Anesthesia progress最新文献

In complex maxillofacial fractures in which orotracheal and nasotracheal intubation are otherwise contraindicated, alternatives for airway management include tracheostomy and submental intubation (SMI). In this case, SMI was used successfully, although it did result in accidental endobronchial intubation intraoperatively that was quickly recognized and managed appropriately. SMI can be a useful method for securing a patient's airway, but like all surgical approaches, it does carry the potential for complications. We report a case involving the use of SMI during which an unintended endobronchial intubation occurred.

Nasotracheal intubation can reveal unexpected findings like a foreign body in the airway. In such instances, expeditious decision-making is crucial to achieve ideal outcomes. This case report describes a petroleum jelly-based foreign body discovered in the nasopharynx during nasotracheal intubation and the subsequent airway management. A 64-year-old man with no prior history of adverse anesthetic events presented to an oral surgery office for extraction of teeth and placement of implants. While video laryngoscopy for nasotracheal intubation was performed, a blue foreign body was discovered inside the tip of the nasal endotracheal tube. Subsequent attempts to locate the source of the foreign body revealed in the nasopharynx a strip of blue gelatinous foreign body which was removed with suction. Due to the persistent presence of foreign body residues in the nasopharynx, orotracheal intubation was performed. Nasopharyngeal foreign bodies may elude even the most thorough preoperative medical history review and airway assessment. Therefore, it is reasonable for practitioners to ask explicitly about any foreign bodies in the nasal passages. Practitioners should become familiar with cognitive aids for relevant airway emergency management techniques and equipment for expeditious decision-making when unexpected foreign bodies are found.

Hepatic compromise poses significant impacts upon the care of patients undergoing routine dental treatment. When sedation or general anesthesia is planned for dental treatment or oral and maxillofacial surgery, an understanding of basic liver function and clinical evaluation can assist in adapting treatment modifications for patients with limited function due to previous disease and resultant organ transplantation efforts. Beginning with a basic overview of hepatic physiology, this review will outline the specific functions of digestion, metabolism, synthesis, and detoxification involving the liver. Specific clinical considerations will be reviewed regarding comorbidities that develop prior to and after liver transplantation that often impact a patient's suitability for ambulatory and office-based care. Lastly, choices in both local anesthetics, sedative medications, general anesthetics, and postoperative analgesics utilized in dental treatment will be discussed.

Objective: Dilution of concentrated epinephrine prior to intravenous use during clinical emergencies can delay urgent interventions. The objective of this study was to determine whether diluted epinephrine remains stable and sterile over time in common hospital settings.

Methods: Epinephrine samples were prepared by clinically relevant double dilution techniques. Samples were stored in 10-mL syringes and incubated under 1 of 4 simulated hospital environments with a mixture of lighting and temperature settings: 4°C/20°C, with or without fluorescent lighting. Samples were incubated for 0, 15, 30, 60, or 90 days. Capillary zonal electrophoresis was used to quantify the concentration of epinephrine and/or presence of any degradation products. All samples were tested for the presence of bacterial growth using blood agar cultures.

Results: Diluted epinephrine samples remained stable for up to 90 days in all 4 simulated clinical storage conditions. No bacterial colony-forming units were detected in any of the environmental samples regardless of incubation duration, light, or temperature conditions.

Conclusion: Diluted epinephrine for anticipated clinical emergencies may remain clinically useful for up to 90 days, thus improving patient safety, access to medications, and overhead costs by reducing waste.

Pfeiffer syndrome (PS) is a rare inherited disorder that affects the craniofacial and extremity bones but can also include anomalies of the upper and lower airways. Among the 3 subtypes, PS types 2 and 3 are the most severe. We describe the anesthetic management of a 10-year-old boy with PS type 2 scheduled for dental treatment under general anesthesia. Because of his history of Chiari malformation, avoiding neck hyperextension was recommended to prevent worsening of his neurologic function. Preoperative computed tomography revealed significant nasal stenosis but no tracheal anomalies. Considering the difficulty of nasotracheal intubation, we planned for an oral intubation. General anesthesia was induced using sevoflurane, nitrous oxide, and oxygen along with an oropharyngeal airway. After lidocaine was topically applied to the oropharynx, fiber-optic orotracheal intubation was performed under spontaneous ventilation to minimize head and neck movement. Anesthesia was maintained using desflurane and remifentanil, and no postoperative complications were observed. General anesthesia for patients with PS requires careful planning, which should include preoperative assessment of the airway to determine the feasibility of nasotracheal intubation and identify airway irregularities.

Most invasive dental procedures elicit some degree of bleeding which ultimately leads to clotting and eventual hemostasis. However, patients with inherited coagulation disorders may exhibit prolonged or, in some cases, excessive bleeding requiring multiple perioperative interventions. Von Willebrand disease is the most common inherited coagulopathy and often manifests via easy bruising, epistaxis, or prolonged bleeding. Hemophilia A (factor VII) and B (factor IX) are factor deficiencies that are clinically indistinguishable and managed according to severity and the required dental treatment. Other coagulopathies are rare (ie, inheritance is autosomal recessive) and may only become evident in homozygotes or compound heterozygotes. Current lab values and medical consultation with the patient's hematologist are imperative prior to rendering invasive dental treatment. There are a myriad of sedation and general anesthesia considerations, including risks for epistaxis with nasal instrumentation and bruising with improper patient positioning. Preoperative treatment with desmopressin or factor replacement may be required and generally should facilitate normal hemostasis. Additional therapies should be considered to help ensure adequate postoperative hemostasis, including pressure dressings, resorbable clotting materials, laser therapy, and oral rinses.