In February 2019, the pharmaceutical manufacturer, American Regent, Inc (Shirley, NY) reintroduced droperidol to the US drug market. Droperidol is a butyrophenone, the same drug class as the typical antipsychotic agent haloperidol, and acts as a dopamine D2 receptor antagonist producing antiemetic and sedative-hypnotic effects. Not only has it been used along with fentanyl to produce a state of neuroleptic analgesia, previously marketed in combination as Innovar (Janssen Pharmaceutica, Beerse, Belgium) and since discontinued, but it also has a compelling history as an antiemetic agent. In fact, anesthesia providers who treated patients in the late 20th century likely remember it
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EDITORIAL
DDS, MS
SCIENTIFIC REPORTS
DDS, MSc,,
DDS, MSc,,
DMD,
DDS, and
MD, MSc
Dental professionals are at an increased risk for exposure to the severe acute respiratory syndrome coronavirus 2 with aerosol-generating procedures (AGPs), and dental anesthesia practices have additional risks due to airway management procedures. The purpose of this pilot study was to examine the extent of splatter on dental personnel that may occur with AGPs and coughing in a dental anesthesia practice. A Dentoform model was fitted into a dental mannequin and coated with Glo Germ to detect splatter during simulated dental AGPs produced with use of a high-speed handpiece, an ultrasonic scaler, and an air-water syringe, all in conjunction with high-volume suction. A simulated cough was also created using a ventilator programmed to expel Glo Germ within the velocity and volume parameters of a natural cough with dental personnel in their customary positions. A UV light was used after each procedure to systematically evaluate the deposition of Glo Germ splatter on each person. After AGPs were performed, splatter was noted on the face, body, arms, and legs of the dentist and dental assistant. The simulated cough produced more extensive splatter than AGPs; additional Glo Germ was seen on the shoes, the crown of the head, and the back of the dental personnel. Therefore, it is recommended that full personal protective equipment consistent with AGPs be used and changed between patients to reduce the risk of contamination and infection for dental personnel and patients.
DDS, PhD,
DDS, PhD,
DDS,
DDS,
DDS, PhD, and
DDS, PhD
This study investigated the effects of a unilateral stellate ganglion block (SGB) on ipsilateral and contralateral masseter muscle blood flow during permissive hypercapnia. Eight male Japanese white rabbits were anesthetized with isoflurane. Observed variables included heart rate (HR), blood pressure (BP), left common carotid artery blood flow (LCBF), left and right masseter muscle tissue blood flow (LMBF and RMBF), and left femoral quadriceps muscle tissue blood flow (LQBF). Variable measurements were taken at a baseline end-tidal carbon dioxide tension (EtCO2) of 40 mm Hg and repeated at an elevated EtCO2 of 60 mm Hg prior to and after administration of a left SGB. HR decreased, while systolic BP was elevated during hypercapnia and after the SGB. LCBF increased during hypercapnia and after the SGB. LMBF and RMBF decreased to 75% and LQBF decreased to 60% of their respective baseline values during hypercapnia. After the SGB, LMBF was restored, reapproximating its baseline, but RMBF and LQBF further decreased to 55 and 45% of their respective baseline values. In conclusion, unilateral SGB restored the ipsilateral masseter muscle blood flow that had been reduced during hypercapnia. In contrast, the SGB exacerbated the hypercapnia-induced reduction in blood flows in the contralateral masseter muscle and the femoral quadriceps muscle.
DDS, PhD,
DDS, PhD,
DDS,
DDS,
DDS, PhD, and
DDS, PhD
Pain management is important for alleviating patients' suffering and early recovery. Although analgesic combinations are known to be effective, a comparison of the effectiveness of different combinations has never been performed specifically for ramus osteotomy procedures. Therefore, the purpose of this observational retrospective cohort study was to identify an effective combination for pain management throughout the intraoperative and immediate postoperative period for patients undergoing bilateral ramus osteotomy procedures. Inclusion criteria consisted of patients who had undergone bilateral mandibular ramus osteotomies over a 2-year period. The analyzed predictor variables included patient gender, age, body weight, operation, anesthetic method, duration of operation, intraoperative use of fentanyl, nonsteroidal anti-inflammatory drugs (NSAIDs), and intravenous acetaminophen administered in the operating room at the end of the surgery. The outcome variable was the necessity for additional rescue analgesics (yes/no) in the recovery room. Bivariate statistics and multivariate analysis were computed with a p-value of <0.05. The study sample was comprised of 78 patients requiring bilateral mandibular ramus osteotomies. From the multivariate analysis, the combination of NSAIDs-acetaminophen-fentanyl was an independent factor for no additional rescue analgesics during the first 1 hour after bilateral ramus osteotomies, indicating that the combination is significantly effective for bilateral ramus osteotomies compared with the other combinations. Considering that this study consisted of a small sample size, the results of this study suggest that some of the combinations, particularly NSAIDs-acetaminophen-fentanyl, are more effective than NSAIDs alone for postoperative pain control immediately following bilateral ramus osteotomy procedures.
CASE REPORTS
DDS, PhD,
DDS, PhD, and
DDS, PhD
Lithium carbonate is a medication used for the management of various mental disorders. The present report describes a case of prolongation of rocuronium bromide in a patient concurrently taking lithium carbonate. A 64-year-old woman was scheduled to undergo cystectomy under general anesthesia. The patient took lithium carbonate (600 mg/d) for treatment of bipolar affective disorder. General anesthesia was induced with propofol, fentanyl, remifentanil, and sevoflurane. After loss of consciousness, rocuronium bromide (50 mg) was administered, and the trachea was intubated. Approximately 1 hour after the administration of rocuronium, the degree of residual muscle relaxant was evaluated using a nerve stimulation device. No muscle contraction occurred with train-of-four (TOF) stimulation. Following administration of sugammadex (200 mg) the TOF ratio increased to 95%. The ionic size of lithium is similar to that of sodium; therefore, lithium is transported into the cell with sodium. The resting membrane potential decreases, leading to a reduction in the height of the action potential. Thus, the effect of the remaining lithium may have been superimposed on the rocuronium neuromuscular blockade. Evaluation with a nerve stimulation device in patients taking lithium is crucial before extubation because of the risk of rocuronium potentiation.
DMD,
DMD,
MD, DDS, PhD, and
DDS
Tracheopulmonary complications following placement of a nasogastric (NG) feeding tube are uncommon but can cause significant morbidity and mortality. In this case report, an 83-year-old woman of American Society of Anesthesiologists class IV with underlying pulmonary disease required placement of an NG feeding tube after surgical treatment of primary squamous cell carcinoma of the tongue. Malpositioning of the NG feeding tube into the right pleural space was confirmed by computed tomography. Removal of the NG feeding tube resulted in a tension pneumothorax that necessitated chest tube placement. Because of the difficulty of blind NG feeding tube placement in this patient, the subsequently placed NG feeding tube was successfully positioned with the aid of a video laryngoscope. This case report illustrates the risk of NG feeding tube malpositioning in a nasally intubated patient undergoing head and neck surgery and discusses improvements in techniques for proper NG feeding tube placement.
DDS,
DDS,
DDS, PhD,
DDS, PhD,
MD, PhD, and
DDS, PhD
Inflammatory bowel disease (IBD) is a group of chronic inflammatory disorders of the gastrointestinal tract including ulcerative colitis (UC) and Crohn's disease. Pain management can be challenging in patients with IBD because there are limitations on the use of analgesics. Use of nonsteroidal anti-inflammatory drugs is not recommended in patients with IBD because there is risk of relapse of IBD and an overall increase in disease activity. Opioids, although frequently used for treating severe acute pain, can have additional risks and complications in patients with IBD such as ileus, toxic megacolon, and narcotic bowel syndrome. Furthermore, little information is available in the literature on pain management in these patients undergoing noncolorectal surgery. This report describes 2 patients with UC in whom postoperative pain following oral and maxillofacial surgery was managed by intravenous patient-controlled analgesia with pentazocine. Apart from the development of acute dystonia in 1 case that was likely due to the use of droperidol for prevention of postoperative nausea and vomiting, postoperative pain was well controlled by pentazocine in both patients without any complications or UC exacerbations.
DDS, PhD,
MD,
MD, PhD,
MD, PhD,
MD, and
MD, PhD
Head and neck reconstructive surgery involving tissue flaps is often complex requiring the development of an individualized anesthetic plan. The following case report describes the anesthetic management of an 87-year-old man considered at high risk for postoperative delirium due to advanced age and blindness undergoing general anesthesia for resection of squamous cell carcinoma of the right side of the nose and reconstructive surgery with a scalping forehead flap. Ultrasound-guided local anesthetic maxillary and supraorbital nerve blocks were successfully used perioperatively to reduce the need for alternative analgesics associated with higher risks of complications such as postoperative nausea, vomiting, and delirium.
BRIEF COMMUNICATIONS FROM THE JAPANESE DENTAL SOCIETY OF ANESTHESIOLOGY
DDS, PhD,
DDS, PhD,
DDS, and
DDS, PhD
This is a case report of methemoglobinemia presumably caused by the combined use of prilocaine (propitocaine) and nitroglycerin under general anesthesia. Methemoglobinemia is reportedly caused by the administration of prilocaine at a dose of ≥8 mg/kg. Moreover, ≥3 μg/kg/min of nitroglycerin can also trigger methemoglobinemia. In this patient, methemoglobinemia occurred despite neither drug having been administered at the aforementioned doses. Even if individual doses of drugs predisposed to causing methemoglobinemia are low, combined use may increase the risk of methemoglobinemia.
DDS, PhD,
DDS,
DDS, PhD,
DDS, PhD, and
DDS, PhD
This is a case report of anaphylaxis in which the basophil activation test (BAT) was used to identify the etiological agent. Although skin tests are considered the most effective methods for identifying anaphylactic triggers, the test itself presents a risk of inducing anaphylaxis. The BAT is advantageous because of its inherent lack of risk, high sensitivity and specificity to identify the suspected anaphylactic agents, and diagnostic accuracy comparable to conventional skin testing. Therefore, in the future, the BAT is likely to become the preferred test for the detection of allergens over conventional skin tests.
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A patient undergoing a bilateral sagittal split and LeFort 1 maxillary osteotomy performed under general anesthesia required emergent intraoperative exchange of a potentially damaged nasotracheal tube. This exchange was smoothly performed under constant indirect visualization using the McGrath MAC video laryngoscopy system. After the exchange, ventilation of the patient dramatically improved. The removed endotracheal tube was torn 19 cm from the distal tip. The McGrath MAC was useful for visualizing the glottis and confirming the entire course of the tube exchange despite the patient's having a difficult airway (Cormack-Lehane grade 3).
CONTINUING EDUCATION IN MEMORY OF NORMAN TRIEGER, DMD, MD
DDS, MBA, MPH and
DDS
Pseudocholinesterase deficiency, sometimes called butyrylcholinesterase deficiency, is a rare disorder in which the neuromuscular blocking drugs succinylcholine and mivacurium cannot be metabolized properly in the blood plasma. This disorder can either be acquired as a result of certain comorbidities or it can be inherited genetically. Anesthesia providers must understand the pathophysiology of pseudocholinesterase deficiency and be prepared to safely and effectively manage patients who show signs and symptoms consistent with the disorder after the use of the indicated neuromuscular blocking drugs. This article summarizes the pharmacologic and physiologic data relevant to understanding the basic pathophysiology associated with pseudocholinesterase deficiency and illustrates a case study of a young woman suspected of having the disorder after a prolonged delay in emergence from general anesthesia.
DEPARTMENTS
DDS, PhD
Hyman J, Park C, Lin H-M, et al. Olanzapine for the prevention of nausea and vomiting after ambulatory surgery: a randomized controlled trial. Anesthesiology. 2020;132:1419–1428.
Postdischarge nausea and vomiting after ambulatory surgery is a common problem that is not adequately addressed in current practice. This prospective, randomized, double-blind, parallel-group, placebo-controlled study was designed to test the hypothesis that oral olanzapine is superior to placebo at preventing postdischarge nausea and vomiting. In a single-center trial of 140 patients, the authors compared a single preoperative dose of olanzapine 10 mg to a placebo, in adult female patients 50 years old
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It is with great sadness that the Australian Society of Dental Anesthesiology (AusSDA), the Society for Advancement of Anesthesia in Dentistry (SAAD, UK), and the International Federation of Dental Anesthesiology Societies (IFDAS) announce the passing of our friend and colleague Dr Douglas Stewart on May 22, 2020. After cardiac complications, Doug died in the style for which he was known, with his daughters at his side and jazz playing in the background.
For 4 decades, Doug was at the forefront of dental sedation education and safety in Australia and the United Kingdom. In 1996, he became the director of the
Anesthetic Management Using Remimazolam for Dental Treatment in a Pediatric Patient With Dravet Syndrome
Musashi SawadaDDS, PhD,
Shoichi HonmaDDS, PhD,
Akira IidaDDS, PhD,
Ryo AtsutaDDS,
Yoshiyuki IshidaDDS, PhD, and
Kazuaki FukushimaDDS, PhD
Anesthetic Management of a Dental Patient With Familial Mediterranean Fever
Aki KawauchiDDS, PhD,
Shin SatoMD, PhD,
Ayumi NakayamaDDS,
Masami HasegawaDDS, and
Shigeru MaedaDDS, PhD
Anesthetic Management of a Patient With Ankylosing Spondylitis Undergoing Orthognathic Surgery
Yuko YoshidaDDS, PhD,
Takeo SugitaDDS, PhD,
Yi-Hsun YangDDS,
Shigeru IshiiDDS, PhD, and
Hirofumi ArisakaMD, DDS, PhD
Commentary: Inhalational Induction Without Vascular Access Should Be Rare in OMS
Akshay GovindDMD, MD, MPH
Letter to the Editor
Stuart LieblichDMD
Monheim LM. Analgesia in dentistry now and in the future. Anesth Prog. 1971;18(5):100–106 and J Am Analg Soc. 1971:9:1(abstract).
Joseph A. Giovannitti JrDMD,
Morton B. RosenbergDMD, and
James C. PheroDMD
A Review of Current Literature of Interest to the Office-Based Anesthesiologist
Mark A. SaxenDDS, PhD
Perfect Time for a Fresh Perspective
Kyle J. KramerDDS, MS
The Cost of Learning From Our Mistakes
Joel M. WeaverDDS, PhD
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