Anesthetic management of a pediatric patient with Dravet syndrome: A case report.

INTRODUCTION: Dravet syndrome (DS) is a rare and severe myoclonic epilepsy, with onset commonly occurring in infancy. Seizures are triggered by various causes, including fever, bathing, and light stimulus. DS is refractory to drug treatment. Moreover, status epilepticus (SE) can cause serious encephalopathy and epilepsy-related deaths. There are very few reports of general anesthesia in DS patients. Herein, we report our experience with the anesthetic management of a pediatric patient with DS. PATIENT CONCERNS AND DIAGNOSES: A 5-year-old boy (height, 112 cm; weight, 19 kg) was diagnosed with DS through SCN1A genetic testing, which revealed a de novo novel missense mutation. His medical history included drug-resistant epilepsy, developmental delay, and hypotonia. His seizures tended to be triggered daily by a rise in body temperature (BT), bathing, and light stimulus. He could not receive adequate dental treatment due to DS, although he had previously undergone dental treatment under restraint at the pediatric dentistry department of our hospital. INTERVENTIONS AND OUTCOMES: The patient was scheduled for intensive dental treatment under general anesthesia due to noncooperation, and DS-related limitations. By considering the risk posed by elevated BT, seizure-inducing drugs were avoided, and general anesthesia was completed as planned, uneventfully. Although fluctuation of BT occurred during the procedure, it was finally controlled at the end of anesthesia at about the same level as at anesthesia induction. However, small seizures and a single generalized convulsion were observed accompanied by fever on postoperative day 1. The patient was discharged from the hospital without major problems on postoperative day 3, because of detailed planning and close preoperative cooperation with the attending pediatrician. CONCLUSION: It is essential to pay attention to managing BT and to avoid drugs that induce seizures during anesthesia for patients with DS. Cautious preoperative planning for anesthesia based on evaluation of the patient and rapid postoperative response in collaboration with the attending pediatrician is necessary in case an epileptic seizure occurs.

Risk Factors for Pulmonary Complications After Major Oral and Maxillofacial Surgery With Free Flap Reconstruction.

Background Postoperative pulmonary complications (PPCs) are common and result in increased morbidity and mortality. A variable incidence of PPCs has been reported in patients who have undergone major oral and maxillofacial surgery with free flap reconstruction, which is one of the most extensive forms of head and neck cancer surgery, and perioperative risk factors for PPCs in these patients have not been fully elucidated. Furthermore, the ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia) score and Gupta risk index have not been investigated in patients undergoing head and neck cancer surgery. This study aimed to identify perioperative risk factors for PPCs after major oral and maxillofacial surgery with free flap reconstruction. Methodology This was a single-center, retrospective cohort study of 118 patients who had undergone major oral and maxillofacial surgery with free flap reconstruction between 2009 and 2020. PPCs were defined as pneumonia, hypoxemia caused by atelectasis, pleural effusion, pulmonary embolism, pulmonary edema, bronchospasm, pneumothorax, and acute respiratory failure. Predictors of PPCs were identified in univariate and multiple Poisson regression analyses. Results The incidence of PPCs was 18.6% (22/118 patients). The most frequent PPC was pneumonia. No preoperative patient-related parameter was identified to predict PPCs. In univariate analysis, the only predictor was anesthesia time ≥1,140 minutes (odds ratio = 3.0, p = 0.036). Multivariable Poisson regression identified two independent predictors of PPCs, namely, anesthesia time ≥1,140 minutes (incidence rate ratio (IRR) = 2.18, 95% confidence interval (CI) = 1.1-4.3, p = 0.024) and a large amount of intraoperative fluid (IRR = 1.00018, 95% CI = 1.000018-1.000587, p = 0.037). Conclusions Patients undergoing major oral and maxillofacial surgery with free flap reconstruction are at high risk of PPCs. Longer anesthesia time and administering a large amount of fluid during surgery were significantly correlated with the risk of PPCs.

High initial target blood concentration in target-controlled infusion: A randomized controlled trial.

OBJECTIVE: Our previously modified propofol intravenous sedation (IVS) method using a target-controlled infusion (TCI) pump with initial target blood concentration (TBC) set at 2.2 µg/ml enables the prediction of the personal optimal intraoperative TBC during induction with a minimal gap. This study aimed to verify whether this method can be useful in case of higher initial TBCs to reduce induction time. METHODS: Forty-five patients scheduled to undergo oral surgery under IVS with propofol were randomly divided into three groups (group 1, TCI started with TBC set at 2.2 µg/ml; group 2, TBC was set at 2.6 µg/ml; group 3, TBC was set at 3.0 µg/ml). Immediately after reading the calculated brain concentration when the target sedation was achieved (value A), the initial TBC was manually reset to value A. We manually controlled the intraoperative TBC to maintain moderate sedation, according to the clinical signs and bispectral index values. Of the regulated TBC values, the value farthest from value A was defined as value B. The maximum discrepancy between values B and A and the induction time were compared among the three groups. RESULTS: The maximum discrepancy (mean ± standard deviation [SD]) was significantly larger in group 3 (1.0 ± 1.3 µg/ml, p = .005) and group 2 (0.8 ± 0.2 µg/ml p = .008) than in group 1 (0.5 ± 0.3 µg/ml). The induction time (mean ± SD) was significantly shorter in group 3 (124 ± 126 min, p = .004) and group 2 (135 ± 33 min, p = .006) than in group 1 (245 ± 1913 min). With the initial TBC set at 2.6 µg/ml, the maximum discrepancy was large at 0.8 µg/ml, but with a small SD (0.2 µg/ml). CONCLUSION: Considering this discrepancy, this method with an initial TBC set at 2.6 µg/ml may be acceptable for clinical use for moderate sedation (UMIN 000017197).

Prolongation of the effect of a single dose of rocuronium in a patient with postpolio syndrome under desflurane anesthesia: a case report.

Postpolio syndrome (PPS) is widely known to manifest as muscle weakness in patients affected by poliomyelitis in early childhood. This is caused by the long-term overwork of motor nerves regenerated from surviving nerve cells. We report a characteristic delay in recovery from muscle relaxation after administering rocuronium to a patient with PPS under general anesthesia with desflurane. A 59-year-old woman was scheduled to undergo surgical debridement for jaw osteonecrosis. She had a history of poliomyelitis at the age of 2 years, and was diagnosed with PPS at the age of 51 years. General anesthesia was induced with 80 mg propofol, 50 µg fentanyl, and 30 mg (0.69 mg/kg) rocuronium, and maintained with desflurane and remifentanil. The durations of train-of-four (TOF) count 0 and 1 were 96 and 37 min, respectively. Five minutes after discontinuing desflurane, the TOF count was 4. Three minutes after administering 200 mg sugammadex, the TOF ratio was 0.83, and the tracheal tube was subsequently removed. In summary, the effect of a single dose of rocuronium on twitch in TOF monitoring was significantly prolonged in a patient with PPS, which may have been exacerbated by desflurane.

Cross-sectional study of propofol dose during intravenous sedation for dental surgery in patients with long-term oral benzodiazepine therapy: A secondary publication.

OBJECTIVES: The amount of propofol required for intravenous sedation (IVS) in patients on long-term oral benzodiazepine (BZD) therapy may be affected by drug interactions and central changes in sensitivity. However, there is no research on the effect of long-term oral BZD use on the amount of propofol required for IVS. We aimed to clarify the difference between the total propofol dose required for IVS in patients with or without long-term oral BZD therapy. MATERIAL AND METHODS: Among patients treated for 4 years, the total administered dose required for IVS with propofol alone and local anesthesia for the extraction of bilateral impacted mandibular wisdom teeth, was retrospectively compared between patients with continuous oral BZD use for ≥6 months (BZD group; n = 24) and those without such use (control group; n = 307). The aimed sedation level was the Ramsay sedation scale 3-4. RESULTS: The amount of propofol required for IVS was significantly lower in the BZD group compared to the control group (4.83 ± 1.30 vs. 5.91 ± 1.25 mg/kg/h, p < .001; 95% confidence interval, -1.22 to -0.94 mg/kg/h; Cohen's d, 0.84). The required propofol dose was not influenced by preoperative oral BZD administration on the day of extraction (presence [n = 13] vs. absence [n = 11]: 4.9 ± 1.3 vs. 4.8 ± 1.7 mg/kg/h, p = .83). Long-term oral BZD therapy remained a significant factor for a lower required propofol dose after adjusting for age with multiple linear regression analysis. The underlying mechanism cannot be an additive action process but might pertain to competitive inhibition via an enzyme involved in glucuronate conjugation or competitive albumin binding. CONCLUSIONS: Clinicians should understand that patients on long-term oral BZDs therapy might require less propofol for IVS than those not on BZDs, irrespective of whether BZDs were taken preoperatively on the day of surgery.

The Effect of Music on Preoperative Anxiety in an Operating Room: a Single-Blind Randomized Controlled Trial.

OBJECTIVE: This study aimed to determine the effect of music as an intervention on relieving preoperative anxiety in patients with dental fear in an outpatient operating room (OR) before intravenous sedation (IVS). METHODS: Sixty adult patients with dental fear undergoing dental surgery under IVS were divided into 2 groups (music and nonmusic). The music group listened to music in the waiting room until immediately before the initiation of IVS whereas the nonmusic group did not. Patient anxiety was objectively measured using heart rate variability (HRV) analysis to assess the low-frequency/high-frequency ratio as an indication of sympathetic or parasympathetic nervous system activity. Subjective preoperative anxiety was evaluated with a visual analog scale (VAS). RESULTS: Heart rate variability analysis failed to demonstrate any significant difference between the 2 groups from baseline to start of IVS. There were also no significant differences between the 2 groups regarding changes in VAS scores. CONCLUSION: Music intervention was not found to reduce preoperative anxiety in patients with dental fear before IVS in the dental outpatient OR as determined by HRV analysis or VAS scores.

Utility of a Structured Teaching Approach, Rehearsal, and Training for Patients With Autism Spectrum Disorder to Avoid Physical Restraint During Induction of Anesthesia.

PURPOSE: We aimed to determine whether the use of a structured teaching approach, rehearsing, and training (SRT) for anesthesia induction in patients with autism spectrum disorder (ASD) could reduce the need for physical restraint. DESIGN: Retrospective observational study METHODS: We retrospectively analyzed 63 patients (4 to 40 y old) with ASD who underwent general anesthesia for dental treatment. Patients were divided into SRT (n = 22) and non-SRT (n = 41) groups. In the SRT group, patients were presented with a visual guide based on a structured teaching approach at the pre-anesthetic consultation. The guide comprised photographs of the places, tools, and processes that the patient would experience prior to anesthesia induction. Patients then practiced these processes (rehearsal). Patients in the non-SRT group were administered anesthesia in a conventional manner without SRT. FINDINGS: The percentage of patients needing physical restraint was significantly lower in the SRT (3/22, 13%) than in the non-SRT group (21/41, 51%, P < .001). CONCLUSIONS: The SRT method reduces the need for physical restraint in patients with ASD during anesthesia induction.

Anesthetic Management of a Rett Syndrome Patient at High Risk for Respiratory Complications.

Rett syndrome (RTT) is a rare genetic disorder that can present challenges in airway management during general anesthesia. This is a case report involving a 23-year-old woman with RTT who received an intubated general anesthetic 3 times for dental treatment. The patient also had severe scoliosis, was bedridden, and had dysphagia. These contributing factors likely led to the development of postoperative respiratory complications including pneumonia after the first case. As a result, several changes were incorporated into the 2 subsequent anesthetic plans in efforts to reduce the risk of such complications. Despite these measures, the patient was suspected of having bronchitis postoperatively after the second anesthetic, although the third occurred uneventfully. Anesthetic management alterations included use of desflurane for anesthetic maintenance and postoperatively delaying oral intake and instituting active postural changes.

Anesthetic management of a patient with 15q tetrasomy for dental treatment / Manejo anestésico de paciente com tetrassomia 15q para tratamento odontológico

Abstract Background and objectives 15q tetrasomy is a chromosomal abnormality that is a part of the heterogeneous group of extra structurally abnormal chromosomes. This syndrome is characterized by epilepsy, central hypotonia, developmental delay and intellectual disability, and autistic behavior. This is the first report of the anesthetic management of a patient with this syndrome. Case report We administered general anesthesia for dental treatment in a patient with 15q tetrasomy. Conclusions Appropriate planning for the prevention of complications such as seizures and hypotonia, and for delayed emergence from anesthesia, is required. Specifically, choosing short-acting drugs that do not induce seizures, together with suitable monitoring, resulted in successful anesthetic management of the patient with 15q tetrasomy.

Resumo Justificativa e objetivos Tetrassomia 15q é uma anomalia cromossômica que faz parte do grupo heterogêneo de cromossomos extras, estruturalmente anormais. Essa síndrome é caracterizada por epilepsia, hipotonia central, atraso no desenvolvimento e deficiência intelectual e comportamento autista. Este é o primeiro relato do manejo anestésico de um paciente com essa síndrome. Relato de caso Administramos anestesia geral para tratamento odontológico em um paciente com tetrassomia 15q. Conclusões Um planejamento adequado para prevenir complicações como convulsões e hipotonia e para emergência tardia da anestesia é necessário. O manejo anestésico bem-sucedido do paciente com tetrassomia 15q foi o resultado específico da escolha de fármacos de curta duração que não induzem convulsões e monitoração adequada.

[Anesthetic management of a patient with 15q tetrasomy for dental treatment]. / Manejo anestésico de paciente com tetrassomia 15q para tratamento odontológico.

BACKGROUND AND OBJECTIVES: 15q tetrasomy is a chromosomal abnormality that is a part of the heterogeneous group of extra structurally abnormal chromosomes. This syndrome is characterized by epilepsy, central hypotonia, developmental delay and intellectual disability, and autistic behavior. This is the first report of the anesthetic management of a patient with this syndrome. CASE REPORT: We administered general anesthesia for dental treatment in a patient with 15q tetrasomy. CONCLUSIONS: Appropriate planning for the prevention of complications such as seizures and hypotonia, and for delayed emergence from anesthesia, is required. Specifically, choosing short-acting drugs that do not induce seizures, together with suitable monitoring, resulted in successful anesthetic management of the patient with 15q tetrasomy.

General Anesthesia for a Patient With Pelizaeus-Merzbacher Disease.

We report the successful management of general anesthesia for a patient with Pelizaeus-Merzbacher disease (PMD). PMD is one of a group of progressive, degenerative disorders of the cerebral white matter. The typical clinical manifestations of PMD include psychomotor retardation, nystagmus, abnormal muscle tone, seizures, and cognitive impairment. General anesthesia for a patient with PMD may be difficult mainly because of seizures and airway complications related to poor pharyngeal muscle control. In addition, the possibility of exacerbation of spasticity should be considered. A 20-year-old man with PMD required removal of impacted wisdom teeth under general anesthesia. General anesthesia was induced with thiamylal, fentanyl, and desflurane. Anesthesia was maintained with desflurane and continuous intravenous remifentanil under bispectral index and train-of-4 monitoring. Anesthesia lasted 1 hour 20 minutes and was completed uneventfully. Airway complications, seizures, and exacerbation of spasticity did not occur postoperatively. Preoperatively, our patient had no history of epilepsy attacks or aspiration pneumonia, and no clinical symptoms of gastroesophageal reflux disease. Therefore, exacerbation of spasticity was one of the most likely potential complications. Identification of these associated conditions and evaluation of risk factors during preoperative examination is important for performing safe anesthesia in these patients.

Acute angle-closure glaucoma after general anesthesia for bone grafting.

Acute angle-closure glaucoma (AACG) is a rare complication of general anesthesia. The coexistence of individual risk factors for postoperative AACG and factors associated with intraocular hypertension are considered to be required for postoperative AACG to develop. We present a case of AACG after general anesthesia for oral bone grafting in a patient with no preoperative eye symptoms. In this case, several factors such as postoperative care in a darkened room, psychological stress, and postoperative hypertension may have precipitated the event in this patient, who may have had preexisting undiagnosed elevated intraocular pressure. The interval between the earliest appearance of symptoms at 9 hours and the ultimate diagnosis was 36 hours. In the postoperative period following general anesthesia, any patient is at risk for AACG. It is important that a postoperative diagnosis of AACG should be considered and a timely consultation with an ophthalmologist be considered if a postoperative patient complains of red eyes, visual disorder, eye pain, headache, and nausea.

Phenotype of tumor lymphatic vessels is a prognostic factor in human tongue squamous cell carcinoma.

Tumor metastasis to lymph nodes occurs through the lymphatic vessels located in the tumor circumference. However, few studies have focused on the phenotypes of lymphatic vessels around these tumors. We investigated the characteristics of the lymph vessels of tongue squamous cell carcinoma (SCC) and compared them to clinicopathological characteristics. A total of 43 patients diagnosed as having tongue SCC consulted Hokkaido University Hospital were examined. The lymphatic vessels were identified by antibody D2-40 and the number and diameter of tumor lymphatic vessels were measured. The proliferative activity of lymphatic endothelial cells was also examined by immunostaining using antibody MIB-1. We then measured the DNA density of lymphatic endothelial cells in normal and tumor tissues. The number of tumor lymphatic vessels significantly increased in highly metastatic cases of tongue SCC, particularly in cases with a large number of micro lymphatic vessels. A significant correlation was found between the metastatic and proliferative activity of tumor lymphatic endothelial cells. Moreover, the DNA density of tumor lymphatic endothelial cells increased compared to normal tissues. These results suggest that the phenotypes of tumor lymphatic endothelial cells are an indicator of lymph node metastasis of tongue SCC.