Dravet syndrome (DS) is an epilepsy syndrome characterized by seizures triggered by increases in body temperature as a result of fever or bathing or visual stimuli, such as lights or shapes ; these seizures are easily superimposable, intractable, and refractory to drug treatment. In patients with DS, perioperative seizure control is a focus of management. Here, we report our experience providing anesthetic management using remimazolam (RMZ) during dental treatment in a pediatric patient with DS. A 3-year and 5-month-old girl (weight, 13.8 kg ; height, 90 cm) had experienced multiple convulsive seizures since the age of 3 months and had been diagnosed as having DS based on genetic testing at 1 year of age. She had been treated with antiepileptic drugs but had also been occasionally admitted for emergency treatment because of convulsive seizures. For the planned dental treatment, slow induction with nitrous oxide, oxygen, and sevoflurane was performed and a venous route was secured. Oral intubation was performed after the administration of RMZ, remifentanil, and rocuronium. Anesthesia was maintained with air, oxygen, RMZ, and remifentanil. The patient’s intraoperative temperature and other vital signs were stable, and the prescribed dental treatment was completed. No fever or seizures were observed during the perioperative period, and she was allowed to go home after confirming the absence of any abnormalities in her recovery. RMZ is a short-acting benzodiazepine that may be useful for the anesthetic management of pediatric patients with DS because of its potential to prevent seizures.

  We herein report the case of a 19-year-old woman with microgenia caused by temporomandibular joint (TMJ) ankylosis. The patient had a height of 155.8 cm and weight of 37.7 kg during the first surgery. To resolve severe disturbance of the mouth opening, TMJ mobilization and coronoidotomy were scheduled under general anesthesia. We performed intubation using surgical tracheostomy under conscious sedation, and the intraoperative course was uneventful. Four years after the first surgery, a second surgery for the extraction of wisdom teeth was scheduled before surgery to correct the deformity of the jaw. As the patient’s mouth opening range increased from 5 mm to 30 mm, we planned mask ventilation and nasal endotracheal intubation. Further, to avoid hypoxia due to hypoventilation, oxygenation was monitored using the oxygen reserve index (ORi^TM). General anesthesia was induced using propofol and remifentanil, and mask ventilation was easily attainable ; however, it was difficult to visualize the epiglottis using the McGRATH^TM MAC (McGRATH X BLADE). Consequently, we could not ventilate using a mask, and the oral airway device was ineffective. Finally, the insertion of a supraglottic airway device (Ambu^® AuraFlex^TM) resulted in an effective seal, and the patient could be ventilated. We tried to expand the space in the pharynx using the McGRATH^TM MAC and insert a fiberscope through the nasal passage. This method allowed completion of fiber-optic nasal intubation. The ORi^TM was maintained from 0.2 to 0.4, and SpO₂ was maintained at 100％ during the intubation period.

  Angina Bullosa Haemorrhagica (ABH) is a hematogenous blister that can appear in the submucosa of the oral cavity because of sudden vascular collapse. We experienced a case in which a submucosal hemorrhage caused by physical stimulation of the soft palate during the induction of anesthesia led to the development of ABH upon further physical stimulation after the patient had returned to the post-surgical ward. The patient was a 59-year-old man (height, 183 cm ; weight, 68 kg). He was scheduled for tooth extraction and marginal resection under general anesthesia for gingival carcinoma of the left mandible. The surgery was completed in 2 hours and 54 minutes, and the duration of anesthesia was 4 hours and 10 minutes. Approximately five minutes after returning to the post-surgical ward, oral suctioning was performed at the patient’s request. At this time, a hematogenous blister of approximately 10×10 mm was observed on the right side of the soft palate. Five minutes later, the size of the area had expanded to approximately 25×25×10 mm. Concerned about further enlargement, the patient underwent decompression by incision and aspiration. In this case, the soft palate became negatively pressurized by the physical stimulation from the suctioning of the oral cavity after returning to the ward and by the process of draining blood and saliva, resulting in the further expansion of the hematochezia because of submucosal hemorrhage, or ABH. This case reaffirms the need for patient-friendly intraoral manipulation during general anesthesia procedures.

  Vocal cord paralysis is a known complication following tracheal intubation. If paralysis occurs in bilateral vocal cords, it can cause obstruction of the glottic airflow, resulting in respiratory distress and the need for a surgical airway. We report the case of an 8-year-old boy with autism who underwent general anesthesia for the extraction of an impacted tooth. The patient was born with a very low birth weight and had unilateral vocal cord paralysis as a result of long-term intubation. Because of the potential for tracheal intubation to cause vocal cord paralysis on the non-paralyzed side, a laryngeal mask (LMA) was inserted after slow induction. To secure the surgical site, an LMA with a flexible metallic shaft (AuraFlex^TM) was fixed at a distance from the surgical site. General anesthesia was maintained with sevoflurane, and propofol was administered before the end of the surgery. Spontaneous breathing was maintained throughout the operation to avoid aspiration arising from gastroesophageal reflux. Before removing the LMA, a fiberscope was used to confirm that there was no change in the vocal cord. Because this patient had difficulty staying in the hospital and a strong preference for day surgery, he was sent home after adequate confirmation of his recovery from anesthesia and with an emergency response plan fully in place. With the increasing number of dental treatments being performed in children with complex medical needs, it is important to consider carefully whether procedures should be performed on a case-by-case basis and to devise protocols for minimizing potential complications.

  A patient with multiple facial traumas was orally intubated. Ten days after intubation, a change in the intubation route (from oral to nasal) was performed prior to surgery. Due to anticipated damage, contamination, and bleeding in the oral cavity, the procedure was performed using a video laryngoscope (McGRATH^TM MAC), a bronchial fiberscope, and a tube exchanger. The procedure was conducted under general anesthesia while preserving spontaneous breathing and was completed without a decrease in SpO₂. A detailed plan and careful procedure are important when changing the intubation route in cases with airway abnormalities.

  Telemedicine is defined as the promotion of health and medical practices using information communication technologies. Telemedicine is expected to reduce the number of patients who are unable to receive appropriate medical care because of the shortage of medical doctors and to resolve the difficulty of providing medical treatments during home visits to patients living in rural areas. Teleanesthesia refers to the need for telemonitoring by remote anesthesiologists to support general anesthesia being provided by doctors or nurses in areas experiencing a shortage of anesthesiologists. Many reports have described its usefulness in both Japan and abroad. We have developed a telemonitoring system that uses a small device for measuring vital signs, which we have included in the systemic management of patients in dental clinics and home-visit dental treatments. Although telemonitoring by dental anesthesiologists is a clinically applicable method that is expected to contribute to improving patient safety, there are some unresolved issues. In particular, appropriate management for patients who suddenly experience medical emergencies is a top priority issue, as remote dental anesthesiologists cannot treat these patients directly. Hence, it is essential to include telemedicine modules in dental anesthesiology education for on-site dental service providers to facilitate emergency medical treatment for these patients.

  The importance of dental anesthesiologists and dental hygienists who can administer anesthesia, such as general anesthesia and sedation, is increasing in parallel with the increasing number of dental patients with special needs. This article provides basic knowledge about day-care general anesthesia and sedation required for special needs dentistry, from the selection of patients who are eligible for day-care general anesthesia and sedation to their post-return care, for members of the Japanese Dental Society of Anesthesiology.