Anesthetic Management Using a Laryngeal Mask Airway in a Child With Congenital Bronchial Atresia.

Congenital bronchial atresia is a relatively rare malformation that causes a segmental obstruction of the bronchus during the fetal period. The peripheral lung distal from the obstructed bronchus becomes hyperinflated because of the unidirectional flow through collateral check-valve entry. Positive pressure ventilation during general anesthesia may cause a rupture of the bulla, resulting in pneumothorax. An 8-year-old girl, who had to undergo oral surgery, was diagnosed as having congenital bronchial atresia and one-fifth of her lung was poorly ventilated. We planned to perform general anesthesia under spontaneous respiration using a laryngeal mask, which was well tolerated.

Optimal and safe standard doses of midazolam and propofol to achieve patient and doctor satisfaction with dental treatment: A prospective cohort study.

BACKGROUND: The incidences of morbidity and mortality caused by pharmacosedation for dental treatment have not yet reached zero. Adverse events are related to inappropriate respiratory management, mostly originating from an overdose of sedatives. Since sedation is utilized for the satisfaction of both the dentist and the patient, the optimal dose should be minimized to prevent adverse events. We attempted to define the optimal doses of midazolam and propofol required to achieve high levels of patient and dentist satisfaction. METHODS: One thousand dental patients, including those undergoing third molar extractions, were enrolled in this study. A dose of 1 mg of midazolam was administered at 1-minute intervals until adequate sedation was achieved. Propofol was then infused continuously to maintain the sedation level. Both the patients and the dentists were subsequently interviewed and asked to complete a questionnaire. A multivariate logistic regression analysis was used to examine the factors that contributed to patient and dentist satisfaction. RESULTS: The peak midazolam dose resulting in the highest percentage of patient satisfaction was 3 mg. Both a lower dose and a higher dose reduced patient satisfaction. Patient satisfaction increased with an increasing dosage of propofol up until 4 mg/kg/hr, reaching a peak of 78.6%. The peak midazolam dose resulting in the highest percentage of dentist satisfaction (78.8%) was 2 mg. Incremental propofol doses reduced dentist satisfaction, in contrast to their effect on patient satisfaction. The strongest independent predictors of patient satisfaction and dentist satisfaction were no intraoperative memory (OR, 5.073; 95% CI, 3.532-7.287; P<0.001) and unintentional movements by the patient (OR, 0.035; 95% CI, 0.012-0.104; P<0.001), respectively. No serious adverse events were reported. CONCLUSION: We found that 3 mg of midazolam and 3 mg/kg/hr of propofol may be the optimal doses for maximizing both patient and dentist satisfaction. Although this level of sedation is relatively light, memory loss and an absence of unintentional patient movements can be expected without adverse events.

Strategies for training standardized patient instructors for a competency exam.

The Common Achievement Test (CAT) in Japan, which will be implemented in 2005, involves a medical interview that is the core task to be completed by students during an Objective Structured Clinical Examination (OSCE). Standardized/Simulated Patient instructors (SPs), posing as patients in medical interviews, are trained in standard fashion in terms of expression of symptoms as well as the emotional affect of actual patients. Institution of appropriate training programs for SP instructors in the CAT is also necessary. We trained seven individuals to function as standardized patients (in-school SPs) during a three-day SP training program described in this article. Following completion of the OSCE, we conducted a comparison study among evaluations completed by the evaluators and two types of SP instructors. We observed high correlation, according to Spearman significance testing, between scores of evaluators and those of both newly trained in-school SPs and veteran SPs who had more than five years of experience. Correlation coefficients between the veteran SPs (r=0.77) and the in-school SPs (r=0.73) were nearly identical. These results suggest that our training program for SP instructors is an effective protocol, particularly with respect to reliability and efficiency.