Immunoglobulin A (IgA) deficiency is one of the most common immune disorders characterized by increased susceptibility to infections, especially involving the respiratory tract and mucosal surfaces of the mouth, gingiva, and nasal sinus. Because dental surgery and general anesthesia may pose an increased risk for systemic infections, management of IgA-deficient patients requires caution during dental procedures and intubated general anesthesia. We report a 5-year-old female patient with IgA deficiency who underwent extraction of 18 deciduous teeth under general anesthesia. Antibiotic prophylaxis and antiseptic mouthwash were used perioperatively to reduce bacteremia risks. Nasotracheal intubation was carefully performed after applying topical disinfectants and epinephrine-containing gauze packing into the nasal cavity to minimize trauma. The patient was carefully monitored overnight in the hospital and discharged without any signs or symptoms of infection the next day. Dental anesthesia providers must be aware of the potential implications for safe practice when managing patients with IgA deficiency.
{"title":"Dental Treatment Under General Anesthesia With Nasal Intubation in a Patient With Selective Immunoglobulin A Deficiency.","authors":"Yuho Sakuma, Mika Ogawa, Chie Nakagawa, Kodai Momota, Emi Kaji, Kingo Matsumura, Saori Morinaga, Kentaro Nogami, Mizuko Ikeda","doi":"10.2344/anpr-70-02-13","DOIUrl":"10.2344/anpr-70-02-13","url":null,"abstract":"<p><p>Immunoglobulin A (IgA) deficiency is one of the most common immune disorders characterized by increased susceptibility to infections, especially involving the respiratory tract and mucosal surfaces of the mouth, gingiva, and nasal sinus. Because dental surgery and general anesthesia may pose an increased risk for systemic infections, management of IgA-deficient patients requires caution during dental procedures and intubated general anesthesia. We report a 5-year-old female patient with IgA deficiency who underwent extraction of 18 deciduous teeth under general anesthesia. Antibiotic prophylaxis and antiseptic mouthwash were used perioperatively to reduce bacteremia risks. Nasotracheal intubation was carefully performed after applying topical disinfectants and epinephrine-containing gauze packing into the nasal cavity to minimize trauma. The patient was carefully monitored overnight in the hospital and discharged without any signs or symptoms of infection the next day. Dental anesthesia providers must be aware of the potential implications for safe practice when managing patients with IgA deficiency.</p>","PeriodicalId":94296,"journal":{"name":"Anesthesia progress","volume":"70 3","pages":"140-141"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11080969/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41242875","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
When muscle relaxants are used to facilitate intubation, a significant amount of residual neuromuscular blockade remains when reversal drugs are not administered; however, routine reversal is not a universal practice. While most anesthesiologists routinely reverse neuromuscular blockade if muscular weakness is suspected at the time of extubation, others caution against the routine use of anticholinesterase reversal agents, which have been associated with impaired upper airway and breathing function with increased risk of adverse postoperative respiratory events. Neostigmine has neuromuscular blocking properties when given in the absence of neuromuscular blockade and can induce paradoxical reduction in the train-of-four ratio (TOF ratio). This study tested the hypothesis that TOF ratios in patients receiving neostigmine at the time of postanesthesia care unit admission would not be less than TOF ratios in patients randomly assigned to receive a saline placebo. The authors also tested the hypothesis that the incidence of postextubation adverse respiratory symptoms and muscle weakness would not be increased in the neostigmine group. One hundred twenty patients undergoing general anesthesia received a small dose of rocuronium to facilitate intubation. Ninety patients achieved a TOF ratio of 0.9 to 1.0 and received either neostigmine or saline. Patients were subsequently monitored for muscle strength and postextubation respiratory adverse events. No significant difference in these parameters was noted between the 2 groups, leading the authors to conclude that administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness. Comment: This study is accompanied by an editorial (Brull SJ, Naguib M. How to catch unicorns (and other fairytales). Anesthesiology. 2018;128:1–3) that discusses long-standing beliefs and misconceptions about the relative risk and benefits of administering muscle relaxants. The editors praise the study by Murphy et al for debunking 4 common myths. First, the study shows no evidence that neostigmine, at a dose of 40 lg/ kg, induces signs or symptoms of neuromuscular weakness, contradicting previous reports. Second, it challenges the belief that clinical assessment alone (eg, 5second head lift) is sufficient to assess adequate muscle recovery and underscores the need for quantitative neuromuscular assessment (TOF ratio). The study also challenged the widely held belief that neuromuscular recovery can be subjectively assessed by watching or feeling the response to TOF stimulation. Finally, the ‘‘time elapsed’’ principle of reversal is debunked. This principle stated that reversal was not necessary if the duration since the last dose of neuromuscular blocking agent was greater than 1 or 2 elimination half-lives, noting that 21% of patients failed to recover to a TOF ratio of 0.9 in 163 minutes after a single dose of 0.3 mg/ kg rocuronium. The editorial prov
{"title":"A Review of Current Literature of Interest to the Office-Based Anesthesiologist.","authors":"Mark A Saxen","doi":"10.2344/anpr-70-03-154","DOIUrl":"10.2344/anpr-70-03-154","url":null,"abstract":"When muscle relaxants are used to facilitate intubation, a significant amount of residual neuromuscular blockade remains when reversal drugs are not administered; however, routine reversal is not a universal practice. While most anesthesiologists routinely reverse neuromuscular blockade if muscular weakness is suspected at the time of extubation, others caution against the routine use of anticholinesterase reversal agents, which have been associated with impaired upper airway and breathing function with increased risk of adverse postoperative respiratory events. Neostigmine has neuromuscular blocking properties when given in the absence of neuromuscular blockade and can induce paradoxical reduction in the train-of-four ratio (TOF ratio). This study tested the hypothesis that TOF ratios in patients receiving neostigmine at the time of postanesthesia care unit admission would not be less than TOF ratios in patients randomly assigned to receive a saline placebo. The authors also tested the hypothesis that the incidence of postextubation adverse respiratory symptoms and muscle weakness would not be increased in the neostigmine group. One hundred twenty patients undergoing general anesthesia received a small dose of rocuronium to facilitate intubation. Ninety patients achieved a TOF ratio of 0.9 to 1.0 and received either neostigmine or saline. Patients were subsequently monitored for muscle strength and postextubation respiratory adverse events. No significant difference in these parameters was noted between the 2 groups, leading the authors to conclude that administration of neostigmine at neuromuscular recovery was not associated with clinical evidence of anticholinesterase-induced muscle weakness. Comment: This study is accompanied by an editorial (Brull SJ, Naguib M. How to catch unicorns (and other fairytales). Anesthesiology. 2018;128:1–3) that discusses long-standing beliefs and misconceptions about the relative risk and benefits of administering muscle relaxants. The editors praise the study by Murphy et al for debunking 4 common myths. First, the study shows no evidence that neostigmine, at a dose of 40 lg/ kg, induces signs or symptoms of neuromuscular weakness, contradicting previous reports. Second, it challenges the belief that clinical assessment alone (eg, 5second head lift) is sufficient to assess adequate muscle recovery and underscores the need for quantitative neuromuscular assessment (TOF ratio). The study also challenged the widely held belief that neuromuscular recovery can be subjectively assessed by watching or feeling the response to TOF stimulation. Finally, the ‘‘time elapsed’’ principle of reversal is debunked. This principle stated that reversal was not necessary if the duration since the last dose of neuromuscular blocking agent was greater than 1 or 2 elimination half-lives, noting that 21% of patients failed to recover to a TOF ratio of 0.9 in 163 minutes after a single dose of 0.3 mg/ kg rocuronium. The editorial prov","PeriodicalId":94296,"journal":{"name":"Anesthesia progress","volume":"70 3","pages":"154-155"},"PeriodicalIF":0.0,"publicationDate":"2023-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41242874","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
For decades, the dental profession has provided anesthesia services in office-based, ambulatory settings to alleviate pain and anxiety, ranging from local anesthesia to general anesthesia. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a substantial lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article will illuminate the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medicine has implemented to manage such problems, and introduce a method for addressing these issues with the dental anesthesia medication safety paradigm.
{"title":"Medication Safety: Reducing Anesthesia Medication Errors and Adverse Drug Events in Dentistry Part 1.","authors":"Daniel S Sarasin, Jason W Brady, Roy L Stevens","doi":"10.2344/anpr-66-03-10","DOIUrl":"https://doi.org/10.2344/anpr-66-03-10","url":null,"abstract":"<p><p>For decades, the dental profession has provided anesthesia services in office-based, ambulatory settings to alleviate pain and anxiety, ranging from local anesthesia to general anesthesia. However, despite a reported record of safety, complications occasionally occur. Two common contributing factors to general anesthesia and sedation complications are medication errors and adverse drug events. The prevention and early detection of these complications should be of paramount importance to all dental providers who administer or otherwise use anesthesia services. Unfortunately, there is a substantial lack of literature currently available regarding medication errors and adverse drug events involving anesthesia for dentistry. As a result, the profession is forced to look to the medical literature regarding these issues not only to assess the likely severity of the problem but also to develop preventive methods specific for general anesthesia and sedation as practiced within dentistry. Part 1 of this 2-part article will illuminate the problems of medication errors and adverse drug events, primarily as documented within medicine. Part 2 will focus on how these complications affect dentistry, discuss several of the methods that medicine has implemented to manage such problems, and introduce a method for addressing these issues with the dental anesthesia medication safety paradigm.</p>","PeriodicalId":94296,"journal":{"name":"Anesthesia progress","volume":"66 3","pages":"162-172"},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.2344/anpr-66-03-10","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41224650","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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