Sedation with dexmedetomidine in elderly patients during dental surgery: a retrospective case series

OBJECTIVES: The number of elderly patients with systemic basal disease requiring invasive dental treatment has increased. Appropriate prediction of surgical invasiveness and combined use of psychosedation are thought to contribute to safe whole-body management. Dexmedetomidine (DEX) exhibits analgesic and anti-anxiolytic properties and causes mild respiratory depression. Studies regarding DEX use in elderly non-intubated patients are scarce. We aimed to use retrospective data to determine an effective dose of DEX to induce adequate sedation in elderly patients undergoing invasive dental surgery under local anesthesia. MATERIALS AND METHODS: One hundred two patients aged 70 to 96 years were presumably appropriately controlled with sedation. DEX was administered at an initial loading dose of 2.0 to 3.1 µg/kg/hr for 10 minutes. We divided the patients into five groups by age and compared their blood pressures and heart rates. RESULTS: In all five groups, blood pressure decreased suddenly at approximately 15 and 20 minutes after DEX administration. A marked decrease in blood pressure was noted in patients aged 75 to 79 years. CONCLUSION: For elderly patients aged 75 years and above, the initial loading dose of DEX needs to be reduced to lower than half that required for young and middle-age adults.

Sedation with dexmedetomidine in elderly patients during dental surgery: a retrospective case series

OBJECTIVES@#The number of elderly patients with systemic basal disease requiring invasive dental treatment has increased. Appropriate prediction of surgical invasiveness and combined use of psychosedation are thought to contribute to safe whole-body management. Dexmedetomidine (DEX) exhibits analgesic and anti-anxiolytic properties and causes mild respiratory depression. Studies regarding DEX use in elderly non-intubated patients are scarce. We aimed to use retrospective data to determine an effective dose of DEX to induce adequate sedation in elderly patients undergoing invasive dental surgery under local anesthesia.@*MATERIALS AND METHODS@#One hundred two patients aged 70 to 96 years were presumably appropriately controlled with sedation. DEX was administered at an initial loading dose of 2.0 to 3.1 µg/kg/hr for 10 minutes. We divided the patients into five groups by age and compared their blood pressures and heart rates.@*RESULTS@#In all five groups, blood pressure decreased suddenly at approximately 15 and 20 minutes after DEX administration. A marked decrease in blood pressure was noted in patients aged 75 to 79 years.@*CONCLUSION@#For elderly patients aged 75 years and above, the initial loading dose of DEX needs to be reduced to lower than half that required for young and middle-age adults.

Anxiety before dental surgery under local anesthesia: reducing the items on state anxiety in the State-Trait Anxiety Inventory-form X

BACKGROUND: It is important to evaluate preoperative anxiety and prepare sedation when performing dental surgery under local anesthesia. Spielberger's State-Trait Anxiety Inventory (STAI) is useful for predicting preoperative anxiety. State anxiety is defined as a subjective feeling of nervousness. Reduction in the number of the state anxiety items (questions) will be clinically important in allowing us to predict anxiety more easily. METHODS: We analyzed the STAI responses from 1,252 patients who visited our institution to undergo dental surgery under local anesthesia. Multiple linear regression analysis was conducted for 9 groups comprising anxiety level determinations using the STAI; we then developed a coefficient of determination and a regression formula. We searched for a group satisfying the largest number of requirements for regression expression while setting any necessary conditions for accurately predicting anxiety before dental surgery under local anesthesia. RESULTS: The regression expression from the group determined as normal for preoperative state anxiety was deemed the most suitable for predicting preoperative anxiety. CONCLUSIONS: It was possible to reduce the number of items in the STAI by focusing on “Preoperative anxiety before dental surgery.”

QT-interval prolongation due to medication found in the preoperative evaluation

QT prolongation is an electrocardiographic change that can lead to lethal arrhythmia. Acquired QT prolongation is known to be caused by drugs and electrolyte abnormalities. We report three cases in which the prolonged QT interval was improved at the time of operation by briefly discontinuing the drugs suspected to have caused the QT prolongation observed on preoperative electrocardiography. The QTc of cases 1, 2, and 3 improved from 518 to 429 ms, 463 to 441 ms, and 473 to 443 ms on discontinuing the use of a gastrointestinal prokinetic agent, a proton pump inhibitor, and a molecular targeted drug, respectively. These cases were considered to have drug-induced QT prolongation. We reaffirmed that even drugs administered for conditions unrelated to cardiac diseases can have adverse side effect of QT prolongation. In conclusion, our cases indicate that dental surgeons should be aware of the dangerous and even potentially lethal side effects of QT prolongation. For safe oral and maxillofacial surgery, cooperation with medical departments in various fields is important.

Oral surgery under local anesthesia with dexmedetomidine sedation in a morbidly obese patient with aortic dissection

We report a case of a morbidly obese man with an aortic aneurysm, in whom dental surgery was performed before elective cardiac surgery. His aortic aneurysm required emergency surgery. However, because of his morbid obesity, elective cardiac surgery was planned. Considering the high risk of infective endocarditis, dental surgery was required. Our patient was at a high risk of aortic rupture caused by hypertension and breathing difficulty in the supine position. Dexmedetomidine (DEX) is an anti-anxiety, sedative, and analgesic medicine that can stabilize circulatory dynamics and minimize blood pressure fluctuations. We administered intravenous DEX for sedation of the patient in Fowler's position. In conclusion, our understanding of the risk factors of DEX enabled us to perform safe invasive oral treatment.

Wisdom teeth extraction in a patient with moyamoya disease

Moyamoya disease is a rare neurovascular disorder that involves constriction of certain arteries in the brain. In patients with moyamoya disease, it is very important to prevent cerebral ischemic attacks and intracerebral bleeding caused by fluctuating blood pressure and increased respiration. A 40-year-old woman with moyamoya disease was scheduled for extraction of her right upper and lower impacted wisdom teeth. Her lower impacted wisdom tooth was situated close to the inferior alveolar nerve. We decided to continue her oral antiplatelet therapy and planned intravenous sedation with analgesic agents administered approximately five minutes prior to extraction of the root of the mandibular wisdom tooth. Oral analgesic medications were regularly administered postoperatively to alleviate pain and anxiety. During the perioperative period, no cerebrovascular event occurred, and the wisdom teeth were successfully extracted as per the planned procedure. It is thought that the perioperative risks of wisdom tooth extraction in patients with moyamoya disease can be minimized with the use of our protocols.

Sedative methods used during extraction of wisdom teeth in patients with a high level of dental anxiety

INTRODUCTION: Intravenous sedation is performed to ensure smooth and safe surgery. Dental anxiety is a reaction to an unknown danger. The Spielberger's state-trait anxiety inventory (STAI) can be used to simultaneously evaluate the levels of state and trait anxiety. State anxiety is defined as subjective feelings of nervousness. This study assessed the presurgical anxiety using STAI and performed intravenous sedation for patients whose level of state anxiety was > stage IV. Based on our clinical experience, it is believed that higher doses of sedatives are needed to induce the desired levels of sedation in patients with a high level of state anxiety. OBJECTIVES: This study examined whether the sedative consumption of the patient with a high anxiety level increased. PATIENTS AND METHODS: Patients with state anxiety scores of > or =51 were included in Group V, and those with state anxiety scores ranging from 42 to 50 were placed in Group IV. To induce sedation, intravenous access was established, and a bolus dose of 3.0 mg midazolam was administered intravenously. Sedation was maintained by administering a continuous infusion of propofol, which was aimed at achieving an Observer's Assessment of Alertness/Sedation scale of 10-12/20. In this study, midazolam was initially administered when the body movements appeared to occur or the blood pressure increased. This was followed by the administration of higher doses of propofol if low sedation was observed. RESULTS: There were no significant differences in the patient demographics, duration of sedation, and doses of local anaesthetic agents between Groups IV and V. The midazolam dose and mean propofol dose needed to maintain comparable levels of sedation were significantly higher in Group V than in Group IV. CONCLUSION: In female patients, whose level of preoperative state anxiety is more than Stage V of STAI, a large quantity of sedatives is needed for intravenous sedation.