During anesthesia for orthognathic surgery, deliberate hypotensive anesthesia is often used to reduce bleeding and provide a satisfactory bloodless surgical field. However, predicting whether deliberate hypotension can be controlled effectively is difficult. The purpose of this study was to investigate factors influencing the stability of deliberate hypotension.
Patients who underwent orthognathic surgery under total intravenous anesthesia with deliberate hypotension using sodium nitroprusside (SNP) between January 2011 and December 2014 were included in this study. Each patient’s age, sex, mean blood pressure (MBP) after hospital admission, MBP upon arrival in the operating room, and MBP after the induction of anesthesia (MBPIA) were retrospectively extracted from their anesthesia records. The MBPs, bispectral index value, fentanyl dose, remifentanil infusion rate, and SNP infusion rate (SNPDH) were also recorded for a 30-minute period of deliberate hypotension at between 10 and 40 minutes after the initiation of continuous SNP. A mean 30-minute MBP value of between 50 mmHg and 65 mmHg and a maximum value of less than 80 mmHg were defined as stable results ; other values were considered unstable. A multivariable logistic regression analysis was performed with the stability of deliberate hypotension as the primary outcome.
A total of 223 patients were divided into the stable group (n=121) or the unstable group (n=102). The surgical method (odds ratio=2.15 ; 95%CI, 1.07-4.33 ; p=0.031), MBPIA (odds ratio=0.96 ; 95%CI, 0.93-0.99 ; p=0.008), and SNPDH (odds ratio=0.07 ; 95%CI, 0.01-0.58 ; p=0.013) were independently associated with the stability of deliberate hypotension.
During orthognathic surgery, a high blood pressure after anesthetic induction was found to be associated with the unstable management of deliberate hypotension.
Childhood-onset Basedow-Graves’ disease is a rare disease with an incidence of 5%. We report a case of childhood-onset Basedow-Graves’ disease that exhibited tachycardia at the time of a preoperative physical examination and subsequently presented with delirium, tachycardia, nausea, and vomiting during the postoperative period after a fourth application of general anesthesia.
The woman (age, 16 years and 3 months) had undergone surgery under general anesthesia on three occasions for the correction of a unilateral cleft lip and palate. No abnormalities were detected during the previous perioperative periods. A secondary unilateral chelioplasty and nose repair under general anesthesia were scheduled.
A preoperative physical examination performed one month before the currently reported surgery showed no abnormal values except for sinus-rhythm tachycardia (106 beats/min). Although her heart rate was 155 beats/min at the time of admission, her heart rate decreased and stabilized to a range of within 85-105 beats/min while under general anesthesia. However, her heart rate suddenly increased to 165 beats/min and the patient developed delirium, sweating, shivering, and systemic redness during the discharge period after anesthesia. Five minutes after extubation, the redness disappeared and her blood pressure decreased to 140/80 mmHg ; however, the patient’s nausea and anxiety persisted for 30 hours. Consequently, we consulted the Department of Internal Medicine regarding the patient’s thyroid function. The patient was diagnosed as having childhood-onset Basedow-Graves’ disease and was orally treated with thiamazole and bisoprolol fumarate. The patient was discharged two days after the start of pharmaceutical treatment after exhibiting a decrease in her heart rate and the disappearance of anxiety.
Preoperatively, the patient exhibited poor subjective symptoms of Basedow-Graves’ disease ; therefore, the disease could not be diagnosed preoperatively in this patient. Subsequently, the patient developed thyrotoxic storm-like symptoms postoperatively. Therefore, undiagnosed tachycardia with an onset ranging from childhood to adolescence might be a useful clue in screening for undiagnosed Basedow-Graves’ disease.
Fibromyalgia syndrome (FMS) is characterized by chronic widespread dysfunctional pain in specific regions. Although intravenous sedation (IVS) is often required for dental procedures in patients with FMS, pain attacks sometimes occur during the perioperative period. We report a case in which a patient with FMS underwent two third-molar-extraction procedures under IVS. A 22-year-old woman with mild FMS was scheduled to undergo right-upper- and right-lower-third-molar extractions under IVS. Sedation was induced with 2 mg of midazolam and 20 mg of propofol. Subsequently, the continuous administration of propofol was initiated at a rate of 2 mg/kg/h. After infiltrative anesthesia was performed using 2% lidocaine with 1 : 80,000 adrenaline, the tooth-extraction procedure was started. During mandibular drilling, she experienced pain and began to hyperventilate. Following the immediate administration of 40 mg of propofol and 1 mg of midazolam, the rate of propofol administration was increased to 5 mg/kg/h and her hyperventilation disappeared. Although the tooth extractions were accomplished without subsequent pain, systemic pain attacks occurred for a week after the surgery. After two years, she was once more scheduled to undergo left-upper- and left-lower-third-molar extractions under IVS. Sedation was induced with 2 mg of midazolam, and the continuous administration of propofol was initiated at a rate of 5 mg/kg/h. Not only infiltrative anesthesia, but also a left-inferior alveolar nerve block was performed before the start of the tooth extractions. She did not complain of systemic pain during or after the surgery. Even in patients with mild FMS, sufficient local anesthesia and sedation levels are required during dental procedures under IVS to prevent pain attacks throughout the perioperative period.
Microcuff pediatric endotracheal tubes® (HALYARD, currently AVANOS ; Alpharetta, USA) have been reported to prevent air leaks when used with a low cuff pressure, and preformed-Microcuff tubes have been used in Japan since 2015. The purpose of this study was to evaluate the usability of preformed-Microcuff tubes in Japanese children under the age of 2 years and undergoing oral surgery. Patients aged from 2 months to <2 years who underwent cheiloplasty or palatoplasty under general anesthesia at Osaka University Dental Hospital between April 2016 and October 2017 were included in this study. We retrospectively extracted the patient’s background information, endotracheal tube size, tube exchange rate, and any associated complications. No severe complications were observed in a total of 173 cases. The tube exchange rate for cuffed tracheal tubes was found to be lower than those of previous reports for uncuffed tracheal tubes ; however, the cuffed tracheal tubes were found to be too large in six of our cases and needed to be exchanged (3.5% of all cases in this series). We used larger Microcuff tubes than that recommended by HALYARD in patients aged one and a half years and older who were undergoing a second palatoplasty. Unplanned extubation occurred in two patients aged 8 and 18 months, and prolonged hoarseness after surgery was observed in one patient. We found that preformed Microcuff tubes can be used in Japanese children under the age of 2 years undergoing cheiloplasty or palatoplasty with a low tube exchange rate and no severe complications.
During perioperative management after operations performed under general anesthesia, serious complications caused by delays in the treatment of patients with difficult airway maintenance are a concern.
Although many studies have reported that surgery is beneficial for patients with limited mouth opening, general anesthesia is frequently required for such operations. Difficulties with intratracheal intubation can be expected in patients with limited mouth opening. Hence, face masks or laryngeal masks are often used for airway management in these patients. However, intratracheal intubation is necessary for intraoral surgery, so the postoperative timing of the extubation must be carefully determined.
Here, we report the accomplishment of a successful perioperative management by a collaboration between medical and dental departments in a patient with severe limited mouth opening and micrognathia who underwent mobilization of the right temporomandibular joint and a dissection of bilateral processus muscularis.