Repeated anesthetic management for a patient with Klippel-Feil syndrome.

Klippel-Feil syndrome (KFS) is a rare disease characterized by a classic triad comprising a short neck, a low posterior hairline, and restricted motion of the neck due to fused cervical vertebrae. We report repeated anesthetic management for orthognathic surgeries for a KFS patient with micrognathia. Because KFS can be associated with a number of other anomalies, we therefore performed a careful preoperative evaluation to exclude them. The patient had an extremely small mandible, significant retrognathia, and severe limitation of cervical mobility due to cervical vertebral fusion. As difficult intubation was predicted, awake nasal endotracheal intubation with a fiberoptic bronchoscope was our first choice for gaining control of the patient's airway. Moreover, the possibility of respiratory distress due to postoperative laryngeal edema was considered because of the surgeries on the mandible. In the operating room, tracheotomy equipment was always kept ready if a perioperative surgical airway control was required. Three orthognathic surgeries and their associated anesthetics were completed without a fatal outcome, although once the patient was transferred to the intensive care unit for precautionary postoperative airway management and observation. Careful preoperative examination and preparation for difficult airway management are important for KFS patients with micrognathia.

Recovery of dynamic balance after general anesthesia with sevoflurane in short-duration oral surgery.

PURPOSE: Recovery of dynamic balance, involving adjustment of the center of gravity, is essential for safe discharge on foot after ambulatory anesthesia. The purpose of this study was to assess the recovery of dynamic balance after general anesthesia with sevoflurane, using two computerized dynamic posturographies. METHODS: Nine hospitalized patients undergoing oral surgery of less than 2 h duration under general anesthesia (air-oxygensevoflurane) were studied. A dynamic balance test, assessing the ability of postural control against unpredictable perturbation stimuli (Stability System; Biodex Medical), a walking analysis test using sheets with foot pressure sensors (Walk Way-MG1000; Anima), and two simple psychomotor function tests were performed before anesthesia (baseline), and 150 and 210 min after the emergence from anesthesia. RESULTS: Only the double-stance phase in the walking analysis test showed a significant difference between baseline and results at 150 min. None of the other variables showed any differences among results at baseline and at 150 and 210 min. CONCLUSION: The recovery times for dynamic balance and psychomotor function seem to be within 150 min after emergence from general anesthesia with sevoflurane in patients undergoing oral surgery of less than 2-h duration.

Fitting complete dentures after multiple tooth extraction in a patient with severe dementia.

Complete dentures were constructed after tooth extraction for a 71-year-old uncommunicative patient with Alzheimer's disease. Although she had never previously used them, her husband requested the fitting of complete maxillary and mandibular dentures. Thirteen teeth were extracted under local anesthesia and intravenous sedation (IVS), followed by impression-making under IVS. Denture fabrication and adjustment were carried out under mild physical restraint. A tissue conditioner was applied to the fitting surface of the denture base followed by regular denture adjustments. The time required for the patient to eat a meal decreased from 90 minutes without dentures to 30 minutes with dentures due to an improvement in swallowing. Important factors in the successful fitting and use of dentures in this patient were the use of IVS to control behavior during treatment, the treatment plan focused on painless denture use, and oral care by the patient's husband.

Clinical study of anesthetic management during dental treatment of 25 patients with cardiomyopathy.

This retrospective study analyzed the management of 25 patients with hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), or dilated phase of hypertrophic cardiomyopathy (dHCM) treated in the outpatient clinic of the Department of Dental Anesthesiology at Hokkaido University. A total of 87 dental treatment sessions were completed. Intravenous sedation was used significantly more often for patients with HCM than those who had DCM. This seemed to be because dental anesthesiologists expected sedative drugs to suppress hyperdynamic circulatory changes caused by mental stress. Intraoperative complications occurred during 19 treatments. The incidence of circulatory complications increased when participants with DCM also reported dental fear. For participants with HCM who reported dental fear, circulatory complications occurred only when sedation was not used. It is not clear whether complications were related to cardiac function or dental treatment. Therefore, it is important to continually monitor patients with these conditions and to be prepared to handle complications that may arise during dental treatment.

Recovery of postural stability following conscious sedation with midazolam in the elderly.

PURPOSE: To investigate the differences in recovery of postural stability, after obtaining similar intravenous sedation levels with midazolam, in elderly and younger patients undergoing dental surgery. METHODS: We studied 15 elderly patients (>65 years) and 15 younger patients (<55 years) after intravenous sedation. Midazolam was carefully titrated over 4-5 min until slow response to verbal commands, ptosis of the eyelid, or slight slurring of speech was obtained. Parameters were postural balance tests and an addition test, as a psychomotor function test. RESULTS: The dose of midazolam in the elderly group (0.045 +/- 0.012 mg.kg(-1)) was 62% of that in the younger group (0.074 +/- 0.026 mg.kg(-1)). In evaluation of the percentile rank of a balance test with a visual feedback system, which contained a dynamic balance element, recovery at 60 min in the elderly group was significantly slower than that in the younger group. However, the recovery times for the balance test and the addition test, at which the significantly changed values were restored to the baseline values, were 120 min and 90 min, respectively, in both groups. CONCLUSION: In the recovery from sedation, elderly patients had more difficulty in acquiring postural adjustment during movement than in maintaining a standing posture. If the dose is carefully administered, however, even elderly patients might be able to return home 2 h after midazolam administration, as could the younger patients.