Takashi Hitosugi

Discrepancy between electroencephalography and hemodynamics in a patient with Cockayne syndrome during general anesthesia

Cockayne syndrome is a kind of progeria with autosomal chromosome recessiveness described first by Cockayne in 1936. Patients with this syndrome were characterized by retarded growth, cerebral atrophy, and mental retardation. We experienced an anesthetic management of a patient with Cockayne syndrome, who underwent dental treatment twice. The primary concern was discrepancy between electroencephalography and hemodynamics. The values of bispectral index showed a sharp fall to 1 digit and suppression ratio more than 40, while hemodynamics was stable during induction of anesthesia with sevoflurane 8%. We should pay attention to anesthetic depth in the central nervous system in patients with Cockayne syndrome. Titration of anesthetics should be performed by the information from electroencephalography.

Perioperative airway management of a patient with Beckwith-Wiedemann syndrome

Airway obstruction in pediatric patients always poses a challenge for anesthesiologists. Beckwith-Wiedemann syndrome causes various abnormalities such as macroglossia and omphalocele. Patients with these abnormalities often need corrective surgeries. Management of difficult airway caused by conditions such as macroglossia in patients with this syndrome could be challenging. We encountered a case of difficult airway in an infant with Beckwith-Wiedemann syndrome. It was predicted that macroglossia might cause difficult ventilation, intubation, and extubation. Preoperative assessment and preparations for difficult airway should be considered.

Postoperative Alopecia Following Oral Surgery

Postoperative alopecia is an uncommon complication and its outcome is an esthetically drastic change. Although its mechanism has not been clearly reported, risk factors might be positioning and prolonged operative time during oral surgeries. In addition, perioperative stressful conditions might influence the biological clock of the hair cycle. This report presents 2 cases of postoperative alopecia after oral surgery. Prevention of alopecia with type of headrest, change in head positioning, and avoidance of continuous compression is important.

Airway Management for a Pediatric Patient With a Tracheal Bronchus

Tracheal bronchus is an ectopic bronchus almost arising from the right side of the tracheal wall above the carina. The incidence of a tracheal bronchus is reported as 0.1 to 3%. We experienced a patient with tracheal bronchus that was incidentally found at induction of anesthesia. Endotracheal intubation in a patient with tracheal bronchus might cause obstruction of the tracheal bronchus, although in this case, ventilation was not impaired.

Changes in nasotracheal tube depth in response to head and neck movement in children

A tracheal tube is often inserted via the nasal cavity for dental surgery. The position of the tube tip is important, given that the head position sometimes changes during surgery. Head movement induces changes in the length of the trachea (t‐length) and/or the distance between the nare and the vocal cords (n‐v‐distance). In this study, we investigated the changes in t‐length and n‐v‐distance in children undergoing nasotracheal intubation.

Flexible laryngeal mask airway management for dental treatment cases associated with difficult intubation

Nasotracheal intubation is generally a useful maxillofacial surgery that provides good surgical access for intraoral procedures. When nasotracheal intubation is difficult, laryngeal mask airway (LMA) insertion can be performed, and the flexible LMA™ (FLMA) is also useful for anesthetic management. However, the FLMA provides limited access to the mouth, which restricts the insertion of instrumentation and confines the surgical field available. Here, we present our experience using the FLMA airway management for dental treatment cases involving difficulty with intubation.

The anesthetic management for a special needs patient with trisomy 18 accompanying untreated tetralogy of Fallot

Abstract Special needs patients with mental retardation are recognized to have poorer oral health condition. Oral health related quality of life reflects daily activity and well-being. Dental treatment under general anesthesia is often an option for such patients. Trisomy 18 is characterized by congenital heart disease, craniofacial abnormality and mental retardation. Congenital heart disease can be greater risk during anesthesia. In the case of trisomy 18 with untreated tetralogy of Fallot, especially right-to-left shunting and/or pulmonary artery stenosis may reduce pulmonary blood flow, and may develop life-threatening hypoxemia. We anesthetized a patient with trisomy 18 accompanying untreated tetralogy of Fallot for dental treatment. The hemodynamics including cardiac output has been monitored non-invasively using electrical velocimetry method. Its systemic vascular resistance and pulmonary vascular resistance were maintained appropriately, and dental treatments were successfully completed.

Influence of Fasting Duration on Body Fluid and Hemodynamics

Fasting before general anesthesia aims to reduce the volume and acidity of stomach contents, which reduces the risk of regurgitation and aspiration. Prolonged fasting for many hours prior to surgery could lead to unstable hemodynamics, however. Therefore, preoperative oral intake of clear fluids 2 hours prior to surgery is recommended to decrease dehydration without an increase in aspiration risk. In this study, we investigated the body fluid composition and hemodynamics of patients undergoing general anesthesia as the first case of the day versus the second subsequent case. We retrospectively reviewed the general anesthesia records of patients over 20 years old who underwent oral maxillofacial surgery. We investigated patient demographics, preoperative fasting time, anesthetic time, urine output, infusion volume, and opioid and vasopressor use. With respect to body fluid and hemodynamics, we extracted the data from the induction of anesthesia through 2 hours of anesthesia time. Thirty patients were suitable for this study. Patients were divided into 2 groups: patients who underwent surgery as the first case of the day (am group: n = 15) and patients who underwent surgery as the second case (pm group: n = 15). There were no significant differences between the 2 groups in patient demographics. In the pm group, fasting time for a light meal (832 minutes) was significantly longer than for the am group (685 minutes), p = .005. In the pm group, fasting time for clear fluids (216 minutes) was also significantly longer than for the am group (194 minutes), p = .005. Body fluid composition was not significantly different between the 2 groups. In addition, cardiac parameters intraoperatively were stable. In the pm group, vasopressors were used in 4 patients at the induction of anesthesia (p = .01). There were not statistically significant changes in cardiac function or body fluid composition between patients treated as the first case of the day vs patients who underwent surgery with general anesthesia as the second case of the day.

The Anesthetic Management for a Patient With Trisomy 13

&NA; Trisomy 13 is a chromosomal disorder that occurs in complete or partial mosaic forms. It is characterized by central apnea, mental retardation, seizure and congenital heart disease. The survival of the patients with trisomy 13 is the majority dying before one month. Trisomy 13 is the worst life prognosis among all trisomy syndromes. It is reported the cause of death is central apnea. Special needs patients with mental retardation are recognized to have poorer oral health condition. Oral health related quality of life reflects daily activity and well‐being. Dental treatment under general anesthesia is sometimes an option for such patients. This patient had received ventricular septal defect closure surgery at 2‐year‐old. In addition, he had mental retardation and seizure. Dental treatment had been completed without any cerebral and cardiovascular events under non‐invasive monitoring with not only cardiac electric velocimetry, but also epileptogenic activity. In addition, postoperative respiratory condition was maintained stable in room air.

In dental office, supine abdominal thrust is recommended as an effective relief for asphyxia due to aspiration

In dental office, sudden cardiac arrest and asphyxia due to aspiration of dentalmaterial into the trachea are twomajor life-threatening emergencies. Especially, asphyxia is leading cause of death. During dental surgery patients are usually in the dental chair, which is usually not stable for external chest compression. We previously reported the usefulness to stabilized the dental chair by using a stool for effective chest compression, and this procedure is recommended in the ERC guideline 2015 [1]. In the case of asphyxia, however, no actual procedure has not been suggested. During dental surgery patients are usually in supine or semi-recumbent position in the dental chair. These positioning may be a greater risk of falling something in the oropharynx [2-4]. Every small dental material, including orthoprosthesis or evulsion tooth, might be fallen into the oropharynx, and might cause accidental ingestion or airway obstruction due to aspiration into the trachea. Dentists, therefore, should be extremely attentive in handling of small instruments and or material, as airway obstruction could be happened during any intervention related to the oral cavity. Airway obstruction is a serious situation and requires emergency response. In the case of asphyxia, a lot of references recommended that removal of the material with back blows and/or abdominal thrust (Heimlich maneuver) should initially be attempted [5,6]. Heimlich maneuver is the most common life-saving technique for dislodging foreign body out from the respiratory tract. However, this technique is usually applied in the standing position, as asphyxia is often caused in restaurants or dining room by foodstuff, which obstructs in the pharynx. During dental surgery, in contrast, airway obstruction mainly occurs in the trachea ascribed to aspiration of dental material, and patients are usually in reclined position. Raising the patient in the sitting position may let the material slip into the deeper space in the trachea or the bronchus. On the contrary, it let the material in the pharynx be aspirated into the trachea. Abdominal thrust, therefore, should not be performed in the standing position or sitting position to avoid secondary falling of the materials in the dental office. In addition, it should be noted that abdominal thrust is useful in the case of severe airway obstruction. Abdominal thrust is invalid if airway is open even a little and has leakage. We, therefore, confirm it before performing abdominal thrust as it may give serious damage to visceral organs as same as chest compression. Abdominal thrust is feasible also in supine position. Sanuki examined the peak airway pressure in the manikin when supine abdominal thrust [7]. His group demonstrated that abdominal thrust in supine position showed higher peak pressure and was easier to perform than that in the standing position; peak airway