【要旨】 漢方薬の魅力は歯科医師・医師であれば創薬できることです．西洋薬の創薬は製薬メーカーしかできません．ところが生薬の足し算である漢方薬は，誰でもアイディアを出すことができます．そして歯科医師・医師であれば，患者さんに自分で創り上げた漢方薬を処方し，治療を行うことが可能なのです．西洋薬剤ですべてが解決できないときに，そんな領域を自身で創薬した漢方薬で治すことが可能なのです．

 自分で漢方薬を創薬するには，まず既存の漢方薬を使いこなせるようになりましょう．既存の漢方薬はこの数十年漢方エキス製剤という形で進歩しました．148種類の漢方製剤が保険適用されています．まず，その使い方を会得し，そして使用し，漢方エキス製剤では不足な部分を新しく創薬される漢方薬で補うのです．

 漢方エキス製剤は複数の生薬を煮出してエキス剤にしたものに賦形剤を加えてエキス製剤にしています．生薬を煎じるのであれば加減が可能ですが，エキス製剤では生薬の加減ができません．エキス製剤の登場で携行や保存，内服が容易になりましたが，一方の弊害としては漢方の進歩が止まりました．

 新しい漢方薬を作るには複数の漢方エキス製剤の併用，または漢方エキス製剤に生薬エキスを加えるなどでも可能です．一方で，まったく新しい生薬を見つけ，まったく新しい生薬の組合せを考案することも可能なのです．その延長には生薬と西洋薬の組合せも選択肢の一つになります．そして，歯科学・医学を含めたサイエンスは進歩するのです．

 【要旨】 日本を含む各国の学会が作成した気道管理ガイドラインの考え方は，頭頸部外科・口腔外科手術患者には適用の難しい部分もある．気管挿管，マスク換気が不可能な場合，JSAガイドラインが推奨する声門上器具挿入は咽喉病変をもつ患者では慎重に行うべきか，あるいは禁忌である．CICVに陥って前頸部からの気道確保が必要になっても，頸部病変や組織の瘢痕化があると熟練の外科医でも難渋するかもしれない．患者の気道，併存疾患，施設の状況（物品，人員）を考慮して個別の対応が求められる．挿管の困難度を予測する最も確実な方法は，直前の口腔観察である．適切な口腔粘膜の局所麻酔と，自発呼吸を抑制しない軽度の鎮静を併用して，患者に大きな苦痛を与えずに咽喉周囲の観察が可能である．ビデオ喉頭鏡の所見を外科医や看護師と共有することは有用で，無理な挿管操作を続けず早期に意識下の気管切開に変更する判断の一助となる．困難気道への対処はデバイスの選択にとどまらない．気道確保操作の間，酸素飽和度を安全な範囲に維持する方策として高流量酸素の鼻腔投与が普及しつつある．鎮静下気管挿管を安全かつできるかぎり快適に行うには鎮静薬・鎮痛薬の適切な投与が不可欠である．調節性に富む短時間作用性の薬剤が適しているが，気道の浮腫や出血が生じると薬剤投与を止めても気道や自発呼吸は必ずしも元の状態には戻らない．覚醒と抜管は気道管理の最も危険な時期であるが，それが十分に認識されているとはいいがたい．抜管に関わる多職種が共通の認識をもつことが何より重要である．

  The use of ultrasound-guided mandibular and maxillary nerve blocks during gnathoplasty is a recent development. In this report, we describe infrazygomatic approaches using out-of-plane needling to perform ultrasound-guided mandibular and maxillary nerve blocks. We also explain the advantages of mandibular and maxillary nerve blocks when applied in conjunction with general anesthesia to achieve stable hemodynamic control in a patient with LDS undergoing orthognathic jaw surgery.

  Recurrent nerve palsy after general anesthesia is a rare complication with an incidence of 0.1％ or less. Here, we report two cases of diagnosed unilateral recurrent nerve palsy after general anesthesia for orthognathic surgery.

  Case 1 was a 32-year-old female (155 cm, 63 kg) scheduled to undergo a sagittal split ramus osteotomy (SSRO). Nasotracheal intubation was performed using a Portex Cuffed Maxillofacial Nasal Directional Endotracheal Tube^® (∅6.5 mm) and a McGRATH MAC Video laryngoscope^®. The patient’s head was retroflexed 40° for 1 hour and 56 min. After the general anesthesia, the patient became dysphonic and required 3 months to recover vocalization.

  Case 2 was a 38-year-old female (159 cm, 57 kg) scheduled to undergo an SSRO and Le FortⅠosteotomy. Nasotracheal intubation was performed using the same tube as that used in Case 1, and the patient’s head was retroflexed 40° for 4 hours and 51 min. The endotracheal cuff pressure was monitored using a disposable pressure transducer connected to the pilot balloon during the operation. The cuff pressure changed according to surgical manipulation, but the mean value was 28.4±3.2 cmH₂O. After the general anesthesia, the patient became dysphonic and required 48 days to recover vocalization.

  During orthognathic surgery, the nasotracheal tube cuff can compress the recurrent nerve inside the thyroid cartilage. Consequently, nerve palsy can occur even if the operation time is relatively short or the cuff pressure is appropriate. Repeated tracheal tube cuff pressure changes during orthognathic surgery may increase the risk of developing recurrent nerve palsy.

  Glucagon-like peptide receptor agonists (GLP-1RAs) are used to improve glycemic control in type 2 diabetes. Semaglutide, a GLP-1RA, delays gastric emptying, resulting in sustained satiety and weight loss. However, concerns exist regarding an increased aspiration risk during the perioperative period. This report presents a patient with recurrent vomiting induced by GLP-1RA before surgery.

  A 64-year-old male was scheduled to undergo a mandibulectomy under general anesthesia for medication-related osteonecrosis. The patient had diabetes mellitus, chronic renal failure requiring hemodialysis, hypertension, and hypothyroidism. The patient received weekly subcutaneous semaglutide, with the last injection administered four days before surgery. He was admitted to the hospital two days before surgery and vomited a moderate amount of undigested stomach contents during the night on the day of admission. Vomiting recurred during hemodialysis on the following day, at dinner, and at midnight. He reported a history of repeated vomiting prior to admission. A nasogastric tube was inserted while the patient was awake before the induction ; however, no gastric contents were aspirated. After oxygenation in the semi-Fowler’s position, rapid sequence induction was performed using remifentanil, propofol, and rocuronium, followed by nasal intubation. No vomiting occurred during the anesthesia induction.

  We experienced general anesthesia to a patient with type 2 diabetes with repeated vomiting suspected to be caused by GLP-1RAs. Anesthesiologists should confirm that patients are receiving GLP-1RAs for gastrointestinal symptoms such as vomiting preoperatively and consider the induction of anesthesia, including rapid sequence induction similar to that in patients with full stomachs.

  A 12-year-old boy (height, 123 cm ; weight, 20 kg) with a history of cerebral palsy, West syndrome, and severe intellectual disability was brought to our hospital for evaluation of gingival hypertrophy and snoring.

  The patient’s condition was diagnosed as drug-induced gingival hyperplasia, and surgery was planned. He had previously undergone general anesthesia and had consulted an anesthesiologist at another hospital. We subsequently requested an otolaryngology evaluation to assess the patient’s airway. Fibreoptic bronchoscopy was prepared as a precaution, but video laryngoscopy was used for intubation. After confirming the absence of bleeding from the surgical field or laryngeal edema, the patient was extubated and transferred to the ICU. On the second postoperative day, the patient exhibited labored breathing due to swelling in the submandibular region. Accordingly, we again requested an otolaryngology evaluation to assess airway edema. A nasal airway was inserted because the airway around the soft palate had narrowed owing to postoperative pharyngeal edema. It was removed on the fifth postoperative day, and the patient was discharged on the sixth postoperative day. The patient’s physician was requested to reduce the phenobarbital dosage, which was identified as a possible cause.

  Drug-induced gingival hyperplasia can develop rapidly, leading to sleep-related breathing disorders. If severe, it may cause difficulty in securing the airway or postoperative airway stenosis due to surgical stress. Careful airway management is, therefore, essential during the perioperative period.

  We report a case of psychogenic non-epileptic seizures (PNES) after intravenous sedation and tooth extraction. The patient was a 29-year-old woman who was scheduled to undergo intravenous sedation because of her fear of the treatment. The patient was currently being treated for chronic pain, somatoform disorder, and dissociative disorder and had been prescribed diazepam (DZP) for PNES. A dental procedure was performed under intravenous sedation with propofol (PPF). Immediately after the procedure, the patient had a seizure with convulsions and became unresponsive ; as her condition did not improve and the seizure was difficult to manage, the patient was transported to an emergency hospital. After a detailed examination at the emergency hospital, the incident was identified as a PNES seizure. Wisdom tooth extraction was scheduled for a later date, and the procedure was performed under local anesthesia. Limb convulsions occurred during the local anesthesia, which were alleviated by the administration of DZP ; the tooth was successfully extracted. After the tooth extraction, the patient had a PNES seizure similar to the seizure that occurred during the first treatment, but she improved after the administration of midazolam (MDZ). The patient was discharged home on the same day. The trigger of this patient’s PNES episodes was thought to be stress brought on by her fear of dental treatment, the securement of an intravenous line before the start of sedation, and vascular pain caused by PPF. Detailed patient information and perioperative stress should be considered when planning treatment. The administration of MDZ was effective at the onset of PNES.

  Mixed connective tissue disease (MCTD) is a rare systemic autoimmune disease characterized by the main features of overlapping connective tissue diseases. The disease is also defined by the presence of anti-U1-ribonucleoprotein (RNP) antibodies and the Raynaud phenomenon. We report the administration of general anesthesia in a patient with MCTD. A 53-year-old female (height, 161.2 cm ; weight, 50.4 kg) was scheduled to receive a partial tongue resection under general anesthesia for the treatment of tongue cancer. Around 2000, swelling in both hands and Raynaud’s symptoms developed, and she was confirmed as being positive for the anti-U1-RNP antibody and was diagnosed with MCTD. The patient also developed interstitial pneumonia and idiopathic thrombocytopenic purpura. Because a decreased platelet count was observed in the preoperative evaluation, the doses of eltrombopag olamine and prednisolone were increased. A chest CT scan showed reticular ring shadows and ground-glass opacities in both lower lung fields. For the general anesthesia, steroid coverage was provided by the intravenous administration of hydrocortisone. To prevent exacerbation of the interstitial pneumonia, the oxygen concentrations were maintained at 60％ during induction and emergence and at 30％ during maintenance. Anesthetic induction was performed with remifentanil and propofol, and anesthetic maintenance was performed with sevoflurane and remifentanil. After the induction of anesthesia, the securement of a venous tract in the upper extremities was difficult. MCTD presents with a variety of clinical manifestations, including symptoms of various autoimmune diseases, and the severity of these manifestations varies greatly from person to person. Therefore, understanding the symptoms and severity of MCTD is an important component of perioperative management.

  Patients with severe chronic obstructive pulmonary disease (COPD) are highly predisposed to respiratory complications under general anesthesia. Herein, we report the case of a 69-year-old man with severe COPD, forced expiratory volume 1.0 sec rate 37％, underwent surgery for the excision of a large intra-mandibular tumor. Intravenous sedation was chosen over general anesthesia to avoid the acute exacerbation of COPD and the impossibility of postoperative extubation. This intravenous sedation was managed using dexmedetomidine and fentanyl because it is hard to ensure adequate analgesia during surgery with local anesthetics alone. To monitor fentanyl-induced respiratory depression, we used the impedance and thoracic kinematic measurement belts to monitor respiratory movements as well as capnography and intranasal pressure measurements to monitor airway obstruction. Fentanyl administration was discontinued when the amplitude of intranasal pressure waveform decreased to approximately 25％ of the pre-sedation level. Subsequently, a 25 μg dose was administered when the amplitude rose to approximately 75％. We could monitor the relative decrease in respiratory flow continuously via the gradual decrease in the nasal pressure amplitude. However, it was difficult to monitor the decrease in respiratory flow based on the shape of the capnography waveform. The intranasal pressure measurement and waveform of the thoracic kinematics belt could adjust the fentanyl dosage appropriately and perform adequate analgesia for the procedure without any respiratory complications.

  The high frequency variability index (HFVI) has recently gained attention for its potential role in managing general anesthesia. HFVI monitoring quantifies high frequency components as a measure of parasympathetic nervous system activity. This approach enables the non-invasive and continuous monitoring of patient stress, including acute pain, during anesthesia. One notable advantage of HFVI monitoring is its potential to prevent intraoperative opioid overdose. We used HFVI monitoring during the anesthetic management of a 30-year-old woman with a history of delayed awakening from previously administered general anesthetics. She had previously undergone a mandibular distraction osteogenesis procedure in 2019 followed by a maxillary osteotomy in 2022. Both of these procedures were performed under total intravenous anesthesia with propofol ; afterwards, the patient experienced prolonged arousal times of 29 and 39 minutes, respectively, from the end of surgery until extubation. The delayed awakening was thought to have been associated with the use of opioids (fentanyl, remifentanil) or the intravenous anesthetic (propofol). To reduce the likelihood of delayed awakening, propofol was avoided during the presently reported treatment and opioid dosing was adjusted using HFVI monitoring. This approach resulted in successful anesthetic management without delayed awakening. HFVI monitoring may be valuable as an indicator of pain management during anesthesia.

  An 80-year-old woman was scheduled to undergo a left maxillary sequestrectomy for medication-related osteonecrosis of the jaw (MRONJ). An aortic stenosis (AS) had been diagnosed when the patient was about 78 years old, and she had been under observation since then. She subsequently developed subjective symptoms of shortness of breath during exertion and was referred to the cardiology department of our hospital. A cardiac ultrasound revealed severe symptomatic AS. Because MRONJ can be a risk factor for infective endocarditis (IE), surgery for MRONJ was performed prior to transcatheter aortic valve implantation (TAVI).

  Anesthesia was induced using remimazolam besilate and remifentanil hydrochloride under the continuous administration of noradrenaline, and the patient was managed using total intravenous anesthesia. A single dose of phenylephrine hydrochloride was also administered during the operation to manage her circulation. The patient’s hemodynamics were stable during the operation, and the scheduled surgery was completed. After extubation, the patient’s circulation and respiration both remained stable, and the patient was returned to the general ward and discharged on postoperative day 8. TAVI was performed 107 days after the surgery for MRONJ. For the perioperative management of patients with severe aortic stenosis, it is important to minimize cardiovascular responses during anesthesia induction, as there is a risk of coronary circulatory collapse and cardiac arrest arising from hypotension. In the presently reported case, the combination of remifentanil hydrochloride, which is unlikely to cause circulatory depression when administered alone, with remimazolam besilate, which is thought to have a smaller effect on circulatory depression, enabled severe hypotension to be avoided, allowing safe perioperative management.

 【要旨】 気管支鏡は挿管困難や気道管理において重要な役割をもつため，すべての歯科麻酔科医は気管支鏡の構造と使用法に精通しておく必要があるといえる．本稿では，気管支鏡の使用における正しく安全な知識・手技とコツ，気管支鏡ガイド挿管の方法と，有用な補助用具，また各種再使用型製品に加えて，COVID-19を機に注目される単回使用型製品の特徴などについて紹介する．

 【要旨】 本稿では，経鼻気管挿管における ① 消毒方法，② 止血薬の選択，③ 挿管経路，④ 使用する喉頭鏡，⑤ 褥瘡予防の5つの観点について，経験ではなく科学的根拠に基づく知見を概説する．研究の結果，ベンザルコニウム塩化物は持続的な抗菌効果に優れ，菌血症リスクの低減に有効である可能性が示された．エピネフリンとトラマゾリンは鼻出血の抑制において同等の効果を示し，安全性に大きな差はなかった．挿管経路に関しては，右鼻腔の使用が左鼻腔よりも鼻出血の頻度を低減し，挿管時間を短縮する結果が得られた．McGrath MAC喉頭鏡はAirwayscopeやMacintosh喉頭鏡と比較して視野を改善し，挿管時間を短縮する効果が確認された．また，3Mマイクロフォーム^TMサージカルテープは経鼻挿管時の鼻圧迫創傷を予防する効果を示し，柔軟性とコストパフォーマンスの面でも優位性が認められた．これらの成果は，経験に基づく従来の方法に代わり，科学的根拠に基づいた経鼻気管挿管の安全性と効率性を向上させる新たな標準手技の確立に貢献するものである．