A retrospective analysis of outpatient anesthesia management for dental treatment of patients with severe Alzheimer's disease

BACKGROUND: The number of patients with Alzheimer's disease is growing worldwide, and the proportion of patients requiring dental treatment under general anesthesia increases with increasing severity of the disease. However, outpatient anesthesia management for these patients involves great risks, as most patients with Alzheimer's disease are old and may show reduced cardiopulmonary functions and have cognitive disorders. METHODS: This study retrospectively investigated 43 patients with Alzheimer's disease who received outpatient anesthesia for dental treatment between 2012–2017. Pre-anesthesia patient evaluation, dental treatment details, anesthetics dose, blood pressure, duration and procedure of anesthesia, and post-recovery management were analyzed and compared between patients who underwent general anesthesia or intravenous sedation. RESULTS: Mean age of patients was about 70 years; mean duration of Alzheimer's disease since diagnosis was 6.3 years. Severity was assessed using the global deterioration scale; 62.8% of patients were in level ≥ 6. Mean duration of anesthesia was 178 minutes for general anesthesia and 85 minutes for intravenous sedation. Mean recovery time was 65 minutes. Eleven patients underwent intravenous sedation using propofol, and 22/32 cases involved total intravenous anesthesia using propofol and remifentanil. Anesthesia was maintained with desflurane for other patients. While maintaining anesthesia, inotropic and atropine were used for eight and four patients, respectively. No patient developed postoperative delirium. All patients were discharged without complications. CONCLUSION: With appropriate anesthetic management, outpatient anesthesia was successfully performed without complications for dental treatment for patients with severe Alzheimer's disease.

Telephone follow-up care for disabled patients discharged after receiving dental treatment under outpatient general anesthesia

BACKGROUND: Patients were subjected to post-discharge follow-up (by telephone) in order to investigate the potential complications of outpatient general anesthesia or deep sedation that could develop in disabled dental patients discharged from the hospital. The ultimate aim of this study was to establish an appropriate response measure for such complications. METHODS: The caregivers of 79 disabled patients who underwent dental procedures under general anesthesia at our outpatient clinic were interviewed over telephone. Necessary care instructions were provided during the phone calls when required. The patient satisfaction level regarding the telephonic follow-up care was surveyed by additional telephone calls. RESULTS: Most of the patients did not suffer any serious complications; however, some reported fever and bleeding. The data obtained in this study can be utilized towards the development of caregiver education pertaining to the ambulatory general anesthesia of dental patients with disabilities. CONCLUSIONS: Additionally, we hope that the findings of this study will help minimize the effects of complications experienced by disabled dental patients undergoing ambulatory general anesthesia, as well as increase the overall patient satisfaction level.

Analysis of unanticipated admission after outpatient anesthesia

BACKGROUND: Outpatient anesthesia is becoming more universal because of patient comfort and reduced health care cost. But unanticipated admission after outpatient anesthesia poses patient discomfort and increases cost. We investigated past medical records to evaluate the incidence and the causes of unanticipated admission after outpatient anesthesia. METHODS: Total number of outpatient anesthesia were 1268 patients between November 2007 and June 2009. Medical records were retrospectively analyzed about 35 patients who admitted unexpectedly. RESULTS: The overall mean rates of admissions during the study period was 2.8 percent. The principal reasons for admissions were observation, surgery related admissions, medical disease, wish of patients and anesthesia related admissions. CONCLUSIONS: The incidence of unanticipated admission was 2.8%, department of general surgery had the highest admission rate and observation was the most common cause of unanticipated admission.

Effects of fentanyl and midazolam on emergence agitation following ketamine anesthesia in children

BACKGROUND: Recently, a high incidence of emergence agitation (EA) has been reported in children after sevoflurane or desflurane anesthesia. However, in case of ketamine, there are few up-to-date studies about EA in children. This study observed effects of fentanyl and midazolam on emergence agitation and the recovery profile following ketamine anesthesia for outpatient surgery in preschool children. METHODS: Seventy-five children, aged 1-7 years, undergoing brief procedure under intravenous ketamine anesthesia were randomly allocated one of three groups; saline-ketamine, fentanyl-ketamine, midazolam-ketamine. Patients were premedicated with normal saline or fentanyl 0.5microg/kg or midazolam 0.05 mg/kg 5 min before administration of ketamine. Ketamine was given in an initial dose of 1.5 mg/kg and additional dose of 0.5 mg/kg ketamine was given as needed during operative procedure. The incidence of EA and other adverse effects and stay time at recovery room and day surgery center (DSC) were noted. RESULTS: The incidence of emergence agitation was 20 % in control group, 12 % in fentanyl group, and 16 % in midazolam group. Most common adverse effects during recovery was vomiting. There were no significant differences in incidence of emergence agitation, adverse effects and stay time at recovery room and DSC among the three groups. CONCLUSIONS: In children undergoing brief outpatient surgery with ketamine anesthesia, emergence agitation was not significantly reduced by addition of fentanyl 0.5microg/kg or midazolam 0.05 mg/kg. No significant differences were observed among the three groups with respect to adverse effects and recovery profile.

Clinical Analysis of Outpatient Anesthesia in Children with Middle Ear Ventilation Tube Insertion / 대한마취과학회지

BACKGROUND: Pediatric outpatient anesthesia is beneficial because it is more comfortable to children and more convenient for families, but delayed discharge causes distress for parents and children and increases health care personnel workload. Therefore, we examined past medical records to evaluate factors affecting discharge time in pediatric outpatient anesthesia. METHODS: We reviewed the anesthetic and post-anesthetic care records of 119 children who required ventilation tube insertion for ambulatory surgery, and who were anesthetized and monitored by an anesthesiologist between June 2001 and February 2004. Data were classified according to the anesthetic technique and agents used, duration of operation and anesthesia, and complications in the recovery room. We then examined the relationships between these factors and discharge time. RESULTS: Compared to intravenous anesthesia, endotracheal anesthesia increased anesthesia time (P <0.05), but not discharge time. Ketamine dosage was found to be closely correlated with discharge time (P <0.01), and complications in the recovery room delayed discharge time (P <0.05). CONCLUSION: We conclude that excessive ketamine use and postoperative complications delay discharge in pediatric outpatient anesthesia. More attention should be paid to minimize ketamine use and reduce postoperative complications so as not to delay discharge in pediatric outpatient anesthesia.

Propofol-N2O versus Seveflurane-N2O during Outpatient Knee Arthroscopic Surgery Using the Laryngeal Mask Airway: Hemodynamic Responses and Recovery Profiles / 대한마취과학회지

BACKGROUND: The increasing number of outpatient surgery which requiring the rapid, smooth induction of anesthesia with rapid recovery may lead to the use propofol or sevoflurane. Our objective was to compare the hemodynamic responses and recovery profiles obtained by sevoflurane inhalation with propofol infusion using a laryngeal mask airway (LMA) in an ambulatory setting. METHODS: Forty patients undergoing knee arthroscopic surgery were randomized into two groups. The laryngeal mask airway insertion was accomplished by using the voluntary maximal vital capacity breathing method (VCB) with sevoflurane 7% in nitrous oxide 50% (sevoflurane group) or by the infusion of propofol (target: 7microgram/ml) (propofol group). Under BIS monitoring (40-60), anesthesia was maintained by sevoflurane (2-3%) or propofol (range of 3.7-4.2microgram/ml) with spontaneous respiration. Time to loss of consciousness (LOC) and LMA insertion from induction of anesthesia, hemodynamic responses, end tidal CO2, and recovery profiles were evaluated. RESULTS: The mean time to LOC and to successful LMA insertion were similar in the groups. Hemodynamic responses in the sevoflurane group were not significantly different from those of the propofol group. However, in both groups, systolic and diastolic blood pressure were lower at the time of loss of consciousness and 5 min of after LMA insertion versus preinduction and LMA insertion values (P<0.05). Heart rate was significantly lower in the propofol group (P<0.05). After cessation of anesthesia, hemodynamic responses and to the time for LMA removal or to the time for responding to a verbal command were similar in both groups. CONCLUSIONS: Sevoflurane inhalation and propofol infusion anesthesia with spontaneous respiration provided comparable conditions for outpatient surgery.

A Clinical Review of the Deep Sedation Anesthesia with Midazolam, Fentanyl and Esmolol for the Facial Chemical Peeling / 대한마취과학회지

To investigate the clinical usefulness of the intravenous anesthesia of the facial chemical peeling with midazolam(0.1 mg/kg)-fentanyl(3 ug/kg) - esmolol(initial 500 ug/kg,maintenance 200 ug/kg/min), the authors took 133 cases into consideration. The results of the statistical evaluation were as follows: 1) Most of the cases were small pox scar(70.7%). 2) One point five percent of the cases dreamed during anesthesia. 3) Ninety-four point seven percents of the cases were in the emotion of "Peaceful and relaxed" and 60.1% of them were in the mood of Pleased or very pleased and the others were "So and so". 4) Ninety-one point seven percents of the cases were willing to choose the same anesthetic method next time. 5) Fifty-two point six percents of the cases showed hypertensive episodes during anesthesia. 6) The incidence of the cases with SaO lower than 85% was 36.8%. The anesthetic technique with intravenous midazolam-fentanyl-esmolol for the facial chemical peeling with trichloroacetic acid(TCA) gives the patient comfortness and preference for this anesthetic technique. Close monitoring of the respiration is needed, because it can depress respiratory function. And control of the high blood pressure during anesthesia seems to be needed.

The Effects of Esmolol on cardiovascular and Centroneural System in Anesthesia with Ketamine and Midazolam for Chemical Facial Peeling / 대한마취과학회지

One of the indications of outpatient surgery is chemical peeling of the face. It usually requires deep sedation with analgesia of short duration. For this purpose we tried to use ketamine(1 mg/kg) and midazolam(0.1 mg/kg) but experienced frequent hypertension and tachycardia. We tried to use beta blocker, esmolol for the of control blood pressure and heart rate. The patients were divided into two groups. In control group, eighty-five patients were anesthetized with bolus intravenous injection of I mg/kg of ketamine and 0.1 mg/kg of midazolam. In esmolol group, eighty-three patients reed a continuous infusion of esmolol(500 mcg/kg/min for initial dose, followed by 200 mcg/kg/min for maintenance) in addition to midazolam(0.1 mg/kg) and ketamine(1 mg/kg). During operation, we observed systolic, diastolic blood pressure and peripheral oxygen saturation(SaO2). All patients were allowed to breathe spontaneously. There was no case of airway obstruction and SaO2 value was over 98% in most cases. So we investigated the effects of esmolol on blood pressure,heart rate,emergence sequelae and patients acceptance in the anesthesia with ketamine and midazolam in the patient of facial chemical peeling. The results were as follows: 1) No one could recall. 2) There were no differences on the status of mood, emotion and patient's positive acceptance between two groups 3) Blood pressure and heart rate were increased during anesthesia with midazolam and ketamine. But esmolol attenuated this response, significantly(P<0.05). We concluded that esmolol added benefits of control of blood pressure and heart rate in the anesthesia of facial chemical peeling. But the control of the high blood pressure is not so easy, so it is needed to find out the optimal dosage of esmolol for complete blocking of the sympathetic response without complications.

The Cardiovascular Changes of Propofol-Fentanyl as a Sedative-analgesic for Outpatient Lithotripsy / 대한마취과학회지

Intravenous anesthesia, using sedative for the rapid loss of consciousness and analgesic for the potent and short-acting effect, has been widely done. So tbis study is aimed to see if propofol-fentanyl are effective enough for extracorporeal shock wave lithotripsy(ESWL) used for outpatient and how it will effects on cardiovascular system. Above all, 45 patients were selected randomly and their blood pressure(BP), heart rate(HR), respiratory rate(RR) and arterial oxygen saturation(SaO2) were measured shortly before giving propofol and fentanyl. Then, after giving propofol and fentanyl, BP,HR, RR and SaO2 were measured as the adequate depth of anesthesia. And after 5 to 10 minutes, ESWL was done. Involuntary movements and pain were checked as additional depth of anesthesia. With the time, HR and SaO2 showed statistically significant decrease with no clnical meanings. And there was no special treatment for involuntary movements founded in 8 patients but 13 patients suffering from pain were given additional fentanyl. In conclusion, intravenous anesthesia with propofol and fentanyl works effectively for ESWL. Therefore if during ESWL, cardiopulmonary functions are monitored carefully, intravenous anesthesia with propofol and fentanyl will be an effective and safe anesthesia.

The Anesthesia for Outpatient Facial Chemical Peeling Using Ketamine and Midazolam / 대한마취과학회지

The surgeries based on the outpstient department have increased recently. One of the indications of outpatient surgery is chemical peeling of the face that usually re- quires only deep sedation of short duration. The purpose of this study was to evaluate the effeets of ketamine and midszolam for out patient facial chemical peeling. Fifty-nine unpremedicated patients undergoing chemical peeling of the face were anesthetized with bolus intravenous injection of 1mg/kg of ketamine and 0.1 mg/kg of midazolam. Additional dose of ketamine(10-20mg) was given as needed. During operation, we observed systolic and diastolic blood pressure with noninvasive blood pressure monitor and peripheral oxygen saturation(SpO2) with pulse oximeter. All patients were allowed to breathe spontane- ously without ventilatory support during the operation. There was no case of airway ob- struction and SpO2 value was over 97% in most cases. The systolic and diastolic blood pressure and pulse rate were increased after the injection of ketamine and midazolam. And we observed the untoward effect of anesthetics such as the purposeless movement(6.8%), involuntary phonation(3.4%), skin rash(3.4%) and headache(1.7%). In postoperative analysis about the recall, bad dream, mood, and the degree of satisfaction of this type of anesthesia, the rate of patient's positive acceptance was high(86.4%) and the reeovery time was 58min. We conclude that combination of intravenous ketamine and midszolam can produce satisfactory anesthesia with few complications for outpatient chemical peeling surgery of the face.

Clinical Evaluation of Outpatient Anesthesia for Pediatric General Sugery / 대한마취과학회지

Anesthesia for thoracic surgery is most commonly performed with the patient in the lateral decubitus position, with nondependent hemithorax comprising the operation field. When one-lung ventilation is employed, the nondependent lung is nonventilated and collapsed, while the dependent lung is ventilated. Consequently one-lung ventilation creates an obligatory right to left transpulmonary shunt through the nondependent nonventilated lung. Therefore one-lung ventilation results in a much larger alveolar-arterial oxygen tension-difference P(A-a)O2 and lower PaO2 than does two-lung ventilation. The present study was to evaluate oxygenation effect of selective CPAP to nondependent lung in the 17 thoracic surgical patients. Arterial blood gases were analysed, systolic blood pressures and heart rates were measured at following stages. Stage I; lateral decubitus position before chest opening Stage II; 15 min after chest opening and one lung ventilation stage III; 15 min after application of selective CPAP 5 cmHO to the nondependent lung stage IV; 40 min after application of selective CPAP 5 cmHO to the nondependent lung The results were as follows: 1) In stage II, the value of PaO2 was significantly lower as compared to that in stage I(224.9+/-78.0 vs 418.2+/-63.1 mmHg, P<0.01). 2) In stage III and IV, the values of PaC4 were significantly higher.as compared to that in stage II(333.8+/-97.1, 364.5+/-88.6 vs 224,9+/-78.0 mmHg, P<0.01). 3) In stage III, the value of PaCO2 was significantly lower as compared to that in stage II(37.1+/-2.9 vs 38.2+/-2.7 mmHg, P<0.05). 4) In stage IV, the value of pH was significantly lower as compared to that in stage III(7.37+/-0.05 vs 7.38+/-0.05 P<0.05). 5) Systolic blood pressures and heart rates remained unchanged at all times. We concluded that application of 5 cmHO CPAP to the nondependent lung during one-lung ventilation is one of most efficacious maneuvers to increase PaO2, accompanying less surgical interference.