Pyruvate produced from glucose in the glycolytic system is converted to acetyl CoA by the pyruvate dehydrogenase complex (PDHC) and transferred to the tricarboxylic acid cycle. In PDHC deficiency, excess pyruvate is converted to lactate, resulting in lactic acidosis. Here, we report the use of general anesthesia in an outpatient with PDHC deficiency.

  The patient was a 21-year-old woman with a body weight of 38.1 kg and a height of 140 cm. The patient was diagnosed as having PDHC deficiency after the observation of high lactate and pyruvate levels. After premedication with midazolam, anesthesia was induced using thiamylal sodium. Rocuronium was administered during anesthesia induction only, and a muscle relaxation monitor was used. The anesthesia was maintained using 1.0 vol％ sevoflurane and 0.05–0.1 μg/kg/min of intravenous remifentanil infusion. Acetate Ringer’s solution was administered as an intravenous fluid. No significant changes in vital signs

were observed, and the lactate level was normal during an arterial blood gas analysis that was performed during the surgery. Sugammadex sodium was administered at the end of the treatment. During general anesthesia in patients with PDHC deficiency, conditions such as hypothermia, hypoxemia, hypocarbia, and postoperative stress can cause an increase in lactate levels ; consequently, appropriate care and management is required. No complications were observed after the anesthesia in the presently reported outpatient.

  Total anomalous pulmonary venous connection (TAPVC) was once a common congenital heart disease associated with high morbidity and mortality rates in infancy. However, currently, the prognosis for surgical treatment is better, with an early mortality rate of 2％–15％ and a 10-year survival rate of approximately 90％. We report the general anesthetic management of a pediatric patient with developmental delay and pulmonary arterial hypertension after surgery for TAPVC.

  A 7-year-old boy (weight, 18 kg ; height, 111 cm) was diagnosed with TAPVC at 14 days of age owing to hypoxemia and underwent radical TAPVC surgery at 16 days of age. Postoperatively, he developed pulmonary arterial hypertension and cerebellar infarction, and continued to receive treatment, thereafter. Long-term warfarin was administered for cerebral infarction, and as his progress was good, we decided to discontinue this medication. At that time, we planned to perform dental treatment under general anesthesia.

  Considering the patient’s respiratory reserve and degree of mental developmental delay, slow anesthetic induction was performed without the use of sedatives. We also prepared circulatory agents to address perioperative hypotension and nitric oxide inhalational therapy in the case of increased pulmonary vascular resistance.

  When anesthetizing a child after radical surgery for TAPVC, anesthesiologists should determine the appropriate time for surgery after assessing the postoperative risks and the patient’s preoperative general condition. Additionally, anesthesiologists should consider the induction method in light of the child’s level of mental development and circulatory changes, and prepare adequately for emergency situations.

  In non-obstetric surgeries on pregnant women, the health of the fetus must be evaluated and managed in addition to ensuring maternal safety. Controlling seizures is of particular importance for pregnant patients with epilepsy, as seizures could suppress respiration and lead the fetus experiencing hypoxia.

  We performed general anesthesia in a 32-year-old woman with epilepsy ; at the time, the patient was in her 26th week of pregnancy. An obstetrician confirmed the health of the pregnant woman and the fetus. A neurologist suggested that the patient’s serum level of carbamazepine might be reduced because of fatigue and emotional stress, which could lead to an epileptic seizure. Consequently, the patient’s serum level of carbamazepine was measured on the morning of the surgery. Anesthesia was rapidly induced using fentanyl, propofol, and rocuronium. The patient was intubated using a fiberscope, as she had a restricted mouth opening. Anesthesia was maintained with desflurane and remifentanil. The fetal heartbeat was periodically checked intraoperatively using fetal ultrasound cardiography. The fetal heart rate was stable at 135–139 beats per minute, and no bradycardia was noted. The operation was completed without any problems, and the patient had a good respiratory condition after extubation. Both the mother and the fetus subsequently progressed uneventfully, and the baby was born by normal vaginal delivery ; no morphological or functional abnormalities were found. When performing general anesthesia during pregnancies complicated by epilepsy, preventing seizures by collaborating with a neurologist is important.

  Working in collaboration with the obstetrician/gynecologist to perform appropriate fetal monitoring appropriate for the number of weeks of pregnancy is also important.

 【要旨】 歯科遠隔医療は，患者が自宅や仕事場などで歯科医とオンラインでコミュニケーションを取りながら治療を受けることができるサービスだ．遠隔医療のメリットとしては，通院の手間や時間を省くことができるほか，忙しい人や遠方に住んでいる人にとっても利便性が高い点が挙げられる．一方で，緊急の治療が必要な場合など，遠隔医療では対応できないこともあり万能ではない．遠隔医療は，あくまでも対面診療の補完として用いられる．歯科の遠隔医療は，歯科医と患者の信頼関係を築きながら適切な治療を提供するために，正確な情報の共有や定期的なフォローアップが重要だ．今後も技術の進化や法制度の整備により，歯科の遠隔医療が一層普及し，患者の利便性や医療の質の向上に貢献していくことが期待される．