Prediction of appropriate formula for nasotracheal tube size in developmental disability children.

OBJECTIVES: Developmental disability children have differences in growth. Therefore, tube size selection is important for nasotracheal intubation. In our previous study for healthy children undergoing dental surgery, height was the most suitable factor to predict nasotracheal tube size. The aim of this study was to find the most suitable formula for selection of nasotracheal tube size for them, retrospectively. MATERIAL AND METHODS: Developmental disability children aged 2 to 10 years were included in this study. They were intubated nasotracheally from April 2012 until May 2017. Their actually intubated tube sizes were checked. The predicted tube sizes were calculated according to the formulas by the backgrounds: the diameter of the trachea at the 6th cervical (C6), 7th cervical (C7), and 2nd thoracic vertebrae (T2) in X-ray. The actually intubated tube sizes were compared with predicted sizes. Data were analyzed using Spearman's regression analysis. RESULTS: The tube sizes with 5.0, 5.5, and 6.0 mm ID were intubated in 75 patients. The age-based formula was the most suitable; the correlation coefficients (r2) were 0.9027 (vs age), 0.5434 (vs height), 0.3779 (vs weight), 0.0785 (vs C6), 0.2279 (vs C7), and 0.3065 (Th2) (p < 0.01). However, 0.5-mm smaller size tubes were more frequently intubated actually. Their correspondence rate to the predicted size was 48% (5.0 mm), 52% (5.5 mm), and 39% (6.0 mm), respectively. CONCLUSION: The age-based formula could be the most suitable for predicting nasotracheal tube size in developmental disability children aged 2 to 10 years. One smaller size by the age formula was most suitable at first trial tube. CLINICAL RELEVANCE: The present data indicate that the selection of nasotracheal tube using one smaller size by the age formula (ID = 4 + age [years]/4) might be useful for developmental disability children.

Predicting the appropriate size of the uncuffed nasotracheal tube for pediatric patients: a retrospective study.

OBJECTIVES: The selection of an appropriate size of tracheal tube is important for airway management. For nasotracheal intubation, passing the nasal cavity should be taken into account for the selection of tube size. The aim of this study was to investigate the selection of appropriate size of nasotracheal tube in pediatric patients retrospectively. MATERIALS AND METHODS: The 1-12-year patients underwent dental procedures under general anesthesia intubated nasotracheally. The correlation between height, age, weight, the tracheal diameters at C6, C7, Th2 on the chest X-ray, and actually performed tube sizes were calculated. In addition, we compared the relationships between the predicted tube size and actually the intubated tube size. RESULTS: The tube sizes intubated actually were between 4.0 and 6.0-mm ID. The formula by height could be most suitable for tube size. The correspondence rates for the tube with 4.5- and 5.0-mm ID were 78% and 53%. When they were predicted as 5.5- or 6.0-mm ID, 0.5 mm smaller size tube were intubated actually; 56% and 70%. When the predicted tube size was 4.0-mm ID, 0.5 mm larger size tube was intubated actually; 66%. CONCLUSIONS: The formula by height could be most suitable for the selection of size for pediatric nasotracheal intubation. When the predicted tube size was 5.5 or 6.0-mm ID, 0.5 mm smaller size should be chosen at first. In the case of 4.0-mm ID, 0.5 mm larger size should be chosen for first trial. CLINICAL RELEVANCE: The present data indicate that the selection of nasotracheal tube using the formula by height might be useful.

Comparison of recovery in pediatric patients: a retrospective study.

OBJECTIVE: The recovery after general anesthesia is influenced by the choice of inhalational agent. Stimulations might make patient's agitate. However, the recovery using no touch technique might be safer. In this study, we compared the recovery time, awakening end-tidal concentration, and respiratory complications among inhalational anesthetics in pediatric patients using no touch technique, retrospectively. MATERIAL AND METHODS: The subjects were pediatric patients aged 3 months to 11 years under general anesthesia using sevoflurane, isoflurane, or desflurane. Background, awakening end-tidal concentration, respiratory complications, the time of eye open, body movement, and extubation were recorded. RESULTS: A total of 170 patients were included in the study. There were no respiratory complications during emergence. Awakening end-tidal concentration in desflurane was 0.98%, sevoflurane (0.39%), and isoflurane (0.25%). In patients received desflurane, the time of body movement, eye open, and extubation were significantly shorter than patients who received other anesthetics (p < 0.05). CONCLUSIONS: The recovery from desflurane was significantly shorter among three inhalational anesthetics with no touch technique. In addition, no airway-related complication occurred. CLINICAL RELEVANCE: The recovery from desflurane might be useful to predict emergence by end-tidal inhalational concentration.

Usefulness of a stool to stabilize dental chairs for cardiopulmonary resuscitation (CPR).

BACKGROUND: Cardiopulmonary resuscitation (CPR) requires immediate start of manual chest compression (MCC) and defibrillation as soon as possible. During dental surgery, CPR could be started in the dental chair considering difficulty to move the patient from the dental chair to the floor. However, all types of dental chairs are not stable for MCC. We previously developed a procedure to stabilize a dental chair by using a stool. EUROPEAN RESUSCITATION COUNCIL (ERC) guideline 2015 adopted our procedure when cardiac arrest during dental surgery. The objective of this study was to verify the efficacy of a stool as a stabilizer in different types of dental chairs. METHODS: Three health care providers participated in this study, and 8 kinds of dental chairs were examined. MCC were performed on a manikin that was laid on the backrest of a dental chair. A stool was placed under the backrest to stabilize the dental chair. The vertical displacement of the backrest by MCC was recorded by a camcorder and measured by millimeter. Next, the vertical displacement of the backrest by MCC were compared between with and without a stool. RESULTS: In all 8 dental chairs, the method by using a stool significantly reduced the vertical displacements of the backrest by during MCC. The reduction ratio (mean [interquartile range]) varied between nearly 27 [20] and 87 [5] %. In the largest stabilization case, the displacement was 3.5 [0.5] mm with a stool versus 26 [5.5] mm without a stool (p <  0.001). CONCLUSIONS: Our procedure to stabilize dental chairs by using a stool reduced the displacement of a backrest against MCC in all chairs. CLINICAL RELEVANCE: Effective MCC could be performed in dental chairs by using a stool when sudden cardiac arrest occurs during dental surgery.

Changes in nasotracheal tube depth in response to head and neck movement in children.

BACKGROUND: A tracheal tube is often inserted via the nasal cavity for dental surgery. The position of the tube tip is important, given that the head position sometimes changes during surgery. Head movement induces changes in the length of the trachea (t-length) and/or the distance between the nare and the vocal cords (n-v-distance). In this study, we investigated the changes in t-length and n-v-distance in children undergoing nasotracheal intubation. METHODS: Eighty patients aged 2-8 year undergoing dental surgery were enrolled. After nasotracheal intubation with an uncuffed nasotracheal tube (4.5-6.0 mm), the tube was fixed at the patient's nares. The distance between the tube tip and the first carina was measured using a fibrescope with the angle between the Frankfort plane and horizontal plane set at 110°. The location of the tube in relation to the vocal cords was then checked. These measurements were repeated at angles of 80° (flexion) and 130° (extension). The t-length and n-v-distance were then calculated using these measurements. RESULTS: On flexion, the t-length shortened significantly from 87.5 ± 10.4 mm to 82.9 ± 10.7 mm (P = 0.017) and the n-v-distance decreased from 128.1 ± 10.7 mm to 125.6 ± 10.4 mm (P = 0.294). On extension, the t-length increased significantly from 87.5 ± 10.4 mm to 92.7 ± 10.1 mm (P = 0.007) and the n-v-distance increased from 128.1 ± 10.7 mm to 129.4 ± 10.7 mm (P = 0.729). The change in t-length was significantly greater than that in the n-v-distance. CONCLUSION: A change in the position of the tracheal tube tip in the trachea depends mainly on changes in t-length during paediatric dental surgery.

Postoperative Alopecia Following Oral Surgery.

Postoperative alopecia is an uncommon complication and its outcome is an esthetically drastic change. Although its mechanism has not been clearly reported, risk factors might be positioning and prolonged operative time during oral surgeries. In addition, perioperative stressful conditions might influence the biological clock of the hair cycle. This report presents 2 cases of postoperative alopecia after oral surgery. Prevention of alopecia with type of headrest, change in head positioning, and avoidance of continuous compression is important.

Low-dose carperitide (α-human A-type natriuretic peptide) alleviates hemoglobin concentration decrease during prolonged oral surgery: a randomized controlled study.

PURPOSE: Surgical injury stimulates the renin-angiotensin-aldosterone system (RAAS) and causes antidiuresis, leading to postoperative oliguria. Carperitide (α-human A-type natriuretic peptide) is a cardiac peptide hormone secreted from the atrium. This peptide hormone enhances diuresis by suppressing the RAAS. In our experience, carperitide alleviates decreased hemoglobin (Hb) concentration during elective surgery. In the current study, we investigated the relationship between low-dose carperitide (0.01 µg/kg/min) and Hb concentration during oral surgery. METHODS: Patients (ASA-PS: I-II, 40-80 years old) undergoing oral maxillofacial surgery (duration of operation >8 h) were enrolled in this study. Patients were divided into two groups: the carperitide group received carperitide at 0.01 µg/kg/min and the control group received normal saline. Body fluid water [including total body water (TBW), extracellular water (ECW), and intracellular water (ICW)], urine volume, and chemical parameters such as Hb concentration, PaO2, and serum electrolytes were evaluated every 2 h. RESULTS: In the carperitide group (n = 15), Hb decreased from 12.6 ± 1.1 to 10.8 ± 1.5 g/dl, while it decreased from 12.6 ± 1.4 to 9.5 ± 1.3 g/dl in the control group (n = 15) (p < 0.05). Urine volume (2557.3 ± 983.5 mL) in the carperitide group was significantly more than it was in the control group (1108.8 ± 586.4 mL; p < 0.001). There were no significant differences in clinical characteristics, body fluid water, PaO2, and serum electrolytes between the two groups. In addition, there were no perioperative clinical respiratory and hemodynamic complications in the groups. CONCLUSION: The Hb concentration in the group administered low-dose carperitide at 0.01 µg/kg/min remained higher than that in the control group during surgery. Administration of low-dose carperitide may therefore reduce the risk of blood transfusion during surgery.

Risk Factors for Pressure Ulcers at the Ala of Nose in Oral Surgery.

A quality review revealed pressure ulcers at the ala of nose in 16 cases (2.2%) over 3 years. We therefore retrospectively investigated the risk factors for alar pressure ulcers from nasal tubes. Male gender was the highest risk factor (odds ratio = 9.1411; 95% confidence interval = 1.680-170.58), and the second highest risk factor was duration of anesthesia (odds ratio = 1.0048/min of anesthesia; 95% confidence interval = 1.0034-1.0065). Male gender and duration of anesthesia appear to be risk factors for nasal tube pressure ulcers at the ala of nose in patients.

The Anesthetic Management for a Patient With Trisomy 13.

Trisomy 13 is a chromosomal disorder that occurs in complete or partial mosaic forms. It is characterized by central apnea, mental retardation, seizure and congenital heart disease. The survival of the patients with trisomy 13 is the majority dying before one month. Trisomy 13 is the worst life prognosis among all trisomy syndromes. It is reported the cause of death is central apnea. Special needs patients with mental retardation are recognized to have poorer oral health condition. Oral health related quality of life reflects daily activity and well-being. Dental treatment under general anesthesia is sometimes an option for such patients. This patient had received ventricular septal defect closure surgery at 2-year-old. In addition, he had mental retardation and seizure. Dental treatment had been completed without any cerebral and cardiovascular events under non-invasive monitoring with not only cardiac electric velocimetry, but also epileptogenic activity. In addition, postoperative respiratory condition was maintained stable in room air.

[Anesthetic Management of a Patient with Rett Syndrome Presenting Severe Breath Holding and Massive Aerophagia].

We anesthetized a patient with Rett syndrome pre- senting intense breath holdings and severe aerophagia for dental treatment The patient had shown an intense breath holding plunging into hypoxia during slow induction with sevoflurane in previous anesthesias. Therefore, we chose rapid sequence induction with intravenous propofol and rocuronium and intubated orally. The length of glottis to tracheal bifurcation was shorter than average patient After a gastric tube was inserted and the content was aspirated, the orotracheal tube was changed to nasotracheal one. When she recovered from anesthesia at the quite deep stage, her saliva poured from nose and orally and began severe aerophagia. Once again, deep depth of anesthesia was kept, and we minimized stimulations for her. By. this approach, anesthesia was achieved uneventfully. In this case, she had signs of early-awakening from anesthesia.

Risk Factors for Postoperative Shivering After Oral and Maxillofacial Surgery.

PURPOSE: Postoperative shivering is a frequent complication of anesthesia. However, there are few reports about postoperative shivering in oral and maxillofacial surgery. Postoperative shivering in patients after osteotomy was observed from April 2008 to September 2015. This retrospective study investigated the risk factors of postoperative shivering in oral and maxillofacial surgery. PATIENTS AND METHODS: Anesthesia records of patients who underwent an osteotomy of the maxilla or mandible were checked. A patient's background (gender, age, height, and weight), anesthesia time, operative time, fentanyl, remifentanil, fluid volume, urine volume, blood loss volume, agent for anesthetic maintenance, rectal temperature at the end of surgery, and type of surgery were recorded in addition to the occurrence of postoperative shivering. In the univariate analysis, the Fisher exact test and the χ2 test were used, and a multivariable analysis was performed using stepwise logistic regression to determine risk factors of postoperative shivering. RESULTS: In this study, 233 cases were investigated, and 24 patients (11.5%) had postoperative shivering. The occurrence of postoperative shivering was correlated with blood loss volume (shivering group, 633.9 ± 404.8 mL; nonshivering group, 367.0 ± 312.6 mL; P < .01) and core temperature at the end of surgery (shivering group, 37.2 ± 0.6°C; nonshivering group, 37.5 ± 0.5°C; P < .01). Two variables were associated with postoperative shivering. Rectal temperature at the end of surgery was the highest risk factor (odds ratio = 2.560277; 95% confidence interval, 1.236774-5.327362), and blood loss volume was the next highest risk factor (odds ratio = 0.997733; 95% confidence interval, 0.999-0998). CONCLUSION: Clinicians should pay attention to postoperative shivering not only in patients with hypothermia but also in patients with substantial blood loss.

Anesthetic Management of a Patient With Emanuel Syndrome.

Emanuel syndrome is associated with supernumerary chromosome, which consists of the extra genetic material from chromosome 11 and 22. The frequency of this syndrome has been reported as 1 in 110,000. It is a rare anomaly associated with multiple systemic malformations such as micrognathia and congenital heart disease. In addition, patients with Emanuel syndrome may have seizure disorders. We experienced anesthetic management of a patient with Emanuel syndrome who underwent palatoplasty. This patient had received tracheotomy due to micrognathia. In addition, he had atrial septal defect, mild pulmonary artery stenosis, and cleft palate. Palatoplasty was performed without any complication during anesthesia. Close attention was directed to cardiac function, seizure, and airway management.

[Intravenous Sedation and Repeated "the Same Day General Anesthesia" for a School-age Boy with Dandy-Walker Syndrome and Dentinogenesis].

Dandy-Walker syndrome (DWS) is characterized by perfect or partial defect of the cerebellum vermis and cystic dilatation of the posterior fossa communicating with the fourth ventricle. Common clinical signs are mental retardation, cerebellar ataxia, and those of increased intracranial pressure (ICP). Associated congenital anomalies are craniofacial, cardiac, renal, and skeletal abnormalities. We experienced a case of intravenous sedation and six times of "the same day" general anesthesia for a school-aged boy (10-13 years old) with DWS and hypodentinogenesis. The patient underwent an examination and dental treatments. We had to pay attention to airway management tracheal tube selection and control of ICP. In addition, we should prevent tooth injuries through mishaps during tracheal intubations, since all-tooth-hypoplasia with fragile dental crowns was strongly suggested in this case. Detailed postoperative care is also required for general anesthesia afflicted with DWS.

[Anesthesia Management of a Patient with Pulmonary Atresia, Intact Ventricular Septum, Major Aortopulmonary Collateral Artery and Tetralogy of Fallot].

The patient was a 6-year-old girl with pulmonary atresia, intact ventricular septum and major aortopulmonary collateral artery with tetralogy of Fallot Her Sp(O2) was around 60% under room air, and she could not walk long. She underwent dental treatment under general anesthesia. Invasive monitoring using pulmonary artery catheter should have been avoided, since the risk of monitoring greatly exceeds that of the treatment. The patient entered the operating room with her mother, and anesthesia was induced with intravenous midazolam, propofol and vecuronium. She was intubated orally first and impedance cardiography monitoring was started. FI(O2) was maintained at 0.5-1.0. Increases in airway pressure and Pa(CO2) were appropriately avoided. Dental treatment is important for infants with cardiac disease not only to reduce their pain, but also to reduce the risk of infection. It often requires general anesthesia. We have to conduct it with less invasiveness and less stress.

Alternative Methods for Nasotracheal Intubation and Extubation in a Patient With Apert Syndrome.

Apert syndrome is a rare autosomal dominant disorder characterized by craniofacial abnormalities, craniosynostosis and syndactyly. Nasotracheal intubation for a patient with Apert syndrome can be a challenge because of abnormal facial anatomy. We experienced the anesthetic management of a patient with Apert syndrome who underwent partial resection of mandible and cleft palate repair with nasotracheal intubation. Nasotracheal intubation using a gastric tube and extubation using an airway exchange catheter proved useful in this case of airway compromise.

[Anesthetic management of a patient with osteogenesis imperfecta combined with mandibular defect].

Osteogenesis imperfecta (OI) is a rare hereditary disorder characterized by an excessive tendency to bone fractures and retarded growth. We report an anesthetic management of the patient with OI who has the history of vertebral bone fracture by coughing. A 44-year-old female underwent mandibular resection and reconstruction with a metal instrument due to ossifying fibroma 35 years ago. Since then, she had undergone mandibular resection and shaving the instrument several times because of recurrence of the tumor and/or fracture of the instrument. This time, some parts of the instrument were removed under general anesthesia since it had exposed from the skin. Difficulty in mask ventilation and intubation was predicted due to the defect of mandible and some muscles supporting the tongue and the pharynx. Awake fiber-optic nasotracheal intubation, therefore, was performed in consideration of airway obstruction. Dexmedetomidine was administered to reduce the risk of bone fracture in addition to low doses of midazolam and fentanyl. Considering incomplete respiration after extubation, the tracheal tube was extubated after inserting the tube exchanger into the trachea through the tube. The tube exchanger was pulled out after confirming spontaneous respiration and upper airway patency. The patient was cooperative, and respiratory and hemodynamic conditions were stable throughout.

Positional Change Used to Manage Postextubation Respiratory Failure in a Child With Cerebral Palsy.

Dental treatment for patients with cerebral palsy (CP) is often performed under general anesthesia due to involuntary movements that can render dental treatment difficult. Since CP is often accompanied by spasticity, care must be taken when positioning patients during general anesthesia. We report the management of a 14-year-old girl with CP and epilepsy undergoing general anesthesia for dental treatment who experienced respiratory failure due to acute thoracoabdominal muscle hypertonia after extubation. She had a history of cardiac arrest due to respiratory failure caused by acute muscle hypertonia and successful resuscitation. General anesthesia was induced after careful positioning of the patient to prevent spastic muscle stretching, and the dental treatment was completed without complications. However, upon awakening after extubation, the patient developed respiratory failure due to acute muscle hypertonia. The patient was resedated and repositioned from a supine to a sitting position, and her symptoms improved. There was no recurrence of muscle hypertonia, and she recovered fully without complications. In this case, respiratory failure associated with acute muscle hypertonia was successfully managed by position change after initial treatment with positive-pressure ventilation and propofol. It is important to be prepared for the possibility of respiratory failure associated with acute muscle hypertonia and its countermeasures when providing general anesthesia for patients with CP.

Simple Method for the Creation of a Bacteria-Sized Unilamellar Liposome with Different Proteins Localized to the Respective Sides of the Membrane.

Artificial cells are membrane vesicles mimicking cellular functions. To date, giant unilamellar vesicles made from a single lipid membrane with a diameter of 10 µm or more have been used to create artificial cells. However, the creation of artificial cells that mimic the membrane structure and size of bacteria has been limited due to technical restrictions of conventional liposome preparation methods. Here, we created bacteria-sized large unilamellar vesicles (LUVs) with proteins localized asymmetrically to the lipid bilayer. Liposomes containing benzylguanine-modified phospholipids were prepared by combining the conventional water-in-oil emulsion method and the extruder method, and green fluorescent protein fused with SNAP-tag was localized to the inner leaflet of the lipid bilayer. Biotinylated lipid molecules were then inserted externally, and the outer leaflet was modified with streptavidin. The resulting liposomes had a size distribution in the range of 500-2000 nm with a peak at 841 nm (the coefficient of variation was 10.3%), which was similar to that of spherical bacterial cells. Fluorescence microscopy, quantitative evaluation using flow cytometry, and western blotting proved the intended localization of different proteins on the lipid membrane. Cryogenic electron microscopy and quantitative evaluation by α-hemolysin insertion revealed that most of the created liposomes were unilamellar. Our simple method for the preparation of bacteria-sized LUVs with asymmetrically localized proteins will contribute to the creation of artificial bacterial cells for investigating functions and the significance of their surface structure and size.

Comparison of different methods of more effective chest compressions during cardiopulmonary resuscitation (CPR) in the dental chair.

Introduction: When performing cardiopulmonary resuscitation (CPR) on a patient who has suffered a cardiopulmonary arrest during dental treatment, few dental chairs have sufficient stability to perform effective chest compressions. We previously proposed a method of stabilizing the backrest of a dental chair using a support stool. As a result, we confirmed that the vertical displacement of the backrest could be significantly reduced. In the present study, we verified the effectiveness of the stool stabilization method using several dental chairs (flat and curved) with significantly different backrest shapes. Methods: Vertical displacement of the backrests of dental chairs was recorded. Data were obtained at three different stool positions (without a stool, under the chest at the level that participants were performing manual chest compressions, and under the shoulders). Reduction displacement ratios were calculated to evaluate the effectiveness of the stool positions. Results: The method significantly reduced the vertical displacement of the backrest for all types. When the curvature of the backrest was large, the reduction in vertical displacement was 40% when the stool was placed under the chest at the level of manual chest compressions and 65% when placed underneath the shoulder. In the case of a flat dental chair, this reduction was 90% when using a stool in either position, compared to no stool. Conclusion: When we need to perform CPR on a patient in the dental chair, placing a stool under the shoulders allows effective manual chest compression by firmly supporting the backrest of a dental chair of any shape.