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.

 【要旨】 遠隔医療は情報通信機器を活用した健康増進，医療に関する行為と定義されている．遠隔医療を導入することで医師不足により適切な医療を受けることができない患者の減少，僻地での訪問診療に対する困難性の解消などが期待される．遠隔麻酔とは麻酔科医が不足する地域における医療施設の医師または看護師に対し，遠隔モニタリングを用いて麻酔科専門医が麻酔の支援を行うことであり，国内外を問わずその有用性に関する報告が散見される．われわれは小型バイタルサイン測定機器を活用した遠隔モニタリングシステムを開発し，歯科医院および歯科訪問診療時の患者全身管理へ導入してきた．歯科麻酔科医による遠隔モニタリングは臨床応用可能な方法であり，患者の安全性向上に寄与することが期待されるが，課題も多い．特に患者急変時の対応は最優先課題であり，現場の歯科医療従事者に対する歯科麻酔学教育の充実を図ることが不可欠である．

 【要旨】 障害者数の増加に伴い，全身麻酔法や精神鎮静法などの麻酔管理を安全に実施できる，歯科麻酔科医および歯科麻酔学会認定歯科衛生士の重要性が増加している．本稿では，障害者歯科における日帰り全身麻酔および精神鎮静法の適応患者の条件から帰宅後管理までの基本的な知識を，日本歯科麻酔学会登録医および認定歯科衛生士を取得あるいは目指している会員に向けて解説した．