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Anesth Prog. 2006 Summer; 53(2): 66–69.
PMCID: PMC1614219

JDSA Journal Abstracts

Anesth Prog. 2006 Summer; 53(2): 66.

Effects of Lidocaine Jelly with 1 : 100,000 Epinephrine on the Incidence and Intensity of Epistaxis during Nasotracheal Intubation Y. Fukui, M. Yamakage, A. Namiki J JPN DENT SOC ANESTHESIOL 2005; 33: 681- 686

Nasotracheal intubation (NTI) is often required during dental and maxillofacial surgery. Epistaxis is one of the complications of NTI, which leads to difficulties during intubation and to blood aspiration. We examined whether the insertion of a nasopharyngeal airway lubricated with lidocaine jelly and epinephrine could decrease the incidence and intensity of epistaxis during NTI.

One hundred (ASA physical status I or II) elective patients (age 19–64 years) who were scheduled to undergo NTI were selected for this study. The subjects were randomly assigned to two groups: a control group (n = 50), in which subjects received NTI using a nasopharyngeal airway lubricated with only 2% lidocaine jelly, and an Epinephrine group (n = 50), in which subjects received NTI using a nasopharyngeal airway lubricated with li-docaine jelly and with 1 : 100,000 epinephrine. Anesthesia was induced by propofol (2.0 mg/kg) and fenta-nyl (2 μg/kg), and maintained with 5% sevoflurane in nitrous oxide (4 L/min) and oxygen (2 L/min) during the NTI. Nasopharyngeal tubes (6.0, 7.0, and 8.0 mm in internal diameter) lubricated with lidocaine jelly with or without epinephrine were inserted into the nasopha-ryngeal airway in order of increasing size and placed there for 30 seconds before the insertion of a nasotra-cheal tube. An independent, unbiased anesthesiologist evaluated nasal and pharyngeal bleeding as follows: no bleeding, mild bleeding (a little blood on the tip of the nasopharyngeal airway), and moderate bleeding (an obvious blood on the whole airway). Hemodynamic changes during the induction of anesthesia were also recorded.

The two groups were comparable with respect to all characteristics. There was no difficulty in intubation due to epistaxis. As the airway tube size was progressively increased, the epinephrine group showed significantly less incidence and less intensity of epistaxis than did the control group. There were no significant differences in hemodynamic changes between the two groups during the induction of anesthesia.

The results obtained in this study indicate that a na-sopharyngeal airway lubricated with lidocaine jelly and 1 : 100,000 epinephrine helps to reduce the incidence and intensity of epistaxis during NTI without an increase in hemodynamic response.

Anesth Prog. 2006 Summer; 53(2): 66–67.

Usefulness of Dexmedetomidine for Intravenous Conscious Sedation A. Yamashita, T. Kunimatsu, K. Itsumura, K. Higuchi, S. Koide, M. Matsumoto, N. Nishida, M. Furuya, H. Arisaka, K. Yoshida J JPN DENT SOC ANESTHESIOL 2005; 33: 687- 692

It is well known that dexmedetomidine (Dex) provides sedation and slight analgesic effects without respiratory depression, and recently, it has been widely used as a sedative, particularly for intubated patients at intensive care units. However, it has not been fully investigated whether Dex is appropriate for intravenous, conscious sedation in dental outpatients. We studied the usefulness of Dex for the intravenous conscious sedation in dental outpatients. Six μg/kg/hr of Dex was administered as a loading dose for 10 minutes, and 0.5 μg/kg/hr as maintaining dose for an additional 30 minutes (n = 7). After 20–30 minutes, heart rate and blood pressure decreased 20–30%, compared to the control values, and remained low during the recovery stage. Respiratory function was not significantly affected compared to the control values. Twenty-five minutes after the start of Dex administration, the bispectral index decreased to 59 ± 18.6, then gradually recovered to basal levels after terminating the Dex administration. All subjects experienced antegrade amnesia, and one subject experienced retrograde amnesia. There were no significant differences in electrical tooth pulp tests compared to the control. All subjects were able to stand up 35.3 ± 10.3 minutes following termination of Dex administration. However, an additional recovery period of approximately 50 minutes was necessary for street fitness.

These results suggest that Dex satisfies numerous necessary criteria for intravenous conscious sedation in dental outpatients. However, further studies are necessary to (i) determine whether it can be used in patients with weak cardiac function, (ii) study the simultaneous use of local anesthetics containing epinephrine, and (iii) reduce the recovery period by altering the maintenance dose. In addition, it will be necessary to establish new criteria for evaluating the conditions under which Dex could be used for intravenous conscious sedation in dental out-patients.

Anesth Prog. 2006 Summer; 53(2): 67.

Clinical Analysis of 217 Patients with Dysgeusia S. Yamazaki, T. Shibaji, M. Nakano, A. Maeda, M. Sakamoto, S. Mashu, Y. Ikeda, M. Umino, K. Toda, N. Suzuki J JPN DENT SOC ANESTHESIOL 2005; 33 693- 700

Symptoms of dysgeusia and the therapeutic effect were analyzed in 217 patients (47 males and 170 females). Fifty-eight point five percent of the patients were more than 60 years old. The subjective symptom of highest frequency was continuous, unpleasant taste without food, and diminished perception of taste was second. Forty-three point eight percent of the patients had been suffering from dysgeusia for more than 1 year. Gloss-odynia was most frequently accompanying disease in the orofacial region. Among systemic diseases, dysgeusia has been most frequently caused by hypertension. Use of hypnotics and anti-anxiety drugs were the most likely reason to cause dysgeusia. In taste assessment with the filter paper disk method, only 39.6% of the patients could judge a sweet solution correctly, 39.3% could taste a salty solution, 35.0% tasted a sour solution, and 41.7% tasted a bitter solution. Salivary secretions were measured during a 10 minutes interval in 50 patients; 54.0% of these patients secreted less than 5 mL, which was significantly lower than normal. In blood examinations, serum zinc concentration was low in 17.6% of the patients, and within normal range in 77.2%. According to the SDS (Self-rating Depression Scale), 37.0% of the patients were in a slightly depressive state, and 22.7% were in a moderately depressive state. For the treatment of dysgeusia, drug therapy with zinc, general psychotherapy, dietary advice, and changes in usage of drugs causing dysgeusia were applied. Moreover, for the treatment of accompanying diseases, drug therapy with anti-anxiety agents, cevimeline and others, psychosomatic treatment, and acupuncture therapy were continued. Duration of treatment was less than 1 year in 77.4% of the patients. However, in some patients treatment continued for more than 5 years. Clinical effects were excellent in 22.8% of the patients, and good in 56.7%. ‘Excellent’ means that the symptom of dysgeusia was completely cured, and ‘good’ means that the symptom was improved in comparison with the baseline established at their first visit to our hospital. It has been reported that zinc deficiency will develop dysgeusia as main factor. However in this study, serum zinc concentration of 77.2% of the patients with dysgeusia was within normal range. Our findings suggest that dysgeusia may have been developed by local, systemic, and psychogenic factors in our patients. However, further controlled studies of the cause of dysgeusia are necessary.

Anesth Prog. 2006 Summer; 53(2): 67–68.

Anesthetic Management of a Patient with Costello Syndrome T. Sanuki, S. Sugioka, K. Hashimoto, A. Miyano, M. Ishikawa, H. Matsui, T. Ueno, T. Asai, Y. Komasa, J. Kotani J JPN DENT SOC ANESTHESIOL 2005; 33: 701- 704

Costello syndrome is a rare, inherited disease and characterized by mental and growth retardation, redundant skin, and papillomata. There are only a few reports of this syndrome's management under general anesthesia, and there is none concerned with dental anesthesia. We report our experience with general anesthesia during dental treatment on a patient with Costello syndrome.

The patient was an 8-year old girl: 120 cm height and 28 kg body weight. She had also been suffering from epilepsy since age 5 and taking antiepileptics. Intensive dental treatment involving many teeth was performed under ambulatory general anesthesia due to her mental retardation. No premedication was administered. Induction and maintenance of anesthesia was done with sevoflurane and nitrous oxide in oxygen. We could not clearly identify the vocal cords with cricoid pressure, but were able to intubate using a 5.0 mm I.D. nasotracheal tube. There were no problems during the treatment. Extubation was performed after confirming consciousness, spontaneous breathing, and normal reflex response. There were no postoperative complications.

In the anesthetic management of a patient with Costello syndrome, cardiac disease, difficult airway and upper airway obstruction by papillomata, and laryngeal edema are frequent problems. Cardiac disease (e.g., hypertrophic cardiomyopathy, ventricular septal defect, pulmonary stenosis) is a common concomitant condition in patients with Costello syndrome. Short neck, macroglossia, and laryngeal malformation are the symptoms of Costello syndrome, which result in difficult intubation. Papillomata and laryngeal edema occur easily by mechanical stimulation of intubation. Our patient had no cardiac disease, and we could successfully perform tracheal intubation by applying cricoid pressure. After extubation, no upper airway obstruction was seen probably due to the prophylactic administration of steroid during the treatment and gentle endotracheal intubation. We used a nasotracheal tube to aid the establishment of occlusion in our patient. However, it may be possible that other airway devices such as a laryngeal mask airway can be used in other circumstances.

Anesth Prog. 2006 Summer; 53(2): 68.

The Effect of General Anesthesia Information Provided to Patients on the Patient's Anxiety Level J. Yatabe, K. Fukuda, T. Handa, N. Saita, K. Tsunakawa, M. Saijo, M. Kasahara, K. Miyachi, Y. Koukita, T. Ichinohe, Y. Kaneko J JPN DENT SOC ANESTHESIOL 2005; 33: 705- 708

The purpose of this study was to evaluate the effect of providing information about general anesthesia to patients on the level of patient anxiety. One hundred thirty-two ASA physical status I or II patients (70 males and 62 females) scheduled for elective oral surgery from November 2001 to June 2002 were enrolled in the study.

Anesthetic information was provided to patients in the outpatient clinic 3 weeks prior to the proposed surgery. The contents of this information included: the basic principles of general anesthesia, the anesthetic procedures and processes, monitoring during the operation, blood and fluid transfusion, as well as potential side effects or complications. The level of anxiety was assessed using visual analogue scale (VAS) scores before and immediately after the information was provided. The VAS consisted of a 100 mm line with the extremes defined as 0 anxiety and maximal anxiety. After the state-anxiety scores were calculated from the following regression equation; A-state = 4.49 VAS + 23.82, all patients were classified as either high anxiety group or low anxiety group according to the Japanese version of Spielberger's State-Trait Anxiety Inventory (STAI).

The results were as follows: 1) The mean ages of patients were 39.7 ± 17.0 years in males and 35.8 ± 18.4 years in females. There were no significant differences between the two genders in age. 2) The VAS scores after the anesthetic information was provided (15.1 ± 19.9 in males and 24.5 ± 19.2 in females) were significantly lower than the scores before the information was given in both male and female patients (26.6 ± 25.6 in males and 34.8 ± 25.8 in females). 3) 11.7% of female patients with low anxiety increased their VAS scores to high anxiety level after anesthetic information was given. 4) The VAS scores for patient's anxiety about general anesthesia were significantly decreased in patients informed by the anesthesia attending physician (28.9 ± 23.6 before being given the information and 13.8 ± 15.2 after the information was provided), and unchanged in patients informed by other staff (31.3 ± 27.4 before and 22.9 ± 21.7 after).

In conclusion, this study suggests that patient's anxiety level about general anesthesia can be significantly reduced, and in particular, the anxiety level was lower when a certified anesthesia instructor provided such information as compared to when a non-certified instructor provided the information.

Anesth Prog. 2006 Summer; 53(2): 68–69.

Preemptive Analgesic Effect of Intravenous Flurbiprofen after Orthognathic Surgery T. Handa, Y. Koukita, J. Yatabe, N. Saita, K. Tsunakawa, K. Fukuda, T. Ichinohe, Y. Kaneko J JPN DENT SOC ANESTHESIOL 2005; 33: 709- 713

It has been reported that preoperative intravenous administration of flurbiprofen reduces postoperative pain after abdominal hysterectomy and minor ear, neck, and nose surgery in a preemptive manner. This study was aimed to examine whether preemptive analgesic effect could be achieved when administering the same dose of intravenous flurbiprofen before surgery, and compared it to the effect wherein the same dose was administered after surgery in patients undergoing orthognathic procedures. After obtaining informed consent, 47 adult female patients with mandibular protrusion (ASA physical status 1), requiring sagittal split ramus osteotomy were assigned to one of the two groups. In one group (n = 24), flurbiprofen 1 mg/kg was administered at the beginning of surgery (PRE group) and in the other group (n = 23), flurbiprofen was administered during mucous membrane suturing immediately before the completion of surgery (POST group).

Approximately 90 minutes before induction, all patients received 10 mg of diazepam and 150 mg ranitidine orally. General anesthesia was induced by intravenous administration of 5 μg/mL fentanyl and propofol using target-controlled infusion technique setting at 3.5 μg/mL plasma target concentration, and tracheal intubation was facilitated with 0.1 mg/kg vecuronium intravenously. Anesthesia was maintained with 67% nitrous oxide in oxygen, 3–3.5 μg/mL plasma target concentration of propofol, continuous infusion of vecuronium bromide at a rate of 0.06 mg/kg/h and field block using 16 mL (8 mL in each site) of 2% lidocaine containing 12.5 μg/mL epinephrine on the operation site. For postoperative pain relief, diclofenac suppository was administered in increments of 50 mg at patient's request. Postoperative analgesia induced by flurbiprofen axetil was assessed using three variables. The first variable was the time from the end of the operation to the point when the patient first requested diclofenac suppository, this was regarded to be the period of analgesics effect of flurbiprofen axetil. The second variable was the number of patients who didn't request diclofenac suppository longer than 5 hours after completion of flurbiprofen axetil. The last variable was the frequency of patient's request for analgesics both within 24 and 48 hours postoperatively. Analgesic duration was defined as the time from the completion of surgery until the first request of diclofenac suppository.

The following results were obtained. 1) Analgesic duration was not statistically different between the 2 groups, although there was a tendency for longer duration in the PRE group. 2) Number of patients having prolonged analgesic duration was similar in the 2 groups (70.8% in the PRE group vs 65.2% in the POST group). 3) Frequency of diclofenac suppository requests during the first 24 hours and 24 to 48 hours after surgery was not significantly different between the PRE and POST groups.

In conclusion, this study showed that intravenous 1 mg/kg flurbiprofen did not significantly provide preemptive analgesic effects in patients undergoing sagittal split ramus osteotomy.

Anesth Prog. 2006 Summer; 53(2): 69.

Patients' Satisfaction Regarding Intravenous Sedation Induced by Midazolam or Propofol for Implantation K. Takano, N. Kojima, A. Kiyokawa, M. Keino, K. Akiyama, K. Uriu, R. Shimada, M. Sasao, I. Noguchi, and H. Fukayama J JPN DENT SOC ANESTHESIOL 2005; 33: 714- 719

We report the results of a questionnaire on the patients' satisfaction of intravenous sedation in patients undergoing dental implantation.

Sixty patients were divided into 2 groups according to the type of the answer to the first question (Table 1): 1) Memory Group (Mem Group,n = 39), some memory during the operation; 2) Complete Amnesia Group (Amn Group,n = 21), no memory during the operation.

There were no differences between the 2 groups based on age, gender, height, weight, recovery time, total doses of midazolam and propofol, or the injection rate of propofol (Table 2). The duration of operation and the duration of management of intravenous sedation were shorter in the Amn Group (54 and 86 minutes) than in the Mem Group (77 and 113 minutes), and the injection rate of midazolam (0.054 mg/kg/hr) in the Amn Group was faster than in the Mem Group (0.041 mg/kg/hr). In the Mem Group, 31 patients (79.5%) felt comfortable or no discomfort during the operation. However, 8 patients (20.5%) in the Mem Group expressed a little discomfort such as pain, vibration, or noise by the instrument, a little anxiety, and instability of depth of sedation. In the Amn Group, 18 patients (85.7%) answered that unconsciousness and complete amnesia were comfortable. However, 3 patients (14.3%) indicated that they preferred some memory to be left during the operation. In response to a question about the preferred method for a subsequent operation, all patients in the Amn Group chose the same method, whereas, 4 of the 39 patients, answered that either kind of methods would be acceptable in the Mem Group. Two of the Mem Group patients wrote that no memory was preferred.

It seems that most patients are satisfied with the sedation method and that they tend to prefer complete amnesia. It is plausible that a combination of midazolam and propofol could provide longer and better amnesia with less venous pain and anti-depressant effect. And rather than increasing the dosages, sufficient local anesthesia, gentle operation, and proper oral suction should be considered for a more satisfactory result.


Articles from Anesthesia Progress are provided here courtesy of American Dental Society of Anesthesiology
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