Initial loading of dexmedetomidine and continuous propofol sedation for prevention of delayed recovery: A randomized controlled trial.

BACKGROUND: Sedation with continuous dexmedetomidine and bolus midazolam administration provides a lower incidence of unacceptable patient movement during procedures but requires a longer recovery time. The authors aimed to compare recovery time and unacceptable patient movement during sedation with initial loading of dexmedetomidine followed by continuous propofol infusion with those during sedation with continuous dexmedetomidine and bolus midazolam administration. METHODS: In this prospective randomized controlled trial, 54 patients undergoing dental surgery and requiring intravenous sedation were assigned to either the dexmedetomidine and propofol group (n = 27, dexmedetomidine administered at 6 µg/kg/h for 5 minutes, followed by continuous propofol infusion using a target-controlled infusion) or the dexmedetomidine and midazolam group (n = 27, dexmedetomidine administered at 0.2-0.7 µg/kg/h continuously after the same initial loading dose with bolus midazolam). A bispectral index of 70 through 80 was maintained during the procedure. Patient movement that interfered with the procedure and time from the end of sedation to achieving a negative Romberg sign were assessed. RESULTS: Times from the end of sedation to achieving a negative Romberg sign in the dexmedetomidine and propofol group (median, 14 minutes [interquartile range, 12-15 minutes]) were significantly shorter (P < .001) than in the dexmedetomidine and midazolam group (median, 22 minutes [interquartile range, 17.5-30.5 minutes]). The incidence of unacceptable patient movement was comparable between groups (n = 3 in the dexmedetomidine and propofol group, n = 4 in the dexmedetomidine and midazolam group; P = .999). CONCLUSIONS: Sedation with a single loading dose of dexmedetomidine followed by continuous propofol infusion can prevent delayed recovery without increasing unacceptable patient movement. PRACTICAL IMPLICATIONS: The combination of dexmedetomidine and propofol may provide high-quality sedation for ambulatory dental practice. This clinical trial was registered in the University Hospital Medical Information Network Clinical Trials Registry. The registration number is UMIN000039668.

Dexmedetomidine and Midazolam Sedation Reduces Unexpected Patient Movement During Dental Surgery Compared With Propofol and Midazolam Sedation.

PURPOSE: Owing to its unpredictability, unexpected patient movement is one of the most important problems during surgery while under monitored anesthesia care with sedation. The purpose of this study was to compare unexpected patient movement during dental surgery while under dexmedetomidine and propofol sedation. MATERIALS AND METHODS: The authors designed and implemented a prospective randomized controlled trial. Patients undergoing dental surgery requiring intravenous sedation were randomly assigned to dexmedetomidine and midazolam (dexmedetomidine group) or propofol and midazolam (propofol group) sedation. In each group, midazolam 0.02 mg/kg was administered in conjunction with continuous administration of dexmedetomidine or propofol to maintain a bispectral index value of 70 to 80. Unexpected patient movement interfering with the procedure was defined as acceptable, defined as no body movement or only 1 controllable movement, or unacceptable, defined as at least 2 controllable movements or any uncontrollable movement. The primary outcome was unexpected patient movement, and the secondary outcome was defined as snoring and cough reflex. Other variables included demographic and procedural characteristics. Continuous or ordinal variables were analyzed using the Student t test or Mann-Whitney test. Dichotomous or categorical variables were analyzed using the χ2 test or Fisher exact test. A P value less than.05 was considered statistically significant. RESULTS: Eighty-eight patients were enrolled in the study (dexmedetomidine group, n = 44; propofol group, n = 44). There were no relevant differences between groups for demographics and baseline variables. Intraoperative unacceptable patient movement occurred more commonly in the propofol group (n = 13; 30%) than in the dexmedetomidine group (n = 4; 9%; P = .015). Intraoperative snoring occurred more commonly in the dexmedetomidine than in the propofol group (P = .045). Incidence and number of cough reflexes were comparable between groups. CONCLUSION: Dexmedetomidine and midazolam sedation decreases unexpected patient movement during dental surgery compared with propofol and midazolam sedation.

Airway management for glossopexy in infants with micrognathia and obstructive breathing.

STUDY OBJECTIVES: To identify airway management and tracheal intubation techniques for glossopexy in infants with preexisting airway obstruction under general anesthesia. DESIGN: Retrospective, observational study. SETTINGS: Operating room of a university hospital between January 2003 and March 2015. All operations were performed by oral and maxillofacial surgeons. PATIENTS: Thirteen patients who received general anesthesia for glossopexy and reversal after 7 months. MEASUREMENTS: The medical records of these infants were retrospectively examined to evaluate the following: age, sex, height and weight at surgery, preoperative airway status, tracheal intubation route (oral or nasal), method for inducing general anesthesia, method for establishing the airway during mask ventilation, apparatus used for tracheal intubation, Cormack-Lehane classification when using a Macintosh laryngoscope and video laryngoscope, and the need for airway placement after extubation. RESULTS: Prone positioning and/or an airway of some kind before surgery were required in 38.5% of infants needing glossopexy. Difficult mask ventilation was common, occurring in 50% of the patients, and the incidence of airway placement during mask ventilation was significantly higher in infants with preoperative complete or incomplete obstruction (100%) than in infants with snoring (25%). Of these high-risk infants, 25% could not be intubated with a direct laryngoscope or Glidescope Cobalt and required fiberoptic intubation. CONCLUSION: There are severe cases of infants with difficult mask ventilation and difficult tracheal intubation in which a fiberscope is required because video laryngoscopy fails to improve the view of the larynx.

Haemostatic management for oral surgery in patients supported with left ventricular assist device--a preliminary retrospective study.

We investigated haemostatic management, frequency of postoperative bleeding, and prognosis of patients who had left ventricular assist devices, and who were having oral surgical procedures between April 2002 and March 2014, to identify risk factors for bleeding and find out which were the best methods of haemostasis. Medical records were examined retrospectively and we recorded details of the patients, and frequency of bleeding together with factors associated with it. Twenty-nine patients had 39 oral operations, and there were 17 bleeds (44%). The first procedure for each patient was used for statistical calculations. Duration of bleeding tended to be longer for patients with implantable devices (median (interquartile range, IQR) 12.0 (3-18) days) than for those with extracorporeal devices (median (IQR) 3.0 (1-4) days; p=0.079). There was a significantly greater difference in prothrombin time-international normalised ratio (PT-INR) before and after operation in patients who bled, whose median (range) was 0.85 (0.2-1.81), than in those who did not (median (IQR) 0.16 (-0.09-0.31) (p=0.015). There were moderate correlations with postoperative bleeding were seen for the difference between preoperative and postoperative PT-INR (r=0.479, p=0.012) and PT-INR value when bleeding (r=0.407, p=0.035). In conclusion, postoperative bleeding occurred after oral operations in 17/29 patients with left ventricular assist devices by a median (IQR) of 0.85 (0.2-1.81) of the preoperative value.

A prospective, randomized controlled trial of conscious sedation using propofol combined with inhaled nitrous oxide for dental treatment.

PURPOSE: Adverse reactions during propofol sedation include a decrease in arterial blood pressure, propofol-induced pain on injection, and airway complications. The purpose of this study was to investigate whether combined use of intravenous propofol and inhaled nitrous oxide could decrease the hypotensive and other adverse effects of propofol. PATIENTS AND METHODS: We designed and implemented a prospective, randomized controlled trial. Patients undergoing dental procedures requiring intravenous sedation were randomly allocated to 2 groups: group P comprised those receiving sedation with propofol alone, and group N+P comprised those receiving sedation with 40% nitrous oxide inhalation and propofol. During the dental procedures, the sedation level was maintained at an Observer's Assessment of Alertness/Sedation scale score of 4 by adjusting propofol's target plasma concentration. Nitrous oxide inhalation was the predictor variable, whereas the hemodynamic changes, amount and concentration of propofol, and adverse events were the outcome variables. RESULTS: Eighty-eight patients were successfully analyzed without any complications. The total amount of propofol was significantly less in group N+P (249.8 ± 121.7 mg) than in group P (310.3 ± 122.4 mg) (P = .022), and the mean concentration of propofol was significantly less in group N+P (1.81 ± 0.34 µg/mL) than in group P (2.05 ± 0.44 µg/mL) (P = .006). The mean blood pressure reduction in group N+P (11.0 ± 8.0 mm Hg) was significantly smaller than that in group P (15.8 ± 10.2 mm Hg) (P = .034). Pain associated with the propofol injection and memory of the procedure were less in group N+P (P = .011 and P = .048, respectively). Nitrous oxide did not affect respiratory conditions or recovery characteristics. CONCLUSIONS: The results of this study suggest that nitrous oxide inhalation combined with propofol sedation attenuates the hypotensive effect and pain associated with propofol injections, along with potentiating the amnesic effect.

Arteriosclerosis can predict hypotension during anesthesia induction in patients 40 years and older.

STUDY OBJECTIVES: To identify the factors that predict blood pressure (BP) changes during induction of general anesthesia, and the relationship between the level of arteriosclerosis and BP changes during anesthesia induction. DESIGN: Prospective, case-control observational study. SETTINGS: Operating room of a university hospital. PATIENTS: Seventy-two patients who received general anesthesia for oral and maxillofacial surgery. MEASUREMENTS: Brachial-ankle pulse wave velocity (baPWV) and central BP were measured. The primary variable was the parameters affecting BP changes during the induction of general anesthesia. For additional analyses, the parameters were compared between high and low PWV groups (1606 cm/s was the cutoff value of baPWV). To measure the relationships between the parameters and BP changes, bivariate and multiple linear regression analyses were performed. RESULTS: Seventy-two patients (including 41 men) with a mean age of 61.7 years and a median baPWV value of 1606 cm/s were evaluated. Significantly higher values for age, central BP, preoperative systolic BP (SBP), amount of decrease in SBP and diastolic BP, and number of patients with diabetes mellitus (DM) and hypertension were observed in the high PWV group. Multiple linear regression analysis demonstrated that age, baPWV, and DM were factors independently associated with the amount of decrease in SBP. CONCLUSION: In patients 40 years and older, age, baPWV, and DM are thought to be effective predictors of the amount of decrease in SBP during induction of general anesthesia.

The effect of nitrous oxide inhalation on the hypotensive response to propofol: a randomized controlled trial.

OBJECTIVE: Decrease in arterial blood pressure is a prominent adverse reaction during propofol (Disoprivan; AstraZeneca K.K., Osaka, Japan) sedation. The purpose of this prospective randomized study was to explore the effects of nitrous oxide (N2O) on the hypotensive response during propofol sedation. STUDY DESIGN: Twenty-six healthy volunteers received intravenous sedation with propofol alone (group P, n=13) or a combined technique using 20% N2O and propofol (group N+P, n=13). Propofol was administered by a target-controlled infusion system to attain and maintain a plasma propofol concentration of 1.5µg/mL. Hemodynamic and autonomic parameters were measured. RESULTS: Mean arterial pressure decreased in both groups, the hypotensive response in group N+P being significantly smaller than in group P. Reduction in the low-frequency power of systolic blood pressure variability, indicative of sympathetic nervous activity, was also smaller in group N+P than in group P. CONCLUSIONS: Addition of N2O to propofol sedation can attenuate the hypotensive effect of propofol.