Sugammadex is a modified type of γ-cyclodextrin that contains 8-thiopropionate side chains. Although it facilitates a rapid reversal of neuromuscular blockade induced by rocuronium, intraoperative anaphylaxis has been occasionally reported. Here, we report three cases of immediate cutaneous reactions against sugammadex after dental or oral surgeries performed under general anesthesia. All three patients were given a bolus of sugammadex (2.0-3.6 mg/kg) just before extubation. In all three patients, a possible allergic reaction occurred within 4 min of sugammadex injection. In the most severe case, the patient developed hypotension (systolic arterial blood pressure : 60 mmHg) and a rash on her upper body. After the administration of 5 micrograms of adrenaline, her symptoms diminished, and no further symptoms appeared. The other two patients developed skin symptoms, such as rashes and wheals. No other serious symptoms were observed, and adrenalin was not required. The incidence of allergic reaction to sugammadex seems to be higher in Japan than in other countries. Even at our hospital, we have encountered three patients with allergic reactions out of 494 patients (0.61%) treated with sugammadex. Whether sugammadex it self or the sugammadex-rocuronium complex causes allergic reactions remains unknown. Overdoses of sugammadex should be avoided, and the rational application of sugammadex based on the monitoring of neuromuscular blockade is recommended. Since the allergic reactions appeared within a few minutes in our three cases, careful observation of the skin and hemodynamics is necessary after sugammadex injection.
In Japan’s super-aging society, it is becoming increasingly necessary to treat patients with cardiovascular or cerebrovascular disease who are undergoing treatment with anticoagulants and antiplatelets. Generally, guidelines for antithrombotic therapy recommend switching from antithrombotics to heparin sodium during the perioperative period. We studied 10 patients undergoing antithrombotic therapy who were scheduled to undergo oral and maxillofacial surgery. The frequency of bleeding complications was compared between patients receiving antiplatelet drugs alone and those receiving both antiplatelet and anticoagulant drugs during the perioperative period. According to our protocol, antiplatelet drugs and/or warfarin potassium were terminated 4 to 10 days prior to surgery, and heparin sodium was administered intravenously with an infusion pump at a dose of 10,000 units per day. Six hours prior to the operation, the heparin sodium infusion was terminated. Six patients received antiplatelet drugs alone. Heparin sodium was restarted 1 day postoperatively in two patients, but all the patients were switched back to oral antiplatelet therapy. No bleeding complications occurred among the six patients. In another four patients receiving warfarin potassium and antiplatelet drugs, heparin sodium was restarted 1 or 2 days after the operation. Warfarin sodium and antiplatelet drugs were restarted 1 to 7 days after the operation in three of these four patients (all except Patient 10). Otherwise, bleeding complications occurred in all four patients. In Patient 10, postoperative bleeding from the wound area in the soft palate continued for 10 days postoperatively ; this patient suffocated because of a large hemorrhagic mass and cardiopulmonary arrest. This study did not provide enough data to show that bleeding complications may occur when a combination of heparin, warfarin potassium, and antiplatelet drugs is restarted.
Cornelia de Lange syndrome (CdL) is characterized by growth disturbance, mental retardation, congenital heart disease and multiple malformations.
We report the case of a 21-year-old patient with CdL and tetralogy of Fallot (TOF) who was scheduled to undergo dental treatment under general anesthesia because of multiple tooth caries. Radical cardiac surgery had not been performed. We consulted a cardiologist regarding the patient’s cardiac condition prior to the operation. Furthermore, mental retardation prevented us from making a precise assessment of the general status. TOF is a complex of congenital cardiac malformations requiring careful attention to hemodynamics stability and infectious endocarditis. The main points of anesthetic management were the avoidance of anoxic spells and trismus. An anoxic spell can be caused by stress, and its mechanism results in an increase in right-to-left blood flow because of pulmonary spasm. We planned a slow induction with the maintenance of spontaneous breathing and fiberoptic intubation as the airway management. Then, a mask with one hole was prepared. The purpose of this device was to administer the inhalation anesthetic to the patient while operating via fiberoptic intubation. Using this device, nasal intubation was successfully established. Anesthesia was maintained with remifentanil and propofol. During the operation, the patient’s blood pressure, heart rate and arterial oxygen saturation remained stable.
The general anesthesia was well maintained, and no perioperative complications occurred. The preoperative creation of an anesthetic plan in cooperation with medical specialists that is capable of coping with various situations, including hospitalization after the operation, is important.
We herein report a case of psychogenic non-epileptic seizures during dental treatment under inhalation sedation in a patient with a dental phobia.
A 21-year-old woman with epilepsy, panic disorder, and autism spectrum disorder underwent nitrous oxide inhalation sedation for dental treatment because of a dental phobia. Unlike previous visits, she did not speak on the day of treatment. Sedation was induced by the inhalation of 100% oxygen followed by 20% nitrous oxide. Immediately after treatment, the patient did not react to verbal stimulation and exhibited convulsions of the eyelids and arms. We suspected that an epileptic seizure had occurred and started an intravenous drip of 250 mg of phenytoin. However, the convulsions did not cease, and we therefore administered 5 mg of diazepam. The convulsions ceased thereafter, but the patient still did not respond to verbal stimulation. During the arm drop test, the patient’s arm moved to avoid her face. She gradually recovered consciousness and became able to talk. However, the convulsions recurred, and her consciousness level decreased. Phenytoin was restarted and the convulsions gradually ceased, but the patient remained unresponsive ; she was therefore transported to a high care unit. Her consciousness level subsequently recovered, and she was discharged from the hospital the next day.
We initially believed that the convulsions and loss of consciousness had been caused by an epileptic seizure. However, phenytoin and diazepam were ineffective, and her arm avoided her face when it was dropped ; thus, we also considered the possibility of a psychogenic non-epileptic seizure. Dental treatment in a lightly sedative state might cause psychogenic non-epileptic seizures in patients with increased stress.
Even in patients with epilepsy, the accurate diagnosis of seizures is important to ensure that appropriate measures are taken.
We report our experience administering general anesthesia to a pediatric patient with a pacemaker because of polysplenia syndrome. A six-year-old girl weighing 16 kg underwent extirpation of a submandibular sialolith under general anesthesia. The pacemaker mode was AAIR, and the lower heart rate was set at 90 beats/min. The infusion of acetated Ringer’s solution was started 2 hours prior to the operation. Before anesthesia induction, the pacing mode was changed to AAI. Sevoflurane in oxygen was administered for anesthesia induction, and nasotracheal intubation was performed. Anesthesia was maintained with fentanyl and sevoflurane in oxygen. A monopolar electric surgical scalpel was used for the operation, and the reference electrode was subsequently fixed on the scapula, away from the abdominal pacemaker. As a result, anesthesia was managed without electromagnetic interference.
Polysplenia syndrome is characterized by left atrial isomerism and bilateral left sidedness of visceral organs. In addition, it presents with bradyarrhythmias, such as sinus node dysfunction and/or complete atrioventricular block, and it is associated with the interruption of the inferior vena cava accompanied by azygos continuation. In the present patient, the preoperative infusion of acetated Ringer’s solution and early ambulation were attempted to avoid thrombosis arising from the hypovolemic condition. In cases with polysplenia syndrome, the possibility of perioperative deep vein thrombosis requires careful attention.
A 37-year-old man (weight : 66 kg, height : 178 cm) was scheduled to undergo the extraction of wisdom teeth and an accompanying cystic lesion. He had a history of febrile convulsions during childhood. Anesthesia was induced intravenously using propofol and fentanyl. Nasal-tracheal intubation was then facilitated with rocuronium bromide. The anesthesia was maintained with O2-air-sevoflurane, with an end-tidal sevoflurane concentration of under 2.4%. The surgical procedures were performed uneventfully, and no specific problems occurred during the operation. At the end of the surgery, sugammadex (200 mg) was administrated intravenously to reverse the neuromuscular blockade. The tracheal tube was extubatd after sufficient spontaneous breathing was resumed (end-tidal carbon dioxide, 45-50 mmHg ; end-tidal sevoflurane, 0.3%). After extubation, a generalized tonic convulsion occurred involving a loss of consciousness and respiratory arrest. Manual ventilation was impossible, and the patient’s Spo2 level decreased to 70%. The convulsion lasted approximately one minute. On the day after surgery, the results of an electroencephalograph, brain CT and biochemical study were normal. Therefore, the cause of the convulsion remains uncertain. However, several case reports of convulsion after the administration of sevoflurane, sugammadex sodium, and propofol have been reported. Careful attention should be paid to the general condition of patients with a history of convulsions (even during early childhood) when using these drugs.
Cuff damage during nasotracheal intubation is not uncommon. We treated a case with cuff damage caused by a fixation screw during nasotracheal intubation.
A 22-year-old woman (height, 158 cm ; weight, 52 kg) was scheduled to undergo a plate removal and genioplasty after a Le Fort Ⅰ osteotomy and bilateral sagittal split ramus osteotomy.
After the induction of anesthesia, a 6.5-ID tracheal tube (ParkerTM) was introduced via the right nostril and tracheal intubation was easily achieved. However, the cuff could not be filled with air, and an air leak was discovered during artificial ventilation. After extubation, the cuff was found to have been torn and a scratch was found on the tube. A second attempt through the right nostril using a tracheal tube of the same size produced the same result. Subsequently, a 6.5-ID tracheal tube (MallinckrodtTM) was introduced via the left nostril. As a result, the third nasotracheal intubation was successful, with no damage to the cuff occurring.
A computed tomography examination of the head obtained before surgery showed that the tip of a fixation screw had penetrated the right nasal cavity. The cuff damage was suspected to have been caused by the fixation screw, since the locations of the cuff damage and the screw coincided.
When nasotracheal intubation is performed, it is important to check not only the narrowness of the nasal cavity and the nasal septal spur, but also the position of fixation screws remaining after surgery for jaw deformities using a computed tomography examination of the maxillofacial region.
Left bundle branch block (LBBB) can be caused by cardiovascular abnormalities, and its existence makes the diagnosis of acute myocardial ischemia or infarction difficult using electrocardiography (ECG). Here, we describe our experience providing anesthetic management to a patient who developed a transient complete LBBB (CLBBB) during the perioperative period.
A 58-year-old woman was scheduled to undergo a biopsy for oral floor cancer under general anesthesia. During the preoperative screening, a 12-lead ECG showed evidence of a CLBBB and tachycardia (106 beats/min), which had not been observed on previous ECG examinations. To check for the existence of underlying cardiovascular diseases, echocardiography and coronary angiography were performed. Since these examinations did not show evidence of myocardial ischemia and suggested normal cardiac function, the general anesthesia was performed as scheduled. Upon arrival in the operating room, an ECG showed normal conduction. During the general anesthesia, however, an LBBB suddenly appeared when the heart rate (HR) increased to 97 beats/min just after the injection of a local anesthesia containing adrenaline. A few minutes later, the HR decreased and the LBBB disappeared. While the patient was awakening from the general anesthesia, the HR increased to 83 beats/min and the LBBB re-appeared. Seven hours after the general anesthesia, the LBBB disappeared ; however, inverted T waves were observed in the precordial leads.
In the present case, the CLBBB was transient and was accompanied by an increase in the HR. This kind of transient LBBB is reportedly called rate-dependent LBBB. In addition, the inverted T waves observed in the precordial leads in the present case were not a symptom of myocardial ischemia, but rather an example of a previously reported phenomenon known as cardiac memory.
Even if an underlying cardiovascular disease does not exist, CLBBB sometimes causes a delayed contraction of the left ventricle and a subsequent decrease in the left ventricular ejection fraction, followed by the circulation insufficiency, during general anesthesia. The appropriate management of circulatory dynamics, such as avoiding tachycardia, should be carefully performed perioperatively.
Mitochondrial dysfunction can cause mitochondrial encephalomyopathy, which sometimes results in multiple organ failure. General anesthesia in patients with mitochondrial encephalomyopathy carries a risk of malignant hyperthermia and metabolic acidosis because of starvation arising from the necessary restriction of oral intake before surgery. We report a case of day-care general anesthesia in a patient with mitochondrial encephalomyopathy combined with hypercreatinekinasemia who underwent dental treatment.
The patient was a 17-year-old woman with a body weight of 50 kg and a height of 140 cm. The patient was diagnosed as having cytochrome C oxidase partial deficiency-type mitochondrial encephalomyopathy. Since she was uncooperative with the dental treatment, we planned to perform general anesthesia.
Water intake was restricted for 2 hours before the induction of anesthesia. Anesthesia was induced using oxygen, midazolam, propofol, and remifentanil. Rocuronium was injected under train of four monitoring. The anesthesia was maintained using total intravenous anesthesia under controlled ventilation. We adjusted the infusion rate of propofol and remifentanil while referring to the bispectral index values. For the transfusion, Ringer’s acetate solution with 1.8% glucose was used. The patient’s respiratory and hemodynamic variables were stable, and an arterial blood gas analysis remained at normal levels throughout the anesthesia. At the end of the treatment, sugammadex was administered, and the patient was extubated. No complications were observed after the anesthesia.
Dissociative identity disorder (DID) is characterized by the existence of two or more separate and distinct personalities on an ongoing basis. Although the incidence of DID has been increasing in Japan, dental treatments for such patients remain rare. Here, we report our experience providing general anesthesia to a patient with DID and generalized anxiety disorder.
A 30s woman had been diagnosed as having DID at the age of 24 years, and her condition was being managed with medication. Although more than nine personalities had appeared as of the presently reported treatment, her original personality had not appeared for several years. She had numerous dental caries and an extreme fear of dental treatments. Therefore, we planned to perform dental treatments under general anesthesia.
Anesthesia was maintained with 3.0 μg/ml of propofol and 0.05-0.1 μg/kg/min of remifentanil hydrochloride. Since DID patients can respond to anesthetics differently than healthy adults, we used a BIS monitor to ascertain the depth of the anesthesia. Furthermore, the dentists, nurses, and other staff members shared information during the perioperative period. As a result, while changes in the patient’s personality were observed, no serious mental disturbances occurred.
Nasotracheal tubes can be damaged during oral and maxillofacial surgery, because the nasotracheal tube is positioned close to the surgical field. We experienced a case of nasotracheal tube damage during a Le Fort type Ⅰosteotomy.
A 17-year-old woman who was classified as having ASA-PS 1 underwent a Le Fort type Ⅰosteotomy and sagittal split ramus osteotomy under general anesthesia. Nasotracheal intubation was performed via her right nostril. Sixty minutes after the start of the Le Fort type Ⅰosteotomy, the tidal volume decreased slightly and a leaking sound arising from the surgical site was detected. Although we tried to inflate the tube cuff, we could not supply air to the pilot balloon. Accordingly, gauze was tightly packed in the pharynx. The artificial ventilation was improved using pressure control ventilation with a positive end expiratory pressure. After extubation, a cut in the nasotracheal tube at a point 22 cm from the tube tip was observed. The depth of the tube damage was limited to the inflation-line.
The osteotomy line in a Le Fort type Ⅰosteotomy starts from the lateral margin of the piriform aperture and runs toward the posterior section of the maxillary tuberosity. Together with the nature of this surgical procedure, the site of tube damage in this case suggests that the nasotracheal tube was damaged during the osteotomy at the lateral margin of the piriform aperture. In addition, since the depth of the tube damage was limited to within the inflation-line, gauze packing in the pharynx compensated for the air leakage, and artificial ventilation was successfully maintained using pressure control ventilation with a positive end expiratory pressure.
We treated a patient with Sturge-Weber Syndrome who experienced a postoperative convulsion induced by metoclopramide.
The patient was a 34-year-old woman (height : 153 cm, weight : 50 kg) with right side hemiplegia and mental retardation. She had first experienced convulsions at 3 months of age. Since then, the patient had been treated with an oral anticonvulsant agent and the number of convulsions had been reduced. She had not experienced any convulsions since the age of 15 years. She was diagnosed as having Sturge-Weber Syndrome based on a hemangioma in the right trigeminal Ⅰ and Ⅱ branch region. She had also been diagnosed as having schizophrenia and was taking perospirone orally.
Dental treatment under general anesthesia was planned because of the presence of numerous dental caries and severe periodontal disease requiring tooth extraction. Anesthesia was induced by the inhalation of sevoflurane through a mask and was maintained by the inhalation of desflurane and the intravenous administration of remifentanil. No abnormal events, including convulsions, were observed at the time of the emergence from the anesthesia. Because of post-operative vomiting while the patient was in the ward, 10 mg of metoclopramide were administered through an intravenous line. At 2 h and 40 min after the start of metoclopramide administration, a tetanic convulsion, loss of consciousness, temporary respiratory arrest and cyanosis occurred ; soon after, the patient recovered from the respiratory arrest and consciousness disorder, although the cyanosis persisted. Although she gradually recovered from the convulsions and consciousness disorder, the myoclonic convulsion persisted and she was orally treated with 0.5 g of 50% carbamazepine. Four hours after the first attack, she resumed dietary intake and could walk around the ward. The patient was discharged on the second postoperative day.
Although perioperative stress and the anesthetic agents were both possible causes, the convulsions were most likely induced by the administration of metoclopramide after general anesthesia, even though the convulsions were well controlled using an anti-convulsion agent.
A case of awake fiber optic intubation using dexmedetomidine and a translaryngeal block for enlarged reoperative surgery performed ten days after the initial operation is reported. The patient was a 63-year-old woman. She had undergone the removal of a section of her left cheek mucosa because of a malignant tumor. A left cervical dissection and a left lateral femoral flap were also performed. Ten days later, enlarged reoperative surgery was considered ; however, mask ventilation was thought to be difficult, as her mouth could only open to about 20 mm. Using dexmedetomidine and a translaryngeal block, awake nasal fiber optic intubation (AFOI) was performed. Dexmedetomidine was continuously administered at a starting dose of 6 μg/kg/h under oxygen administration. In addition, 2 ml of 4% lidocaine was injected into the trachea through a 22 gauge needle to obtain the translaryngeal block. The patient coughed because of a tracheal reflex. After inserting the notched nasal airway into the right nasal cavity, AFOI was performed. The Ramsay score during the procedure was level 2, and the patients was cooperative. The percutaneous oxygen saturation level was 98%-100%, and spontaneous respiration was maintained. No coughing reflex was observed when the fiber optic bronchoscopy passed through the glottis. One day after the surgery, the patient reported that she did not feel any distress or discomfort during the intubation procedure. Thus, AFOI using dexmedetomidine and a translaryngeal block for enlarged reoperative surgery was successfully performed.
A 7-year-old girl with autism was scheduled to undergo dental treatment under general anesthesia. A preoperative electrocardiogram showed sinus tachycardia (143 beats/min). The patient was underweight (BMI : 13.9), and she did not have goiter or exophthalmos. Anesthesia was induced with oxygen, nitrous oxide and sevoflurane, and nasotracheal intubation was facilitated with intravenous rocuronium bromide. Although a sufficient anesthesia depth was maintained with nitrous oxide and sevoflurane, hyperthyroidism was suspected because of ongoing tachycardia (around 140 beats/min). Blood samples were thus obtained to measure the serum thyroid hormone level. Her heart rate was controlled at 110 beats/min using 0.2 mg of propranolol hydrochloride administered twice during the operation. Except for the tachycardia, both the dental treatment and the general anesthesia were completed uneventfully. Blood tests performed during the operation showed a T3 level of 510 μg/dl (standard value : 70-176 μg/dl), a T4 level of 27.8 ng/dl (standard value ; 4.8-10.5 ng/dl), and a TSH level of less than 0.1 μU/ml (0.53-5.16 μU/ml), confirming a diagnosis of hyperthyroidism. The patient was diagnosed as having Basedow’s Disease based on a TSH-TSAb (thyroid stimulating hormone-thyrotropin receptor antibody) level of 2,292% (less than 120%), a euthyroid status has since been maintained using thiamazole (20 mg/day).
Chromosome 5p deletion syndrome (5p-syndrome) is an inheritable disease involving mental retardation, malformations of the larynx, muscle weakness and scoliosis, and some cranio-facial features (morphological microretrognathia, low-set ears, premature hair graying, etc.). Airway management for patients with 5p-syndrome can be problematic, including technical difficulties with intubation. The monitoring of neuromuscular blockade would be preferable, since 5p-syndrome can present with muscle weakness.
Here, we present a rare case report of 5p-syndrome in a 24-year-old male who exhibited breathing difficulty during a mandibular third molar extraction. The patient had been scheduled to receive treatment under intravenous anesthesia (IVA). However, a worsening of his respiratory condition led us to change the anesthetic management from IVA to general anesthesia using a laryngeal mask airway under spontaneous breathing.
This case illustrates the importance of securing a respiratory tract when managing 5p-syndrome patients, especially those receiving dental treatment requiring irrigation.