Ayşe Hande Arpaci

Anesthetic approach to patient with Down syndrome and Hallervorden-Spatz disease who underwent tooth extraction.

Sir, Hallervorden-Spatz disease (HSD) is a rare neurological condition, caused by iron accumulation, which causes degeneration of the central nervous system. Blood and cerebrospinal fluid iron levels are normal. Accompanying Down syndrome (DS) is very rare.[1,2] We present our anesthetic approach with midazolam, metoclopramide, and ranitidine combination for tooth extractions of a mentally retarded, DS patient with HSD. We did not come across the use of this combination for HSD patients during the literature search. A 16-year-old male with DS, dystonia, dysarthria, gait disturbances, and sudden onset of psychotic symptoms with the diagnosis of HSD referred to Ankara University, Faculty of Dentistry, Oral and Maxillofacial Surgery Department (Turkey, 2015), for tooth extraction. General anesthesia was considered because of cooperation difficulty, agitation, and motion disorders. At preoperative examination, thyromental distance = 5 cm, sternomental distance = 10 cm, mandibulohyoid distance = 3 cm, Mallampati class was IV, atlanto-occipital joint extension was limited, and he had macroglossia. The patient was considered as a difficult intubation case. Oxygen saturation, heart beat rate, and noninvasive blood pressure were tracked. The patient with University of Michigan Sedation Scale (UMSS)-1 was oxygenized and was administered 2 mg of intravenous midazolam and metoclopramide intravenous 10 mg and ranitidine intravenous 50 mg to increase lower esophagus sphincter pressure and neutralize stomach acid. Anesthesia was maintained with 1 mg/kg of intravenous ketamine. Convenient mouth opening was achieved at UMSS 3. Extractions were carried out with no additional anesthetic agents or methods. After anesthesia termination, UMSS 1 and sufficient respiration was achieved in 4 min, general condition was good, and the patient was sent to service. In conclusion, treatment plans for HSD patients require general anesthesia when difficult intubation criteria and cooperation difficulty are present.[1,2] Sedoanalgesia under monitored anesthesia care, with titration of short-term anesthetics, and achieving UMSS 3 provides sufficient mouth opening for minor dental surgery procedures. Probable complications are prevented; mortality is decreased, fast recovery and early discharge is provided. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pediatric tooth extractions under sedoanalgesia.

Objective: The present study aims to evaluate intravenous ketamine and inhalation sedation in children, their unwanted side-effects and surgeon satisfaction. Methods: In this study, data of 922 children aged between 1-18 who underwent tooth extraction under sedoanalgesia in our department between September 2015-January 2016 were gathered and anesthesia approaches, unwanted side effects and surgical satisfaction was investigated. Postoperative recovery emergence agitation or delirium was evaluated with Watcha Behavior Scale (WBS). Results: Patients were grouped and compared according to acceptance of intravenous line placement (Group-1) or not (Group- 2). Group 1 received intravenous ketamine anesthesia (n=822), Group 2 received inhalation anesthesia with sevoflurane (n=100). Number of patients, age, weight and gender was significantly different in two groups. When side effects were investigated nausea was observed in 30 patients (3.6%), skin rashes were observed in 26 patients (3.2%) in Group-1 while skin rashes were observed in one patient (1%) in Group 2. 95% of surgeons reported intravenous anesthesia, 18% of surgeons reported inhalation anesthesia to be the anesthesia of choice. Emergence of postoperative recovery agitation (WBS≥3) was observed more frequent in Group 2 (p<0.05) than Group 1. Conclusion: Ketamine, which has analgesic, hypnotic and amnestic effects and which does not alter pharyngeal and laryngeal reflexes thus minimizes aspiration possibility, is a safe and effective anesthetic agent for tooth extractions of the pediatric population under sedoanalgesia.

Sedoanaljezi altında minör dental cerrahi girişimlerde anestezi deneyimlerimiz

Purpose: The majority of dental practice is implemented under local anesthesia and do not require monitorization. However it is crucial to monitor the patient and apply the appropriate treatment when dental care is accompanied by health problems. In this study our goal is to present and evaluate the data obtained by Monitored Anesthesia Care (MAC) of patients who couldn’t be administered local anesthesia, instead been applied sedoanalgesia. Material and Method: Data of 621 patients between the age of 1-75 years who administered to the operating room of Ankara University Faculty of Dentistry, Department of Oral and Maxillofacial Surgery during one year for minor surgery attempts (tooth extraction) were examined. Intraoperative and postoperative side effects as well as parameters recorded on the anesthesia forms were evaluated. Results: As result of evaluations; in all patients aged between 1-75, minor surgery attempts (tooth extraction) were carried out under MAC which Observer Assessment of the Alertness/Sedation Scale (OAA/S): 3 level was aimed. Intraoperatively rashes occurred in %4, nausea was observed in %3.2 of all patients. Postoperatively nausea was observed in %6.4, vomitus was seen in %7.2 of all patients. No other side effects or complications were observed. Conclusion: When OAA/S:3 level is achieved in MAC with intravenous anesthetics, minor surgery attempts (tooth extractions) can be trustfully carried out