Anesthesia Progress Volume 67: Issue 1

Tracheotomy is occasionally performed to prevent postoperative airway obstruction especially for invasive surgical procedures involving head and neck cancer. When performed under general anesthesia, attention must be paid to avoid rupture of the tracheal tube cuff during the incision into the trachea. In this study, changes in the position of the endotracheal tube tip during extension of the head and neck for a tracheotomy were investigated. Twelve patients underwent placement of a tracheotomy during surgical procedures for oral cancer. After nasal intubation, the distance between the tube tip and the carina was measuring using a fiberoptic scope with the patient's head placed at an angle of 110°. Patients were repositioned for tracheotomy by placing a pillow under the shoulders and extending the head and neck at an angle of 140°. The distance measurements were subsequently repeated. The difference between the first and second measurements was calculated and analyzed statistically using a paired t test. On average the patients were 69.5 ± 9.0 years in age. The distance between the tube tip and the carina at an angle of 140° (3.6 ± 1.1 cm) was significantly longer than that at an angle of 110° (1.7 ± 1.0 cm) (p < 0.001). The migration in the positioning of the endotracheal tube tip was 1.9 ± 0.7 cm (range: 0.7–3.7 cm) upon extension. In 3 cases, the tube cuff was ruptured during incision of the trachea. The endotracheal tube tip may migrate in the cephalad direction approximately 2 cm as a result of the extension of the patient's head and neck during a tracheotomy. Therefore, consideration should be given to advancing the endotracheal tube tip towards the caudal side and to confirming the position of the tube and cuff during a tracheotomy.

To compare the effectiveness of a combination of 10% lidocaine, 10% prilocaine, and 4% tetracaine versus 20% benzocaine for use as a topical anesthetic agent prior to dental injections. A double-blind randomized prospective clinical trial was conducted with 26 participants receiving a topical anesthetic of 20% benzocaine (control) and 26 participants receiving a compound topical anesthetic mixture of 10% lidocaine, 10% prilocaine, and 4% tetracaine (experimental) prior to a maxillary infiltration injection. The procedure was conducted by 1 operator with the Wand^® injection system. Pain was assessed directly with visual analog scale (VAS) scores and indirectly by measuring changes in heart rate at 4 different time points. Complications associated with the application of the topical anesthetics were also assessed. The experimental group had a significantly higher mean VAS score of 19.5 ± 19.7 mm versus 14.2 ± 14.6 mm for the control group (p < .001). No significant differences in heart rate at any of the 4 measured time points compared with baseline were noted for either group. The experimental group had a significantly higher incidence of complications, including tissue sloughing, when compared with the control group (p < .001). Participants in the control group reported significantly lower VAS scores than those in the experimental group. Both types of topical anesthetic showed similar impacts on alterations to heart rate. No benefits were seen with the use of 10% lidocaine, 10% prilocaine, and 4% tetracaine as a topical anesthetic prior to a maxillary infiltration of local anesthetic when compared with 20% benzocaine.

Vagal nerve stimulation (VNS) is an established adjunctive treatment for patients with refractory epilepsy. VNS is effective in many cases, but few patients achieve complete elimination of seizures. Furthermore, VNS can cause respiratory complications, such as obstructive sleep apnea. This report describes the successful anesthetic management of a 28-year-old woman with a VNS device who underwent dental treatment under general anesthesia. She was morbidly obese and had undergone placement of a VNS device secondary to drug-resistant epilepsy 2 years prior but continued to experience daily epileptic seizures. Because of concerns about the risk of perioperative epileptic seizures and apneic events, use of the dedicated VNS device magnet was planned if such complications occurred. Total intravenous anesthesia was induced with propofol and remifentanil and a bispectral index sensor was used to help monitor brain wave activity for evidence of seizures along with the depth of anesthesia. Postoperatively, the patient received positional therapy and supplemental oxygen while being closely monitored in recovery. The anesthetic course was completed uneventfully without need of the VNS magnet. A thorough understanding of the mechanics of a VNS device, including proper use of the VNS magnet, is critical for an anesthesiologist during the perioperative period.

The editorial staff of Anesthesia Progress acknowledges all of our 2019 reviewers. We value your time and effort in ensuring the quality of the articles published in Anesthesia Progress. List of reviewers with the number of reviews completed by each in 2019:

Jeff Bennett, DMD (3)

Robert Bosack, DDS (1)

Jason Brady, DDS (1)

Jeffrey N. Brownstein, DDS (1)

Brian Chanpong, DDS, MSc (1)

Bryant Cornelius, DDS, MBA, MPH (1)

James DiFranco, DDS, MS (4)

Melissa Drum, DDS, MS (1)

Rick Finder, DMD (1)

Andrea Fonner, DDS (2)

Mari Cynthia Fukami, DMD, MS (2)

Pooja Gangwani,

Use of the Microcuff^® During General Anesthesia for Patients With Scoliosis

Toshiyuki Kishimoto DDS, PhD,

Shintaro Hayashi DDS,

Yasunori Nakanishi DDS,

Takashi Goto DDS, PhD,

Kensuke Kosugi DDS, PhD, and

Satoru Sakurai DDS, PhD

Perfect Time for a Fresh Perspective

Endotracheal Tube Migration Associated With Extension During Tracheotomy

Comparing the Efficacy of a Compound Topical Anesthetic Versus Benzocaine: A Pilot Study

Anesthetic Management of a Patient With a Vagal Nerve Stimulator

Use of the Microcuff^® During General Anesthesia for Patients With Scoliosis

Anesthetic Management of a Patient With Systemic Sclerosis and Microstomia

An Avulsed Tooth Detected Prior to Insertion of a Laryngeal Mask Airway

Alternative Transoral Application of Nasopharyngeal Airways

Anesthetic Management of a Pediatric Patient With Cardiofaciocutaneous Syndrome

Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 2

Literature Review for Office-Based Anesthesia

Lodenius A, Maddison K, Lawther B, Scheinin M, Eriksson L, Eastwood P, Hillman D, Fagerlund M, Walsh J. Upper airway collapsibility during dexmedetomidine and propofol sedation in healthy volunteers. Anesthesiology. 2019;131(5):962–973.

Reviewers

Use of the Microcuff^® During General Anesthesia for Patients With Scoliosis

Anesthetic Management of a Patient With Systemic Sclerosis and Microstomia

Endotracheal Tube Migration Associated With Extension During Tracheotomy

An Avulsed Tooth Detected Prior to Insertion of a Laryngeal Mask Airway

Alternative Transoral Application of Nasopharyngeal Airways