Anesthetic Management of a Patient With Multiple Sclerosis.

A 54-year-old woman diagnosed with multiple sclerosis (MS) at the age of 19 years was scheduled to undergo temporomandibular joint mobilization. She was currently in a remission phase from her MS but with persistent sequelae, including impaired eyesight and muscle weakness of the limbs. In addition, the blood vessels in her upper limbs were compromised by the formation of internal shunts secondary to vascular prosthesis replacements for plasma exchange therapy in MS. After a previous joint mobilization surgery, her temporomandibular joint developed adhesions with resultant trismus. One of the adverse effects of general anesthesia can be exacerbations of MS symptoms. Minimizing mental and physical stress caused by surgical and anesthetic procedures and maintenance of stable body temperature are important considerations. Awake intubation was performed under sedation with midazolam and fentanyl. After intubation, anesthesia was induced with propofol, remifentanil, and rocuronium. Maintenance of anesthesia was achieved with oxygen-N2O-sevoflurane, remifentanil, fentanyl, and rocuronium. In this case, no adverse events occurred intraoperatively. However, the patient experienced lingering weakness of the limbs in the postoperative period, and activities of daily living of the patient were affected.

Anesthetic Management of a Patient With Charcot-Marie-Tooth Disease.

Charcot-Marie-Tooth disease (CMTD) is a hereditary peripheral neuropathy and is characterized by progressive muscle atrophy and motor-sensory disorders in all 4 limbs. Most reports have indicated that major challenges with general anesthetic administration in CMTD patients are the appropriate use of nondepolarizing muscle relaxants and preparation for malignant hyperthermia in neuromuscular disease. Moderate sedation may be associated with the same complications as those of general anesthesia, as well as dysfunction of the autonomic nervous system, reduced perioperative respiratory function, difficulty in positioning, and sensitivity to intravenous anesthetic agents. We decided to use intravenous sedation in a CMTD patient and administered midazolam initially and propofol continuously, with total doses of 1.5 mg and 300 mg, respectively. Anesthesia was completed in 3 hours and 30 minutes without adverse events. We suggest that dental anesthetic treatment with propofol and midazolam may be effective for patients with CMTD.

Anesthetic Management of a Patient With Ehlers-Danlos Syndrome.

We describe the case of a 37-year-old woman who had been diagnosed with Ehlers-Danlos syndrome (EDS) 4 years earlier and was scheduled to undergo removal of synovial chondromatosis in the temporomandibular joint. EDS is a heritable connective tissue disorder and has 6 types. In this case, the patient was classified into EDS hypermobility type. The major clinical feature of this type is joint hypermobility. The patient had sprain or subluxation of the elbows and ankles and dislocation of the knees. Anticipated problems during general anesthesia would be affected by the disease type. For this patient, extra attention was directed to positional injury-induced neuropathy and articular luxation, cutaneous injuries, injuries related to intubation and ventilation, and postoperative pain. Anesthesia was induced with propofol, remifentanil, and rocuronium and maintained with oxygen-air-desflurane, propofol, remifentanil, fentanyl, and rocuronium. In this case, the patient was safely managed without adverse events.

[Dextran-induced anaphylactic shock during general anesthesia: a case report].

We describe a case of dextran-induced anaphylactic shock during general anesthesia. A 34-year-old woman was scheduled for partial hepatic resection under general anesthesia. General anesthesia was induced with intravenous remifentanil, thiamylal and rocuronium, and was maintained with oxygen, air, sevoflurane and remifentanil. The patient developed hypotension (from 90/50 to 49/27 mmHg in 20 min) together with tachycardia (111 beats x min(-1)) and desaturation (83%) subsequent to intravenous infusion of Saviosol (dextran 40). We made a diagnosis of anaphylactic shock on the basis of clinical manifestations and administered adrenaline and hydrocortisone. The patient's blood pressure and oxygen saturation immediately improved, and the operation was resumed. No postoperative complications were evident, and the postoperative course was uneventful. Although low molecular weight dextran is often used as plasma expander or to prevent thromboembolism, it can cause severe hypotension or bronchospasm during general anesthesia.

[Anesthetic management using muscle relaxant in a patient with amyotrophic lateral sclerosis].

A 31-year-old woman with amyotrophic lateral sclerosis (ALS) with respiratory muscle paralysis was scheduled for tracheotomy. After applying standard neuromuscular monitoring devices, general anesthesia was induced and maintained with propofol, remifentanil, rocuronium, and sevoflurane. Sugammadex is a potent agent for reversal of neuromuscular blockade by rocuronium. The patient emerged from general anesthesia smoothly using sugammadex; however, assisted respiration was continued for possible prolongation of the effect of muscle relaxant. The postoperative course was uneventful, and she was discharged without any discomfort.

[Two cases of anaphylactoid reaction after administration of sugammadex].

Anaphylaxis during anesthesia is a rare but life-threatening event. Sugammadex is a recently introduced drug that was specifically designed for the reversal of rocuroium and vecuronium-induced neuromuscular block. We describe the cases of a 74-year-old man and a 29-year-old man who developed an anaphylactoid reaction to sugammadex, presenting with cardiovascular collapse. Initial management consisted of fluid administration and intermittent i.v. ephedrine, epinephrine, and hydrocortisone. The patients made uncomplicated recovery and were discharged.

[Anesthesia for laser surgery of a tracheal tumor involving the carina: preservation of spontaneous breathing using remifentanil].

We describe anesthetic management of a patient with airway stenosis due to a tracheal tumor involving the carina. A 68-year-old man developed dyspnea and was scheduled for YAG laser surgery under general anesthesia. Awake fiberoptic intubation was selected for anesthesia induction, and percutaneous cardiopulmonary support (PCPS) was ready to be established prior to induction of anesthesia. Anesthesia was maintained with remifentanil (0.05 microg x kg(-1) x min(-1)) and propofol (2 mg x kg(-1) x hr(-1)), and spontaneous breathing was preserved throughout the surgical procedure. The operation was completed successfully without any adverse events, and PCPS was not used. In this patient, preservation of spontaneous breathing using remifentanil was found to be useful for airway management.

[Anesthetic management of a patient with Becker muscular dystrophy].

We experienced anesthetic management of a patient with Becker muscular dystrophy. He had advanced dilated cardiomyopathy and high serum CK in the preoperative examinations. Anesthesia was planned to avoid triggering malignant hyperthermia or rhabdomyolysis and hemodynamic changes. Propofol, remifentanil and a minimum dose of rocuronium bromide were used for anesthetic induction and maintainance. Arterial pressure, cardiac output and stroke volume variation were monitored by Flotrac sensor. There were no adverse events observed during the anesthetic management. In conclusion, total intravenous anesthesia with the administration of rocuronium and circulatory monitoring by Flotrac sensor could be safe and efficient for anesthetic management of patients with Becker muscular dystrophy.

Severe gag reflex during dental treatment associated with hiatus hernia: A case report.

AIMS: This report presents a case wherein severe gagging during dental treatment was linked to hiatus hernia. METHODS AND RESULTS: A 22-year-old man with a severe gagging problem presented with a chief complaint of pain localized to the lower molars. Oral examination revealed inadequate plaque control, demineralization of the enamel surface on buccal-gingival margins of all teeth, and inflamed gingival tissue surrounding the coronal portion of both mandibular third molars; panoramic radiography revealed that they were horizontally impacted. As the patient reported experiencing vomiting and heartburn for the past two months, he was referred to the internal medicine department before scheduling surgical tooth extraction. Hiatus hernia and reflux esophagitis were diagnosed, and the severity of gagging was significantly reduced by modifying the patient's eating behavior and administering a proton pump inhibitor. Although intravenous sedation was still required for surgical extraction of the impacted third molars, preventive treatments, such as tooth cleaning and fluoride application, could be performed without the need for pharmacological intervention. CONCLUSION: While gagging is often attributed to conditioning responses and iatrogenic factors, interdisciplinary consultation for successful management may facilitate the elucidation of local anatomical and systemic causes.

[Assessment of disposable crystal laryngoscope blade].

We evaluated Disposable Crystal Laryngoscope Blades in terms of preventing infection. Most anesthesiologists were satisfied with the view offered by the Disposable Crystal Laryngoscope Blade; however more force is necessary to lift the epiglottis during intubation. It may be more difficult to use by residents, inexperienced anesthesiologist, or emergency medical technicians, although the Disposable Crystal Laryngoscope blade is useful for preventing infection.

[Anesthetic management of a child with Angelman's syndrome].

Angelman syndrome is a hereditary disease described by Angelman. The clinical features of Angelman syndrome are characterized by mental retardation, puppet-like ataxia, easily excitable personality, seizures, paroxysmal laughter, strabismus and macroglossia. A 4-year-old girl with Angelman syndrome underwent strabismus repair under general anesthesia. Anesthesia was slowly induced with sevoflurane in oxygen and maintained with air, oxygen, propofol and remifentanil. Tracheal intubation was performed after administration of rocuronium. During and after anesthesia, no adverse events regarding circulatory and respiratory systems occurred. However, this case demonstrates that it is necessary to pay attention to airway troubles including the difficulty of tracheal intubation, management of body temperature and chronotropic action or respiratory depression by anesthetic agents.

Anesthetic Management of a Patient With Restless Legs Syndrome: A Case Report.

Restless legs syndrome (RLS) is a neurological sensory disorder associated with sensory and motor symptoms that most commonly occur at night and during periods of rest. It is characterized by altered or abnormal sensations primarily in the legs and the urge to move the associated limbs. Perioperative procedures, including general anesthesia, can cause exacerbations of RLS. This is a case report of a suspected RLS exacerbation in a 22-year-old woman who had no formal diagnosis of RLS despite reporting symptoms that met all essential diagnostic criteria by the International RLS Study Group. Despite her previous diagnoses of dehydration induced-muscle pain or nocturnal cramps, we suspected her to have RLS. The patient underwent general anesthesia for a bilateral sagittal split ramus osteotomy using a combined inhalational and intravenous anesthetic technique with sevoflurane, propofol, remifentanil, and dexmedetomidine. After successful completion of the surgery and returning to the ward, she began moving her lower extremities and complaining of unpleasant sensations in both ankles. Bed rest exacerbated the suspected RLS symptoms despite a continuous infusion of dexmedetomidine. The RLS symptoms continued to worsen and spread to her upper extremities. After increasing the dexmedetomidine infusion from 0.2 to 0.4 µg/kg/h, almost all symptoms improved, and she slept for 3 hours. Upon awakening, the unpleasant sensations were completely relieved by walking and stretching. The patient was formally diagnosed with RLS by a neurologist after discharge. In this case, an infusion of dexmedetomidine was helpful in successfully managing a suspected exacerbation of RLS.

[Neurokinin-1 receptor antagonists for postoperative nausea and vomiting: a systematic review and meta-analysis]. / Antagonistas do receptor da neurocinina­1 no tratamento de náusea e vômito no pós­operatório: Revisão sistemática e meta­análise.

BACKGROUND: Postoperative Nausea and Vomiting (PONV) is a common complication of general anesthesia. Several kinds of antiemetics, including 5-Hydroxytryptamine3 (5-HT3) receptor antagonists and Neurokinin-1 (NK-1) receptor antagonists, have been used to treat PONV. OBJECTIVES: To compare the antiemetic effect of NK-1 receptor antagonists, including fosaprepitant. DATA SOURCES: Online databases (PubMed, MEDLINE, Scopus, The Cochrane Library databases) were used. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS: Randomized Controlled Trials (RCTs) performed in patients over 18 years with ASA-PS of I-III, aimed to assess the efficacy of antiemetics including NK-1 receptor antagonists and 5-HT3 receptor antagonists, and compared the incidence of PONV were included. STUDY APPRAISAL AND SYNTHESIS METHODS: All statistical assessments were conducted by a random effect approach and odds ratios and 95% Confidence Intervals were calculated. RESULTS: Aprepitant 40mg and 80mg significantly reduced the incidence of vomiting 0-24hours postoperatively (Odds Ratio [OR = 0.40]; 95% Confidence Interval [95% CI 0.30-0.54]; p < 0.001, and OR = 0.32; 95% CI 0.19-0.56; p < 0.001). Fosaprepitant could also reduce the incidence of vomiting significantly both 0-24h and 0-48hours postoperatively (OR = 0.07; 95% CI 0.02-0.24; p < 0.001 and OR = 0.07; 95% CI 0.02-0.23; p < 0.001). LIMITATIONS: Risk factors for PONV are not considered, RCTs using multiple antiemetics are included, RCTs for fosaprepitant is small, and some bias may be present. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Aprepitant and fosaprepitant can be effective prophylactic antiemetics for postoperative vomiting. However, more studies are required for higher-quality meta-analyses. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42019120188.

Anesthetic Management of Patient With Dravet Syndrome: A Case Report.

Dravet syndrome (DS) is a rare and severe form of epilepsy that begins in infancy. This is particularly burdensome because repeated epileptic seizures lead to cognitive decline. We describe the case of a 12-year-old girl who was diagnosed with DS and was scheduled to have gingival reduction around her mandibular molars. Despite the patient being intellectually disabled, she was able to cooperate somewhat during medical procedures, including intravenous cannulation. Under the assumption that the major problem with anesthesia for DS would be the regulation of body temperature-induced seizures, we used body temperature management equipment to maintain the patient's body temperature during the procedure. We opted for intravenous sedation and administered a total dose of 4.5 mg midazolam throughout the procedure. Anesthesia was completed within 1 hour and 20 minutes without any adverse events. To the best of our knowledge, no previous studies have documented the anesthetic management of DS. In this case, no adverse events occurred perioperatively. However, the patient's temperature rose to that which indicated a slight fever despite the use of a standard cooling technique.

Postoperative nausea and vomiting following lower limb surgery†:a comparison between single-injection intraarticular anesthesia and continuous epidural anesthesia.

Study Objective : the incidence of postoperative nausea and vomiting (PONV) following single-injection intraarticular anesthesia was compared to that following continuous epidural anesthesia. Design : Prospective, double-blind, randomized study. Setting : University-affiliated teaching hospital. Patients : Forty-eight patients finally participated in this study, and each group contained twenty-four patients. Interventions : Patients scheduled to undergo lower limb surgery under general anesthesia were randomly allocated into two groups, to receive either single-injection intraarticular or continuous epidural anesthesia for postoperative analgesia. Measurements : The incidence and severity of PONV, complete response rates (i.e., no vomiting or rescue antiemetic use), and pain scores were recorded 2, 24, and 48 h postoperatively. Main results : No significant differences between groups were observed in the incidence and severity of PONV, rescue antiemetic use, or complete response rate at any of the time points, but only the use of rescue analgesics was significantly less in continuous epidural anesthesia group during the 2-24h postoperative period (P=0.04). Conclusion : While the use of single-injection intraarticular anesthesia following lower limb surgery did not prevent PONV more than continuous epidural anesthesia in this study, the intraarticular technique still provides greater simplicity, safety, and cost-effectiveness. J. Med. Invest. 66 : 303-307, August, 2019.

Compliance with infection control practices when taking dental x-rays: Survey of a Japanese dental school.

The aim of this study was to assess knowledge, attitude, behavior, and compliance concerning infection control among dental practitioners in a dental university hospital in Japan. A 12-item questionnaire about infection control during radiographic procedures was distributed to 686 dental personnel working at Osaka Dental University. The questionnaire collected information on occupation and the use of gloves, holders, door handles, control panels, dental chairs, protectors, tube head, tube arms, tube cones, and keyboards for personal computers. To identify misunderstandings about, and thus noncompliance with, current infection control practices, the percentage of correct answers (PCA) was calculated. Understanding and compliance with the current practices was considered low when <75% and high when ≥75%. In addition, contaminated objects in the clinical setting were examined using black light. PCA was low for one question on using gloves in film positioning and high for three questions on using protective film barriers, regardless of the respondents' occupation. PCA was generally high for three questions on practicing hand hygiene before putting on gloves, methods to protect film holders, and methods to protect radiographic equipment, but was low among some subjects. PCA was generally low for four questions on using film protective barriers, developing images from unprotected films, practicing hand hygiene after removing gloves, and awareness of a procedures manual for taking intraoral x-rays, but was high among some subjects. Saliva contamination of radiographic equipment was confirmed by direct visualization using black light. Awareness was low of infection control measures to be used during intraoral projection. This study indicates the need for additional education and training to improve infection control practices, through, for example, using a standard procedures manual for all dental practitioners and visual evidence (visualization) of contamination.

Management of infusion reactions associated with cetuximab treatment: A case report.

Cetuximab is a drug targeting the epidermal growth factor receptor, which is indicated for the treatment of unresectable advanced or recurrent head and neck or colorectal cancer. Cetuximab also enhances the cytotoxic effects of radiation in squamous cell carcinoma. The severity of infusion reactions (IR) is categorized from grade 1 to 5; grades 3 and 4 are associated with life-threatening reactions (anaphylaxis), whereas grade 5 indicates death. The incidence of grade 3-4 IR with premedication is reported to be 1.1%. We herein describe a case of a 77-year-old man who developed IR during intravenous administration of cetuximab. The patient developed grade 3-4 anaphylaxis with pruritus, rash and urticaria, followed by hypotension and bradycardia. The timely diagnosis and treatment with intravenous infusion of a vasopressor drug and Ringer's acetate solution proved to be effective. The case presented herein demonstrated an unfeatured aspect of cetuximab-related IR as dermatological reactions over the entire body followed by circulatory collapse.

[Effects of a novel method of anesthesia combining propofol and volatile anesthesia on the incidence of postoperative nausea and vomiting in patients undergoing laparoscopic gynecological surgery]. / Efeitos de um novo método de anestesia combinando propofol e anestesia volátil sobre a incidência de náusea e vômito no pós-operatório em pacientes submetidas à laparoscopia ginecológica.

BACKGROUND: We investigated the effects of a novel method of anesthesia combining propofol and volatile anesthesia on the incidence of postoperative nausea and vomiting in patients undergoing laparoscopic gynecological surgery. METHODS: Patients were randomly divided into three groups: those maintained with sevoflurane (Group S; n = 42), propofol (Group P; n = 42), or combined propofol and sevoflurane (Group PS; n = 42). We assessed complete response (no postoperative nausea and vomiting and no rescue antiemetic use), incidence of nausea and vomiting, nausea severity score, vomiting frequency, rescue antiemetic use, and postoperative pain at 2 and 24h after surgery. RESULTS: The number of patients who exhibited a complete response was greater in Groups P and PS than in Group S at 0-2h (74%; 76% and 43%; respectively, p = 0.001) and 0-24h (71%; 76%, and 38%; respectively, p < 0.0005). The incidence of nausea at 0-2h (Group S = 57%; Group P = 26% and Group PS = 21%; p = 0.001) and 0-24h (Group S = 62%; Group P = 29% and Group PS = 21%; p < 0.0005) was also significantly different among groups. However, there were no significant differences among groups in the incidence or frequency of vomiting or rescue antiemetic use at 0-24h. CONCLUSION: Combined propofol and volatile anesthesia during laparoscopic gynecological surgery effectively decreases the incidence of postoperative nausea.

Effects of a novel method of anesthesia combining propofol and volatile anesthesia on the incidence of postoperative nausea and vomiting in patients undergoing laparoscopic gynecological surgery.

BACKGROUND: We investigated the effects of a novel method of anesthesia combining propofol and volatile anesthesia on the incidence of postoperative nausea and vomiting in patients undergoing laparoscopic gynecological surgery. METHODS: Patients were randomly divided into three groups: those maintained with sevoflurane (Group S, n=42), propofol (Group P, n=42), or combined propofol and sevoflurane (Group PS, n=42). We assessed complete response (no postoperative nausea and vomiting and no rescue antiemetic use), incidence of nausea and vomiting, nausea severity score, vomiting frequency, rescue antiemetic use, and postoperative pain at 2 and 24h after surgery. RESULTS: The number of patients who exhibited a complete response was greater in Groups P and PS than in Group S at 0-2h (74%, 76% and 43%, respectively, p=0.001) and 0-24h (71%, 76% and 38%, respectively, p<0.0005). The incidence of nausea at 0-2h (Group S=57%, Group P=26% and Group PS=21%, p=0.001) and 0-24h (Group S=62%, Group P=29% and Group PS=21%, p<0.0005) was also significantly different among groups. However, there were no significant differences among groups in the incidence or frequency of vomiting or rescue antiemetic use at 0-24h. CONCLUSION: Combined propofol and volatile anesthesia during laparoscopic gynecological surgery effectively decreases the incidence of postoperative nausea. We term this novel method of anesthesia "combined intravenous-volatile anesthesia (CIVA)".

[Anesthetic management of a teenage athlete who developed arrhythmia during general anesthesia].

A 17-year-old man with fracture of the mandible underwent open fixation under general anesthesia. He was an athlete of the rugby suffering the fracture in a match. His preoperative physical examinations were normal except for I degrees atrioventricular block on electrocardiogram (ECG). During anesthesia, atrioventricular dissociation and frequent premature ventricular contractions were induced by the stimulation of nasotracheal intubation and the administration of atropine for the reversal of muscle relaxation. We thought the cause of the arrhythmia is the athlete's heart which may be vagotonic and may induce vagal reflex or fatal arrhythmia. This case demonstrates that it is necessary to pay attention to chronotropic action associated with the intubation of nasopharynx, the handling of laryngoscope and the usage of drugs for the anesthetic management of the athlete.