Dexmedetomidine sedation with and without midazolam for third molar surgery.

Twenty-four patients were randomly divided into 2 groups. Intraoperatively, one group received a continuous intravenous infusion of dexmedetomidine alone, whereas the other received a continuous dexmedetomidine infusion plus a small dose of midazolam. Early measurements of patient anxiety and psychomotor performance were lower in patients who had received midazolam. This difference was not seen later in the appointment. An amnesic effect was observed in those patients who received midazolam. This effect, however, did not translate into increased patient satisfaction in the group receiving midazolam. Our findings suggest a prolonged discharge time for patients who had been given midazolam that may be clinically significant. Overall, dexmedetomidine showed an unpredictable sedative response and may be less practical than more common alternatives for oral surgery procedures.

The influence of changes in trunk and pelvic posture during single leg standing on hip and thigh muscle activation in a pain free population.

BACKGROUND: Thigh muscle injuries commonly occur during single leg loading tasks and patterns of muscle activation are thought to contribute to these injuries. The influence trunk and pelvis posture has on hip and thigh muscle activation during single leg stance is unknown and was investigated in a pain free population to determine if changes in body posture result in consistent patterns of changes in muscle activation. METHODS: Hip and thigh muscle activation patterns were compared in 22 asymptomatic, male subjects (20-45 years old) in paired functionally relevant single leg standing test postures: Anterior vs. Posterior Trunk Sway; Anterior vs. Posterior Pelvic Rotation; Left vs. Right Trunk Shift; and Pelvic Drop vs. Raise. Surface EMG was collected from eight hip and thigh muscles calculating Root Mean Square. EMG was normalized to an "upright standing" reference posture. Repeated measures ANOVA was performed along with associated F tests to determine if there were significant differences in muscle activation between paired test postures. RESULTS: In right leg stance, Anterior Trunk Sway (compared to Posterior Sway) increased activity in posterior sagittal plane muscles, with a concurrent deactivation of anterior sagittal plane muscles (p: 0.016 - <0.001). Lateral hip abductor muscles increased activation during Left Trunk Shift (compared to Right) (p :≤ 0.001). Lateral Pelvic Drop (compared to Raise) decreased activity in hip abductors and increased hamstring, adductor longus and vastus lateralis activity (p: 0.037 - <0.001). CONCLUSION: Changes in both trunk and pelvic posture during single leg stance generally resulted in large, predictable changes in hip and thigh muscle activation in asymptomatic young males. Changes in trunk position in the sagittal plane and pelvis position in the frontal plane had the greatest effect on muscle activation. Investigation of these activation patterns in clinical populations such as hip and thigh muscle injuries may provide important insights into injury mechanisms and inform rehabilitation strategies.

A comparison of fospropofol to midazolam for moderate sedation during outpatient dental procedures.

Moderate intravenous (IV) sedation combined with local anesthesia is common for outpatient oral surgery procedures. An ideal sedative agent must be safe and well tolerated by patients and practitioners. This study evaluated fospropofol, a relatively new sedative/hypnotic, in comparison to midazolam, a commonly used benzodiazepine, for IV moderate sedation during oral and maxillofacial surgery. Sixty patients were randomly assigned to either the fospropofol or the midazolam group. Each participant received 1 µg/kg of fentanyl prior to administration of the selected sedative. Those in the fospropofol group received an initial dose of 6.5 mg/kg, with 1.6 mg/kg supplemental doses as needed. Those in the midazolam group received initial doses of 0.05 mg/kg, followed by 0.02 mg/kg supplemental doses. The quality of sedation in each patient was evaluated with regard to (a) onset of sedation, maintenance, and recovery profile; (b) patient and surgeon satisfaction; and (c) hemodynamic stability and adverse effects. The fospropofol group demonstrated shorter physical recovery times than midazolam patients, taking a mean of 11.6 minutes versus 18.4 minutes for physical recovery (P = .007). Cognitive recovery comparison did not find any difference with a mean of 7.5 minutes versus 8.8 minutes between the 2 drug groups (P = .123). The fospropofol group had a higher rate of local anesthetic injection recall (90.5 vs 44.4%, P = .004). Other parameters of recall were comparable. Two adverse effects demonstrated significance, with more patients in the midazolam group experiencing tachycardia (48.2 vs 9.4%, P = .001), and more patients in the fospropofol group experiencing perineal discomfort (40.6 vs 0, P < .001). No significant difference was found in any other measures of sedation safety, maintenance, or satisfaction. Fospropofol, when administered intravenously by a dentist anesthesiologist at the indicated dose in this study, appears to be a safe, well-tolerated alternative to midazolam for intravenous moderate sedation during minor oral surgery procedures.

Comparison of propofol-remifentanil versus propofol-ketamine deep sedation for third molar surgery.

This study aimed to compare continuous intravenous infusion combinations of propofol-remifentanil and propofol-ketamine for deep sedation for surgical extraction of all 4 third molars. In a prospective, randomized, double-blinded controlled study, participants received 1 of 2 sedative combinations for deep sedation for the surgery. Both groups initially received midazolam 0.03 mg/kg for baseline sedation. The control group then received a combination of propofol-remifentanil in a ratio of 10 mg propofol to 5 µg of remifentanil per milliliter, and the experimental group received a combination of propofol-ketamine in a ratio of 10 mg of propofol to 2.5 mg of ketamine per milliliter; both were given at an initial propofol infusion rate of 100 µg/kg/min. Each group received an induction loading bolus of 500 µg/kg of the assigned propofol combination along with the appropriate continuous infusion combination . Measured outcomes included emergence and recovery times, various sedation parameters, hemodynamic and respiratory stability, patient and surgeon satisfaction, postoperative course, and associated drug costs. Thirty-seven participants were enrolled in the study. Both groups demonstrated similar sedation parameters and hemodynamic and respiratory stability; however, the ketamine group had prolonged emergence (13.6 ± 6.6 versus 7.1 ± 3.7 minutes, P = .0009) and recovery (42.9 ± 18.7 versus 24.7 ± 7.6 minutes, P = .0004) times. The prolonged recovery profile of continuously infused propofol-ketamine may limit its effectiveness as an alternative to propofol-remifentanil for deep sedation for third molar extraction and perhaps other short oral surgical procedures, especially in the ambulatory dental setting.

Correlation of isokinetic and novel hand-held dynamometry measures of knee flexion and extension strength testing.

OBJECTIVES: Describe inter-rater reliability of, and correlations between a novel method of isometric knee extension and flexion and eccentric knee flexion strength using hand-held dynamometry and isokinetic testing for flexion/extension in the knees of athletic participants. Document strength data normalized to the individual's limb muscle mass. DESIGN: Observational and reliability study. METHODS: Inter-rater reliability for each of the hand-held dynamometry measures was established in both legs of 10 volunteers (6 male). During routine annual screening, 216 male professional football (soccer) players were examined using these same measures in addition to performing an isokinetic evaluation of knee flexion and extension strength. Intra-class correlation coefficients for inter-rater reliability, Pearson r correlations between hand-held dynamometry and isokinetic dynamometry were calculated. Peak torque, peak torque normalized to: body weight; lean body mass; and lean limb mass were documented. RESULTS: Excellent inter-rater reliability was demonstrated with intra-class correlation2,1 values of 0.90, 0.91, and 0.96, for the eccentric hamstrings, isometric hamstrings, and isometric quadriceps measures respectively. Medium to high correlations (r=0.322-0.617) which were all significant (p<0.001) were found for the comparisons between the hand-held dynamometry and isokinetic measures. CONCLUSIONS: We present 3 novel and reliable methods of examining knee flexion and extension strength using hand-held dynamometry which require less skill and strength on the part of the examiner than previous measures. Correlations between these measures and isokinetic dynamometry are documented. The hand-held dynamometry examinations took less than 4 min per player to conduct and may be useful in clinical practice where isokinetic examination can be difficult to implement.

Parker flex-tip and standard-tip endotracheal tubes: a comparison during nasotracheal intubation.

The placement of endotracheal tubes in the airway, particularly through the nose, can cause trauma. Their design might be an important etiologic factor, but they have changed little since their introduction. Recently Parker Medical (Bridgewater, Conn) introduced the Parker Flex-Tip (PFT) tube, suggesting that it causes less trauma. This study aimed to compare the PFT endotracheal tube to a side-beveled, standard-tip endotracheal tube (ETT) for nasotracheal intubation (Figures 1 and 2). Forty consecutive oral surgery patients requiring nasotracheal intubation were randomized to receive either a standard ETT or the PFT tube. Intubations were recorded using a fiber-optic camera positioned proximal to the Murphy eye of the tube. This allowed visualization of the path and action of the tube tip as it traversed the nasal, pharyngeal, laryngeal, and tracheal airway regions. Video recordings made during intubation and extubation were evaluated for bleeding, trauma, and intubation time. Both bleeding and trauma were recorded using a visual analogue scale (VAS) and by 3 different evaluators. The PFT received significantly better VAS values than the standard tubes from all 3 raters (P < 0.05) in both the extent of trauma and bleeding. Since the intubations were purposefully conducted slowly for photographic reasons, neither tube displayed a time advantage. This study suggests that the PFT tube design may be safer by causing less trauma and bleeding than standard tube designs for nasotracheal intubation.

Physiologic signs during dental treatment in overweight vs normal weight children.

PURPOSE: This study compared physiologic effects of position change on overweight (OW) and normal-weight (NW) children during a preventive appointment. METHODS: A cross-sectional, case-controlled design assigned a convenience sample to either overweight (>85th percentile) or normal-weight groups (25th to 85th percentile) by body mass index (BMI). A trained examiner measured blood pressure (BP), heart rate (HR), oxygen saturation (SpO2), and 5 pulmonary functions in preoperative, upright seated, supine, and postoperative upright seated positions. Anxiety was measured using the Corah Dental Anxiety Scale. RESULTS: NW and OW groups' anxiety scores did not differ (P=.69). Mean BMIs were 20.1 and 39.7 for NW and OW subjects, respectively. Overall, BP between groups was not different (P=.051), although systolic BP for OW subjects tended to be higher. Systolic and diastolic BP dropped for both groups with supine positioning (P< or =.001). During this change, HR did not change for NW, but dropped for OW subjects (P=.001). SpO2 was significantly different between groups following position change, but not within each group. Forced vital capacity and forced expiratory volume were higher in the OW group (P< or =.01), but 2 peak expiratory measures (PEF and PEF25-75 were not (P=.05). CONCLUSION: Heart rate and oxygen saturation respond differently to positional changes in overweight patients.

Foreign body obstruction preventing blind nasal intubation.

A healthy young male patient was scheduled for dental care under nasotracheal intubated general anesthesia. The presence of a plastic calculator key complicated the intubation. This case report describes the event and reviews some possible techniques for coping with an airway that becomes obstructed by a foreign object.