Patient-controlled sedation using remimazolam during third molar extraction: a case report

Dental sedation plays a pivotal role in alleviating patient anxiety during various procedures. Remimazolam, a benzodiazepine derivative, stands out for its distinctive attributes, particularly its rapid onset of sedation coupled with a brief duration, making it an invaluable option for dental applications. The patient was admitted for the extraction of impacted third molars via patient-controlled sedation and not only demonstrated stable vital signs but also expressed a high level of satisfaction with the procedure. An in-depth analysis of plasma remimazolam concentrations and changes in the Patient State Index revealed negative correlation patterns, highlighting the inherent potential of remimazolam in achieving effective sedation. This expanded research scope aims to provide a more nuanced understanding of the pharmacological responses to remimazolam in dental sedation scenarios. This case report offers valuable insights into the evolving landscape of dental sedation methodologies and paves the way for a more informed and evidence-based approach to the use of remimazolam in patient-controlled sedation.

Identification of an effective and safe bolus dose and lockout time for patient-controlled sedation (PCS) using dexmedetomidine in dental treatments: a randomized clinical trial

Background

This study investigated a safe and effective bolus dose and lockout time for patient-controlled sedation (PCS) with dexmedetomidine for dental treatments. The depth of sedation, vital signs, and patient satisfaction were investigated to demonstrate safety.

Methods

Thirty patients requiring dental scaling were enrolled and randomly divided into three groups based on bolus doses and lockout times: group 1 (low dose group, bolus dose 0.05 µg/kg, 1-minute lockout time), group 2 (middle dose group, 0.1 µg/kg, 1-minute), and group 3 (high dose group, 0.2 µg/kg, 3-minute) (n = 10 each). ECG, pulse, oxygen saturation, blood pressure, end-tidal CO2, respiratory rate, and bispectral index scores (BIS) were measured and recorded. The study was conducted in two stages: the first involved sedation without dental treatment and the second included sedation with dental scaling. Patients were instructed to press the drug demand button every 10 s, and the process of falling asleep and waking up was repeated 1-5 times. In the second stage, during dental scaling, patients were instructed to press the drug demand button. Loss of responsiveness (LOR) was defined as failure to respond to auditory stimuli six times, determining sleep onset. Patient and dentist satisfaction were assessed before and after experimentation.

Results

Thirty patients (22 males) participated in the study. Scaling was performed in 29 patients after excluding one who experienced dizziness during the first stage. The average number of drug administrations until first LOR was significantly lower in group 3 (2.8 times) than groups 1 and 2 (8.0 and 6.5 times, respectively). The time taken to reach the LOR showed no difference between groups. During the second stage, the average time required to reach the LOR during scaling was 583.4 seconds. The effect site concentrations (Ce) was significantly lower in group 1 than groups 2 and 3. In the participant survey on PCS, 8/10 in group 3 reported partial memory loss, whereas 17/20 in groups 1 and 2 recalled the procedure fully or partially.

Conclusion

PCS with dexmedetomidine can provide a rapid onset of sedation, safe vital sign management, and minimal side effects, thus facilitating smooth dental sedation.

Could Fixed Implants Be a Viable Treatment Option in Disabled Patients? A Clinical Retrospective Study

PURPOSE

To verify the survival rates and marginal bone loss (MBL) of implants in patients with different disability types.

MATERIALS AND METHODS

Clinical and radiographic assessments were performed in a total of 189 implants for fixed implant prostheses in 72 patients. Data were collected on loaded implants at least 1 year in function, and the mean observation time was 37.3 months. Implant survival was examined, and MBL was observed around the implants of two groups (mental disability vs physical disability) based on age, sex, implant location (anterior vs posterior), and prosthetic connection (internal vs external).

RESULTS

Of the 189 implants, 4 failed; the total implant survival rate was 97.8% across a mean of 37.3 months. The cumulative survival rate at 85 months in a Kaplan-Meier survival curve analysis was 94.3% ± 3% in patients with mental disability and 50% ± 35.4% in patients with physical disability, which was a statistically significant difference between the disability groups (P = .006). Fisher exact test showed significant differences in MBL only with age (P < .001). The implant MBL by disability type-adjusted for age and observation period-showed significant differences in multiple linear regression analyses (P = .003).

CONCLUSION

The implant survival rates in patients with disability were in line with those reported for nondisabled patients. The MBL of the implants was within the physiologic bone loss after implant loading. Implants in patients with mental disability showed higher cumulative survival rates than in patients with physical disability, but also a higher amount of MBL. Within the limitations of this study, dental implants for patients with disability are viable. These results can establish future implant treatment plans for this population. Int J Oral Maxillofac Implants 2023;38:562-568. doi: 10.11607/jomi.9880.

Analysis of the annual changes in dental institutions that claimed dental sedatives in Korea and the types of sedatives using health care big data

Background

Dentists make various efforts to reduce patients' anxiety and fear associated with dental treatment. Dental sedation is an advanced method that dentists can perform to reduce patients' anxiety and fear and provide effective dental treatment. However, dental sedation is different from general dental treatment and requires separate learning, and if done incorrectly, can lead to serious complications. Therefore, sedation is performed by a limited number of dentists who have received specific training. This study aimed to investigate the proportion of dentists who practice sedation and the main sedatives they use in the context of the Republic of Korea.

Methods

We used the customized health information data provided by the Korean National Health Insurance. We investigated the number of dental hospitals or clinics that claimed insurance for eight main sedatives commonly used in dental sedation from January, 2007 to September, 2019 at the Health Insurance Review and Assessment Service. We also identified the changes in the number of dental medical institutions by region and year and analyzed the number and proportion of dental medical institutions prescribing each sedative.

Results

In 2007, 302 dental hospitals prescribed sedatives, and the number increased to 613 in 2019. In 2007, approximately 2.18% of the total 13,796 dental institutions prescribed sedatives, increasing to 3.31% in 2019. In 2007, 168 institutions (55.6%) prescribed N₂O alone, and in 2019, 510 institutions (83.1%) made claims for it. In 2007, 76 (25.1%) hospitals made claims for chloral hydrate, but the number gradually decreased, with only 29 hospitals (4.7%) prescribing it in 2019. Hospitals that prescribed a combination of N₂O, chloral hydrate, and hydroxyzine increased from 27 (8.9%) in 2007 to 51 (9%) in 2017 but decreased to 38 (6.1%) in 2019. The use of a combination of N₂O and midazolam increased from 20 hospitals (6.6%) in 2007 to 51 hospitals (8.3%) in 2019.

Conclusion

While there is a critical limitation to the investigation of dental hospitals performing sedation using insurance claims data, namely exclusion of dental clinics providing non-insured treatments, we found that in 2019, approximately 3.31% of the dental clinics were practicing sedation and that N₂O was the most commonly prescribed sedative.

Air leakage due to the cuff hanging on the vocal cords during nasotracheal intubation: a case report

Nasotracheal intubation is commonly performed under general anesthesia in oral and maxillofacial surgery. For the convenience of surgery, nasal Ring-Adair-Elwyn (RAE) tubes are mainly used. Because the nasal RAE tubes were bent in an "L" shape, the insertion depth was limited. Particularly, it is necessary to accurately determine the appropriate depth of the RAE tubes in children. Several types of nasal RAE tubes are used in the medical market, which vary in material and length. We performed endotracheal intubation using a nasal RAE tube for double-jaw surgery, but air leakage persisted even when the air pressure in the cuff was increased. When checked with a laryngoscope, it was confirmed that the tube was pushed out, and the cuff was caught on the vocal cords, causing air leakage. Since inserting the tube deeply did not solve the problem, replacing it with a nasal RAE tube (Polar™, Preformed Tracheal Tube, Smith Medical, Inc., USA) did not cause air leakage; thus, we reported this case.

Analysis of changes and trends in the use of sedatives in dental sedation using data from the National Health Insurance in Korea

Background

Although dental sedation helps control anxiety and pain, side effects and serious complications related to sedation are gradually increasing. Due to the introduction of new drugs and sedation methods, insurance rates, legal regulations, drugs, and methods used for dental sedation are inevitably changed. In the Republic of Korea, National Health Insurance is applied to all citizens, and this study investigated changes in the use of sedatives using this big data.

Methods

This study used customized health information data provided by the Healthcare Insurance Review & Assessment Service of Korea. Among patients with a record of use of at least one of eight types of sedatives for dental sedation between January 2007 and September 2019 were selected; the data of their overall insurance claims for dental treatment were then analyzed.

Results

The number of patients who received dental sedation was 786,003, and the number of dental sedation cases was 1,649,688. Inhalational sedation using nitrous oxide (N₂O) accounted for 86.8% of all sedatives that could be claimed for drugs and treatment. In particular, it was confirmed that the number of requests for sedation using N₂O sharply increased each year. Midazolam showed an increasing trend, and in the case of chloral hydrate, it gradually decreased.

Conclusion

According to our analysis, the use of N₂O and midazolam gradually increased, while the use of chloral hydrate gradually decreased.

Analysis of behavioral management for dental treatment in patients with dementia using the Korean National Health Insurance data

Background

The global population is aging rapidly, and accordingly, the number of patients with dementia is increasing every year. Although the need for dental treatment increases for various reasons in patients with dementia, they cannot cooperate during dental treatment. Therefore, behavioral management, including sedation (SED) or general anesthesia (GA), is required for patients with dementia. Thus, this study aimed to investigate the trends and effects of SED or GA in patients with dementia undergoing dental treatment in South Korea based on the Korean National Health Insurance claims data.

Methods

This study utilized customized health information data provided by the Health Insurance Review and Assessment Service. Among patients with records of using sedative drugs during dental treatment from January 2007 to September 2019, patients with the International Classification of Diseases-10 code for dementia (F00, F01, F02, F03, and G30) were selected. We then analyzed the full insurance claims data for dental care. Age, sex, sedative use, and dental treatment of patients were analyzed yearly. In addition, the number of cases of GA or SED per year was analyzed, and changes in behavioral management methods with increasing age were investigated.

Results

Between January 2007 and September 2019, a total of 4,383 (male, 1,454; female, 2,929) patients with dementia received dental treatment under SED or GA. The total number of SED and GA cases were 1,515 (male, 528 ; female, 987) and 3,396 (male, 1,119 ; female, 2,277) cases, respectively. The total number of cases of dental treatment for 4,383 patients with dementia was 153,051 cases, of which 2.22% were under GA and 0.98% were under SED. Midazolam was the most commonly used drug for SED.

Conclusion

Although gingivitis and pulpitis were the most common reasons for patients with dementia to visit the dentist, GA or SED for patients with dementia was frequently used in oral and maxillofacial or periodontal surgery.

An anesthetic management of head and neck cancer reconstructive surgery in a patient having hemophilia A: a case report

Hemophilia A is a hemorrhagic disease caused by coagulation factor VIII deficiency. In head and neck cancer surgery, especially during a reconstructive one, complications can occur. These include hematomas due to bleeding which can then lead to flap ischemia, necrosis, and impaired wound healing. There are fewer cases of reconstructive surgery in patients with hemophilia A. Here in we report, a reconstructive surgery that involved mass resection, partial glossectomy (right), selective neck dissection (right, Levels I, II, III, IV), and reconstruction at the lateral arm free flap (left) in a 25-year-old man with hemophilia A. The surgery was successfully performed without any complications after pretreatment with Factor VIII concentrate, which has not been reported earlier.

Analysis of application of dental sedation in attention deficit hyperactivity disorder (ADHD) patients using the Korean National Health Insurance data

Background

Attention deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. It has a worldwide pooled prevalence of 5.29%. The characteristics of ADHD can increase the probability of dental treatment, while special behavior management can be required to allow proper treatment. In South Korea, the use of sedation in dental treatment has rapidly increased in recent decades. The present study aimed to investigate the trend and effects of sedation in patients with ADHD undergoing dental treatment in South Korea.

Methods

The study used customized health information data provided by the Korean National Health Insurance Service. Among patients with the record of sedative use during the period from January 2007 to September 2019, those with International Classification of Diseases-10 codes for ADHD (F90, F91) were selected; the data of their overall insurance claims for dental treatment were then analyzed. The patients' age, gender, sedative use, and dental treatment were analyzed per year. The annual number of general anesthesia or sedation cases was also analyzed, and changes in the method of behavior management with increasing age were examined.

Results

The study involved 7,654 patients with ADHD (6,270 males; 1,384 females). The total number of dental treatments was 137,778, while the number of sedation cases was 16,109, among which 13,052 involved male patients and 3,057 female patients. The number of general anesthesia cases was 631, among which 538 involved male patients and 93 female patients. The most frequently used sedation method in the dental treatment of patients with ADHD was N₂O inhalation. The percentage of sedation cases was highest in patients aged 4 years, and it decreased with increasing age.

Conclusion

In South Korea, both sedation and dental treatments were slightly more common in patients with ADHD than in the general population. With increasing age, the frequency of dental treatments and the percentage of sedation cases decreased.

Predictors of Red Blood Cell Transfusion in Bimaxillary Orthognathic Surgery: A Retrospective Study

Background: Orthognathic surgery requires red blood cell (RBC) transfusions more frequently than other oral and maxillofacial surgeries. The purpose of this study was to identify reliable predictors for RBC transfusion during bimaxillary orthognathic surgery (BOS). Methods: This retrospective study reviewed 1,616 electronic medical records of patients who underwent BOS during a 5-year period at Seoul National University Dental Hospital. The perioperative variable data were collected from electronic medical records and analyzed by dividing patients into the two groups (non-transfusion and transfusion group). Results: Of the 1,616 patients, 1,311 patients were excluded. The remaining 305 patients were divided into non-transfusion (NTF, n = 256) and transfusion (TF, n = 49) groups. Univariate logistic regression analysis revealed that age, body mass index, the presence of several adjunctive surgeries (including genioplasty, extraction, and mandibular angle reduction), preoperative hemoglobin (Hb) and prothrombin time, surgical time, amount of fluid infusion and blood loss, and mean pulse rate during surgery were significant factors predicting RBC transfusion. Multivariate logistic regression analysis revealed that preoperative Hb and blood loss amount during surgery were significantly related to RBC transfusion in BOS patients. Conclusion: Since blood loss amounts could not be measured preoperatively, we found that the independent predictor associated with RBC transfusion during BOS was a low preoperative Hb level.

Risk factors affecting the difficulty of fiberoptic nasotracheal intubation

Background

The success rate of intubation under direct laryngoscopy is greatly influenced by laryngoscopic grade using the Cormack-Lehane classification. However, it is not known whether grade under direct laryngoscopy can also affects the success rate of nasotracheal intubation using a fiberoptic bronchoscpe, so this study investigated the same. In addition, we investigated other factors that influence the success rate of fiberoptic nasotracheal intubation (FNI).

Methods

FNI was performed by 18 anesthesiology residents under general anesthesia in patients over 15 years of age who underwent elective oral and maxillofacial operations. In all patients, the Mallampati grade was measured. Laryngeal view grade under direct laryngoscopy, and the degree of secretion and bleeding in the oral cavity was measured and divided into 3 grades. The time required for successful FNI was measured. If the intubation time was > 5 minutes, it was evaluated as a failure and the airway was managed by another method. The failure rate was evaluated using appropriate statistical method. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were also measured.

Results

A total of 650 patients were included in the study, and the failure rate of FNI was 4.5%. The patient's sex, age, height, weight, Mallampati, and laryngoscopic view grade did not affect the success rate of FNI (P > 0.05). BMI, the number of FNI performed by residents (P = 0.03), secretion (P < 0.001), and bleeding (P < 0.001) grades influenced the success rate. The AUCs of bleeding and secretion were 0.864 and 0.798, respectively, but the AUC of BMI, the number of FNI performed by residents, Mallampati, and laryngoscopic view grade were 0.527, 0.616, 0.614, and 0.544, respectively.

Conclusion

Unlike in intubation under direct laryngoscopy, in the case of FNI, oral secretion and nasal bleeding had a significant effect on FNI difficulty than Mallampati grade or Laryngeal view grade.

A novel technique of submandibular intubation with a camera cable drape: a case report

Submental or submandibular intubation has been reported to cause fewer complications than tracheostomy. However, the risk of infection is always inherent because oral wounds are exposed to microbial flora and bacteria in the oral cavity. A novel technique of submandibular intubation was devised to reduce infection and injury to the soft tissues. We would like to report a novel safe technique that can be performed in patients requiring submental or submandibular intubation. This is the first report of submandibular intubation using a sterile disposable camera cable drape. This novel technique of submandibular intubation is safer, more sterile, easier, and less invasive than conventional submandibular intubation.

A clinical pilot study of jawbone mineral density measured by the newly developed dual-energy cone-beam computed tomography method compared to calibrated multislice computed tomography

Purpose

This clinical pilot study was performed to determine the effectiveness of dual-energy cone-beam computed tomography (DE-CBCT) in measuring bone mineral density (BMD).

Materials and Methods

The BMD values obtained using DE-CBCT were compared to those obtained using calibrated multislice computed tomography (MSCT). After BMD calibration with specially designed phantoms, both DE-CBCT and MSCT scanning were performed in 15 adult dental patients. Three-dimensional (3D) Digital Imaging and Communications in Medicine data were imported into a dental software program, and the defined regions of interest (ROIs) on the 3-dimensional surface-rendered images were identified. The automatically-measured BMD values of the ROIs (g/cm³), the differences in the measured BMD values of the matched ROIs obtained by DE-CBCT and MSCT 3D images, and the correlation between the BMD values obtained by the 2 devices were statistically analyzed.

Results

The mean BMD values of the ROIs for the 15 patients as assessed using DE-CBCT and MSCT were 1.09±0.07 g/cm³ and 1.13±0.08 g/cm³, respectively. The mean of the differences between the BMD values of the matched ROIs as assessed using DE-CBCT and calibrated MSCT images was 0.04±0.02 g/cm³. The Pearson correlation coefficient between the BMD values of DE-CBCT and MSCT images was 0.982 (r=0.982, P<0.001).

Conclusion

The newly developed DE-CBCT technique could be used to measure jaw BMD in dentistry and may soon replace MSCT, which is expensive and requires special facilities.

Treatment of severe pain in a patient with complex regional pain syndrome undergoing dental treatment under general anesthesia: A case report

Complex regional pain syndrome (CRPS) is rare, characterized by pain from diverse causes, and presents as extreme pain even with minor irritation. General anesthesia may be required for dental treatment because the pain may not be controlled with local anesthesia. However, treatment under general anesthesia is also challenging. A 38-year-old woman with CRPS arrived for outpatient dental treatment under general anesthesia. At the fourth general anesthesia induction, she experienced severe pain resulting from her right toe touching the dental chair. Anesthesia was induced to calm her and continue the treatment. After 55 minutes of general anesthesia, the patient still complained of extreme toe pain. Subsequently, two administrations for intravenous sedation were performed, and discharge was possible in the recovery room approximately 5 h after the pain onset. The pain was not located at the dental treatment site. Although the major factor causing pain relief was unknown, ketamine may have played a role.

Effects site concentrations of propofol using target-controlled infusion in dental treatment under deep sedation among different intellectual disability types

Background

We aimed to assess the dose needed to achieve the propofol effect-site concentration using target-controlled infusion in intellectually disabled patients and to detail the most effective method for achieving a safe level of consciousness without hemodynamic changes as well as detail any resulting adverse effects.

Methods

We performed a retrospective review of sedation service records of 138 intellectually disabled patients (51, mental retardation; 36, autism; 30, brain lesion, 12 genetic diseases, 9 dementia) aged over 15 years and weighing over 30 kg. These patients had received propofol via target-controlled infusion in the special care dental clinic of Seoul National University Dental Hospital from May 2008 to September 2018 for restorative treatment (112), minor surgery (13), prosthodontics (7), periodontics treatment (5), and implant (1).

Results

For all groups, the duration of dental treatments was 43 ± 18 minutes, total sedation time was 73 ± 23 minutes, and total BIS values was 57 ± 12. The propofol maintenance dosage values for each group were: mental retardation, 3 ± 0.5 (2–4) µg/ml; autism, 3.1 ± 0.7 (2–5) µg/ml; brain lesion, 2.8 ± 0.7 (1.5–5) µg/ml; genetic disease, 2.9 ± 0.9 (1–4) µg/ml; and dementia 2.3 ± 0.7 (1–3.4) µg/ml.

Conclusions

The dementia group needed a lower dosage to reach a safe, effective propofol effect-site concentration than the other groups. Since there were no complications, deep sedation is a great alternative to general anesthesia for dental treatment of intellectually disabled patients.

Multiple implant therapy with multiple inductions of general anesthesia in non-compliant patients with schizophrenia: A case report

The effectiveness of dental implants in patients with disability, who are non-compliant during treatment, is controversial because of their poor oral health. Thus, oral health-care and management in such patients is concerning. Moreover, limited information is available on prognosis after implant placement. Herein, we describe a patient with schizophrenia who underwent dental implantation under multiple inductions of general anesthesia (5 times) and required conservative treatment and tooth extraction for multiple dental caries and retained roots because of inadequate oral health-care. Postoperatively, fracture of the prosthodontics and progression of dental caries were observed, and with 3 additional inductions of general anesthesia, conservative treatment, implant surgery, and prosthesis implantation were conducted. Postoperative 12-month follow-up since the last prosthesis implantation showed successful results. For patients with schizophrenia, multiple implantation can reduce horizontal bone loss and achieve aesthetic results compared to treatment with removable prosthodontics and could serve as an alternative treatment modality.

Anaphylactic reaction after local lidocaine infiltration for retraction of retained teeth

Although allergic reactions are not rare complications in drug use, anaphylaxis or anaphylactoid reactions to some widely used drugs can embarrass clinicians because anaphylaxis is not easily diagnosed at the time of the event and treatment is unfamiliar to many. Lidocaine is a very popular drug in dental procedures and anaphylactoid reaction to it has been rarely reported. Clinicians who use lidocaine daily should, however, be aware of the possibility of anaphylaxis after its use. Once it occurs, anaphylaxis can be fatal, but if it is quickly diagnosed or suspected, treatment is simpler than most clinicians believe. An 86-year-old woman experienced an anaphylactic reaction 30 min after local infiltration of lidocaine for retraction of retained teeth. The dentist called an anesthesiologist for assistance. Fortunately, an anaphylactic reaction was quickly suspected and after subsequent rapid treatment with the administration of fluid and drug therapy, the patient recovered completely.

Effects on postoperative nausea and vomiting of nefopam versus fentanyl following bimaxillary orthognathic surgery: a prospective double-blind randomized controlled trial

Background

Postoperative nausea and vomiting (PONV) frequently occurs following bimaxillary orthognathic surgeries. Compared to opioids, Nefopam is associated with lower incidences of PONV, and does not induce gastrointestinal tract injury, coagulopathy, nephrotoxicity, or fracture healing dysfunction, which are common side effects of Nonsteroidal anti-inflammatory drugs. We compared nefopam- and fentanyl-induced incidence of PONV in patients with access to patient-controlled analgesia (PCA) following bimaxillary orthognathic surgeries.

Methods

Patients undergoing bimaxillary orthognathic surgeries were randomly divided into nefopam and fentanyl groups. Nefopam 120 mg or fentanyl 700 µg was mixed with normal saline to a final volume of 120 mL. Patients were given access to nefopam or fentanyl via PCA. Postoperative pain intensity and PONV were measured at 30 minutes and 1 hour after surgery in the recovery room and at 8, 24, 48, and 72 hours after surgery in the ward. The frequency of bolus delivery was compared at each time point.

Results

Eighty-nine patients were enrolled in this study, with 48 in the nefopam (N) group and 41 in the fentanyl (F) group. PONV occurred in 13 patients (27.7%) in the N group and 7 patients (17.1%) in the F group at 8 hours post-surgery (P = 0.568), and there were no significant differences between the two groups at any of the time points. VAS scores were 4.4 ± 2.0 and 3.7 ± 1.9 in the N and F groups, respectively, at 8 hours after surgery (P = 0.122), and cumulative bolus delivery was 10.7 ± 13.7 and 8.6 ± 8.5, respectively (P = 0.408). There were no significant differences in pain or bolus delivery at any of the remaining time points.

Conclusion

Patients who underwent bimaxillary orthognathic surgery and were given nefopam via PCA did not experience a lower rate of PONV compared to those that received fentanyl via PCA. Furthermore, nefopam and fentanyl did not provide significantly different postoperative pain control.

Airway management in pediatric tongue flap division for oronasal fistula closure: A case report

Oronasal fistulae (ONF) could remain after surgery in some patients with cleft palate. ONF ultimately requires intraoral surgery, which may lead to perioperative airway obstruction. Tongue flap surgery is a technique used to repair ONF. During the second surgery for performing tongue flap division, the flap transplanted from the tongue dorsum to the palate of the patient acts as an obstacle to airway management, which poses a great challenge for anesthesiologists. In particular, anesthesiologists may face difficulty in airway evaluation and patient cooperation during general anesthesia for tongue flap division surgery in pediatric patients. The authors report a case of airway management using a flexible fiberoptic bronchoscope during general anesthesia for tongue flap division surgery in a 6-year-old child.

Analysis of the effect of oral midazolam and triazolam premedication before general anesthesia in patients with disabilities with difficulty in cooperation

Background

When performing dental treatment under general anesthesia in adult patients who have difficulty cooperating due to intellectual disabilities, anesthesia induction may be difficult as well. In particular, patients who refuse to come into the dental office or sit in the dental chair may have to be forced to do so. However, for adult patients with a large physique, physical restraint may be difficult, while oral sedatives as premedication may be helpful. Here, a retrospective analysis was performed to investigate the effect of oral sedatives.

Methods

A hospital-based medical information database was searched for patients who were prescribed oral midazolam or triazolam between January 2009 and December 2017. Pre-anesthesia evaluation, anesthesia, and anesthesia recovery records of all patients were analyzed, and information on disability type, reason for prescribing oral sedatives, prescribed medication and dose, cooperation level during anesthesia induction, anesthesia duration, length of recovery room stay, and complications was retrieved.

Results

A total of 97 patients were identified, of whom 50 and 47 received midazolam and triazolam, respectively. The major types of disability were intellectual disabilities, autism, Down syndrome, blindness, cerebral palsy, and epilepsy. Analyses of changes in cooperation levels after drug administration showed that anesthesia induction without physical restraint was possible in 56.0% of patients in the midazolam group and in 46.8% of patients in the triazolam group (P = 0.312).

Conclusions

With administration of oral midazolam or triazolam, general anesthesia induction without any physical restraint was possible in approximately 50% of patients, with no difference between the drugs.

Comparative evaluation of the efficacy, safety, and hemostatic effect of 2% lidocaine with various concentrations of epinephrine

BACKGROUND

We evaluated the changes in mean arterial pressure (MAP) and heart rate (HR), and the anesthetic and hemostatic effects, after injection of 2% lidocaine containing various concentrations of epinephrine in rats and mice to determine the appropriate concentration of epinephrine in various anesthetic mixtures.

METHODS

Rats and mice were randomly allocated to experimental groups: 2% lidocaine without epinephrine (L0), 2% lidocaine with epinephrine 1:200,000 (L200), 1:100,000 (L100), and 1:80,000 (L80). Changes in MAP and HR after administration of the anesthetic mixture were evaluated using a physiological recording system in rats. Onset and duration of local anesthesia was evaluated by pricking the hind paw of mice. A spectrophotometric hemoglobin assay was used to quantify the hemostatic effect.

RESULTS

MAP increased in response to epinephrine in a dose-dependent manner; it was significantly higher in the L80 group than in the L0 group at 5 min post-administration. The HR was relatively lower in the L0 group than in the L80 group. The time required for onset of action was < 1 min in all evaluation groups. The duration of action and hemostatic effect of the local anesthetic were significantly better in the L200, L100, and L80 groups than in the L0 group.

CONCLUSION

L200 demonstrated relatively stable MAP and HR values with satisfactory efficacy and hemostatic effect. L200 might be a better local anesthetic for dental patients in terms of anesthetic efficacy and safety.

Orotracheal intubation in a patient with difficult airway by using fiberoptic nasotracheal intubation: A case report

In cases of a difficult intubation where numerous intubation methods, including laryngoscopy, have failed, yet oral intubation is still necessary, the method of tube exchange after fiberoptic nasal intubation may be attempted. Fiberoptic nasal intubation allows intubation to be performed relatively easily when the laryngeal view grade is poor. We report a case in which our attempt at oral intubation for total maxillectomy with laryngoscopy and fiberoptic oral intubation had failed due to an unexpected difficult airway; subsequently, we successfully completed the surgery by performing fiberoptic nasal intubation to secure the airway, followed by using a tube exchanger to exchange to an oral endotracheal tube.

The effect of dental scaling noise during intravenous sedation on acoustic respiration rate (RRa™)

BACKGROUND

Respiration monitoring is necessary during sedation for dental treatment. Recently, acoustic respiration rate (RRa™), an acoustics-based respiration monitoring method, has been used in addition to auscultation or capnography. The accuracy of this method may be compromised in an environment with excessive noise. This study evaluated whether noise from the ultrasonic scaler affects the performance of RRa in respiratory rate measurement.

METHODS

We analyzed data from 49 volunteers who underwent scaling under intravenous sedation. Clinical tests were divided into preparation, sedation, and scaling periods; respiratory rate was measured at 2-s intervals for 3 min in each period. Missing values ratios of the RRa during each period were measuerd; correlation analysis and Bland-Altman analysis were performed on respiratory rates measured by RRa and capnogram.

RESULTS

Respective missing values ratio from RRa were 5.62%, 8.03%, and 23.95% in the preparation, sedation, and scaling periods, indicating an increased missing values ratio in the scaling period (P < 0.001). Correlation coefficients of the respiratory rate, measured with two different methods, were 0.692, 0.677, and 0.562 in each respective period. Mean capnography-RRa biases in Bland-Altman analyses were -0.03, -0.27, and -0.61 in each respective period (P < 0.001); limits of agreement were -4.84-4.45, -4.89-4.15, and -6.18-4.95 (P < 0.001).

CONCLUSIONS

The probability of missing respiratory rate values was higher during scaling when RRa was used for measurement. Therefore, the use of RRa alone for respiration monitoring during ultrasonic scaling may not be safe.

Cardiac arrest due to an unexpected acute myocardial infarction during head and neck surgery: A case report

Major cardiac complication such as acute myocardial infarction can occur unexpectedly in patients without risk factors. We experienced cardiac arrest due to an unexpected acute myocardial infarction in a patient without any risk factors during head and neck reconstructive surgery. The patient was diagnosed with acute myocardial infarction after return of spontaneous circulation. With immediate percutaneous coronary intervention, the patient recovered without complications.

Learning fiberoptic intubation for awake nasotracheal intubation

Background

Fiberoptic nasotracheal intubation (FNI) is performed if it is difficult to open the mouth or if intubation using laryngoscope is expected to be difficult. However, training is necessary because intubation performed by inexperienced operators leads to complications.

Methods

Every resident performed intubation in 40 patients. Success of FNI was evaluated as the time of FNI. First intubation time was restricted to 2 min 30 s. If the second attempt was unsuccessful, it was considered a failed case, and a specialist performed nasotracheal intubation. If the general method of intubation was expected to be difficult, awake intubation was performed. The degree of nasal bleeding during intubation was also evaluated.

Results

The mean age of the operators (11 men, 7 women) was 27.8 years. FNI was performed in a total of 716 patients. The success rate was 88.3% for the first attempt and 94.6% for the second attempt. The failure rate of intubation in anesthetized patients was 4.9%, and 13.6% in awake patients. When intubation was performed in anesthetized patients, the failure rate from the first to fifth trial was 9.6%, which decreased to 0.7% when the number of trials increased to > 30 times. In terms of awake intubation, there was no failed attempt when the resident had performed the FNI > 30 times. The number of FNIs performed and nasal bleeding were important factors influencing the failure rate.

Conclusion

The success rate of FNI increased as the number of FNI performed by residents increased despite the nasal bleeding.

A retrospective analysis of outpatient anesthesia management for dental treatment of patients with severe Alzheimer's disease

Background

The number of patients with Alzheimer's disease is growing worldwide, and the proportion of patients requiring dental treatment under general anesthesia increases with increasing severity of the disease. However, outpatient anesthesia management for these patients involves great risks, as most patients with Alzheimer's disease are old and may show reduced cardiopulmonary functions and have cognitive disorders.

Methods

This study retrospectively investigated 43 patients with Alzheimer's disease who received outpatient anesthesia for dental treatment between 2012–2017. Pre-anesthesia patient evaluation, dental treatment details, anesthetics dose, blood pressure, duration and procedure of anesthesia, and post-recovery management were analyzed and compared between patients who underwent general anesthesia or intravenous sedation.

Results

Mean age of patients was about 70 years; mean duration of Alzheimer's disease since diagnosis was 6.3 years. Severity was assessed using the global deterioration scale; 62.8% of patients were in level ≥ 6. Mean duration of anesthesia was 178 minutes for general anesthesia and 85 minutes for intravenous sedation. Mean recovery time was 65 minutes. Eleven patients underwent intravenous sedation using propofol, and 22/32 cases involved total intravenous anesthesia using propofol and remifentanil. Anesthesia was maintained with desflurane for other patients. While maintaining anesthesia, inotropic and atropine were used for eight and four patients, respectively. No patient developed postoperative delirium. All patients were discharged without complications.

Conclusion

With appropriate anesthetic management, outpatient anesthesia was successfully performed without complications for dental treatment for patients with severe Alzheimer's disease.

Comparison of intraoperative basal fluid requirements in distal pancreatectomy: Laparotomy vs. laparoscopy: A retrospective cohort study

There has been recent progress in intraoperative fluid therapy. However, little is known about intraoperative fluid therapy in laparoscopic surgery. The purpose of this study is to determine whether there are differences in the basal fluid requirements during surgery between laparotomy and laparoscopic distal pancreatectomy.This retrospective cohort study analyzed the electronic medical records of 253 patients who underwent distal pancreatectomy via either laparotomy (73 patients) or laparoscopy (180 patients) between June 2006 and March 2016. The volume of intraoperative fluid administered, postoperative complications, length of hospital stay, and readmission rate were evaluated. The total volume of fluids was calculated as the sum of the volume of crystalloid plus the volume of colloid multiplied by 1.5 or 2.0.Patients who had laparotomy were older and had higher American Society of Anesthesiologists classes. Anesthesia time was longer and estimated blood loss was larger in laparotomy. More colloid (1.8 mL/kg per h vs. 1.2 mL/kg per h, P < .001) and more total calculated fluid (1.5 times: 11.7 mL/kg per h vs. 10.6 mL/kg per h, P = .002; 2.0 times: 12.6 mL/kg per h vs. 11.2 mL/kg per h, P = .001) were infused in laparotomy. Crystalloid (9.0 mL/kg per h vs. 8.9 mL/kg per h, P = .203) did not show significant difference. Postoperative complications were more frequent (63% vs. 45%, P = .008), the hospital stay was longer (18 days vs. 13.4 days, P < .001), and readmission rate was higher (15% vs. 5.6%, P = .02) in laparotomy. By logistic regression analysis, we could find that operation type (laparotomy vs. laparoscopy, odds ratio 1.900, 95% confidence interval 1.072-3.368) and operation time (P = .004) had effect on complications.In patients undergoing distal pancreatectomy, basal fluid requirements were larger in laparotomy compared with laparoscopy. Operation time and estimated blood loss had effects on fluid administration. Postoperative complications were more frequent in laparotomy but we could not find relationships with infused colloid or total calculated fluid volumes. Operation type (laparotomy vs. laparoscopy) and operation time were the only related factors to postoperative complications.

Perioperative red blood cell transfusion in orofacial surgery

In the field of orofacial surgery, a red blood cell transfusion (RBCT) is occasionally required during double jaw and oral cancer surgery. However, the question remains whether the effect of RBCT during the perioperative period is beneficial or harmful. The answer to this question remains challenging. In the field of orofacial surgery, transfusion is performed for the purpose of oxygen transfer to hypoxic tissues and plasma volume expansion when there is bleeding. However, there are various risks, such as infectious complications (viral and bacterial), transfusion-related acute lung injury, ABO and non-ABO associated hemolytic transfusion reactions, febrile non-hemolytic transfusion reactions, transfusion associated graft-versus-host disease, transfusion associated circulatory overload, and hypersensitivity transfusion reaction including anaphylaxis and transfusion-related immune-modulation. Many studies and guidelines have suggested RBCT is considered when hemoglobin levels recorded are 7 g/dL for general patients and 8-9 g/dL for patients with cardiovascular disease or hemodynamically unstable patients. However, RBCT is occasionally an essential treatment during surgeries and it is often required in emergency cases. We need to comprehensively consider postoperative bleeding, different clinical situations, the level of intra- and postoperative patient monitoring, and various problems that may arise from a transfusion, in the perspective of patient safety. Since orofacial surgery has an especially high risk of bleeding due to the complex structures involved and the extensive vascular distribution, measures to prevent bleeding should be taken and the conditions for a transfusion should be optimized and appropriate in order to promote patient safety.

Prognosis following dental implant treatment under general anesthesia in patients with special needs

Background

This study retrospectively investigated outcomes following dental implantation in patients with special needs who required general anesthesia to enable treatment.

Methods

Patients underwent implant treatment under general anesthesia at the Clinic for the Disabled in Seoul National University Dental Hospital between January 2004 and June 2017. The study analyzed medical records and radiographs. Implant survival rates were calculated by applying criteria for success or failure.

Results

Of 19 patients in the study, 8 were males and 11 were females, with a mean age of 32.9 years. The patients included 11 with mental retardation, 3 with autism, 2 with cerebral palsy, 2 with schizophrenia, and 1 with a brain disorder; 2 patients also had seizure disorders. All were incapable of oral self-care due to serious cognitive impairment and could not cooperate with normal dental treatment. A total of 27 rounds of general anesthesia and 1 round of intravenous sedation were performed for implant surgery. Implant placement was performed in 3 patients whose prosthesis records could not be found, while 3 other patients had less than 1 year of follow-up after prosthetic treatment. When the criteria for implant success or failure were applied in 13 remaining patients, 3 implant failures occurred in 59 total treatments. The cumulative survival rate of implants over an average of 43.3 months (15-116 months) was 94.9%.

Conclusions

For patients with severe cognitive impairment who are incapable of oral self-care, implant treatment under general anesthesia showed a favorable prognosis.

Dental anesthesia for patients with allergic reactions to lidocaine: two case reports

Lidocaine, a local anesthetic commonly used in dental treatments, is capable of causing allergies or adverse effects similar to allergic reactions. However, the frequency of such occurrences in actual clinical settings is very rare, and even clinical tests on patients with known allergies to local anesthetics may often show negative results. When adverse effects, such as allergy to lidocaine, are involved, patients can be treated by testing other local anesthetics and choosing a local anesthetic without any adverse effects, or by performing dental treatment under general anesthesia in cases in which no local anesthetic without adverse effects is available. Along with a literature review, the authors of the present study report on two cases of patients who tested positive on allergy skin tests for lidocaine and bupivacaine and subsequently underwent successful dental treatments with either general anesthesia or a different local anesthetic.

Smart syringe pumps for drug infusion during dental intravenous sedation

Dentists often sedate patients in order to reduce their dental phobia and stress during dental treatment. Sedatives are administered through various routes such as oral, inhalation, and intravenous routes. Intravenous administration has the advantage of rapid onset of action, predictable duration of action, and easy titration. Typically, midazolam, propofol or dexmedetomidine are used as intravenous sedatives. Administration of these sedatives via infusion by using a syringe pump is more effective and successful than infusing them as a bolus. However, during intravenous infusion of sedatives or opioids using a syringe pump, fatal accidents may occur due to the clinician's carelessness. To prevent such risks, smart syringe pumps have been introduced clinically. They allow clinicians to perform effective sedation by using a computer to control the dose of the drug being infused. To ensure patient safety, various alarm features along with a drug library, which provides drug information and prevents excessive infusion by limiting the dose, have been added to smart pumps. In addition, programmed infusion systems and target-controlled infusion systems have also been developed to enable effective administration of sedatives. Patient-controlled infusion, which allows a patient to control his/her level of sedation through self-infusion, has also been developed. Safer and more successful sedation may be achieved by fully utilizing these new features of the smart pump.

Anesthetic management for simultaneous drug-induced sleep endoscopy and maxillomandibular advancement in a patient with obstructive sleep apnea

Drug-induced sleep endoscopy (DISE) is used to identify areas of upper airway obstruction, which occurs when patients with obstructive sleep apnea (OSA) snore. DISE enables effective diagnosis and appropriate treatment of the obstruction site. Among surgical treatment methods for OSA, maxillomandibular advancement surgery (MMA) is performed to move a jaw forward; the surgery has a high success rate for OSA treatment. In DISE, anesthetics such as propofol and midazolam must be administered to induce snoring while the patient is deeply sedated for an accurate diagnosis to be made. When inducing deep sedation in a patient with OSA, airway obstruction may increase, causing oxygen saturation to drop; airway interventions are necessary in such cases. Effective DISE and MMA surgery can be performed by administering propofol through target-controlled infusion while monitoring the bispectral index (BIS).

Prognosis after treatment with multiple dental implants under general anesthesia and sedation in a cerebral palsy patient with mental retardation: A case report

Cerebral palsy is a non-progressive disorder resulting from central nervous system damage caused by multiple factors. Almost all cerebral palsy patients have a movement disorder that makes dental treatment difficult. Oral hygiene management is difficult and the risks for periodontitis, dental caries and loss of multiple teeth are high. Placement of dental implants for multiple missing teeth in cerebral palsy patients needs multiple rounds of general anesthesia, and the prognosis is poor despite the expense. Therefore, making the decision to perform multiple dental implant treatments on cerebral palsy patients is difficult. A 33-year-old female patient with cerebral palsy and mental retardation was scheduled for multiple implant treatments. She underwent computed tomography (CT) under sedation and the operation of nine dental implants under general anesthesia. Implant-supported fixed prosthesis treatment was completed. During follow-up, she had the anterior incisors extracted and underwent the surgery of 3 additional dental implants, completing the prosthetic treatment. Although oral parafunctions existed due to cerebral palsy, no implant failure was observed 9 years after the first implant surgery.

Is neuromuscular blocker needed in children undergoing inguinal herniorrhaphy?: A prospective, randomized, and controlled trial

BACKGROUND

Intraoperative neuromuscular blocker is widely used, but is known to be associated with postoperative residual paralysis, which is known to be associated with increased risk of pulmonary complications. Hence, its use should be individualized and restricted to procedures where it is mandatory. We examined whether not using a neuromuscular blocker affects the surgical conditions in children undergoing inguinal herniorrhaphy.

METHODS

Anesthesia was induced and maintained with sevoflurane in 60% nitrous oxide, and the airway was maintained using an I-gel. In total, 66 children aged 1 to 6 years were randomized to receive rocuronium (rocuronium group, n = 33) or saline (control group, n = 33); 61 children of them finished the study. A single surgeon who performed the operation rated the surgical condition of each patient on a 4-point scale (1 = poor, 2 = acceptable, 3 = good, and 4 = excellent). Intraoperative patient movement, recovery time, emergence agitation, and postoperative pain scores were evaluated.

RESULTS

One patient in control group and no patient in rocuronium group showed intraoperative movement. When noninferiority test was done for intraoperative patient movement, with the noninferiority margin of 20%, the difference of absolute risk was 3.3% (95% confidence interval -8.0% to 16.7%) and saline group was noninferior to rocuronium group. All of the patients showed good to excellent surgical conditions, and no difference was found between the 2 groups. The recovery time was shorter in the control group than in the rocuronium group (4.5 ± 1.8 vs 5.6 ± 2.2 minutes, respectively; P = .028).

CONCLUSION

In children aged 1 to 6 years undergoing inguinal herniorhaphy under sevoflurane anesthesia using an I-gel, not using neuromuscular blocker showed similar intraoperative condition and shortened recovery time compared with using neuromouscular blocker.

Comparison of the efficacy and safety of 2% lidocaine HCl with different epinephrine concentration for local anesthesia in participants undergoing surgical extraction of impacted mandibular third molars: A multicenter, randomized, double-blind, crossover, phase IV trial

BACKGROUND

The most commonly impacted tooth is the third molar. An impacted third molar can ultimately cause acute pain, infection, tumors, cysts, caries, periodontal disease, and loss of adjacent teeth. Local anesthesia is employed for removing the third molar. This study aimed to evaluate the efficacy and safety of 2% lidocaine with 1:80,000 or 1:200,000 epinephrine for surgical extraction of bilateral impacted mandibular third molars.

METHODS

Sixty-five healthy participants underwent surgical extraction of bilateral impacted mandibular third molars in 2 separate visits while under local anesthesia with 2% lidocaine with different epinephrine concentration (1:80,000 or 1:200,000) in a double-blind, randomized, crossover trial. Visual analog scale pain scores obtained immediately after surgical extraction were primarily evaluated for the 2 groups receiving different epinephrine concentrations. Visual analog scale pain scores were obtained 2, 4, and 6 hours after administering an anesthetic. Onset and duration of analgesia, onset of pain, intraoperative bleeding, operator's and participant's overall satisfaction, drug dosage, and hemodynamic parameters were evaluated for the 2 groups.

RESULTS

There were no statistically significant differences between the 2 groups in any measurements except hemodynamic factors (P >.05). Changes in systolic blood pressure and heart rate following anesthetic administration were significantly greater in the group receiving 1:80,000 epinephrine than in that receiving 1:200,000 epinephrine (P ≤.01).

CONCLUSION

The difference in epinephrine concentration between 1:80,000 and 1:200,000 in 2% lidocaine liquid does not affect the medical efficacy of the anesthetic. Furthermore, 2% lidocaine with 1:200,000 epinephrine has better safety with regard to hemodynamic parameters than 2% lidocaine with 1:80,000 epinephrine. Therefore, we suggest using 2% lidocaine with 1:200,000 epinephrine rather than 2% lidocaine with 1:80,000 epinephrine for surgical extraction of impacted mandibular third molars in hemodynamically unstable patients.

Efficacy evaluation of syringe pump developed for continuous drug infusion

BACKGROUND

In dental intravenous sedation, continuous intravenous infusion of a low-dose drug requires an infusion pump such as a syringe pump. To develop a new syringe pump for clinical use, the functions of the pump must meet certain international standards. Various safety and efficacy tests must be performed on the syringe pump, as stipulated by these standards, and an approval must be received from the approving agency based on such test results.

METHODS

The authors of the present study developed a novel syringe pump and performed efficacy evaluation by testing its infusion speed at 1 and 25 ml/h, and infusion performance testing at 2 and 24 h. Moreover, performance evaluation was conducted by comparing the novel pump to an existing pump with the infusion speed varied from 1 to 5 ml/h.

RESULTS

In the efficacy testing on the newly developed syringe pump, infusion with the infusion speed initially set to 1 ml/h resulted in infusion speeds of 1.00 and 0.99 ml/h in the 2- and 24-h assessment, respectively. Changing the infusion speed setting to 25 ml/h resulted in an infusion speed of 25.09 and 23.92 ml/h in the 2- and 24-h assessment, respectively. These results show no significant differences when compared with other commercially available pumps.

CONCLUSIONS

The efficacy testing of the newly developed syringe pump showed the accuracy to be within tolerance. Based on these findings, we believe that the newly developed syringe pump is suitable for clinical use.

Developmental procedures for the clinical practice guidelines for conscious sedation in dentistry for the Korean Academy of Dental Sciences

Background

Evidence-based clinical practice guidelines (CPGs) are defined as “statements that are scientifically reviewed about evidence and systematically developed to assist in the doctors' and patients' decision making in certain clinical situations.” This recommendation aims to promote good clinical practice for the provision of safe and effective practices of conscious sedation in dentistry.

Methods

The development of this clinical practice guideline was conducted by performing a systematic search of the literature for evidence-based CPGs. Existing guidelines, relevant systematic reviews, policy documents, legislation, or other recommendations were reviewed and appraised. To supplement this information, key questions were formulated by the Guideline Development Group and used as the basis for designing systematic literature search strategies to identify literature that may address these questions. Guideline documents were evaluated through a review of domestic and international databases for the development of a renewing of existing conscious sedation guidelines for dentistry. Clinical practice guidelines were critically appraised for their methodologies using Appraisal of guidelines for research and evaluation (AGREE) II.

Results

A total of 12 existing CPGs were included and 13 recommendations were made in a range of general, adult, and pediatric areas.

Conclusion

The clinical practice guidelines for conscious sedation will be reviewed in 5 years' time for further updates to reflect significant changes in the field.

Use of ADMS™ during sedation for dental treatment of an intellectually disabled patient: a case report

Dental treatment is often performed under general anesthesia or sedation when an intellectually disabled patient has a heightened fear of treatment or has difficulty cooperating. When it is impossible to control the patient due to the severity of intellectual disability, conscious sedation is not a viable option, and only deep sedation should be performed. Deep sedation is usually achieved by propofol infusion using the target controlled infusion (TCI) system, with deep sedation being achieved at a slightly lower concentration of propofol in disabled patients. In such cases, anesthesia depth monitoring using EEG, as with a Bispectral Index (BIS) monitor, can enable dental treatment under appropriate sedation depth. In the present case, we performed deep sedation for dental treatment on a 27-year-old female patient with mental retardation and severe dental phobia. During sedation, we used BIS and a newly developed Anesthetic Depth Monitor for Sedation (ADMS™), in addition to electrocardiography, pulse oximetry, blood pressure monitoring, and capnometry for patient safety. Oxygen was administered via nasal prong to prevent hypoxemia during sedation. The BIS and ADMS™ values were maintained at approximately 70, and dental treatment was successfully performed in approximately 30 min..

Dexmedetomidine Injection during Strabismus Surgery Reduces Emergence Agitation without Increasing the Oculocardiac Reflex in Children: A Randomized Controlled Trial

Objective

Dexmedetomidine is known to reduce the incidence of emergence agitation, which is a common complication after inhalational anesthesia like sevoflurane or desflurane in children. However, the dose of dexmedetomidine used for this purpose is reported variously and the most effective dose is not known. In this study, we tried to find the most effective dose of dexmedetomidine to reduce the incidence of emergence agitation in children undergoing strabismus surgery without the complications like oculocardiac reflex (OCR) or postoperative vomiting.

Methods

We randomized 103 pediatric patients aged 2–6 years and undergoing elective strabismus surgery into four groups. Anesthesia was induced with sevoflurane and maintained with desflurane. At the start of induction, dexmedetomidine, delivered at 0.25, 0.5, or 1 μg/kg, or saline was infused intravenously in the D0.25, D0.5, D1 groups, respectively. The primary outcome measure was the incidence of emergence agitation and the secondary outcome measure was the incidence of intraoperative OCR, postoperative vomiting, and desaturation events.

Results

The incidence of emergence agitation was 60, 48, 44, and 21% (P = 0.005) and the incidence of intraoperative OCR was 36, 36, 36, and 37% (P = 0.988) in the control, D0.25, D0.5, and D1 groups, respectively. And, postoperative vomiting rate and desaturation events were low in the all groups.

Conclusion

Dexmedetomidine decreased the incidence of emergence agitation without increasing intraoperative oculocardiac reflex. Dexmedetomidine delivered at 1 μg/kg was more effective at reducing emergence agitation than lower doses in children undergoing strabismus surgery under desflurane anesthesia.

Trial Registration

Clinical Research Information Service KCT0000141

Effects of airway evaluation parameters on the laryngeal view grade in mandibular prognathism and retrognathism patients

BACKGROUND

Failure to maintain a patent airway can result in brain damage or death. In patients with mandibular prognathism or retrognathism, intubation is generally thought to be difficult. We determined the degree of difficulty of airway management in patients with mandibular deformity using anatomic criteria to define and grade difficulty of endotracheal intubation with direct laryngoscopy.

METHODS

Measurements were performed on 133 patients with prognathism and 33 with retrognathism scheduled for corrective esthetic surgery. A case study was performed on 89 patients with a normal mandible as the control group. In all patients, mouth opening distance (MOD), mandibular depth (MD), mandibular length (ML), mouth opening angle (MOA), neck extension angle (EXT), neck flexion angle (FLX), thyromental distance (TMD), inter-notch distance (IND), thyromental area (TMA), Mallampati grade, and Cormack and Lehane grade were measured.

RESULTS

Cormack and Lehane grade I was observed in 84.2%, grade II in 15.0%, and grade III in 0.8% of mandibular prognathism cases; among retrognathism cases, 45.4% were grade I, 27.3% grade II, and 27.3% grade III; among controls, 65.2% were grade I, 26.9% were grade II, and 7.9% were grade III. MOD, MOA, ML, TMD, and TMA were greater in the prognathism group than in the control and retrognathism groups (P < 0.05). The measurements of ML were shorter in retrognathism than in the control and prognathism groups (P < 0.05).

CONCLUSIONS

Laryngoscopic intubation was easier in patients with prognathism than in those with normal mandibles. However, in retrognathism, the laryngeal view grade was poor and the ML was an important factor.

Retrospective cohort investigation of perioperative upper respiratory events in children undergoing general anesthesia via a supraglottic airway: A comparison of sevoflurane and desflurane

Desflurane is the most pungent of the currently used volatile anesthetics. We assessed whether the incidence of perioperative upper respiratory events in children undergoing general anesthesia via a supraglottic airway is higher with desflurane than with sevoflurane as maintenance anesthetic.We retrospectively reviewed and analyzed the electronic medical records of consecutive children 1 to 15 years of age who underwent general anesthesia via a supraglottic airway at Seoul National University Bundang Hospital between June 2013 and June 2015. The patients were assigned to the sevoflurane or desflurane group according to the anesthetic used. The characteristics of the patients were compared. The primary outcome variable was the incidence of upper respiratory events.The incidence of upper respiratory events in the 3439 evaluated patients was 0.43% (12/2777) in the sevoflurane group and 0.30% (2/662) in the desflurane group (P = 0.75; odds ratio = 0.69 [95% confidence interval = 0.16-3.13]). The difference between the 2 groups was not significant.Compared with sevoflurane, desflurane does not increase the risk of perioperative upper respiratory events in children receiving general anesthesia via a supraglottic airway.

Identifying the more suitable nostril for nasotracheal intubation using radiographs

Background

One nostril must be selected for nasotracheal intubation. In some cases, structural anomalies within the nasal cavity hinder the insertion of the tube or complications, such as epistaxis, develop. This study examined the possibility of using radiography to select the nostril that would induce fewer complications.

Methods

Four hundred and five patients who underwent nasotracheal intubation under general anesthesia were studied. A 7.0-mm internal diameter nasal right angle endotracheal (RAE) tube and 6.5-mm internal diameter nasal RAE tube were inserted into men and women, respectively. Complications were considered to have developed in cases in which insertion of the tube into the nasal cavity failed or epistaxis occurred. The tube was inserted into the other nostril for insertion failures and hemostasis was performed in cases of epistaxis. The degree of nasal septal deviation was determined from posteroanterior skull radiographs or panoramic radiographs; the incidence of complications was compared depending on the direction of the septal deviation and the intubated nostril.

Results

The radiographs of 390 patients were readable; 94 had nasal septum deviation. The incidence of complications for cases without nasal septum deviation was 16.9%, that for cases in which the tube was inserted into the nostril on the opposite side of the deviation was 18.5%, and that for cases in which the tube was inserted into the nostril with the deviation was 35.0%, showing a high incidence of complications when intubation is performed through the nostril with septum deviation (chi-square test, P < 0.05 ).

Conclusions

Although there were no differences in the incidence rates of complications between intubation through the left nostril and that through the right nostril, radiological findings indicated that incidence of complications significantly increased when the tube was inserted into the nostril with the septum deviation.

Local anesthesia of the temporomandibular joint to reduce pain during mouth opening for dental treatment in a patient with spinal muscular atrophy

Spinal muscular atrophy (SMA) is an autosomal recessive, severe neuromuscular disorder in which degeneration of alpha motor neurons in the spine progressively weakens and ultimately paralyzes the proximal muscles. It occurs in one per 6,000–10,000 infants, and is a genetic disorder with the second-highest mortality rate worldwide. An 18-year-old male patient with SMA was referred for general anesthesia for difficulty in performing dental treatment due to limited mouth opening caused by temporomandibular joint (TMJ) pain. However, the patient had a high risk of general anesthesia complications, so TMJ pain during mouth opening was reduced through local anesthesia of the TMJ. Fortunately, the anesthesia was successful in reducing pain during mouth opening, enabling the patient to receive dental treatment with an adequate mouth opening.

Enhanced Expression of TREK-1 Is Related with Chronic Constriction Injury of Neuropathic Pain Mouse Model in Dorsal Root Ganglion

Neuropathic pain is a complex state showing increased pain response with dysfunctional inhibitory neurotransmission. The TREK family, one of the two pore domain K⁺ (K2P) channel subgroups were focused among various mechanisms of neuropathic pain. These channels influence neuronal excitability and are thought to be related in mechano/thermosensation. However, only a little is known about the expression and role of TREK-1 and TREK-2, in neuropathic pain. It is performed to know whether TREK-1 and/ or 2 are positively related in dorsal root ganglion (DRG) of a mouse neuropathic pain model, the chronic constriction injury (CCI) model. Following this purpose, Reverse Transcription Polymerase Chain Reaction (RT-PCR) and western blot analyses were performed using mouse DRG of CCI model and compared to the sham surgery group. Immunofluorescence staining of isolectin- B4 (IB4) and TREK were performed. Electrophysiological recordings of single channel currents were analyzed to obtain the information about the channel. Interactions with known TREK activators were tested to confirm the expression. While both TREK-1 and TREK-2 mRNA were significantly overexpressed in DRG of CCI mice, only TREK-1 showed significant increase (~9 fold) in western blot analysis. The TREK-1-like channel recorded in DRG neurons of the CCI mouse showed similar current-voltage relationship and conductance to TREK-1. It was easily activated by low pH solution (pH 6.3), negative pressure, and riluzole. Immunofluorescence images showed the expression of TREK-1 was stronger compared to TREK-2 on IB4 positive neurons. These results suggest that modulation of the TREK-1 channel may have beneficial analgesic effects in neuropathic pain patients.

Study on the trends in Korean clinical practice guidelines development

BACKGROUND

The definition of evidence-based clinical practice guidelines (CPGs) is "statements that are systematically developed to assist in the doctors' and patients' decision-making in certain situations." This study aims to establish the concept of evidence-based CPGs and investigate the development status to seek measures to apply evidence-based methods to CPG development for dental sedation in Korea.

METHODS

The study conducted systematic searching methods based on evidence-based CPGs. Articles published between 1995 to 2015 were searched on a Korean database and the international database PubMed. The search was based on keywords related to four subjects (dentistry, clinical practice, guideline, recommendation). Two authors independently reviewed the searched articles to determine their analysis inclusion and the convergence stages, and to arrive at a conclusion through discussion.

RESULTS

A total of 65 Korean CPGs were included. There were 51 medical guidelines, of which seven were dental and seven were Oriental medicine.

CONCLUSIONS

As a basic direction for the development of evidence-based CPGs, this work suggests the following: increased awareness; consensus on the need to supply evidence-based development methods; education, computerization, and systematic observation of evidence-based CPG development methods; continuous research development and distribution of CPGs; and creation of a database for Korean clinical dentistry practice outcomes.

Dexmedetomidine intravenous sedation using a patient-controlled sedation infusion pump: a case report

Dental treatment under sedation requires various sedation depths depending on the invasiveness of the procedure and patient drug sensitivity. Inappropriate sedation depth may cause patient discomfort or endangerment. For these reasons, patient-controlled sedation (PCS) pumps are commonly used. Patients are able to control the sedation depths themselves by pushing the demand button after the practitioner sets up the bolus dose and lock-out time. Dexmedetomidine is an α-2 adrenoreceptor agonist with sedative, analgesic, and anxiolytic properties. It has been widely used for sedation for its minimal respiratory depression; however, there are few studies on PCS using dexmedetomidine. This study assessed the applicability of dexmedetomidine to PCS.