The present treatment options for type I diabetes mellitus, besides precise blood sugar (BS) management with a continuous glucose monitoring (CGM) system that continuously measures BS, include multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII). The latest development is a sensor-augmented pump (SAP) consisting of CSII-incorporated CGM. Here, we present a case with type I diabetes mellitus and an SAP who experienced recurrent postoperative hypoglycemia.
The patient was a 73-year-old woman in whom a sequestrectomy and antral lavage were planned because of implant pericoronitis of the maxillary right premolar. She had been diagnosed as having type I diabetes mellitus at the age of 53 years and had received an SAP implant at the age of 70 years ; no diabetes mellitus-related complications had been reported. Her preoperative BS and hemoglobin A1c (HbA1c) levels were 95 mg/dl and 8.2%, respectively. On the day of the operation, her BS was 185 mg/dl ; the SAP was stopped, and an intravenous drip for maintenance transfusion (4.3% glucose components) containing 4 U of rapid-acting insulin (Novolin®) was started. Furthermore, general anesthesia was completed without a problem, and we restarted the SAP postoperatively. As she reported recurrent postoperative hypoglycemia, we administered a 20% glucose solution and maintenance transfusion intravenously. Her BS stabilized after changing to oral feeding. In this case, because the patient had type I diabetes mellitus and her BS management was expected to be challenging, we decided to stop the SAP during surgery only. Stopping oral ingestion and initiating tube feeding might have caused the postoperative hypoglycemia. Hence, using CGM and with the patient’s consent, we intravenously administered a 20% glucose solution and maintenance transfusion, thereby preventing severe hypoglycemia.
Orofacial or neck surgery can cause airway deformation or abnormal positioning, potentially leading to intubation difficulties. We treated a patient with a history of having undergone a thyroidectomy. Because of the absence of any factors suggesting the possibility of airway difficulty, we chose to perform intubation using a laryngoscope, as usual. During intubation, however, the tracheal tube could not be advanced after passing through the glottis. Fiberscopy showed that the tip of the tube had become stuck on an inner protrusion of the repaired granulated tissue. Therefore, the tube was subsequently inserted while avoiding the border under a fiberscopic view.
For patients with a history of surgery in the neck region, a detailed examination such as computed tomography may be required in addition to careful palpation and inspection. When abnormalities of the trachea are predicted, intubation under fiberscopic guidance or video laryngoscopy might be useful for reducing complications such as tracheal injury.
We report the use of intravenous sedation for dental treatment in a patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency, a condition that induces acute hemolysis and methemoglobinemia under surgical stress, during infection, or subsequent to the administration of oxidant drugs. Intravenous sedation for dental treatment in patients with G6PD deficiency has not been previously reported.
G6PD deficiency occurs frequently in Kurdish Jewish and African-American populations ; it occurs less frequently in the Japanese population, with the asymptomatic variant having an incidence of less than 0.1%. Here, we report the case of a 20-year-old man (height, 157 cm ; weight, 51 kg) with G6PD deficiency who underwent intravenous sedation prior to dental treatment, which involved a pulpectomy and root canal treatment. The patient was sedated using an intravenous infusion of midazolam. Amide-type local anesthesia is known to cause methemoglobinemia. However, the required dental treatment was considered to be difficult to perform using an ester-type local anesthetic agent ; hence, an amide-type local anesthetic agent was used. Acute hemolysis occurring 2 to 3 days after the oxidative stress with anemia and jaundice accompanied by hemoglobinuria are usually observed.
In the present case, the dental treatment was safely and successfully concluded with due attention to the general anesthesia procedure.
Respiratory depression frequently occurs during fiberoptic intubation in patients sedated with benzodiazepines, propofol and opioids. Dexmedetomidine has been used for sedation during fiberoptic intubation because it has a small respiratory depression effect. However, the effectiveness of DEX for fiberoptic nasal intubation remains unclear. We report 4 cases in which dexmedetomidine and fentanyl were used for sedation during fiberoptic nasal intubation.
In Case 1, a total of 1.1 μg/kg of DEX was administered during intubation, but increases in pulse and blood pressure were observed. The DEX plasma concentration was 1.17 ng/ml after the completion of intubation.
In Case 2, a total of 1.2 μg/kg of DEX and 0.9 μg/kg of fentanyl were administered during intubation, but a coughing reflex occurred. After the end of intubation, the DEX serum concentration was 0.84 ng/ml, the fentanyl plasma concentration was 0.54 ng/ml, and the effect-site concentration was 0.91 ng/ml.
In Case 3, a total of 1.0 μg/kg of DEX and 2.3 μg/kg of fentanyl were administered during intubation. After the end of intubation, the DEX serum concentration was 0.91 ng/ml, the fentanyl plasma concentration was 1.39 ng/ml, and the effect-site concentration was 2.19 ng/ml.
In Case 4, a total of 1.0 μg/kg of DEX and 2.0 μg/kg of fentanyl were administered during intubation. After the end of intubation, the DEX plasma concentration was 1.07 ng/ml, the fentanyl plasma concentration was 1.17 ng/ml, and the effect-site concentration was 1.84 ng/ml.
Our findings suggest that when a DEX plasma concentration of 1.0 ng/ml is used for sedation during fiberoptic nasal intubation, the use of 2.0 μg/kg of fentanyl is effective.
Atrial fibrillation (Af) is an abnormal heart rhythm characterized by rapid and irregular beating of the atria. Enhanced activity of the sympathetic nervous system can cause Af perioperatively. The presently reported patient was a 68-year-old man with cervical lymph node metastases from tongue cancer who had undergone radiation therapy. Tachyarrhythmia was observed during the preoperative anesthetic examination, so a cardiology consultation was requested. The patient was subsequently diagnosed as having Af, and antithrombotic therapy was started prior to the operation.
During anesthesia management for the presently reported procedure, we planned to stabilize the hemodynamic status by simulating the effect-site concentration (Ce) of remifentanil. After tracheal intubation, the systolic blood pressure increased to over 180 mmHg, and the Ce of remifentanil was 5.5 ng/ml. Therefore, we planned to maintain the Ce of remifentanil at over 6.0 ng/ml during the neck dissection. After the neck dissection, we reduced the dose of remifentanil while waiting for the result of an intraoperative rapid pathological diagnosis. We then deepened the anesthetic condition after a decision was made to perform an additional resection. Although the Ce of remifentanil was 5.8 ng/ml at the time when the additional resection was started, paroxysmal atrial fibrillation (PAF) occurred. We administered verapamil hydrochloride (5 mg) intravenously, and the cardiac rhythm resumed a sinus rhythm. The pulse rate returned to normal, and the blood pressure decreased. To avoid sympathetic stimulation, we performed tracheal extubation while the Ce of remifentanil was sufficiently high. The Ce of remifentanil is not the only factor affecting the onset of PAF. Preparations for the possible onset of Af should be made as part of preventive management.
Nasotracheal intubation is frequently selected for oral surgical procedures. We experienced a case with pressure sores formed form a nasotracheal tube in which the sores cicatrized, causing nostril stenosis. The patient was a 59-year-old man who had undergone bilateral temporomandibular joint (TMJ) mobilization and bilateral coronoidectomy for bilateral TMJ ankyloses. The anesthesia time was 12 hours. Upon extubation, pressure sores with reddening were observed on the nare. An ointment was applied, and the patient was discharged from the hospital. Three months later at a regular checkup after oral surgery, the patient complained of nostril stenosis. The patient was referred to the Department of Plastic Surgery and a nasal prosthesis was inserted ; widening of the nasal cavity was subsequently observed 1 month later.
Factors affecting pressure sore formation include long operations, a male gender, pressure on the nare exerted by the intubation tube, and skin humidity. In addition to these factors, the patient had a history of diabetes mellitus and atopic eczema, which might have increased the risk of pressure sore formation and delayed healing. Tube fixation or dressing applications can be useful for preventing sore formation from the exertion of pressure on the nare. Furthermore, the Department of Plastic Surgery or Otolaryngology should be consulted promptly when sore formation is observed upon extubation to prevent the development of severe conditions.
Leigh encephalopathy (LE) is a clinical subtype of mitochondrial encephalomyopathy characterized by delayed development of psychomotor functions and regression from infancy. Problems associated with the anesthetic management of patients with mitochondrial disease include the possibility of malignant hyperthermia, the prolongation of muscle relaxation, and lactic acidosis.
A 7-year-old boy with LE had dental caries in his right mandibular first molar. He was uncooperative with dental treatment, and a dental procedure under intravenous sedation (IVS) was planned. Laboratory data including blood tests, an electrocardiogram, a chest X-ray, and chest auscultation did not show any abnormalities. We planned an anesthetic management without the use of propofol in consideration of the possibility of propofol infusion syndrome. Therefore, IVS with dexmedetomidine hydrochloride (DEX) in combination with midazolam (MDZ) was selected.
We initially administered 1 mg of MDZ and loaded DEX at a dose of 3 μg/kg/h over 10 min, subsequently reducing to 0.5 μg/kg/h for maintenance. Additional doses of MDZ were administered so that the OAA/S score was maintained between 2 and 4. During the procedure, the patient’s vital signs were stable, and no signs of respiratory depression were observed.
In conclusion, IVS with DEX in combination with MDZ was useful for the dental treatment of a patient with LE. Further studies are needed to determine the optimal doses of DEX and MDZ.
We herein report the case of a 74-year-old woman who experienced severe neuropathic pain following the placement of five dental implants and the subsequent removal of one implant. Her condition was successfully treated with repeated stellate ganglion blocks (SGB) ; the intravenous infusion of adenosine 5-triphosphate (ATP), magnesium (Mg), and lidocaine ; and the oral administration of amitriptyline and tramadol hydrochloride.
The five dental implants had been placed in the upper jaw approximately two years previously, and the patient had been suffering severe pain in the right upper molar area since that time. One of the dental implants was removed one year after the implant surgery, but the removal resulted in the aggravation of the pain, rather than relief. The patient described the continuous pain as “very cold,” “numbness,” and “thirstiness.” She was unable to eat, and apparent mechanical allodynia and dysesthesia were noted.
The patient received a series of SGB injections and the intravenous infusion of ATP, Mg, and lidocaine. In addition, amitriptyline (10 mg/day) and tramadol hydrochloride (75 mg/day) were orally administered. The treatments were fully effective for pain relief. The patient was diagnosed as having sympathetically maintained pain and peripheral and central neuropathic pain associated with complex regional pain syndrome type 1 following dental implant surgery.
Airway maintenance during oral surgery can be difficult for patients with trismus, tumors in the head and neck region or oral cavity, or a past history of tumor resection. Here, we report a 77-year-old woman who was scheduled to undergo scar revision. At the age of 65 years, she had been diagnosed as having depression. She had also undergone five previous oral and maxillofacial surgeries. Preoperative testing was normal. Her middle face was denting and her mouth-opening capacity was about 15 mm. We opened a field to correspond to in oral cavity by incision preoperatively this time because difficulty of the airway maintenance was expected in the patients that opening and shutting became impossible with lips by a scar after the tumors of oral cavity resection and experienced a successful case for subconscious endotracheal intubation with the sevoflurane by also using McGRATH®MAC. Dentistry anesthesiologists sometimes encounter difficult intubation cases in patients who have previously undergone oral surgery. Difficult intubation cases can occur not only because of the degree of difficulty in the actual intubation, but also because of a patient’s background and surgical history ; in such cases, the selection of an appropriate induction method and anesthetic and the use of an appliance might be necessary to perform general anesthesia safely and easily.
We report a case in which a displaced tooth in the palate made the insertion of a laryngoscope difficult during endotracheal intubation.
A 16-year-old patient with Treacher-Collins syndrome was scheduled to undergo general anesthesia for an iliac bone graft to repair a bone defect in the hard palate. General anesthesia was induced by the spontaneous inhalation of oxygen, nitrous oxide and sevoflurane. As the spontaneous respiration was easily suppressed, mask ventilation and the use of a nasopharyngeal airway became necessary because of airway obstruction. While the patient was unconscious, we attempted to insert a video-laryngoscope (AIRWAY SCOPETM ; MIC Medical Corporation, Japan) into the pharyngeal space but failed because a displaced tooth in the hard palate disturbed its insertion. Next, we tried to insert another video-laryngoscope (KINGVISIONTM ; Acoma Medical, Japan), which had a thinner blade than the AIRWAY SCOPETM. The video-laryngoscope was inserted into the oral cavity and the blade was advanced into the pharyngeal space, but the vocal cords could not be visualized. Finally, we attempted to insert a fiberscope through the oral cavity using the KINGVISIONTM video-laryngoscope while elevating the epiglottic vallecula. This method worked well, and we were able to complete the fiber-optic intubation successfully. Two years later, the patient underwent tooth extraction prior to another procedure requiring general anesthesia. At this time, a partial view of the vocal cord was obtained using the KINGVISIONTM video-laryngoscope, and we successfully completed the fiber-optic intubation.
This experience suggests that potential obstacles, such as dislocated teeth, should be removed prior to general anesthesia and highlights the importance of selecting a suitable laryngoscope to maintain the patient’s airway.
We treated a patient who experienced anaphylactic shock during intravenous sedation.
A 24-year-old woman (height : 167 cm, weight : 57 kg) suffered from atopic dermatitis, bronchial asthma, and food-dependent, exercise-induced anaphylaxis.
Tooth extraction under intravenous sedation was performed using midazolam, propofol, acetaminophen, ampicillin sodium, and lidocaine with 1/80,000 adrenaline. At the end of the procedure, wheals and an erythema response appeared. An anaphylactic response with hypotension, dyspnea, wheezing, the expansion of the wheal and erythema response, edema, stomach ache, and a desire to defecate were observed. Treatment for anaphylaxis was immediately performed including the inhalation of oxygen (5 l/min), the intravenous administration of 0.25 mg of adrenaline, 100 mg of hydrocortisone sodium succinate, 6.6 mg of dexamethasone, and 500 mg of hydrocortisone sodium succinate. The patient was managed in the ICU until postoperative day 2, at which time the edema had improved. A blood examination revealed normal ranges of tryptase and histamine, a high range of non-specific IgE, and positive results for acetaminophen and midazolam, false positive results for propofol and ampicillin sodium, and negative results for lidocaine with 1/80,000 adrenaline in a drug-induced lymphocyte stimulation test (DLST). This case showed systemic changes in circulation, respiration, and her skin. Therefore, the case was considered to have experienced anaphylactic shock. However, the diagnosis of anaphylactic shock was difficult to confirm based on the results of biomarkers and blood examinations, including DLST.
Vagus nerve stimulation (VNS) is a palliative surgical procedure used to treat refractory epilepsy. The present case involved a patient with mental retardation who had received a VNS implant for the treatment of refractory frontal lobe epilepsy in whom epileptic seizures during the induction of and recovery from general anesthesia were prevented by intentional stimulation of a VNS implant.
The patient was a 29-year-old man (height, 156 cm ; weight, 49 kg) who had been diagnosed as having mental retardation and refractory frontal lobe epilepsy. He had been started on oral antiepileptic drugs around the age of 14 years and had undergone VNS insertion at the age of 24 years. A VNS magnet setting mode was also available, allowing intentional stimulation when epileptic seizures were anticipated. Holding a proprietary magnet over the pulse generator for at least one second allowed 60 seconds of stimulation at an output current of 3.25 mA. The patient had been scheduled to undergo tooth extraction for the treatment of bilateral pericoronitis of the upper and lower wisdom teeth under general anesthesia.
Anticipating epileptic seizures during the induction of general anesthesia, we induced anesthesia while activating the magnet setting mode. General anesthesia was induced with propofol and rocuronium bromide, followed by right nasal intubation. No epileptic seizures occurred prior to muscle relaxation. The duration of the operation was 1 hour and 12 minutes. We administered sugammadex sodium once spontaneous respiration was resumed, resulting in a rapid increase in the BIS value and muscular rigidity in the upper extremities. The patient was allowed to recover from the anesthesia with the VNS magnet setting mode activated. No epileptic seizures were anticipated after the patient’s return to the ward.
Electrical stimulation of the left vagus nerve can exert an antiepileptic action by stabilizing the entire cerebral cortex via the solitary nucleus and by inhibiting aberrant excitatory neuronal activity. The electrodes are designed to transmit the stimulation current almost entirely on the central side, minimizing potential clinically problematic side effects such as bradycardia and hypotension. In the present patient, epileptic seizures were anticipated during the induction of and recovery from anesthesia, and activating the magnet setting mode successfully prevented any epileptic seizures from occurring. Our findings suggest that activating the magnet setting mode of VNS implants can effectively prevent epileptic seizures during the perioperative period and while under general anesthesia. However, since the main purpose of VNS is to prevent epileptic seizures, the use of antiepileptic drugs remains essential if an epileptic seizure occurs.