose of this study was to assess the preliminary impact of a modified retraction technique on the incidence of blood and body fluids (BBF) exposure incidents associated with needles during injection. Data from evaluations of students from 2014 and 2015 were obtained and tracked to determine whether the modified retraction technique was “excellent,” “clinically acceptable,” or “clinically unacceptable.” Data were collected to determine if the patient perceived the modified retraction technique as “comfortable” or “correctable when addressed” to help improve student technique for future injections. Likewise, data from the blood-borne exposure database where all information related to BBF exposures is recorded were reviewed and the information separated by year and class. This study presents preliminary data only and because of the small sample size does not lend itself to validation by statistical analysis. However, the technique effectively removes the operator's hand from the field during injection, reducing the risk of accidental intraoral needlestick to the nondominant hand of the operator.
The rare and potentially fatal complication of asystole during direct laryngoscopy is linked to direct vagal stimulation. This case describes asystole in an 85-year-old female who underwent suspension microlaryngoscopy with tracheal dilation for subglottic stenosis. Quick recognition of this rare event with immediate cessation of laryngoscopy resulted in the return of normal sinus rhythm. This incident emphasizes the implications of continued vigilance during laryngoscopy and the importance of communication between the anesthesia and surgical staff to identify and treat this rare complication. The case was successfully concluded by premedication with an anticholinergic and by increasing the depth of anesthesia.
Emanuel syndrome is associated with supernumerary chromosome, which consists of the extra genetic material from chromosome 11 and 22. The frequency of this syndrome has been reported as 1 in 110,000. It is a rare anomaly associated with multiple systemic malformations such as micrognathia and congenital heart disease. In addition, patients with Emanuel syndrome may have seizure disorders. We experienced anesthetic management of a patient with Emanuel syndrome who underwent palatoplasty. This patient had received tracheotomy due to micrognathia. In addition, he had atrial septal defect, mild pulmonary artery stenosis, and cleft palate. Palatoplasty was performed without any complication during anesthesia. Close attention was directed to cardiac function, seizure, and airway management.
We describe the case of a 37-year-old woman who had been diagnosed with Ehlers-Danlos syndrome (EDS) 4 years earlier and was scheduled to undergo removal of synovial chondromatosis in the temporomandibular joint. EDS is a heritable connective tissue disorder and has 6 types. In this case, the patient was classified into EDS hypermobility type. The major clinical feature of this type is joint hypermobility. The patient had sprain or subluxation of the elbows and ankles and dislocation of the knees. Anticipated problems during general anesthesia would be affected by the disease type. For this patient, extra attention was directed to positional injury–induced neuropathy and articular luxation, cutaneous injuries, injuries related to intubation and ventilation, and postoperative pain. Anesthesia was induced with propofol, remifentanil, and rocuronium and maintained with oxygen-air-desflurane, propofol, remifentanil, fentanyl, and rocuronium. In this case, the patient was safely managed without adverse events.
The increasing prevalence of diabetes mellitus in the general population has many implications for the ambulatory anesthesia provider. Complications, particularly associated with poor glycemic control, can affect multiple organ systems and jeopardize the safety of any planned anesthetic. It is essential that anesthesiologists and sedation providers have in-depth knowledge of the pathophysiology of diabetes mellitus and the comorbid conditions that commonly accompany it. Anesthesiologists and sedation providers must also understand certain surgical and anesthetic considerations when planning an effective and safe anesthetic for diabetic patients. This is a 2-part series concerning perioperative glycemic control for patients with diabetes mellitus. Part 1 will focus on the physiology of diabetes and its associated disease states. Part 2 will address the pharmacology associated with the wide variety of medications used to treat the disorder and the most recent guidelines for blood glucose management in ambulatory surgical patients.
Abdulwahab M, see Alkandari SA, 8 Akizuki A, see Kamatani T, 156 Alkandari SA, Dentists' and Parents' Attitude Toward Nitrous Oxide Use in Kuwait (scientific report), 8 Almousa F, see Alkandari SA, 8 Aminoshariae A, see De Veaux CKE, 181 Bell A, see Wolf KT, 84 Boku A, Effective Dosage of Midazolam to Erase the Memory of Vascular Pain During Propofol Administration (case report), 147 Boynes SG, see Alkandari SA, 8 Brady P, see McCarthy C, 25 Brokaw EJ, see Wolf KT, 84 Budenz
Ambulatory, 42 Ambulatory anesthesia, 116, 175 Anaphylactoid reactions, 160 Anaphylaxis, 160 Anatomical variation, 84 Anesthesia, 197 Anesthesia induction, 42 Anesthetic cost, 116 Anesthetic management, 31 Apex locator, 95 Asystole, 197 Benzocaine, 55 Benzodiazepine allergy, 160 BIS, 91 Bispectral index, 185 Body movements, 185 Body temperature, 91 Bradycardia, 95 Buccal infiltration, 3 Cardiac arrest, 34 Cardiopulmonary resuscitation, 62 Cardiorenal syndrome, 34 Cauterization, 95 Charcot-Marie-Tooth disease, 80 CIED, 95 Congenital heart disease, 201 Congestive heart failure, 34 Conscious sedation, 25 Coronary artery steal, 42 Cough reflex, 185 Deep sedation, 185 Defibrillation, 95 Dental anesthesia, 84, 116, 139, 192 Dental education, 62 Dental
Boku A, Inoue M, Hanamoto H, Oyamaguchi A, Kudo C, Sugimura M, Niwa H. Effective dosage of midazolam to erase the memory of vascular pain during propofol administration. Anesth Prog. 2016;63:147–155. This article was incorrectly labeled as a Case Report. Rather, it is a Scientific Report. The online version has now been corrected. Allen Press apologizes for the error.
It is with great sadness that we announce the passing on Monday, November 7, 2016 of Dr James (Jim) K. Grainger, MDS, FRACDS, FICD, FADI, FPFA, after a battle with myeloid leukemia. Jim was one of the elder statesmen of ASDA (the Australian Society of Dental Anaesthesiology) and IFDAS (the International Federation of Dental Anaesthesia Societies), having been involved since their inception and practicing dentistry for almost 60 years. Amongst many awards, he received the highest honors from both ASDA (the Belisario Award) and IFDAS (the Horace Wells Award), and served as president of both societies as well as general