【要約】 本調査は, 歯科治療時におけるメピバカイン塩酸塩製剤を用いた伝達麻酔の有用性を検証した. 日本歯科麻酔学会指導施設のうちの5施設において, 16歳から80歳で歯科治療のために伝達麻酔が必要とされた患者で本調査への参加に同意した者を対象とした. 総症例数は108例で中止症例はなかった. 性別は, 男性45名, 女性63名であった. 治療内容は抜歯が87名で最も多かった. 伝達麻酔は下顎孔が106例, 上顎結節と切歯孔が各1例であった. 下顎孔伝達麻酔に限ると, 使用量は1.8mlが82例で最も多く, 作用発現時間は4.5±2.0分 (mean±SD), 作用持続時間は166.3±75.4分であった. 治療時の痛みは, ｢無痛｣ が68例, ｢ごくわずかな痛み｣ が23例であり, この両者で84.3%を占めた. 全体的な有効性の評価は, ｢有効｣ が100例, ｢やや有効｣ が5例であり, この両者で97.2%を占めた. 全例において, メピバカイン塩酸塩製剤を用いた伝達麻酔と因果関係のある, 出血関連有害事象を含む有害事象はみられなかった. 全体的な有用性の評価は, ｢有用｣ が105例であり, 有効性と有用性との関係をみると, メピバカイン塩酸塩製剤による伝達麻酔が ｢有効｣ かつ ｢有用｣ であると評価された症例が100例 (92.6%) であった. 以上のことから, メピバカイン塩酸塩製剤を用いた歯科領域における伝達麻酔は有効性が高く, 有害事象を認めなかったことから, 十分に有用性が期待できると考えられた.

 【要約】 緒言 : アーティカイン塩酸塩 (アルチカイン塩酸塩) は, 歯科治療に際して世界的に広く使用されているアミド型の局所麻酔薬であるが, 現在日本では薬事承認を受けていない. そこで本邦での歯科用アルチカイン製剤 (OKAD01) の導入を目指し, OKAD01を日本人の口腔粘膜下に投与した際の安全性および血中薬物動態を検討するため, 日本人を対象としたOKAD01の第Ⅰ相試験を行った.

 方法 : 健康な日本人成人男性を対象とした. OKAD01 1カートリッジ (1.7ml) および3カートリッジ (5.1ml) を口腔粘膜下にそれぞれ6名ずつに投与した. OKAD01投与前, 投与終了15, 30, 60分後, および2, 4, 12, 24時間後の血漿中アルチカイン濃度の測定を行った. またOKAD01投与前, 投与後に臨床検査, バイタルサインなどの測定を行い, OKAD01投与による有害事象を検討した.

 結果 : 1カートリッジ群の薬物動態パラメータ値 [平均値±標準偏差 (最小値-最大値)] は, 最高血中薬物濃度 (Cmax) が374.35±97.65 (252.7-514.5) ng/ml, 最高血中薬物濃度到達時間 (Tmax) が0.25±0.00 (0.25-0.25) hであった. また3カートリッジ群では, Cmaxが694.00±175.23 (517.9-970.4) ng/ml, Tmaxが0.42±0.13 (0.25-0.5) hであった. 有害事象は1カートリッジ群に ｢頭痛｣ が1件認められたが, OKAD01との因果関係はなしと判断された.

 結論 : OKAD01を日本人の口腔粘膜に投与した際のCmaxは, 本治験の安全域とした5.0 μg/ml未満であることが確認された. また, OKAD01に関連した有害事象は認められず, OKAD01は, 20歳以上の健常日本人男性に対して忍容性が認められ, 安全性に問題はないと考えられた.

 【要約】 2018年1月から2019年5月の1年5カ月間に, 歯科未設置の循環器病院入院中の心臓手術待機患者10症例に対する抜歯時の歯科周術期管理を経験した.

 訪問歯科診療による口腔内評価で, 歯周ポケット6mm以上かつ出血を認める辺縁性歯周炎, 急性症状の既往をもつ根尖性歯周炎, 明らかな破折や感染を認める歯牙を感染歯牙と評価した. 外来通院と鎮静薬使用可能な心機能状態と評価された症例は, 当診療所外来で, 静脈内鎮静法下での抜歯を行った. 一方, 重症度の高い心機能状態が持続する症例では, 当該の循環器病院内の病棟ベッド上で抜歯を行った.

 周術期の経過を通して, RCRIによるリスク評価には限界があると考えられ, レトロスペクティブにNSQIP, GUPTAを用いて検討を行った. その結果, 必要最小限の抜歯, 外来IVS併用, 処置時間の短縮を念頭に, 症例ごとに管理方針を検討することが肝要であると思われた. さらに, NSQIPとGUPTAにおけるリスク評価3.0%が, 診療形態や, 使用する局所麻酔薬を選択する際の判断基準として有用である可能性が示唆された.

  The patient was a 45-year-old male with right-side tongue cancer (T4aN2b) ; general anesthesia had been planned for a tracheostomy, bilateral radical neck dissection and reconstruction with a rectus abdominis muscle flap. Three days before the scheduled operation, the tumor started bleeding and a tracheotomy was performed under intravenous sedation to prevent airway obstruction resulting from blood clotting. The day before the scheduled surgery, extensive pneumomediastinum and subcutaneous emphysema were identified on a chest computed tomography (CT) image, and the planned operations were deferred. One week later, the size of the pneumomediastinum had clearly decreased, and the operations were performed as previously planned. During the operations, the internal airway pressure was kept lower to prevent tension pneumomediastinum, and after the operations, the patient was sedated with the continuous injection of dexmedetomidine. The operations were performed without any further events, and the postoperative course was also uneventful. In this case, one of the causes of the pneumomediastinum and subcutaneous emphysema was considered to be air leakage or air aspiration into the soft tissues of the neck and the mediastinal space through the tracheostomy wound as a result of events related to a higher airway pressure, such as cuffing. The frequency of pneumomediastinum and subcutaneous emphysema after tracheostomy is relatively rare. However, these complications after a tracheostomy require careful attention.

  Oral and maxillofacial surgery is rarely performed with the patient in a prone position, since the risk of serious complications is increased for patients receiving general anesthesia in this position. Here, we report a case of safe general anesthesia management for an obese patient who was atypically treated in a prone position.

  A 53-year-old man with a body mass index of 33 kg/m² had undergone a mandibular resection for the treatment of oral cancer 2 years previously. To improve postoperative oral dysfunction, iliac bone harvesting and bone grafting surgery were planned with the patient in a prone position under general anesthesia. The case was reviewed by the attending dentists, nurses, and medical appliance vendors. The procedure was carefully simulated using a simulated patient in a prone position on the day before the actual surgery. Anesthesia was induced rapidly, and nasotracheal intubation was performed. The patient was placed in the prone position smoothly and was repositioned in the supine position after bone harvesting without any difficulties. While the patient was in the prone position, the cardiac output and stroke volume decreased, but the respiratory and circulatory dynamics were stable throughout the time spent with the patient in a supine position, even during the changing of positions. The patient was extubated once fully awake, and no postoperative complications were reported. Performing surgery with the patient in a prone position often increases the risk of serious complications because of risk factors for complications, limited surgical experience, and unfamiliarity with appliances. In this study, the preoperative simulation was thought to have helped to prevent complications. During respiratory care, low tidal volume ventilation with PEEP is recommended, and it is important to understand the hemodynamics of patients in a prone position. These considerations enable a safer and smoother general anesthesia management.

  Cryopyrin-associated periodic syndrome (CAPS) is an autosomal dominant inherited disorder characterized by repetitive systemic inflammation. The representative symptoms include fever, fatigue, rashes, headaches and arthralgia, which appear as familial cold auto-inflammatory syndrome (FCAS). FCAS symptoms are triggered by cold stimulation and continue for a few hours or several days. We experienced a surgical case of a 13-year-old female with FCAS. The patient had been treated with canakinumab (IL-1 inhibitor) every two months in the winter, and her symptoms were under control. Since a reduction in body temperature was a concern, we planned to monitor the patient's temperature intraoperatively at the axilla, superficial temporal artery, and rectum. We started by prewarming the patient using a forced-air warming system before the anesthesia induction. General anesthesia was maintained with air-oxygen-sevoflurane and intravenous remifentanil. The initial axillary temperature was 36.0℃, but her temperature rose to 37.6℃ at 45 minutes after the anesthesia induction. The superficial temporal artery temperature rose gradually from 36.6℃ to 37.1℃. The rectal temperature was stable at between 37.4℃ and 37.5℃ throughout. The temperature at these three locations differed by as much as 2℃ at the start of surgery, but the use of forced air warming decreased this difference to 0.4℃ at 60 minutes after the anesthesia induction. The durations of the surgery and anesthesia were 37 minutes and 1 hour, 17 minutes, respectively, and a low body temperature was successfully avoided. The patient was discharged from hospital on the following day without any symptoms of FCAS.