Difficult intubation caused by an immature upper airway in a patient with cri-du-chat syndrome: a case report.

Cri-du-chat syndrome (CdCS) is caused by the deletion of the short arm of chromosome 5. Most patients with CdCS develop intellectual disabilities. Therefore, they have poor oral hygiene and a high caries index. However, treating such patients is not an easy task, because of the difficulty in communication. General anesthesia may be a useful option in adult patients with CdCS and intellectual disability. General anesthesia should be administered very carefully, owing to the presence of comorbid diseases, which may need airway management. Infants with CdCS need general anesthesia if they have a concomitant cardiac anomaly. Intubation is reportedly difficult for such patients was, owing to the structural and functional abnormalities in the larynx and vocal cords. The purpose of this study was to report a case of difficult intubation while inducing general anesthesia in a patient with CdCS during dental treatment, due to a narrow larynx and trachea.

Analysis of the effect of oral midazolam and triazolam premedication before general anesthesia in patients with disabilities with difficulty in cooperation.

BACKGROUND: When performing dental treatment under general anesthesia in adult patients who have difficulty cooperating due to intellectual disabilities, anesthesia induction may be difficult as well. In particular, patients who refuse to come into the dental office or sit in the dental chair may have to be forced to do so. However, for adult patients with a large physique, physical restraint may be difficult, while oral sedatives as premedication may be helpful. Here, a retrospective analysis was performed to investigate the effect of oral sedatives. METHODS: A hospital-based medical information database was searched for patients who were prescribed oral midazolam or triazolam between January 2009 and December 2017. Pre-anesthesia evaluation, anesthesia, and anesthesia recovery records of all patients were analyzed, and information on disability type, reason for prescribing oral sedatives, prescribed medication and dose, cooperation level during anesthesia induction, anesthesia duration, length of recovery room stay, and complications was retrieved. RESULTS: A total of 97 patients were identified, of whom 50 and 47 received midazolam and triazolam, respectively. The major types of disability were intellectual disabilities, autism, Down syndrome, blindness, cerebral palsy, and epilepsy. Analyses of changes in cooperation levels after drug administration showed that anesthesia induction without physical restraint was possible in 56.0% of patients in the midazolam group and in 46.8% of patients in the triazolam group (P = 0.312). CONCLUSIONS: With administration of oral midazolam or triazolam, general anesthesia induction without any physical restraint was possible in approximately 50% of patients, with no difference between the drugs.

A retrospective analysis of outpatient anesthesia management for dental treatment of patients with severe Alzheimer's disease.

BACKGROUND: The number of patients with Alzheimer's disease is growing worldwide, and the proportion of patients requiring dental treatment under general anesthesia increases with increasing severity of the disease. However, outpatient anesthesia management for these patients involves great risks, as most patients with Alzheimer's disease are old and may show reduced cardiopulmonary functions and have cognitive disorders. METHODS: This study retrospectively investigated 43 patients with Alzheimer's disease who received outpatient anesthesia for dental treatment between 2012-2017. Pre-anesthesia patient evaluation, dental treatment details, anesthetics dose, blood pressure, duration and procedure of anesthesia, and post-recovery management were analyzed and compared between patients who underwent general anesthesia or intravenous sedation. RESULTS: Mean age of patients was about 70 years; mean duration of Alzheimer's disease since diagnosis was 6.3 years. Severity was assessed using the global deterioration scale; 62.8% of patients were in level ≥ 6. Mean duration of anesthesia was 178 minutes for general anesthesia and 85 minutes for intravenous sedation. Mean recovery time was 65 minutes. Eleven patients underwent intravenous sedation using propofol, and 22/32 cases involved total intravenous anesthesia using propofol and remifentanil. Anesthesia was maintained with desflurane for other patients. While maintaining anesthesia, inotropic and atropine were used for eight and four patients, respectively. No patient developed postoperative delirium. All patients were discharged without complications. CONCLUSION: With appropriate anesthetic management, outpatient anesthesia was successfully performed without complications for dental treatment for patients with severe Alzheimer's disease.

Learning fiberoptic intubation for awake nasotracheal intubation.

BACKGROUND: Fiberoptic nasotracheal intubation (FNI) is performed if it is difficult to open the mouth or if intubation using laryngoscope is expected to be difficult. However, training is necessary because intubation performed by inexperienced operators leads to complications. METHODS: Every resident performed intubation in 40 patients. Success of FNI was evaluated as the time of FNI. First intubation time was restricted to 2 min 30 s. If the second attempt was unsuccessful, it was considered a failed case, and a specialist performed nasotracheal intubation. If the general method of intubation was expected to be difficult, awake intubation was performed. The degree of nasal bleeding during intubation was also evaluated. RESULTS: The mean age of the operators (11 men, 7 women) was 27.8 years. FNI was performed in a total of 716 patients. The success rate was 88.3% for the first attempt and 94.6% for the second attempt. The failure rate of intubation in anesthetized patients was 4.9%, and 13.6% in awake patients. When intubation was performed in anesthetized patients, the failure rate from the first to fifth trial was 9.6%, which decreased to 0.7% when the number of trials increased to > 30 times. In terms of awake intubation, there was no failed attempt when the resident had performed the FNI > 30 times. The number of FNIs performed and nasal bleeding were important factors influencing the failure rate. CONCLUSION: The success rate of FNI increased as the number of FNI performed by residents increased despite the nasal bleeding.

Anesthetic management for simultaneous drug-induced sleep endoscopy and maxillomandibular advancement in a patient with obstructive sleep apnea.

Drug-induced sleep endoscopy (DISE) is used to identify areas of upper airway obstruction, which occurs when patients with obstructive sleep apnea (OSA) snore. DISE enables effective diagnosis and appropriate treatment of the obstruction site. Among surgical treatment methods for OSA, maxillomandibular advancement surgery (MMA) is performed to move a jaw forward; the surgery has a high success rate for OSA treatment. In DISE, anesthetics such as propofol and midazolam must be administered to induce snoring while the patient is deeply sedated for an accurate diagnosis to be made. When inducing deep sedation in a patient with OSA, airway obstruction may increase, causing oxygen saturation to drop; airway interventions are necessary in such cases. Effective DISE and MMA surgery can be performed by administering propofol through target-controlled infusion while monitoring the bispectral index (BIS).