Effect of midazolam in autism spectrum disorder: A retrospective observational analysis.

BACKGROUND: While midazolam is commonly used as premedication for uncooperative patients, its effects are difficult to predict in patients with autism spectrum disorder for whom abnormalities in gamma-aminobutyric acid have been reported. This study aimed to investigate the influence of autism spectrum disorder on the effect of midazolam when used as premedication. METHODS: This retrospective observational study was performed between April 2017 and August 2018. Before inducing general anesthesia with sevoflurane for dental treatment, 390 uncooperative patients received premedication with midazolam. Ordinal logistic regression analysis was performed with the Observer's Assessment of Alertness/Sedation score 30 min after premedication as the objective variable. Age, sex, American Society of Anesthesiologists physical status class, premedication route, dose per body weight, presence of specific disorders (autism spectrum disorder, intellectual disability, epilepsy, cerebral palsy, and other psychiatric disorders), and regular benzodiazepine or non-benzodiazepine psychotropic administration were included as explanatory variables. Kendall's rank correlation coefficient was used to assess the correlation between the Observer's Assessment of Alertness/Sedation score and cooperation level (1, obvious negative response; 2, negative response; 3, positive reaction; 4, obvious positive reaction) during admission and inhalation induction. All data were extracted from anesthesia and medical records. RESULTS: Age (odds ratio 1.437 [95% confidence interval (CI) 1.213-1.708], P < .001), autism spectrum disorder (1.318 [1.079-1.612], P = .007), benzodiazepine medication (0.574 [0.396-0.827], P = .002), and intramuscular route (1.478 [1.137-1.924], P = .004) were significantly associated with the Observer's Assessment of Alertness/Sedation score, while the score was negatively associated with cooperation levels during admission (τ = -0.714, P < .001) and inhalation induction (τ = -0.606, P < .001). CONCLUSIONS: Patients with autism spectrum disorder may be susceptible to premedication with midazolam; however, regular benzodiazepine administration may reduce the effect.

Evaluation of the effects of manual acupuncture and electroacupuncture at LI4 and LI11 on perception thresholds: a prospective crossover trial.

OBJECTIVE: The objective of the study was to investigate and compare the effects of manual acupuncture (MA) and electroacupuncture (EA) on current perception thresholds (CPTs) using quantitative methods. METHODS: Twenty-nine healthy volunteers participated in this prospective crossover trial, in which three acupuncture methods were compared: control, MA, and EA. Acupuncture needles were inserted to a depth of 15 mm at LI4 and LI11 on the left side and retained for 30 min with or without electrical stimulation at a frequency of 2 Hz (EA and MA, respectively). The needles were removed and participants rested for 30 min. CPT in the left mental region was measured at 2000, 250, and 5 Hz, corresponding to the activation of Aß, Aδ, and C-fibers, respectively, at four time points: baseline, T0; 15 min after needle application, T1; immediately after needle removal, T2; and 30 min after needle removal, T3. In the control session, only a sensory test was performed (without acupuncture). RESULTS: Significant effects of time course on CPT were observed (p < 0.001). CPT values increased significantly at T1, T2, and T3, compared with those at T0, at all stimulation frequencies during MA and EA. Changes in CPT values with EA were not significantly greater than those with MA. CONCLUSIONS: Both MA and EA increased the sensory thresholds of Aß, Aδ, and C-fibers in the mental region for ⩾30 min after needle removal. Additional of electrical stimulation may not confer additional benefits over needling alone. TRIAL REGISTRATION NUMBER: UMIN000017983 (University Hospital Medical Information Network Clinical Trials Registry).

Enhanced Ocular Surface and Intraoral Nociception via a Transient Receptor Potential Vanilloid 1 Mechanism in a Rat Model of Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA), characterized by low arterial oxygen saturation during sleep, is associated with an increased risk of orofacial pain. In this study, we simulated chronic intermittent hypoxia (CIH) during the sleep/rest phase (light phase) to determine the role of transient receptor potential vanilloid 1 (TRPV1) in mediating enhanced orofacial nocifensive behavior and trigeminal spinal subnucleus caudalis (Vc) neuronal responses to capsaicin (a TRPV1 agonist) stimulation in a rat model of OSA. Rats were subjected to CIH (nadir O2, 5%) during the light phase for 8 or 16 consecutive days. CIH yielded enhanced behavioral responses to capsaicin after application to the ocular surface and intraoral mucosa, which was reversed under normoxic conditions. The percentage of TRPV1-immunoreactive trigeminal ganglion neurons was greater in CIH rats than in normoxic rats and recovered under normoxic conditions after CIH. The ratio of large-sized TRPV1-immunoreactive trigeminal ganglion neurons increased in CIH rats. The density of TRPV1 positive primary afferent terminals in the superficial laminae of Vc was higher in CIH rats. Phosphorylated extracellular signal-regulated kinase (pERK)-immunoreactive cells intermingled with the central terminal of TRPV1-positive afferents in the Vc. The number of pERK-immunoreactive cells following low-dose capsaicin (0.33 µM) application to the tongue was significantly greater in the middle portion of the Vc of CIH rats than of normoxic rats and recovered under normoxic conditions after CIH. These data suggest that CIH during the sleep (light) phase is sufficient to transiently enhance pain on the ocular surface and intraoral mucosa via TRPV1-dependent mechanisms.

Clinical Use of Preformed Microcuff® Pediatric Endotracheal Tubes in Japan.

Preformed cuffed oral endotracheal tubes are widely used to intubate children undergoing oral surgery. To evaluate the efficacy and safety of oral Ring-Adair-Elwyn (RAE) Microcuff® pediatric endotracheal tubes, we retrospectively investigated the endotracheal tube exchange rate and associated complications in Japanese children younger than 2 years of age undergoing cheiloplasty or palatoplasty. The exchange rate was 3.5%, and although unplanned extubations occurred in 2 patients, no severe complications were observed. Our results suggest that oral RAE Microcuff® tubes are effective and safe for intubating Japanese children younger than 2 years of age, with a low tube exchange rate and minor complications.

Mandibular advancement impairs swallowing ability more than head extension but less than mouth opening in the supine position.

Mandibular advancement in the supine position may influence swallowing during dental treatment under intravenous sedation. This study investigated the influence of mandibular advancement in the supine position on swallowing ability, compared with head extension and mouth opening. The water swallowing test was performed in 13 healthy, awake, supine, adult subjects under four head and mandibular positions. An electromyogram of the suprahyoid muscles was recorded; the duration and peak amplitude were examined. A greater volume of water remained in the mouth during mouth opening and mandibular advancement relative to the neutral position; the volume in the mandibular advancement position was larger and smaller than that in the head extension position and during mouth opening, respectively. The duration of the electromyogram in the head extension position was longer than that in the mandibular advancement position, without differences in the amplitude. Thus, swallowing ability in the supine position was more impaired with mandibular advancement, relative to neutral and head extension positions, but less than that observed with mouth opening. Although unconfirmed by electromyogram, our findings suggest that head extension might improve airway patency by reducing the impairment of swallowing ability compared with mandibular advancement.

Age-based prediction of uncuffed tracheal tube size in children to prevent inappropriately large tube selection: a retrospective analysis.

BACKGROUND: This study aims to validate our previously reported prediction technique for uncuffed tracheal tube (TT) sizes in children younger than 2 years of age based on a calculated outer diameter (ODCal, mm) in each patient according to the regression equation ODCal = 0.00223 × age (day) + 4.88 and to investigate a better method to select initial TT sizes to decrease re-intubation frequency, especially since large tubes can damage the trachea. METHODS: We included patients younger than 2 years of age who underwent oral surgery under general anesthesia with tracheal intubation between July 2011 and December 2016 at the Osaka University Dental Hospital. The OD of the actual TT and the age in days were extracted from anesthesia records. Agreement rates, estimated numbers of required tubes, and size reduction frequencies were compared to obtain recommended OD (ODRec) values in 2 selection groups: "average selection" in the range "nearest to the ODCal value (ODCal - 0.35 < ODRec ≤ ODCal + 0.35)" and "safe selection" in the range "nearest to the value below ODCal (ODCal - 0.7 < ODRec ≤ ODCal)". RESULTS: The agreement rates for an ODRec in the average selection and safe selection groups were 60.8 and 55.1%, respectively (P = 0.001). The estimated number of required tubes per patient were 1.40 ± 0.51 and 1.47 ± 0.55 (P < 0.001), respectively. The estimated frequencies of size reductions were 13.3 and 4.0% (P < 0.001), respectively. CONCLUSIONS: Because the size reduction frequency is lower despite a slightly higher number of required TTs, selecting an ODRec based on "safe selection" parameters is desirable to avoid complications due to intubation with larger TTs.

Anaphylaxis with delayed appearance of skin manifestations during general anesthesia: two case reports.

BACKGROUND: Anaphylaxis is difficult to diagnose in the absence of skin or mucosal signs and symptoms. We report two cases of anaphylaxis under general anesthesia, in which the initial presentation was in the form of respiratory signs, followed by skin manifestations 10-15 min later. Diagnosis of anaphylaxis was delayed because skin symptoms were absent early on in the presentation. CASE PRESENTATION: In the first case, a 23-year-old male patient with jaw deformity was scheduled to undergo maxillary alveolar osteotomy. After intubation, auscultation indicated a sudden decrease in breath sounds, together with severe hypotension. Approximately 10 min later, flushing of the skin and urticaria on the thigh appeared and spread widely throughout the body. In the second case, a 21-year-old female patient with jaw deformity was scheduled to undergo maxillomandibular osteotomy. Twenty minutes after the start of dextran infusion, her lungs suddenly became difficult to ventilate, and oxygen saturation decreased to 90%. Approximately 15 min later, flushing of the skin and urticaria were observed. CONCLUSION: In both cases, there was a time lag between the appearance of respiratory and skin symptoms, which resulted in a delay in the diagnosis, and hence, treatment of anaphylaxis. Our experience highlights the fact that it is difficult to diagnose anaphylaxis under general anesthesia.

Trigeminal nervous system sensitization by infraorbital nerve injury enhances responses in a migraine model.

Background Although the peripheral and central sensitizations of trigeminal nervous system may be one of the important factors of migraine, the precise mechanism is not fully understood. In this study, we examined the influence of the sensitization of the second division of the trigeminal nerve (V2) by chronic constriction injury (CCI) of the infraorbital nerve (ION) on migraine headache, using the capsaicin-induced migraine model. Methods Male Sprague-Dawley rats were assigned to four groups: (a) sham surgery and topical-dural vehicle application (Sham + Vehicle) group, (b) CCI-ION and topical-dural vehicle application (CCI-ION + Vehicle) group, (c) sham surgery and topical-dural capsaicin application (Sham + Capsaicin) group, (d) CCI-ION and topical-dural capsaicin application (CCI-ION + Capsaicin) group. Behavioral testing and immunohistochemical staining were performed. Results In the behavioral test, the Sham + Capsaicin group showed significantly longer duration of immobilization and shorter duration of exploration compared with the Sham + Vehicle group, which is similar to clinical features of migraine patients. Moreover, CCI-ION enhanced these effects in the CCI-ION + Capsaicin group. Immunohistochemical staining for phospho-extracellular signal-related kinase (pERK) in the trigeminal ganglion (TG) containing first and second divisions of the trigeminal nerve and the trigeminocervical complex (TCC) revealed that pERK expression was significantly increased in the CCI-ION + Capsaicin group compared with the other groups. However, comparing between effects of the peripheral and central sensitizations (in the TG and TCC), from our results, peripheral sensitization would play a much less or not significant role. Conclusions These data demonstrate that the sensitization of V2 could influence the activation and the sensitization of the first division of the trigeminal nerve in the TCC, subsequently exacerbating pain sensation and pain-related behaviors. We have shown for the first time that the existence of the central sensitization of V2 can be an exacerbating factor for migraine related nociceptive thresholds/activation.

Estrogens Exacerbate Nociceptive Pain via Up-Regulation of TRPV1 and ANO1 in Trigeminal Primary Neurons of Female Rats.

Several trigeminal pain disorders show sex differences, and high levels of estrogens may underlie these differences. The interaction between transient receptor potential vanilloid 1 (TRPV1) and anoctamin 1 (ANO1) plays an important role in peripheral nociception. However, whether TRPV1 and ANO1 are involved in estrogen-modulated trigeminal pain sensitivity is unclear. In this study, we examined estradiol (E2) modulation of nociception through behavioral and immunohistological experiments after application of capsaicin (Cap), a selective TRPV1 agonist, onto the ocular surface in ovariectomized rats treated with high-dose E2 (HE) or low-dose E2 (LE) for 2 days. In addition, we used real-time PCR to study the effects of E2 on the expression levels of TRPV1 and ANO1 mRNA in trigeminal ganglia. In the behavioral experiment, the HE group showed significant potentiation of Cap-evoked nocifensive behavior compared with the LE group. Immunohistochemistry showed that Cap evoked a significantly greater number of cells that were immunoreactive for c-Fos, a marker of nociceptive activation, in the trigeminal subnucleus caudalis/upper cervical cord in the HE group than in the LE group. The number of c-Fos-immunoreactive cells in the ventral trigeminal interpolaris/caudalis were similar in the 2 groups. Real-time PCR showed that the levels of TRPV1 and ANO1 mRNA in the HE group were significantly higher than levels in the LE group. Thus, high levels of estrogens may be a risk factor for Cap-evoked nociceptive pain, and estrogen-dependent increases in TRPV1 and ANO1 are likely involved in modulating the nociceptive response in the trigeminal area.

Effective Dosage of Midazolam to Erase the Memory of Vascular Pain During Propofol Administration.

Intravenous sedation with propofol is often administered to anxious patients in dental practice. Pain on injection of propofol is a common adverse effect. This study aimed to determine the age-adjusted doses of midazolam required to erase memory of vascular pain of propofol administration and assess whether the Ramsay Sedation Scale (RSS) after the pretreatment of midazolam was useful to predict amnesia of the vascular pain of propofol administration. A total of 246 patients with dental phobia requiring dental treatment under intravenous sedation were included. Patients were classified according to their age: 30s, 40s, 50s, and 60s. Three minutes after administration of a predetermined dose of midazolam, propofol was infused continuously. After completion of the dental procedure, patients were interviewed about the memory of any pain or discomfort in the injection site or forearm. The dosage of midazolam was determined using the Dixon up-down method. The first patient was administered 0.03 mg/kg, and if memory of vascular pain remained, the dosage was increased by 0.01 mg/kg for the next patient, and then if the memory was erased, the dosage was decreased by 0.01 mg/kg. The effective dosage of midazolam in 95% of each age group for erasing the memory of propofol vascular pain (ED95) was determined using logistic analysis. The accuracy of RSS to predict the amnesia of injection pain was assessed by receiver operating characteristic (ROC) analysis. The ED95 of midazolam to erase the memory of propofol vascular pain was 0.061 mg/kg in patients in their 30s, 0.049 mg/kg in patients in their 40s, 0.033 mg/kg in patients in their 50s, and 0.033 mg/kg in patients in their 60s. The area under the ROC curve was 0.31. The ED95 of midazolam required to erase the memory of propofol vascular pain demonstrated a downward trend with age. On the other hand, it was impossible to predict the amnesia of propofol vascular pain using the RSS.

Premedication with midazolam in intellectually disabled dental patients: Intramuscular or oral administration? A retrospective study

BACKGROUND: The use of midazolam for dental care in patients with intellectual disability is poorly documented. The purpose of this study was to determine which method of premedication is more effective for these patients, 0.15 mg/kg of intramuscular midazolam or 0.3 mg/kg of oral midazolam. MATERIAL AND METHODS: This study was designed and implemented as a non-randomized retrospective study. The study population was composed of patients with intellectual disability who required dental treatment under ambulatory general anesthesia from August 2009 through April 2013. Patients were administered 0.15 mg/kg of midazolam intramuscularly (Group IM) or 0.3 mg/kg orally (Group PO). The predictor variable was the method of midazolam administration. The outcome variables measured were Observer's Assessment of Alertness/ Sedation (OAA/S) Scale scores, the level of cooperation when entering the operation room and for venous cannulation, post-anesthetic agitation and recovery time. RESULTS: Midazolam was administered intramuscularly in 23 patients and orally in 21 patients. More patients were successfully sedated with no resistance behavior during venous cannulation in Group PO than in Group IM (p = 0.034). There were no differences in demographic data and other variables between the groups. CONCLUSIONS: The results of this study suggest that oral premedication with 0.3 mg/kg of midazolam is more effective than 0.15 mg/kg of midazolam administered intramuscularly, in terms of patient resistance to venous cannulation. If both oral and intramuscular routes of midazolam are acceptable in intellectually disabled patients, the oral route is recommended

Effectiveness of dexmedetomidine for emergence agitation in infants undergoing palatoplasty: a randomized controlled trial / Eficácia de dexmedetomidina para o surgimento de agitação em lactentes submetidos à palatoplastia: estudo clínico randomizado

OBJECTIVES: In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty. METHODS: A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n = 35) and saline (n = 35). In the Dex group, Dex (6 µg/kg/h) was administered approximately 10 min before the end of the surgery for 10 min, followed by 0.4 µg/kg/h until 5 min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120 min after arrival in PACU). RESULTS: EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120 min after arrival in PACU. CONCLUSIONS: Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty.

OBJETIVOS: Em crianças, é elevada a incidência de surgimento de agitação (SA) em seguida à anestesia com sevoflurano (Sev). Este estudo teve como objetivo testar a hipótese de que a administração de dexmedetomidina (Dex) reduziria a incidência e a gravidade do SA após anestesia com Sev em lactentes submetidos à palatoplastia. MÉTODOS: Estudo clínico prospectivo randomizado, feito com 70 pacientes submetidos a uma palatoplastia, com 10-14 meses. As crianças foram divididas randomicamente em dois grupos: Dex (n = 35) e solução salina (n = 35). No grupo de Dex, Dex (6 µg/kg/h) foi administrada cerca de 10 minutos antes do fim da cirurgia durante 10 minutos, seguida de 0,4 µg/kg/h até 5 minutos após a extubação. No grupo de solução salina, uma quantidade equivalente de salina foi administrada com o mesmo esquema de dosagem. Após a cirurgia, os pacientes foram transferidos para a unidade de cuidados pós-anestésicos (UCPA). O comportamento e a dor dos bebês foram avaliados com um sistema de pontuação para SA (escala de classificação de 5 pontos) e com uma escala de dor (ED; escala de classificação de 10 pontos), respectivamente. SA e ED foram estimados em seis pontos cronológicos (após a extubação, ao deixar a sala de cirurgia e 0, 30, 60 e 120 minutos após a chegada à UCPA). RESULTADOS: Os escores SA e ED foram significativamente menores no grupo Dex versus grupo salina, desde a extubação até 120 minutos após a chegada à UCPA. CONCLUSÕES: A administração de Dex tem a vantagem de uma redução no SA e na ED, sem quaisquer efeitos adversos. Dex proporcionou uma recuperação satisfatória em lactentes submetidos à palatoplastia.

Effectiveness of dexmedetomidine for emergence agitation in infants undergoing palatoplasty: a randomized controlled trial.

OBJECTIVES: In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty. METHODS: A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n=35) and saline (n=35). In the Dex group, Dex (6 µg/kg/h) was administered approximately 10 min before the end of the surgery for 10 min, followed by 0.4 µg/kg/h until 5 min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120 min after arrival in PACU). RESULTS: EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120 min after arrival in PACU. CONCLUSIONS: Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty.

Selective elimination of isolectin B4-binding trigeminal neurons enhanced formalin-induced nocifensive behavior in the upper lip of rats and c-Fos expression in the trigeminal subnucleus caudalis.

The functional significance of non-peptidergic C-fibers in orofacial pain processing is largely unknown. The present study examined the effects of the selective elimination of isolectin B4 (IB4)-binding (IB4(+)) neurons on formalin-induced face rubbing behavior (FRB) in the upper lip of rats and c-Fos-immunoreactive (c-Fos-IR) cells in the trigeminal subnucleus caudalis (Vc). IB4 conjugated to neurotoxin, saporin (IB4-Sap), blank-saporin (Bl-Sap), or saline (Sal) was injected into the cisterna magna. IB4-Sap treatments significantly decreased IB4(+) terminals in lamina II of Vc and IB4(+) trigeminal ganglia neurons, whereas Sal- and BI-Sap treatments did not. The number of formalin-induced FRB 15-30 min after the formalin injection was significantly higher in IB4-Sap-treated rats than in Sal- or Bl-Sap-treated rats, and was associated with an increase in c-Fos-IR cells. The systemic preadministration of the GABAA antagonist, bicuculline, and agonist, muscimol, had stronger decreasing effects on FRB and c-Fos-IR cells in IB4-Sap-treated rats than the preadministration of Sal, whereas the opposite effects were observed in Sal- and Bl-Sap-treated rats. These results indicate that IB4(+) neurons in the trigeminal nerve play antinociceptive regulatory roles in formalin-induced orofacial pain processing and that GABAA receptor functions at segmental and supratrigeminal sites have complex modulatory influences on antinociceptive roles.

[Effectiveness of dexmedetomidine for emergence agitation in infants undergoing palatoplasty: a randomized controlled trial]. / Eficácia de dexmedetomidina para o surgimento de agitação em lactentes submetidos à palatoplastia: estudo clínico randomizado.

OBJECTIVES: In infants, there is a high incidence of emergence agitation (EA) after sevoflurane (Sev) anesthesia. This study aimed to test the hypothesis that dexmedetomidine (Dex) administration would reduce the incidence and severity of EA after Sev-based anesthesia in infants undergoing palatoplasty. METHODS: A prospective randomized clinical trial was conducted with 70 patients undergoing palatoplasty, aged 10-14 months. Infants were randomly allocated into two groups: Dex (n=35) and saline (n=35). In the Dex group, Dex (6µg/kg/h) was administered approximately 10min before the end of the surgery for 10min, followed by 0.4µg/kg/h until 5min after extubation. In the saline group, an equivalent amount of saline was administered in a similar manner. After the surgery, patients were transferred to the postanesthetic care unit (PACU). The infant's behavior and pain were assessed with scoring system for EA (5-point rating scale) and pain scale (PS; 10-point rating scale), respectively. EA and PS were estimated at six time points (after extubation, leaving the operating room, 0, 30, 60, and 120min after arrival in PACU). RESULTS: EA and PS scores were significantly lower in the Dex group than in the saline group from extubation to 120min after arrival in PACU. CONCLUSIONS: Dex administration has the advantage of a reduced EA and PS without any adverse effects. Dex provided satisfactory recovery in infants undergoing palatoplasty.

Considerations during intravenous sedation in geriatric dental patients with dementia.

OBJECTIVES: We retrospectively assessed the usability and precautions required during intravenous sedation (IVS) for dental treatment in geriatric outpatients with dementia. MATERIALS AND METHODS: We investigated the intraoperative complications in 65 cases (25 geriatric dental patients with dementia) under IVS, from the standpoint of local anesthesia usage, water usage during treatment, and content of treatment. RESULTS: Circulatory complications occurred in 46.2 % and respiratory complications in 52.3 % of all cases (n = 65). Bradycardia occurred in 13.8 % and hypotension in 12.3 % of cases in the former, while coughing spells occurred in 41.5 % and snoring in 16.9 % of cases in the latter. Many of the local anesthesia usage cases did not require water usage, such as during tooth extraction (p < 0.0001). Water usage cases, such as for caries treatment, needed longer sedation and treatment times, resulting in more propofol usage (p < 0.001, p < 0.0001, and p < 0.01, respectively). Many coughing spells developed in the water usage cases (p < 0.05). 81.8 % of snoring and 63.3 % of circulatory complications, such as hypotension and bradycardia, developed in the tooth extraction cases (p < 0.05). CONCLUSIONS: All the scheduled dental treatments in dementia patients were smoothly performed under IVS. However, stringent attention should be paid to the prevention of aspiration of fluids retained in the pharynx, airway obstruction due to therapeutic maneuvers, respiratory inhibition by sedatives, and hemodynamic fluctuations caused by invasive procedures under local anesthesia. CLINICAL RELEVANCE: In the future, with the growing need for dental procedures in dementia patients, dentists will require training in the general management of such patients.

[Management of a child with Swyer-James syndrome who underwent flexible bronchoscopy under general anesthesia].

Swyer-James syndrome (SJS) is a rare syndrome characterized by hyperlucency of one or more lobes of the unilateral lung and decreased pulmonary vascularity which is considered to be secondary to the childhood obliterative bronchiolitis. We report anesthetic management of a girl with SJS who underwent flexible bronchoscopy. A 15-year-old girl weighing 47 kg was referred to our hospital with suspected SJS. She had a history of bronchiolitis in early childhood. On admission, chest radiograph showed a hyperlucent lung with diminished pulmonary vasculature on the left lung. Pulmonary function test revealed slightly restrictive pattern (%VC 69.3%, %FEVa1.0 77.9%). Ventilation and perfusion scanning demonstrated the markedly decreased ventilation (left : right, 33 : 67) and perfusion (left : right, 10 : 90) of the left lung. To rule out the foreign body and bronchial stenosis, flexible bronchoscopy under general anesthesia was planned. Anesthesia was induced with propofol and maintained with propofol and remifentanil. Spontaneous respiration was maintained by using laryngeal mask airway to prevent the pressure alveolar damage by positive pressure ventilation. Flexible bronchoscopy was performed safely by using topical laryngeal lidocaine administration and additional bolus of propofol. Her postoperative course was uncomplicated and she was discharged on the following day.