【要旨】 先天性心疾患（Congenital heart disease：CHD）合併患者の口腔外科手術における麻酔関連有害事象の発生について明らかにするため，大阪母子医療センターで2020年1月から2022年12月の間に全身麻酔下で口腔外科の予定手術を受けた症例を対象に，CHD合併患者とCHD非合併患者とで麻酔関連有害事象の発生を調査した．対象症例は1,111例で，CHD合併患者の割合は8.2%で近年増加傾向にあった．CHD合併患者の年齢の中央値は6歳，手術は唇顎口蓋裂関連手術が半数以上を占めていた．CHD合併患者では，早産・低出生体重児，遺伝子・染色体異常，てんかん，知的能力障害，喘息といった併存疾患を有している割合が多かった．CHD合併患者の麻酔関連有害事象発生率は36.3%で，CHD非合併患者（14.8%）と比較して有意に高く，なかでも，麻酔中の低血圧，徐脈，抜管後の低酸素血症の発生率が高かった．麻酔関連有害事象を目的変数としたロジスティック回帰分析を行った結果，CHD，遺伝子・染色体異常，知的能力障害の合併が独立した麻酔関連有害事象発生要因であった．また，CHD合併患者では術後に集中治療室に入室した症例が多く，デクスメデトミジンを用いた鎮静管理が行われていた．CHD合併患者の口腔外科手術では，術前の他の併存疾患への配慮と，術中の循環変動および抜管後の低酸素血症への対応，ICUでの術後鎮静管理の必要性について検討する必要がある．

  We report a rare case in which the inflation line was not closed at the tip of the endotracheal tube, allowing the cuff to deflate. The patient was an 18-year-old male with Down syndrome who was scheduled to receive dental treatments under general anesthesia with nasotracheal intubation. Anesthesia was slowly induced, and an ivory PVC endotracheal tube with a soft-seal cuff (inner diameter, 5.5 mm ; Smith Medical Japan Inc., Tokyo, Japan) was inserted nasally into the trachea and fixed at a point 23 cm from the nostril opening ; the cuff volume was 5 mL. At this time, we observed that the pilot balloon was deflated and contained a droplet. The cuff had been inspected and was thought to have been normal prior to anesthesia induction. The tube was removed, and another nasotracheal tube was inserted into the trachea, after which successful anesthesia was achieved. When the cuff of the removed endotracheal tube was immersed in water, bubbles were discharged from the tip of the endotracheal tube when the cuff was expanded to some extent (Fig. 1-A). The manufacturer investigated the device and confirmed that a hole was present in the inflation line at the tip of the endotracheal tube (Fig. 1-B, C). An inflation line that is not closed at the tip of the endotracheal tube is a very rare event (Fig. 2, 3). When checking cuffs prior to use, an experienced anesthesiologist should inject air into the cuff until it is sufficiently inflated and then observe the cuff for a short period of time to ensure proper functioning.

  We report the successful use of intermittently scanned continuous glucose monitoring (isCGM) for blood glucose control during general anesthesia in a patient with type 1 diabetes. The patient was an 82-year-old woman (146 cm, 40 kg). At the age of 72 years, she began receiving bisphosphonates suitable for patients at risk for osteoporosis. She was diagnosed as having medication-related osteonecrosis of the jaw (MRONJ) and was scheduled to undergo a mandibular zonal resection under general anesthesia. The patient had type 1 diabetes mellitus, which was being managed with diet and insulin therapy. An isCGM sensor was placed on the left upper arm the day before surgery, and blood glucose control monitoring was performed perioperatively. The anesthesia was rapidly induced. The patient’s blood glucose level was measured using isCGM every 30 min beginning immediately after anesthesia induction. At 1 hour and 30 minutes after anesthesia induction, the patient’s blood glucose level increased to 206 mg/dL ; rapid acting insulin (2 UI) was administered subcutaneously and a 5% glucose infusion was started. The blood glucose level then decreased and remained at 190 mg/dL. Two hours and 30 minutes later, the patient’s blood glucose level once again increased to 204 mg/dL ; insulin (2 UI) was again injected subcutaneously. Thereafter, her blood glucose level remained at around 150 mg/dL until the end of surgery. After 4 hours and 15 minutes of treatment and 5 hours and 17 minutes of anesthesia, her blood glucose level was 126 mg/dL at the end of the procedure. This report describes a patient with type 1 diabetes mellitus who was monitored intraoperatively using isCGM. isCGM enables blood glucose trends to be monitored during enforced periods of fasting before and after surgery, allowing insulin to be administered promptly and preventing persistent hyperglycemia intraoperatively.

  We report a case of lingual neuropathic pain in the post coronavirus disease 2019 (COVID-19) condition. The pain disappeared after mirogabalin (MGB) treatment.

  The patient was a 17-year-old female who complained of a burning pain on her tongue. Approximately 80 days before her initial visit, she tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) and was diagnosed with COVID-19. The morbidity of COVID-19 symptoms was mild. However, the burning pain on her tongue remained after she tested negative for SARS-COV-2. The pain was a persistent burning pain that worsened with eating and talking. On examination, she had marked allodynia on her tongue. The examination results ruled out post-traumatic trigeminal neuropathic pain, burning mouth syndrome, endocrine disorders, oral candidiasis, xerostomia, and zinc or vitamin deficiency. The patient met the World Health Organization criteria for the post COVID-19 condition ; therefore, we diagnosed lingual neuropathic pain in the post COVID-19 condition and started treatment with MGB. After 14 days, the persistent pain decreased. MGB was gradually increased to 20 mg/day. After approximately 3 months, the persistent pain disappeared, and dysesthesia only occurred after eating and talking. MGB was thereafter gradually decreased. Finally, she took 5-10 mg/day only when she became aware of dysesthesia due to factors such as fatigue and stress. However, her initial complaints of persistent pain on the tongue that worsened with eating and talking have disappeared.

  In the diagnosis of neuropathic pain in the trigeminal region, the possibility that SARS-CoV-2 infection is the cause should be considered.

  Local anesthesia of the upper airway during awake intubation is very important to alleviate pain and facilitate the procedure. In this case report, we used a MICRO MIST Nebulizer to allow a patient to inhale lidocaine for local anesthesia of the upper airway, enabling a smooth and safe awake nasal fiberoptic intubation in a patient with severe obesity and cervical abscess. The patient was a 66-year-old male with a height of 168 cm, a weight of 108 kg, and a BMI of 38 kg/m². Cervical abscess incision and debridement under general anesthesia were scheduled for the treatment of acute cervical abscess. Because of severe neck swelling and obesity, anesthesia induction was predicted to be difficult ; we therefore selected full awake nasal fiberoptic intubation with local anesthesia of the upper airway.

  The patient was instructed to inhale a 4% lidocaine mist using a MICRO MIST nebulizer while receiving 8 L/min oxygen. After inhaling the lidocaine, awake fiberoptic nasal intubation was performed. No sedatives were used during the intubation. The oxygen saturation did not decrease during the fiberoptic intubation, and the intubation was performed smoothly with minimal gagging reflex, coughing reflex, swallowing reflex, or body movement. This case report suggests that local anesthesia of the upper airway using a MICRO MIST nebulizer is a useful and safe method for performing awake fiberoptic intubation in patients predicted to have a difficult airway.

  We report a case in which the SpO₂ value decreased because of a suspected local perfusion failure. A 10-year-old boy underwent left-sided cleft lip and iliac bone grafting of the jaw under general anesthesia. An adhesive tape SpO₂ monitor (OXIMAX N-25 Nellcor^TM Oxisensor^TM Ⅲ, Covidien Japan, Tokyo, Japan) was placed on his left index finger. During general anesthesia induction, no abnormal SpO₂ values were observed. Ninety minutes after the placement of the probe, the SpO₂ value, which was 100% immediately before the procedure, began to drop to 94%-95%. Since no problems were found after checking the tube insertion length, auscultating the lung field, and performing a blood gas analysis, we suspected equipment failure and placed a new probe on the left toe ; the SpO₂ value subsequently returned to 98%-100%. We then suspended the surgery and checked the probe on the left index finger. The skin in proximity to the probe was dark purple, and the probe was immediately removed. Overpressure from the probe was thought to have caused the vessels in the fingertip to constrict, decreasing the blood flow and causing hypoperfusion and, consequently, peripheral circulatory failure, resulting in the decrease in SpO₂. Dental anesthesiologists should pay attention to the appropriate attachment of SpO₂ probes.