Safety and Efficacy of IV Dexmedetomidine as an Adjunct to Propofol to Sedate Anxious and Uncooperative Pediatric Dental Patients: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the safety and efficacy of dexmedetomidine (dex) as an adjunct to propofol sedation in pediatric dental patients. STUDY DESIGN: This RCT enrolled 30 anxious ASA-I 2-5 year olds. Allocated into 2 groups either receiving IV propofol (1 mg/kg)(Gp-P) or [IV dex (1ug/kg) with propofol(1 mg/kg)] (Gp-D) after oral midazolam premedication (0.5 mg/kg). Sedation maintained with propofol infusion at 50-75ug/kg/min. Additional bolus/es of propofol (1mg/kg) was/were administered in case of inadequate sedation. Primary outcome was to compare requirement of propofol in two groups. Secondary outcomes were to compare vital signs, depth of sedation, induction, treatment and recovery time, intra & post-operative complications and analgesic requirement post-operatively. RESULTS: Total propofol (in mgs) used and number of additional boluses were significantly higher in group P (p<0.05). Although within normal limits, heart rate was significantly lower in group D. Respiratory rate, oxygen saturation, NIBP were comparable. Depth of sedation achieved was comparable at all steps (p>0.05). Induction time (mins) was significantly lower in Group P (p<0.05), however treatment and recovery time were similar (p>0.05). Desaturation was observed in 3/15(group P) & 0/15(group D). Analgesic requirement post-operatively was significantly higher in group P (p<0.05). CONCLUSION: Dexmedetomidine is a safe and effective adjunct to propofol.

Oral Midazolam Sedation For Uncooperative Children In Outpatient Paedodontics: Time For Reappraisal.

Sedation is frequently desired to facilitate dental procedures in uncooperative paediatric patients. Oromucosal Midazolam sedation is a popular choice among paediatric dentists world wide due to its many advantages such as ease of administration, good efficacy, presence of reversal agents and a wide margin of safety. On the other hand, many investigators have reported that midazolam sedation may not be successful for carrying out all types of dental procedures. This may be attributed to diverse nature of various treatment plans coupled with the extent of behavioural changes in the child and operator's experience. Due to the heterogeneity involved in treatment of paediatric dental procedures, the specific indications for oral midazolam use that ensure its success rate, probably need to be defined. This may enable the clinicians to have a convenient and quicker option for managing the cases rather than facing sedation failure or at times, ending up giving general anaesthetics. This article therefore brings forth the possible causes of midazolam sedation failure and proposes a 'case selection criterion'.

Heister mouth gag aided endotracheal intubation in patients with maxillofacial trauma: A case report.

Securing the airway in patients with maxillofacial trauma is challenging for the anesthesiologist. Pain and facial deformities limit mouth opening and hence direct laryngoscopy. Fractured bone segments, blood, oral secretions, and tissue edema preclude the use of fiber-optic bronchoscopes for intubation of the trachea. We report a successful attempt of orotracheal intubation with a Macintosh blade in a 25-year-old patient with restricted mouth opening with the use of a Heister mouth gag.

Submucous fibrosis secondary to chewing of quids: another cause of unanticipated difficult intubation.

PURPOSE: To report a case of unusual difficult intubation secondary to oral submucosal fibrosis (SMF) associated with malignancy of the hypopharynx. CLINICAL FEATURES: A 57-yr-old male, ASA-I physical status presented for percutaneous nephrolithotripsy. The patient was a known alcoholic and smoker with a habit of chewing quids for the past 36 years. Airway assessment revealed oral SMF and slight difficulty in opening the mouth fully. Mentohyoid and mentothyroid distances were normal. However, during intubation, unanticipated difficulty was encountered. On direct laryngoscopy, the tip of the epiglottis could barely be visualized. Intubation was possible after passing a gum elastic bougie blindly under the epiglottis and negotiating a 7.0 internal diameter tracheal tube over it. Postoperatively, indirect laryngoscopy (IDL) showed severe SMF involving the oral cavity, epiglottis and pyriform fossae and an ulcerative malignancy of the hypopharynx with fixation of the left hemilarynx. CONCLUSION: SMF is a premalignant condition of the oral cavity associated with fibrosis of involved structures that can be associated with malignancy of the aerodigestive tract. Distortion of the airway anatomy may render intubation difficult. IDL maybe useful in the preoperative evaluation of these patients.