Malignant hyperthermia (MH) is a rare but life-threatening pharmacogenetic disorder triggered by volatile anesthetics and/or depolarizing muscle relaxants, resulting in a hypermetabolic crisis. We report a case of postoperative fulminant MH in a 26-year-old man who underwent general anesthesia with desflurane and rocuronium for mandibular fracture repair. Despite a history of multiple uneventful anesthetics, the patient developed acute hypercapnia, tachycardia, muscle rigidity, and rapid hyperthermia during emergence, following sugammadex administration. Initial treatment for presumed bronchospasm and postoperative shivering-including sevoflurane sedation, hyperventilation, and inhaled bronchodilators-proved ineffective. A clinical diagnosis of MH was made based on the progression of clinical findings, and treatment with intravenous dantrolene 100 mg, active cooling, and antipyretics was initiated. The patient responded well to intervention and recovered without sequelae. This case highlights the importance of considering MH even in the postoperative phase, particularly with the use of desflurane and potentially contributory agents such as sugammadex and ondansetron. Early clinical suspicion, rapid administration of dantrolene, and supportive measures are critical for favorable outcomes. Anesthesia providers must remain vigilant for MH at all perioperative stages and ensure that emergency protocols, appropriate drug stock, and staff readiness are in place.
The trigeminocardiac reflex (TCR) is clinically defined as the sudden onset of increased parasympathetic activity resulting from stimulation of the trigeminal nerve. This reflex increases parasympathetic tone and can lead to significant bradycardia and hypotension. We report the case of severe bradycardia and hypotension that occurred under general anesthesia during insertion of a cotton swab into the nasal cavity. A 57-year-old woman was scheduled for nasotracheal intubation for oral surgery, and following loss of consciousness, intubation was initiated using cotton swabs soaked in a solution of 2% lidocaine and 1:100,000 epinephrine that were inserted through the left nostril. The patient immediately developed severe bradycardia and hypotension which were managed with intravenous ephedrine after removing the cotton swabs rather than atropine due to concerns related to closed-angle glaucoma. The patient responded promptly to the ephedrine bolus, and no further complications occurred. It was assumed that the ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve were stimulated by the cotton swabs being inserted into the nasal cavity, triggering the TCR. Anesthesiologists need to be aware of the risks associated with administering mydriatic drugs such as ephedrine and epinephrine, which are relatively contraindicated, as well as atropine to patients with closed-angle glaucoma.
Temporomandibular disorders (TMDs) comprise a group of multifactorial conditions involving the masticatory muscles, temporomandibular joint, and associated structures influenced by biomechanical, neuromuscular, and biopsychosocial factors. Myogenous TMDs may involve muscle hyperactivity, parafunction, and central sensitization, contributing to chronic pain and functional limitation. Oral skeletal muscle relaxants (SMRs) are commonly used as adjunctive pharmacologic therapy; however, these agents vary considerably in mechanism, efficacy, and safety. This review summarizes the pharmacology, clinical evidence, and risk profiles of commonly prescribed SMRs-including cyclobenzaprine, baclofen, tizanidine, and others-within the context of chronic TMD management. Evidence supports short-term benefit for select agents, though data for chronic daily use remain limited. Given concerns regarding sedation, dependence, hepatotoxicity, and interactions with polypharmacy, clinicians should employ these medications judiciously and primarily for acute exacerbations rather than long-term therapy. An evidence-based, multimodal approach remains essential for optimizing care in patients with chronic TMDs.
Mixed connective tissue disease (MCTD) is an autoimmune disorder characterized by overlapping features of multiple connective tissue diseases in addition to anti-U1-ribonucleoprotein (RNP) antibodies and Raynaud's phenomenon. A 53-year-old female patient with MCTD, interstitial pneumonia, and idiopathic thrombocytopenic purpura underwent partial tongue resection under general anesthesia. Perioperative management included steroid coverage and careful titration of the oxygen concentration. Although venous access was difficult, the anesthetic course was uneventful. MCTD can present perioperative challenges including pulmonary and cardiac complications, effects of long-term steroid use, and airway and cardiovascular disturbances. Safe anesthesia for patients with MCTD requires assessment of disease activity and severity across multiple conditions and individualized management accordingly.
Cornelia de Lange syndrome (CdLS) is a rare genetic disorder with a wide variation of presentations affecting several organ systems. Most patients with CdLS have a mutation of the NIPBL (Nipped-B-like protein) gene responsible for making delangin, a protein important in human development. Patients with CdLS typically present with intellectual disability, growth delay, cleft palate, and extremely limited mouth opening. These findings can complicate induction of general anesthesia, airway management, and intubation. Treatment of CdLS is based on clinical presentation and includes pharmacologic, therapeutic, and surgical intervention. Cleft palate repair is common in these patients which may impact the anesthetic plan. Additionally, the anesthesiologist should be aware of associated cardiovascular anomalies, ranging from innocent murmurs to persistent structural defects and leading to increased morbidity and mortality in these patients. This case report discusses CdLS and its implications on the general anesthetic management of a 37-year-old woman undergoing treatment for dental caries in an ambulatory care setting. Although CdLS is a rare genetic disorder, anesthesiologists treating such patients with special needs should be familiar with its presentation and anesthetic considerations.
Objective:Among patients who underwent general anesthesia (GA) multiple times with different methods, we aimed to compare the incidence and severity of postoperative nausea and vomiting (PONV) when the GA method was changed. Methods:Subjects were healthy intellectually disabled patients who underwent multiple dental procedures under GA. Methods of general anesthesia were classified as (1) nitrous oxide-sevoflurane (NOS), (2) sevoflurane-remifentanil (SRF), and (3) propofol-remifentanil (PRF). Patients who experienced PONV had an alternative method of GA utilized for subsequent cases. PONV incident rates and severity scores overall and between groups were calculated and compared statistically for analysis. Results:PONV occurred in 186 (6.5%) of the 2872 cases and in 85 (28.8%) of the 295 patients included in this study. Statistical paired comparisons of the mean incidence of PONV demonstrated a decrease of 25.2% when the GA method was changed from NOS to SRF, 40.4% when changed from NOS to PRF, and 36.4% when changed from SRF to PRF (P < .05). Statistical paired comparisons of the mean 5-point PONV severity score similarly demonstrated a decrease of 0.53 when the GA method was changed from NOS to SRF, 0.92 when changed from NOS to PRF, and 0.62 when changed from SRF to PRF (P < .05). Conclusion:The highest PONV incidence rates and severity were noted with NOS, whereas PONV decreased significantly with SRF and PRF use. The absence of nitrous oxide and use of propofol were suggested as ways to alter the method of general anesthesia to reduce the incidence and improve the severity of PONV.
Objective:This study aimed to compare the effects of remimazolam and propofol on neuromuscular blockade induced by the nondepolarizing neuromuscular blocking agent (NMBA) rocuronium and to evaluate the additional influence of epinephrine-containing lidocaine administered as a local anesthetic during general anesthesia. Methods:A total of 38 patients undergoing Le Fort I osteotomy were randomly assigned to the remimazolam group (R group) or propofol group (P group). All patients also received remifentanil and rocuronium. The rocuronium infusion rate was adjusted to maintain a train-of-four (TOF) ratio of 30% ± 10% and recorded. After administering the local anesthetic solution (2% lidocaine containing 1:80,000 epinephrine), the TOF ratio was recorded every minute for 20 minutes. Results:The mean (SD) continuous infusion rate of rocuronium required to maintain a similar TOF ratio was significantly smaller in R group (5.3 (0.5) µg/kg/min) than in P group (6.5 (0.8) µg/kg/min; P < .001). The mean (SD) TOF ratio before administering the epinephrine-containing lidocaine was 26.4% (11.8%) in P group and 30.1% (11.8%) in R group (P = 1.0) and after administration was 7.5% (7.8%) in P group and 8.3% (10.1%) in R group (P = 1.0), all of which lacked statistical significance. Conclusion:Our results suggested that remimazolam and epinephrine-containing lidocaine administered for local anesthesia enhanced the NMBA effect of rocuronium.
Objective:The widespread availability of the internet in recent years has made it easier to use electronic databases, and bibliometric analysis is now being carried out in a variety of fields. This method aimed to investigate the characteristics and trends of dental anesthesiology research published in Anesthesia Progress, the oldest and most authoritative journal in the field, from its inception in 1966 to 2023. We identified the 50 most-cited articles to evaluate the impact and evolution of research in this field. Methods:The search was conducted by entering "Anesthesia Progress" in the "Source Title" field, which is one of the search items in the Scopus database. The results were sorted by number of citations, and the bibliographic information for the top 50 most-cited articles was downloaded. Results:The analysis revealed that most of these influential papers originated in the United States (60%), highlighting its dominance in dental anesthesiology research. Key topics identified included "sedation" and "local anesthesia," reflecting an increasing emphasis on pain management and psychological support in dental care. The findings also indicated a modest decline in the proportion of scientific reports, suggesting potential stagnation in new research contributions over time. Furthermore, index keyword analysis illustrated a growing specialization in addressing anxiety and pain associated with dental procedures. Conclusion:This study underscores the need for enhanced research and innovation in dental anesthesiology to meet the evolving needs of clinical practice and improve patient care.
Cleft lips and palate are orofacial deformities that require surgical repair in childhood to promote speech development, facial growth, and improved aesthetics. In these cases, preformed oral Ring-Adair-Elwyn (RAE) endotracheal tubes (ETTs) are frequently used for airway management during general anesthesia. Due to its acute U-shaped curve, the oral RAE ETT was our first choice. However, the ability to adjust the intubation depth can be limited because of the preformed curve, and insertion length is fixed based on the internal tube diameter. During neck extension after intubation, the ETT moves away from the carina, which can cause the ETT cuff to compress the vocal cords. Therefore, oral RAE ETTs are associated with a risk of inadvertent ETT malpositioning. Our study assessed ETT positioning in 186 patients in whom oral RAE ETTs were initially used, and we found an 8% incidence rate of inadvertent ETT malpositioning after head and neck extension. In such cases, we replaced the malpositioned oral RAE ETT with a wire-reinforced ETT, which we feel was ideal to serve as a secondary option. Wire-reinforced ETTs tolerate extreme flexion without kinking and can withstand high pressure without collapsing. Although oral RAE ETTs can be advantageous for cleft lip and palate surgery, they can become malpositioned after neck extension and should be assessed accordingly. Consideration for using a wire-reinforced ETT as a replacement is warranted in such instances.
Dexmedetomidine is a relatively new sedative that is promoted as having minimal effects on the ventilatory drive or the propensity for airway obstruction. However, a recent trial demonstrated impaired ventilatory drive and induction of apnea in sedated volunteers. This nonblinded, randomized crossover study examined 9 nonsmoking adults between the ages of 18 and 65 with American Society of Anesthesiologists physical status 1 or 2 and a body mass index of 37 or less. Upper airway collapsibility was measured during low and moderate infusion rates of propofol or dexmedetomidine to produce comparable levels of minimal to moderate sedation. The level of sedation was monitored with bispectral index recordings, electroencephalogram recordings, and 2 clinical sedation scales at discrete points in time and correlated with blood plasma levels of propofol or dexmedetomidine. At comparable levels of minimal and moderate sedation, both drugs produced similar degrees of pharyngeal collapsibility and reductions in ventilatory drive, suggesting that dexmedetomidine does not offer inherent protection against upper airway obstruction or ventilatory depression.Comment: (see * below)Dexmedetomidine is a sedative with modest analgesic efficacy, whereas remifentanil is an opioid analgesic with modest sedative efficacy. Synergy is often observed when sedative-hypnotics are combined with opioid analgesics in anesthetic practice. A 3-phase crossover trial was conducted to study the pharmacodynamic interaction between remifentanil and dexmedetomidine. Thirty healthy volunteers, stratified by age and sex, were recruited to undergo target-controlled infusions of dexmedetomidine, remifentanil, and remifentanil with a fixed dexmedetomidine background concentration. The drug effect was measured with the Patient State Index (PSI-2), an electro-encephalograph-based depth of sedation monitor. These readings were correlated to the Modified Observers Assessment of Alertness and Sedation (MOAA/S) and serial arterial blood samples of dexmedetomidine and remifentanil. Tolerance to laryngoscopy was defined as a MOAA/S score of 0 (no response to name call, shaking or trapezius squeeze, and the ability to achieve a Cormack-Lehane grade 3 direct laryngoscopy). Despite falling asleep, most subjects remained arousable by calling their name, shaking, or delivering a trapezius squeeze. During the dexmedetomidine phase, 13 of 22 patients tolerated laryngoscopy. During the combined dexmedetomidine/remifentanil phase, 15 of 19 patients tolerated laryngoscopy. Although the addition of remifentanil slightly increased the depth of sedation and tolerance to laryngoscopy, there was no evidence of synergy, even when dexmedetomidine infusion concentrations were increased to supraclinical levels. In contrast to these findings, the addition of remifentanil to propofol creates synergy, resulting in the ability to decrease baseline propofol infusion concentrations. Dexmedetomidine potency was also observed to increase with patient age. The authors concluded that, although dexmedetomidine and remifentanil might be useful in minimal sedation, dexmedetomidine cannot be considered a suitable alternative to sedative-hypnotics for the induction of anesthesia.Comment: (see * below)Previously published research has suggested improved recovery scores in patients receiving intraoperative dexmedetomidine infusions; however, the efficacy of dexmedetomidine on coughing and other emergence phenomena is not consistent across studies. This prospective, multicenter, randomized, double-blind, placebo-controlled study sought to determine the optimal dose of intraoperative dexmedetomidine to prevent cough (primary outcome) and improve emergence profiles, as judged by heart rate and the absence of shivering, agitation, delayed recovery, and excessive sedation. A total of 216 adults, age 18 to 75, with American Society of Anesthesiologists physical status 1-3, undergoing elective surgery lasting 1 to 3 hours, were recruited for the study. The mean age for patients accepted into the study was 45 years. Participants were randomly assigned to 1 of 4 groups. At the end of surgery, patients received a single dose of either dexmedetomidine at 1, 0.5, or 0.25 mcg/kg, or a saline placebo. Following surgery, nurses blinded to the intraoperative study infusion recorded vital signs and scored cough, shivering, sedation, and postoperative nausea and vomiting at 10-minute intervals. The 1-mcg/kg dose was best for control of cough, shivering, and agitation. Dose-dependent hypotension was noted in all doses of dexmedetomidine during emergence. None of the dexmedetomidine doses delayed extubation or discharge from the Post-Anesthesia Care Unit. Limitations to this study included the lack of standardization of surgeries and a potential unintended bias due to the hemodynamic changes associated with dexmedetomidine.*Comment: The clinical profile of dexmedetomidine continues to evolve with the appearance of new scientific reports in the anesthesia literature. Early reports on the use of dexmedetomidine demonstrated minimal or insignificant changes in ventilation when used for moderate sedation via continuous infusion without a bolus.1 This led some to speculate that dexmedetomidine might be a better choice for minimal to moderate sedation as compared with the commonly used opioid-sedative-hypnotic combinations like fentanyl and midazolam. This report by Lodenius et al is notable in that it compared dexmedetomidine to propofol, a drug known to reduce upper airway tone.2 Their study demonstrates the potential for airway compromise with dexmedetomidine, even when used as a single sedative drug for well-controlled moderate sedation. The relatively narrow therapeutic window, potential for hypotension, lack of a pharmacologic antagonist, and long half-life further compromises the potential use of dexmedetomidine as a drug for routine moderate sedation in dentistry.The report by Weerink et al further characterize the use of this drug as a potential part of a drug regimen for the induction of general anesthesia and intubation. The synergy achieved by the combination of opioids with sedative-hypnotics such as propofol and barbiturates produces the deep level of consistent unresponsiveness needed to prepare patients for laryngoscopy. Prior to this study, the anesthetic literature suggested that a deep, unarousable level of unresponsiveness was achievable at high doses of dexmedetomidine. Given the potential for hazardous hypotension and bradycardia with increased doses of dexmedetomidine,3 the combination of an opioid with a lower dose of dexmedetomidine attempted to use the principal of balanced anesthesia to lessen these undesirable effects while adding analgesia. This effect was not found, underscoring the fact that the level of sedation and sleep produced by alpha-2 agonists differs significantly from that produced by propofol. Finally, the study by Aouad and colleagues provides useful information on the use of dexmedetomidine as bolus, given by slow injection at the end of surgery. Earlier reports that described the use of dexmedetomidine as an infusion, used for sedation in the intensive care unit, were not as directly applicable the use in the office-based anesthesia setting.Dual antiplatelet therapy (the daily, prophylactic use of acetylsalicylic acid plus a PY2Y12 inhibitor) has become the first choice for patients with acute or stable coronary artery disease to prevent thrombotic complications. Although effective for this purpose, an elevated risk of bleeding has been observed in patients receiving dual antiplatelet therapy and undergoing minor oral surgery such as extractions, dentoalveolar surgery, cyst removal, and periodontal treatment. Some surgeons have considered suspending dual antiplatelet therapy to improve perioperative hemorrhage control; however, withdrawal of dual antiplatelet therapy may result in serious systemic adverse events. This systematic review of 16 published studies examined the risk of bleeding in this population as compared with oral surgery patients receiving single antiplatelet or no antiplatelet therapy. Although dual antiplatelet therapy was associated with significantly greater perioperative bleeding, all studies confirmed that local hemostatic measures were adequate in stopping bleeding. Considering these findings, the interruption of dual antiplatelet therapy prior to minor oral surgery is not recommended.Comment: The recommendation to maintain antiplatelet therapy in patients undergoing minor oral surgery is consistent with the recently published findings of the World Workshop on Oral Medicine VII, which examined studies of patients placed on direct oral anticoagulant drugs.4 That review and analysis noted that all postoperative bleeding events were controlled with local measures and found no important differences in postoperative bleeding when comparing patients who had discontinued antiplatelet therapy to those who maintained it. In contrast to this, there was little for the anesthesiologist on whether to employ nasal intubation versus an alternative form of airway management in this set of patients.According to the 2015 National Survey on Drug Use and Health, marijuana continues to be the most common illicit recreational drug in the United States. Cannabinoids have multisystem effects that can interfere with anesthetic agents and lead to serious consequences. This comprehensive review examines the main physiological effects of cannabinoids and their interactions with common anesthetic drugs.
Ankylosing spondylitis (AS) is a chronic disease that causes inflammation in the spine and joints, leading to ankylosis and contracture as the disease progresses. Patients with AS are prone to bone fractures, particularly cervical spine fractures. Therefore, problems such as intubation difficulties, impaired ventilation, and complications related to stabilizing and securing the patient’s body position can accompany surgery under general anesthesia. Herein, we report the anesthetic management of a 54-year-old patient with mild AS who underwent orthognathic surgery under intubated general anesthesia. The McGRATH MAC video laryngoscope with an X blade was used for tracheal intubation, and the Magic Cast stabilization device was used to secure the patient’s head and neck. The patient remained stable and secure throughout the surgery, which was safely completed. The Magic Cast device was useful for stabilizing the head and neck of a patient with mild AS during orthognathic surgery. However, patients with more severe AS may require additional considerations in preparation for airway and stabilization concerns.
We present the anesthetic management of a 32-year-old patient diagnosed with familial Mediterranean fever (FMF) who underwent dental surgery. To minimize the risk of triggering an FMF attack, careful perioperative planning was implemented. Key preventive measures included avoiding known FMF triggers like cold exposure as well as maintaining stable vital signs and ensuring close temperature control throughout the procedure. The patient had shown resistance to colchicine therapy in the past, necessitating careful consideration of alternative treatments, including the potential use of IL-1 inhibitors. General anesthesia was successfully administered without inducing an FMF acute attack. Effective postoperative pain management was provided, and no FMF-related complications arose during the recovery period. This successful outcome highlights the importance of close collaboration and ongoing communication with the patient’s primary physician and specialists familiar with FMF. Achieving safe anesthetic management for patients with FMF requires meticulous perioperative planning, proactive avoidance of potential FMF triggers, and a collaborative approach across disciplines. These elements are essential to preventing perioperative FMF exacerbations and ensuring smooth, complication-free recovery for patients.
Objective:Anxious patients report more pain during endodontic therapy. This clinical trial aimed to assess the effect of etizolam vs music distraction on inferior alveolar nerve block (IANB) success in patients with high dental anxiety and symptomatic irreversible pulpitis in a mandibular molar. Methods:A total of 110 patients participated in this randomized clinical trial. Preoperative anxiety was assessed using the Modified Corah Dental Anxiety Scale (MDAS). Patients were randomly allocated to a placebo, etizolam, or music distraction (MD) group. Patients in the placebo and etizolam groups consumed either a placebo or etizolam (0.5 mg), respectively, 1 hour before local anesthesia delivery. Patients in the MD group listened to their self-selected music via headphones throughout the visit. All patients received a standard IANB with 2% lidocaine with 1:200,000 epinephrine. Intraoperative pain levels were assessed using the Heft Parker visual analogue scale (HP-VAS). No or mild pain (0-54 mm on HP-VAS) was counted as success, whereas moderate to severe pain (55-170 mm) during endodontic procedure was considered as IANB failure. Results:χ2 test revealed that patients in the MD group exhibited significantly higher local anesthetic success compared to the other 2 groups (P < .01). No significant difference was found in IANB success between the placebo and etizolam groups. Conclusion:IANB success was significantly higher in patients who listened to music during endodontic therapy than in patients who received etizolam or placebo.
Williams syndrome (WS) is a genetic disorder marked by intellectual disability, distinctive craniofacial features, dental abnormalities, and congenital heart defects, particularly supravalvular aortic stenosis—a narrowing above the aortic valve. Patients with WS are at increased risk of perioperative sudden cardiac death, necessitating thorough cardiovascular assessment. Additionally, craniofacial anomalies such as micrognathia and retrognathia may lead to difficult airway management and often require awake intubation. However, awake intubation and hospitalization can be distressing for patients with WS due to their developmental challenges. These facts indicate the importance of identifying during the preoperative assessment for ambulatory general anesthesia those at low risk for cardiovascular complications and airway difficulties. This case report details the successful anesthetic management of a 9-year-old boy with WS undergoing ambulatory general anesthesia for dental treatment by maintaining a balance between myocardial oxygen supply and demand to minimize cardiovascular fluctuations and by paying careful attention to managing his airway. Our case highlights the feasibility and safety of ambulatory general anesthesia for patients with WS, minimizing hospitalization stress and ensuring patient safety.
Objective Previous studies in Canada suggest that mortality and serious morbidity during deep sedation and/or general anesthesia (DS/GA) for dentistry in out-of-hospital facilities are low. The purpose of this study was to estimate the period prevalence of mortality and serious morbidity associated with outpatient DS/GA for dentistry in British Columbia, Canada. Methods Events were identified by retrospectively searching the Chief Coroner of British Columbia database from 1987 to 2019, the College of Dental Surgeons of British Columbia database from 1984 to 2019, and gray literature from 1984 to 2019. A survey of DS/GA providers was conducted to estimate the number of DS/GA procedures provided. Results A total of 3 linked mortality events in which anesthesia could not be ruled out as a contributing factor were identified. No cases of serious morbidity met the inclusion criteria for the study. An estimated 1,019,853 out-of-hospital DS/GA procedures for dental treatment were provided during the study period. This study estimated a period prevalence of mortality and serious morbidity of 2.94 per 1 million out-of-hospital DS/GA procedures for dental treatment when administered by qualified providers over the 36-year study period. Conclusion These findings suggest that the provision of out-of-hospital DS/GA for dental treatment in British Columbia carries a low risk of mortality or serious morbidity.
