When providing medical care to Muslim patients, various considerations need to be made for religious reasons. Here, we report our perioperative management experience treating a 27-year-old unmarried female Muslim patient undergoing orthognathic surgery.

  The patient was a Muslim of Malaysian nationality. She underwent a Le Fort type I osteotomy and sagittal split ramus osteotomy because of a jaw deformity.

  The patient was an unmarried woman who, for religious reasons, was not allowed to show her skin or hair to men. Therefore, male physicians were restricted from entering the room she was in from the time she entered the operating room until the induction of anesthesia was complete and from the time she underwent surgery until her return to the recovery room. Anesthesia was induced with midazolam, fentanyl, and rocuronium bromide and was maintained with sevoflurane, droperidol, fentanyl, and remifentanil. Opioids were used with the patient’s preoperative permission. Postoperatively, the patient was intubated and placed in the recovery room and sedated with dexmedetomidine and midazolam until the next morning.

  Islam has various teachings regarding lifestyle, and Muslims live according to these teachings. Therefore, the perioperative management of Muslim patients requires consideration not only for anesthesia management, but also for prayer, contact with the opposite sex, diet, and fasting.

  There are differences in religious views among countries and individuals, and necessary measures vary from patient to patient. It is necessary to check with the patient in advance and to discuss to what extent the hospital can accommodate the patient. It is also important to obtain the patient’s consent for any treatment that cannot accommodate the patient’s wishes.

  Cuff damage in endotracheal tubes causes a variety of complications because of the reduction in cuff pressure. This report describes a case in which an automatic cuff pressure controller (SmartCuff^® ; Murata Manufacturing Co., Kyoto, Japan) enabled the early detection of cuff damage. A 23-year-old woman underwent a maxillary osteotomy and sagittal split ramus osteotomy under general anesthesia. After rapid induction, the tracheal tube was intubated through the right nostril. The tracheal tube was difficult to guide into the glottis, and Magill forceps were required to introduce the tracheal tube. The anesthesiologist confirmed the absence of leaks in the cuff and the absence of any abnormalities in the capnogram waveform, bilateral lung sounds, or tidal volume. After several minutes, the anesthesiologist started monitoring the cuff pressure using the SmartCuff^® and noticed an alarm. As damage to the cuff was suspected, we considered that reintubation was necessary. A laceration on the cuff of the extubated tube was detected near the tip. The SmartCuff^® is a useful device for cuff pressure management during tracheal intubation because an alarm will quickly sound if any decrease in cuff air pressure is detected. Cuff air leaks can result in a decrease in the ventilation volume, abnormalities in the capnogram waveform, and leak-related sounds. In the present case, the cuff damage activated the alarm of the SmartCuff^® despite the absence of abnormal anesthetic monitoring findings. Therefore, the tracheal tube could be replaced before starting surgery, and the anesthesia was managed safely.

  A 26-year-old woman (case 1) and a 21-year-old man (case 2) were scheduled to undergo dental treatment ; the administration of intravenous sedatives was planned because both patients had histories of vasovagal reflex (VVR). However, during venipuncture, the patients complained of dysphoria, became pale, temporarily lost consciousness, and experienced convulsions. Furthermore, their blood pressure and heart rates dropped, and sinus arrest was observed on electrocardiography. We diagnosed both patients as having experienced VVR episodes. We proceeded to raise their legs and to administer 0.5 mg of atropine or 3 mg of midazolam intravenously, and their symptoms subsequently improved. VVR is usually caused by mental and physical stress-related factors, such as pain, anxiety, fear, tension, hunger, fatigue, and insomnia. We concluded that our patients’ VVR episodes were triggered by pain, and we decided to take preventive measures to reduce pain during venipuncture. We did this by instructing the patients to self-apply a 60% lidocaine tape at the venipuncture site and to leave the tape in place for 3 h prior to the next attempt at venipuncture. This measure successfully prevented VVR episodes from recurring in both cases, with the patients commenting that they felt no pain or discomfort and that the entire procedure was very comfortable. Both patients also requested the application of 60% lidocaine tape before any further venipuncture procedures. In conclusion, we suggest that clinicians assist patients with histories of VVR by applying 60% lidocaine tape over the planned venipuncture site for 3 h prior to needle insertion. This step can prevent pain and pain-induced VVR and thus promote patient satisfaction with their treatments.

  Robin sequence (RS) is a congenital disease with micrognathia, glossoptosis-caused airway obstruction, and cleft palate as primary symptoms. Pediatric patients with RS are prone to airway obstruction when anesthesia is introduced, and intubation can be difficult because of micrognathia, which is problematic for anesthesia management. We provided general anesthesia management for a glossopexy in a 45-day-old female patient with RS. In this case, mask ventilation after introduction would have been challenging because unless the patient was in the lateral decubitus position during sleep, ventilation would be difficult. Thus, a nasopharyngeal airway was inserted under sedation, and anesthesia was introduced after confirming that the upper airway obstruction had improved. As it was difficult to intubate using a GlideScope^® Cobalt (GS) or a Fiberscope (FB) alone, a narrow field of view of the larynx was secured by performing a two-person technique using both a GS and a FB, making intubation feasible. After fixing the tube, the absence of any breathing problems was confirmed, and the patient’s vital signs remained stable. The operation was then started. The patient’s respiratory and vital signs were stable throughout the operation. Postoperatively, the resting SpO₂ remained in the high 90% range, the patient’s breathing was stable even in the supine position, and no hypoventilation was noted. Furthermore, under the guidance of a nurse, the patient’s mother was able to feed the infant without difficulty. Hence, the patient was discharged on postoperative day 2.

  Recent studies have suggested that there is no increase in congenital anomalies at birth in the offspring of women undergoing anesthesia during the first trimester of pregnancy, but anesthesia exposure does increase the risk of spontaneous abortion and a lower birth weight in infants. Thus, the choice of sedatives, analgesics and local anesthesia is challenging in terms of the placental transportability of drugs and the risk of spontaneous abortion. We report the case of a 43-year-old patient in her 13th week of pregnancy who underwent a partial glossectomy. A preoperative pathological examination diagnosed the tumor as an oral intraepithelial neoplasia/carcinoma in situ (OIN/CIS) of the tongue. To reduce fetal drug exposure, a partial glossectomy of the left side of the tongue to be performed under intravenous sedation and with a lingual nerve block was scheduled. Oxygen (2 l/min) was delivered through a nasal cannula. The continuous intravenous infusion of 0.3 μg/kg/h of dexmedetomidine (DEX) was initiated, and 0.5 mg of midazolam was administered ; a bilateral lingual nerve block was then performed. After the additional administration of 1.0 mg midazolam, infiltration anesthesia in the area of the tumor was administered. During the operation, the DEX infusion rate was increased to 0.5 μg/kg/h. Throughout the operation, adequate sedation and amnesia were achieved, and sufficient relief of the pain associated with surgical invasion was obtained using the lingual nerve block without any supplemental infiltration or the administration of opiates. If oral malignancy ablative surgery during the first trimester of pregnancy cannot be deferred, anesthesia management using a nerve block together with intravenous sedation can contribute to a reduction in the detrimental effects of anesthesia during early pregnancy.