Patient-controlled sedation using remimazolam during third molar extraction: a case report

Dental sedation plays a pivotal role in alleviating patient anxiety during various procedures. Remimazolam, a benzodiazepine derivative, stands out for its distinctive attributes, particularly its rapid onset of sedation coupled with a brief duration, making it an invaluable option for dental applications. The patient was admitted for the extraction of impacted third molars via patient-controlled sedation and not only demonstrated stable vital signs but also expressed a high level of satisfaction with the procedure. An in-depth analysis of plasma remimazolam concentrations and changes in the Patient State Index revealed negative correlation patterns, highlighting the inherent potential of remimazolam in achieving effective sedation. This expanded research scope aims to provide a more nuanced understanding of the pharmacological responses to remimazolam in dental sedation scenarios.This case report offers valuable insights into the evolving landscape of dental sedation methodologies and paves the way for a more informed and evidence-based approach to the use of remimazolam in patient-controlled sedation.

The utilization of video laryngoscopy in nasotracheal intubation for oral and maxillofacial surgical procedures: a narrative review

The video laryngoscope is a novel instrument for intubation that enables indirect visualization of the upper airway. It is recognized for its ability to enhance Cormack-Lehane grades in the management of difficult airways.Notably, video laryngoscopy is associated with equal or higher rates of intubation success within a shorter time frame than direct laryngoscopy.Video laryngoscopy facilitates faster and easier visualization of the glottis and reduces the need for Magill forceps, thereby shortening the intubation time. Despite the advanced glottic visualization afforded by video laryngoscopy, nasotracheal tube insertion and advancement occasionally fail. This is particularly evident during nasotracheal intubation, where oropharyngeal blood or secretions may obstruct the visual field on the monitor, thereby complicating video laryngoscopy. Moreover, the use of Magill forceps is markedly challenging or nearly unfeasible in this context, especially in pediatric cases. Furthermore, the substantial blade size of video laryngoscopes may restrict their applicability in individuals with limited oral apertures.This study aimed to review the literature on video laryngoscopy, discuss its clinical role in nasotracheal intubation, and address the challenges that anesthesiologists may encounter during the intubation process.

Air leakage due to the cuff hanging on the vocal cords during nasotracheal intubation: a case report

Nasotracheal intubation is commonly performed under general anesthesia in oral and maxillofacial surgery. For the convenience of surgery, nasal Ring-Adair-Elwyn (RAE) tubes are mainly used. Because the nasal RAE tubes were bent in an “L” shape, the insertion depth was limited. Particularly, it is necessary to accurately determine the appropriate depth of the RAE tubes in children. Several types of nasal RAE tubes are used in the medical market, which vary in material and length. We performed endotracheal intubation using a nasal RAE tube for double-jaw surgery, but air leakage persisted even when the air pressure in the cuff was increased. When checked with a laryngoscope, it was confirmed that the tube was pushed out, and the cuff was caught on the vocal cords, causing air leakage. Since inserting the tube deeply did not solve the problem, replacing it with a nasal RAE tube (Polar TM , Preformed Tracheal Tube, Smith Medical, Inc., USA) did not cause air leakage; thus, we reported this case.

Analysis of changes and trends in the use of sedatives in dental sedation using data from the National Health Insurance in Korea

Background@#Although dental sedation helps control anxiety and pain, side effects and serious complications related to sedation are gradually increasing. Due to the introduction of new drugs and sedation methods, insurance rates, legal regulations, drugs, and methods used for dental sedation are inevitably changed. In the Republic of Korea, National Health Insurance is applied to all citizens, and this study investigated changes in the use of sedatives using this big data. @*Methods@#This study used customized health information data provided by the Healthcare Insurance Review & Assessment Service of Korea. Among patients with a record of use of at least one of eight types of sedatives for dental sedation between January 2007 and September 2019 were selected; the data of their overall insurance claims for dental treatment were then analyzed. @*Results@#The number of patients who received dental sedation was 786,003, and the number of dental sedation cases was 1,649,688. Inhalational sedation using nitrous oxide (N2O) accounted for 86.8% of all sedatives that could be claimed for drugs and treatment. In particular, it was confirmed that the number of requests for sedation using N2O sharply increased each year. Midazolam showed an increasing trend, and in the case of chloral hydrate, it gradually decreased. @*Conclusion@#According to our analysis, the use of N2O and midazolam gradually increased, while the use of chloral hydrate gradually decreased.

An anesthetic management of head and neck cancer reconstructive surgery in a patient having hemophilia A: a case report

Hemophilia A is a hemorrhagic disease caused by coagulation factor VIII deficiency. In head and neck cancer surgery, especially during a reconstructive one, complications can occur. These include hematomas due to bleeding which can then lead to flap ischemia, necrosis, and impaired wound healing. There are fewer cases of reconstructive surgery in patients with hemophilia A. Here in we report, a reconstructive surgery that involved mass resection, partial glossectomy (right), selective neck dissection (right, Levels I, II, III, IV), and reconstruction at the lateral arm free flap (left) in a 25-year-old man with hemophilia A. The surgery was successfully performed without any complications after pretreatment with Factor VIII concentrate, which has not been reported earlier.

An anesthetic management of head and neck cancer reconstructive surgery in a patient having hemophilia A: a case report

Hemophilia A is a hemorrhagic disease caused by coagulation factor VIII deficiency. In head and neck cancer surgery, especially during a reconstructive one, complications can occur. These include hematomas due to bleeding which can then lead to flap ischemia, necrosis, and impaired wound healing. There are fewer cases of reconstructive surgery in patients with hemophilia A. Here in we report, a reconstructive surgery that involved mass resection, partial glossectomy (right), selective neck dissection (right, Levels I, II, III, IV), and reconstruction at the lateral arm free flap (left) in a 25-year-old man with hemophilia A. The surgery was successfully performed without any complications after pretreatment with Factor VIII concentrate, which has not been reported earlier.

A novel technique of submandibular intubation with a camera cable drape: a case report

Submental or submandibular intubation has been reported to cause fewer complications than tracheostomy. However, the risk of infection is always inherent because oral wounds are exposed to microbial flora and bacteria in the oral cavity. A novel technique of submandibular intubation was devised to reduce infection and injury to the soft tissues. We would like to report a novel safe technique that can be performed in patients requiring submental or submandibular intubation. This is the first report of submandibular intubation using a sterile disposable camera cable drape. This novel technique of submandibular intubation is safer, more sterile, easier, and less invasive than conventional submandibular intubation.

Risk factors affecting the difficulty of fiberoptic nasotracheal intubation

Background@#The success rate of intubation under direct laryngoscopy is greatly influenced by laryngoscopic grade using the Cormack-Lehane classification. However, it is not known whether grade under direct laryngoscopy can also affects the success rate of nasotracheal intubation using a fiberoptic bronchoscpe, so this study investigated the same. In addition, we investigated other factors that influence the success rate of fiberoptic nasotracheal intubation (FNI). @*Methods@#FNI was performed by 18 anesthesiology residents under general anesthesia in patients over 15 years of age who underwent elective oral and maxillofacial operations. In all patients, the Mallampati grade was measured.Laryngeal view grade under direct laryngoscopy, and the degree of secretion and bleeding in the oral cavity was measured and divided into 3 grades. The time required for successful FNI was measured. If the intubation time was > 5 minutes, it was evaluated as a failure and the airway was managed by another method. The failure rate was evaluated using appropriate statistical method. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were also measured. @*Results@#A total of 650 patients were included in the study, and the failure rate of FNI was 4.5%. The patient's sex, age, height, weight, Mallampati, and laryngoscopic view grade did not affect the success rate of FNI (P > 0.05). BMI, the number of FNI performed by residents (P = 0.03), secretion (P < 0.001), and bleeding (P < 0.001) grades influenced the success rate. The AUCs of bleeding and secretion were 0.864 and 0.798, respectively, but the AUC of BMI, the number of FNI performed by residents, Mallampati, and laryngoscopic view grade were 0.527, 0.616, 0.614, and 0.544, respectively. @*Conclusion@#Unlike in intubation under direct laryngoscopy, in the case of FNI, oral secretion and nasal bleeding had a significant effect on FNI difficulty than Mallampati grade or Laryngeal view grade.

Multiple implant therapy with multiple inductions of general anesthesia in non-compliant patients with schizophrenia: A case report

The effectiveness of dental implants in patients with disability, who are non-compliant during treatment, is controversial because of their poor oral health. Thus, oral health-care and management in such patients is concerning. Moreover, limited information is available on prognosis after implant placement. Herein, we describe a patient with schizophrenia who underwent dental implantation under multiple inductions of general anesthesia (5 times) and required conservative treatment and tooth extraction for multiple dental caries and retained roots because of inadequate oral health-care. Postoperatively, fracture of the prosthodontics and progression of dental caries were observed, and with 3 additional inductions of general anesthesia, conservative treatment, implant surgery, and prosthesis implantation were conducted. Postoperative 12-month follow-up since the last prosthesis implantation showed successful results. For patients with schizophrenia, multiple implantation can reduce horizontal bone loss and achieve aesthetic results compared to treatment with removable prosthodontics and could serve as an alternative treatment modality.

Lipid emulsion therapy of local anesthetic systemic toxicity due to dental anesthesia

Local anesthetic systemic toxicity (LAST) refers to the complication affecting the central nervous system (CNS) and cardiovascular system (CVS) due to the overdose of local anesthesia. Its reported prevalence is 0.27/1000, and the representative symptoms range from dizziness to unconsciousness in the CNS and from arrhythmias to cardiac arrest in the CVS. Predisposing factors of LAST include extremes of age, pregnancy, renal disease, cardiac disease, hepatic dysfunction, and drug-associated factors. To prevent the LAST, it is necessary to recognize the risk factors for each patient, choose a safe drug and dose of local anesthesia, use vasoconstrictor , confirm aspiration and use incremental injection techniques. According to the treatment guidelines for LAST, immediate application of lipid emulsion plays an important role. Although lipid emulsion is commonly used for parenteral nutrition, it has recently been widely used as a non-specific antidote for various types of drug toxicity, such as LAST treatment. According to the recently published guidelines, 20% lipid emulsion is to be intravenously injected at 1.5 mL/kg. After bolus injection, 15 mL/kg/h of lipid emulsion is to be continuously injected for LAST. However, caution must be observed for >1000 mL of injection, which is the maximum dose. We reviewed the incidence, mechanism, prevention, and treatment guidelines, and a serious complication of LAST occurring due to dental anesthesia. Furthermore, we introduced lipid emulsion that has recently been in the spotlight as the therapeutic strategy for LAST.

Treatment of severe pain in a patient with complex regional pain syndrome undergoing dental treatment under general anesthesia: A case report

Complex regional pain syndrome (CRPS) is rare, characterized by pain from diverse causes, and presents as extreme pain even with minor irritation. General anesthesia may be required for dental treatment because the pain may not be controlled with local anesthesia. However, treatment under general anesthesia is also challenging. A 38-year-old woman with CRPS arrived for outpatient dental treatment under general anesthesia. At the fourth general anesthesia induction, she experienced severe pain resulting from her right toe touching the dental chair. Anesthesia was induced to calm her and continue the treatment. After 55 minutes of general anesthesia, the patient still complained of extreme toe pain. Subsequently, two administrations for intravenous sedation were performed, and discharge was possible in the recovery room approximately 5 h after the pain onset. The pain was not located at the dental treatment site. Although the major factor causing pain relief was unknown, ketamine may have played a role.

The effect of combination treatment using palonosetron and dexamethasone for the prevention of postoperative nausea and vomiting versus dexamethasone alone in women receiving intravenous patient-controlled analgesia / 대한마취과학회지

BACKGROUND: The purpose of this study was to evaluate the effect of palonosetron combined with dexamethasone for the prevention of PONV compared to dexamethasone alone in women who received intravenous patient-controlled analgesia (IV-PCA) using fentanyl. METHODS: In this randomized, double-blinded, placebo-controlled study, 204 healthy female patients who were scheduled to undergo elective surgery under general anesthesia followed by IV-PCA for postoperative pain control were enrolled. Patients were divided into two groups: the PD group (palonosetron 0.075 mg and dexamethasone 5 mg IV; n = 102) and the D group (dexamethasone 5 mg IV; n = 102). The treatments were given after the induction of anesthesia. The incidence of nausea, vomiting, severity of nausea, and the use of rescue anti-emetics during the first 48 hours after surgery were evaluated. RESULTS: The incidence of PONV was significantly lower in the PD group compared with the D group during the 0-24 hours (43 vs. 59%) and 0-48 hours after surgery (45 vs. 63%) (P < 0.05). The severity of nausea during the 6-24 hours after surgery was significantly less in the PD group compared with the D group (P < 0.05). The incidence of rescue antiemetic used was significantly lower in the PD group than in the D group during the 0-6 hours after surgery (13.1 vs. 24.5%) (P < 0.05). CONCLUSIONS: Palonosetron combined with dexamethasone was more effective in preventing PONV compared to dexamethasone alone in women receiving IV-PCA using fentanyl.

Cervical Epidural Anesthesia for Arteriovenous Bridge Graft at Upper Arm in Chronic Renal Failure Patients

PURPOSE: Cervical epidural analgesia is used for pain control in head and neck or upper arm. But it is not commonly used for the purpose of pure regional anesthesia for upper arm surgery. Therefore, we investigated the usefulness of cervical epidural anesthesia (CEA) as a method of regional anesthesia for arteriovenous bridge graft (AVBG) for hemodialysis at upper arm and evaluated the effects of CEA on hemodynamics and respiration. METHODS: One hundred-fifty chronic renal failure patients scheduled for AVBG were randomly assigned. In the sitting position, an epidural catheter was inserted at C6-7 or C7-T1 and 15 ml of 0.375% ropivacaine with fentanyl 20microg was injected. Analgesic level, blood pressure and heart rate were measured at 5-minute intervals after injection of the drug. Arterial blood sampling was taken for aBGA before and twenty minutes after CEA. RESULTS: Average anesthetic dermatomalsensory levels were C3.4+/-1.2~T5.7+/-2.8. During surgery, hypotension was noted in 49% of patients. It was treated with ephedrine or phenylephrine i.v. Baseline PaCO2 changed from 42.4+/-2.9 mmHg to 44.6+/-3.6 mmHg. CONCLUSION: The above results suggest that CEA is suitable for AVBG at upper arm as a regional anesthesia.

Drip infusion method as a useful indicator for identification of the epidural space / 대한마취과학회지

BACKGROUND: Cervical epidural anesthesia (CEA) is used for pain control and surgical procedures of the head and neck or upper arm areas. However, the failure rate of CEA is reported to be high, is the failure rate being quite higher than other sites, because of the anatomical differences of the cervical spine. We hypothesized that the loss of resistance (LOR) method combined with the drip infusion method for confirmation of the cervical epidural space can reduce the failure rate. This study investigated the usefulness of the drip infusion method. METHODS: One hundred chronic renal failure patients undergoing arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. In the cervical epidural puncture, we identified the cervical epidural space using a combination of the LOR method with the drip infusion method. After confirmation of the epidural space with LOR method, we decided it was the true epidural space when fluid dripping to the space was present. Otherwise, if fluid dripping was not present, we designated it was pseudo LOR, and we found the true epidural space using the drip infusion method only. RESULTS: In all cases, the combined LOR with drip infusion method, identify the epidural space. CONCLUSIONS: Combined LOR with drip infusion method is an efficacious method for the confirmation of the cervical epidural space.

Dilutional Hyponatremia during Hysteroscopic Myomectomy: A Case Report / 대한구급학회지

Hysteroscopy is utilized for making the diagnosis and treating a series of uterine disease. It's advantages are more accurate removal of lesion, a short operating time, low morbidity and rapid postoperative recovery. However, serious complications can happen following hysteroscopic surgery. The complications can be divided into the procedure-related, media-related and postoperative events. The procedure-related complications include cervical laceration, uterine perforation, bowel and bladder injury, and hemorrhage. The media-related complications include hyponatremia, gas embolism and excessive fluid absorption. The postoperative events include endometritis and postoperative synechiae. We experienced hyponatermia with pulmonary edema due to excessive fuid absorption in a 52-year-old woman who underwent elective hysteroscopic myomectomy under general anesthesia. She was treated with oxygen therapy, normal saline and furosemide and she recovered without sequelae.