Intravenous Magnesium Sulfate to Deliberate Hypotension and Bleeding after Bimaxillary Orthognathic Surgery; A Randomized Double-blind Controlled Trial.

STATEMENT OF THE PROBLEM: The preoperative or intraoperative administration of intravenous magnesium sulfate has been approved as an accepted medication for stabilizing hemodynamic indices during surgeries. PURPOSE: Intraoperative blood loss during orthognathic surgery is frequently abundant and sometimes requires blood transfusion. The present trial addressed the efficacy of intravenous magnesium sulfate on deliberating hypotension and bleeding reduction in patients undergoing bimaxillary orthognathic surgery. MATERIALS AND METHOD: This randomized double-blinded placebo controlled trial was conducted on 52 consecutive patients who underwent orthognathic surgery. The participants were randomly assigned to two groups receiving intravenous magnesium sulfate 30 mg/kg body weight bolus for 15 minutes immediately before anesthesia induction, followed by 10 mg/kg/hr dissolved in saline via pump infusion (n=26) and the second group received placebo as same bolus volume of normal saline in a 15-minute intravenous infusion which was continued until the end of operation (n=26). Both systolic and diastolic blood pressures were measured before anesthesia induction at baseline, during surgery, and at the end of the surgery. Intraoperative blood loss was also determined. RESULTS: Systolic and diastolic blood pressures did not differ between the two groups at baseline. Although a downward trend of both systolic and diastolic blood pressures was seen during the operation in both groups, the decrease in blood pressures occurred with greater gradient in the group administered magnesium sulfate. Assessing difference in the trend of the changes in systolic and diastolic blood pressures between the two study groups (adjusted for gender, age, mean body mass index, and time of surgery) showed different trends in the changes of blood pressures. No differences were observed in blood loss or blood product requirement between the two groups. CONCLUSION: The administration of intravenous magnesium sulfate can attenuate both systolic and diastolic blood pressures during orthognathic surgery with no significant effect on the volume of blood loss or need for blood transfusion.

Remifentanil, ketamine, and propofol in awake nasotracheal fiberoptic intubation in temporomandibular joint ankylosis surgery.

BACKGROUND: Nasotracheal intubation of patients with temporomandibular joint (TMJ) ankylosis is a challenge for anesthesiologists. Awake fiberoptic intubation (AFOI) is the safest technique in patients with difficult airway. This study compares 3 different techniques of conscious sedation during AFOI in patients with TMJ ankylosis. METHODS: This study comprised 54 patients, American Society of Anesthesiologists physical status 1, scheduled for TMJ surgery. The patients were randomly allocated to remifentanil group (n = 18, 0.75 µg/kg over 30 seconds), ketamine group (n = 18, 0.25 mg/kg over 30 seconds), or propofol group (n = 18, 0.5 mg/kg over 30 seconds) for conscious sedation. The main determinants affecting the patient's outcome included intubation time, intubation conditions, and patient discomfort, which were determined by scoring system. In addition, postoperative patient dissatisfaction, hemodynamic stability, and respiratory impairment were measured. RESULTS: Intubation times were significantly different between groups (P < 0.001), where remifentanil had the shortest time (30.28 seconds). Intubation conditions (scores 0-3) were significantly different between groups (P < 0.001).In this context, remifentanil had score 3 (2-3), which was higher compared with 2 (1-3) for ketamine and 2 (1-2) for propofol. Patient discomfort score was lowest in the remifentanil group. Hemodynamic stability was maintained within groups, and its changes were not significant (P > 0.05). Postoperative patient's dissatisfaction was observed in 2, 3, and 5 patients in remifentanil, ketamine, and propofol groups, respectively. Respiratory impairment (apnea) recorded lowest in the remifentanil group. CONCLUSIONS: Remifentanil was the best agent for AFOI, because it provided shorter intubation time, better intubation conditions, and least patient's complaint.Iranian registry no.: IRCT 201208061674N4 (www.irct.ir).

Jaw osteomyelitis as a complication in osteopetrosis.

Osteopetrosis is a rare bone dysplasia. The disease is characterized by osteoclast dysfunction, producing diffuse symmetrical increase in skeletal bone density and exhibiting various clinical manifestation because of heterogeneous entity. Among them, jaw osteomyelitis, frequently mandibular osteomyelitis, is an important complication encountered in these patients. In this article, 2 patients diagnosed with osteopetrosis with mandibular osteomyelitis would be presented. We used debridement and decortications, removal of hopeless teeth, and topical phenytoin in the management of mandibular osteomyelitis.