Anesthetic management of a pediatric patient with Dravet syndrome: A case report.

INTRODUCTION: Dravet syndrome (DS) is a rare and severe myoclonic epilepsy, with onset commonly occurring in infancy. Seizures are triggered by various causes, including fever, bathing, and light stimulus. DS is refractory to drug treatment. Moreover, status epilepticus (SE) can cause serious encephalopathy and epilepsy-related deaths. There are very few reports of general anesthesia in DS patients. Herein, we report our experience with the anesthetic management of a pediatric patient with DS. PATIENT CONCERNS AND DIAGNOSES: A 5-year-old boy (height, 112 cm; weight, 19 kg) was diagnosed with DS through SCN1A genetic testing, which revealed a de novo novel missense mutation. His medical history included drug-resistant epilepsy, developmental delay, and hypotonia. His seizures tended to be triggered daily by a rise in body temperature (BT), bathing, and light stimulus. He could not receive adequate dental treatment due to DS, although he had previously undergone dental treatment under restraint at the pediatric dentistry department of our hospital. INTERVENTIONS AND OUTCOMES: The patient was scheduled for intensive dental treatment under general anesthesia due to noncooperation, and DS-related limitations. By considering the risk posed by elevated BT, seizure-inducing drugs were avoided, and general anesthesia was completed as planned, uneventfully. Although fluctuation of BT occurred during the procedure, it was finally controlled at the end of anesthesia at about the same level as at anesthesia induction. However, small seizures and a single generalized convulsion were observed accompanied by fever on postoperative day 1. The patient was discharged from the hospital without major problems on postoperative day 3, because of detailed planning and close preoperative cooperation with the attending pediatrician. CONCLUSION: It is essential to pay attention to managing BT and to avoid drugs that induce seizures during anesthesia for patients with DS. Cautious preoperative planning for anesthesia based on evaluation of the patient and rapid postoperative response in collaboration with the attending pediatrician is necessary in case an epileptic seizure occurs.

Takotsubo syndrome after a minimally invasive tooth extraction in a patient without dental phobia: A case report.

Takotsubo syndrome (TTS) is a rare, stress-induced acute cardiac disorder. Its precipitating factors include emotionally or physically stressful events and exogenous and endogenous adrenaline. In this report, we describe a case of atypical TTS in a 73-year-old woman who reported no dental fear and required acute cardiac care in an outpatient setting. She underwent routine extraction of an upper left premolar under local anesthesia. She reported heart palpitations after the injection, and the procedure was completed in 15 min. After presenting symptoms of sweating, pale skin, vomiting, low blood pressure, and ST-segment elevation, cardiologists ordered echocardiography, coronary angiography, and ventriculography. Upon receiving a TTS diagnosis, the patient was hospitalized and administered an intra-aortic balloon pump and beta-blocker. Her symptoms resolved, and she was discharged with no sequelae. We found no precipitating factors in the progression of TTS in this case, which suggests that TTS can develop in the absence of precipitating factors. All general dentists and oral surgeons should recognize the possible risk of TTS, even during minimally invasive dental procedures, such as routine extractions in patients without dental phobia.

High initial target blood concentration in target-controlled infusion: A randomized controlled trial.

OBJECTIVE: Our previously modified propofol intravenous sedation (IVS) method using a target-controlled infusion (TCI) pump with initial target blood concentration (TBC) set at 2.2 µg/ml enables the prediction of the personal optimal intraoperative TBC during induction with a minimal gap. This study aimed to verify whether this method can be useful in case of higher initial TBCs to reduce induction time. METHODS: Forty-five patients scheduled to undergo oral surgery under IVS with propofol were randomly divided into three groups (group 1, TCI started with TBC set at 2.2 µg/ml; group 2, TBC was set at 2.6 µg/ml; group 3, TBC was set at 3.0 µg/ml). Immediately after reading the calculated brain concentration when the target sedation was achieved (value A), the initial TBC was manually reset to value A. We manually controlled the intraoperative TBC to maintain moderate sedation, according to the clinical signs and bispectral index values. Of the regulated TBC values, the value farthest from value A was defined as value B. The maximum discrepancy between values B and A and the induction time were compared among the three groups. RESULTS: The maximum discrepancy (mean ± standard deviation [SD]) was significantly larger in group 3 (1.0 ± 1.3 µg/ml, p = .005) and group 2 (0.8 ± 0.2 µg/ml p = .008) than in group 1 (0.5 ± 0.3 µg/ml). The induction time (mean ± SD) was significantly shorter in group 3 (124 ± 126 min, p = .004) and group 2 (135 ± 33 min, p = .006) than in group 1 (245 ± 1913 min). With the initial TBC set at 2.6 µg/ml, the maximum discrepancy was large at 0.8 µg/ml, but with a small SD (0.2 µg/ml). CONCLUSION: Considering this discrepancy, this method with an initial TBC set at 2.6 µg/ml may be acceptable for clinical use for moderate sedation (UMIN 000017197).

Cross-sectional study of propofol dose during intravenous sedation for dental surgery in patients with long-term oral benzodiazepine therapy: A secondary publication.

OBJECTIVES: The amount of propofol required for intravenous sedation (IVS) in patients on long-term oral benzodiazepine (BZD) therapy may be affected by drug interactions and central changes in sensitivity. However, there is no research on the effect of long-term oral BZD use on the amount of propofol required for IVS. We aimed to clarify the difference between the total propofol dose required for IVS in patients with or without long-term oral BZD therapy. MATERIAL AND METHODS: Among patients treated for 4 years, the total administered dose required for IVS with propofol alone and local anesthesia for the extraction of bilateral impacted mandibular wisdom teeth, was retrospectively compared between patients with continuous oral BZD use for ≥6 months (BZD group; n = 24) and those without such use (control group; n = 307). The aimed sedation level was the Ramsay sedation scale 3-4. RESULTS: The amount of propofol required for IVS was significantly lower in the BZD group compared to the control group (4.83 ± 1.30 vs. 5.91 ± 1.25 mg/kg/h, p < .001; 95% confidence interval, -1.22 to -0.94 mg/kg/h; Cohen's d, 0.84). The required propofol dose was not influenced by preoperative oral BZD administration on the day of extraction (presence [n = 13] vs. absence [n = 11]: 4.9 ± 1.3 vs. 4.8 ± 1.7 mg/kg/h, p = .83). Long-term oral BZD therapy remained a significant factor for a lower required propofol dose after adjusting for age with multiple linear regression analysis. The underlying mechanism cannot be an additive action process but might pertain to competitive inhibition via an enzyme involved in glucuronate conjugation or competitive albumin binding. CONCLUSIONS: Clinicians should understand that patients on long-term oral BZDs therapy might require less propofol for IVS than those not on BZDs, irrespective of whether BZDs were taken preoperatively on the day of surgery.

Cardiovascular Considerations in Anesthetic Management for a Patient With Antiphospholipid Syndrome and Decreased Cardiac Function: A Case Study.

This case report describes the prolonged general anesthetic management of a 41-year-old woman with antiphospholipid syndrome (APS), systemic lupus erythematosus, and previously undiagnosed decreased cardiac function who underwent planned partial resection of the left tongue, tracheostomy, neck dissection, and pedicled flap reconstruction. This was immediately followed by emergent surgery to salvage the flap, and 1 month later, revision of the soft tissue flap was performed. A preoperative echocardiogram was performed because of her various risk factors, which identified lateral wall hypokinesis and reduced left ventricular ejection fraction of 40%, despite no known cardiovascular disease. However, cardiology consult determined no additional treatment was needed before the surgery. Multiple antithrombotic strategies were used, including elastic stockings, intermittent pneumatic compression devises, and heparin bridging. During the general anesthetic, stroke volume variation (SVV) was used to assess cardiac function and guide fluid management. There were no signs of systemic thrombosis, although the free flap reconstruction was abandoned because of a thrombus in the vascular anastomosis. Cardiac function can deteriorate in APS patients because of coronary and/or microvascular thrombosis. Therefore, it is necessary to evaluate cardiac function, regardless of a known history of cardiovascular disease. Moreover, additional monitoring (ie, SVV) may be useful during prolonged general anesthetics for patients with APS and cardiac dysfunction.

General Anesthesia for a Patient With Pelizaeus-Merzbacher Disease.

We report the successful management of general anesthesia for a patient with Pelizaeus-Merzbacher disease (PMD). PMD is one of a group of progressive, degenerative disorders of the cerebral white matter. The typical clinical manifestations of PMD include psychomotor retardation, nystagmus, abnormal muscle tone, seizures, and cognitive impairment. General anesthesia for a patient with PMD may be difficult mainly because of seizures and airway complications related to poor pharyngeal muscle control. In addition, the possibility of exacerbation of spasticity should be considered. A 20-year-old man with PMD required removal of impacted wisdom teeth under general anesthesia. General anesthesia was induced with thiamylal, fentanyl, and desflurane. Anesthesia was maintained with desflurane and continuous intravenous remifentanil under bispectral index and train-of-4 monitoring. Anesthesia lasted 1 hour 20 minutes and was completed uneventfully. Airway complications, seizures, and exacerbation of spasticity did not occur postoperatively. Preoperatively, our patient had no history of epilepsy attacks or aspiration pneumonia, and no clinical symptoms of gastroesophageal reflux disease. Therefore, exacerbation of spasticity was one of the most likely potential complications. Identification of these associated conditions and evaluation of risk factors during preoperative examination is important for performing safe anesthesia in these patients.

Acute angle-closure glaucoma after general anesthesia for bone grafting.

Acute angle-closure glaucoma (AACG) is a rare complication of general anesthesia. The coexistence of individual risk factors for postoperative AACG and factors associated with intraocular hypertension are considered to be required for postoperative AACG to develop. We present a case of AACG after general anesthesia for oral bone grafting in a patient with no preoperative eye symptoms. In this case, several factors such as postoperative care in a darkened room, psychological stress, and postoperative hypertension may have precipitated the event in this patient, who may have had preexisting undiagnosed elevated intraocular pressure. The interval between the earliest appearance of symptoms at 9 hours and the ultimate diagnosis was 36 hours. In the postoperative period following general anesthesia, any patient is at risk for AACG. It is important that a postoperative diagnosis of AACG should be considered and a timely consultation with an ophthalmologist be considered if a postoperative patient complains of red eyes, visual disorder, eye pain, headache, and nausea.

Recovery of dynamic balance after general anesthesia with sevoflurane in short-duration oral surgery.

PURPOSE: Recovery of dynamic balance, involving adjustment of the center of gravity, is essential for safe discharge on foot after ambulatory anesthesia. The purpose of this study was to assess the recovery of dynamic balance after general anesthesia with sevoflurane, using two computerized dynamic posturographies. METHODS: Nine hospitalized patients undergoing oral surgery of less than 2 h duration under general anesthesia (air-oxygensevoflurane) were studied. A dynamic balance test, assessing the ability of postural control against unpredictable perturbation stimuli (Stability System; Biodex Medical), a walking analysis test using sheets with foot pressure sensors (Walk Way-MG1000; Anima), and two simple psychomotor function tests were performed before anesthesia (baseline), and 150 and 210 min after the emergence from anesthesia. RESULTS: Only the double-stance phase in the walking analysis test showed a significant difference between baseline and results at 150 min. None of the other variables showed any differences among results at baseline and at 150 and 210 min. CONCLUSION: The recovery times for dynamic balance and psychomotor function seem to be within 150 min after emergence from general anesthesia with sevoflurane in patients undergoing oral surgery of less than 2-h duration.

Correlation between precise and simple tests in recovery of dynamic balance function after intravenous sedation with midazolam in the elderly.

PURPOSE: Assessing the recovery of dynamic balance after intravenous sedation in the elderly is important for ensuring their safe discharge, especially when they are walking. A reliable, simple dynamic balance test would be useful in daily clinical practice. We observed the recovery of balance after intravenous sedation with midazolam, using computerized dynamic posturography (CDP), and we evaluated the correlation between the CDP result and the results of simple dynamic balance tests. METHODS: Midazolam was administered in divided doses, until the Wilson sedation score reached 3, in 18 elderly male volunteers. The dynamic balance test using CDP with perturbation stimuli was performed before and after sedation. As simple dynamic balance tests, the usual-speed walking (USW) and maximum-speed walking (MSW) tests and a modified timed "up and go" (TUG) test (subjects stand up from a chair, walk 5 m forward and return to the chair with MSW, and sit down again) were performed. RESULTS: The recovery times (defined as the time until the significant difference between the value at each time point and the baseline value disappeared) in the dynamic balance test (CDP), USW test, MSW test, and TUG test, were 80, 40, 80, 80 min, respectively. There was a significant, strong positive correlation between the result of the dynamic balance test (CDP) and the TUG test (P < 0.01; r = 0.70). CONCLUSION: The TUG test is a useful simple dynamic balance/motor test that can be used in daily clinical practice in the elderly.

Recovery of dynamic balance after additional small divided doses of midazolam given intravenously for sedation.

We have previously reported that a dynamic balance test with perturbation stimuli and computerised dynamic posturography sensitively reflected the inhibitory effect on balance of intravenous midazolam sedation given intravenously as a single dose, and recovery time was within 80 min. The purpose of this study was to investigate the recovery of dynamic balance after additional doses of midazolam. Eighteen young adult male volunteers were sedated with midazolam given intravenously. The initial dose was given until the Wilson sedation score reached 3, and an additional dose was given until the same score was obtained 40 min later. They were tested with perturbation stimuli 40, 80, 100, and 120 min after the additional doses had been given. Their recovery time was recorded. The mean (S.D.) initial dose of midazolam was 0.07 (0.005) mg kg(-1), and additional doses were 41 (7)% of the initial dose. The serial changes in bispectral index after initial and additional doses were similar. The recovery time for the dynamic balance test (within 80 min) was the same as that recorded in the previous single-dose study. The recovery time of the psychomotor function test was within 75 min. Additional doses of midazolam aiming for a Wilson sedation score of 3 at a dose about 40% of the initial dose and given 40 min after the initial dose are valid in terms of the maintenance of sedation and recovery of dynamic balance. Complete recovery time, including psychomotor function, was within 80 min of the additional dose of the drug.

Assessment of the recovery of dynamic balance after intravenous sedation with midazolam.

PURPOSE: To assess street fitness after sedation, computerized dynamic posturography (CDP) involving movement of the center of gravity may be more accurate than the conventional computerized static posturography (CSP). The purpose of this study was to evaluate the recovery of dynamic balance function after intravenous sedation by CDP in comparison with CSP, and to find a simple dynamic balance test that is well correlated with CDP. METHODS: The subjects were 20 male volunteers aged 20-27 years. After intravenous injection of midazolam (0.07 mg . kg(-1)), four balance tests were performed. The recovery time and the percentage of subjects showing recovery (difference from the baseline value < or =10%) were compared. As CDP, a test in which unexpected perturbation stimuli are given using an unstable platform was performed. As CSP, standing sway tests were performed. Maximum speed walking (MSW) and usual speed walking (USW) tests were performed as simple balance tests. RESULTS: The recovery time in CDP (80 min) was longer than that in CSP (40-60 min). The percentage of subjects showing recovery in CDP (20%) was significantly lower than that in CSP (55%-70%) 60 min after the administration of midazolam. There was a significant positive correlation between the CDP test and the MSW test (r = 0.67). CONCLUSION: CDP with perturbation stimuli detects the balance inhibitory effects of midazolam with greater sensitivity than CSP. The MSW test is well correlated with CDP with perturbation stimuli.