Type 1 citrullinemia patient with Brugada pattern undergoing general anesthesia for dental extractions: A case report.

Key Clinical Message: The perioperative control of ammonia, reduction of stress, and administration of drugs tolerated in type 1 citrullinemia and Brugada pattern allowed the successful and uneventful management of general anesthesia in the study patient. Abstract: The aim of this study was to report the targeted perioperative management of general anesthesia (GA) adopted for dental extractions in a rare patient with type 1 citrullinemia and Brugada pattern. A male, Caucasian, adult type 1 citrullinemia patient needed dental extractions under GA. The medical history showed neurodevelopmental impairment, growth retardation, epilepsy, and a Type 2 Brugada electrocardiographic pattern in the second precordial lead. The authors focused the anesthesiologic protocol on the prevention of hyperammonemia and fatal arrhythmias. Changes in diet and 10% glucose solution administration prevented protein catabolism due to the fasting period (ammonia was 44 µmol/L preoperatively and 46 µmol/L postoperatively; glycemia was 120 g/dL preoperatively and 153 g/dL postoperatively). The patient received a continuous electrocardiogram, noninvasive blood pressure, pulse oximeter, entropy monitoring, train-of-four monitoring, and external biphasic defibrillator pads. Midazolam, remifentanil, and dexamethasone were administered for pre-anesthesia; thiopental and rocuronium for induction; remifentanil and desflurane for maintenance; sugammadex for decurarization. After the intraligamentary injection of lidocaine 2% with epinephrine 1:100,000 for local anesthesia, the patient developed a transient Type 1 Brugada pattern that lasted a few minutes. The whole procedure lasted 30 min. The patient's discharge to ward occurred 3 h after the end of GA. The perioperative management of ammonia, reduction of stress, and administration of drugs tolerated in Type 1 citrullinemia and Brugada pattern allowed the successful and uneventful administration of GA in the study patient.

Effect of Preoperative Music Therapy Versus Intravenous Midazolam on Anxiety, Sedation and Stress in Stomatology Surgery: A Randomized Controlled Study.

BACKGROUND: Patients undergoing surgery and general anesthesia often experience anxiety, fear and stress, with negative bodily responses. These may be managed by the pre-procedural application of anxiolytic, analgesic, and anesthetic drugs that have, however, potential risks or side effects. Music therapy (MT) can be used as a complementary no-drug intervention alongside standard surgical care before, during and after medical procedures. The aim of this study was to evaluate the effects of preoperative MT intervention compared to premedication with midazolam on levels of anxiety, sedation and stress during general anesthesia for elective stomatology surgery. METHODS: A two-arm randomized and controlled single-center, parallel-group, pre-post event study was conducted. In total, 70 patients affected by stage I or II (both clinically and instrumentally N0) micro-invasive oral cancer and undergoing elective surgery under general anesthesia were assigned to the control group (CG) or to the music therapy group (MTG). MTG patients received preoperative music therapy intervention (MT) from a certified music therapist before surgery, while the CG patients did not receive MT but instead received premedication with intravenous midazolam, 0.02 mg/kg. Anesthesia was the same in both groups. The systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were recorded at the entrance to the operating room, just before the induction of anesthesia and every 5 min until the end of surgery. An anxiety visual analogues scale (A-VAS) was used to evaluate the level of anxiety. The bispectral index (BIS) monitor was used to measure the depth of sedation just before and 10 min after both music intervention and midazolam administration. Stress response was assessed 5 min before and 20 min after surgery via the control of plasma prolactin (PRL), growth hormone (GH), and cortisol levels. The patient global impression of satisfaction (PGIS) was tested 1 h after surgery. Participants in the MTG were asked to answer 3 questions concerning their experience with MT. RESULTS: No statistical differences among the PRL, GH and cortisol levels between the two groups were registered before and after the treatment, as well as for PAS, PAD and HR. Significant differences in the A-VAS scores between the MTG and CG (p < 0.01) was observed. Compared to the CG, MTG patients had a statistically significantly lower BIS score (p = 0.02) before induction. A PGIS score of 86.7% revealed that patients in the MTG were very satisfied, versus 80% in the CG (p < 0.05). CONCLUSION: Preoperative music therapy could be an alternative to intravenous midazolam when aiming to promote a preoperative and post-operative state of anxiolysis and sedation in stomatology surgery, even if no differences were found in terms of the surgery-related stress response according to physiological and hormonal determinations.

In vitro virucidal activity of mouthwashes on SARS-CoV-2.

OBJECTIVES: The objective of the study was to evaluate the in vitro virucidal activity of commercial mouthwashes against SARS-CoV-2 and variants of concern. MATERIALS AND METHODS: Antiviral activity was assessed at different time intervals, based on common use of these products by titrating residual viral infectivity on Vero E6 cells. RESULTS: All the mouthwashes were effective to reduce the infectious titers of SARS-CoV-2 and its tested variants. Mouthwashes Listerine® Cool Mint milder taste and Listerine® Cavity Protection milder taste reduced the infectious viral titer by up to 3.9 log10 after 30 s, while mouthwash Cetilsan® Sugar Free was able to reduce the viral titer by 2.2-2.9 log10 at all tested time intervals. Mouthwash Curasept® ADS DNA Intensive treatment was less effective to decrease viral infectivity (0.7-2.2 log10 TCID50/ml at all tested time intervals). Interestingly, the Gamma variant appeared more resistant to treatment in vitro with the different mouthwashes. CONCLUSIONS: In this study, we were able to assess the ability of different mouthwashes to in vitro decrease the infectivity of SARS-CoV-2 and its variants, and we observed that Gamma variant of concern was more resistant to treatment with mouthwashes.

Brugada Syndrome Updated Risk Assessment and Perioperative Management in Oral Surgery: A Case Series.

Brugada syndrome (BrS) carries the risk of major dysrhythmias increased further by exposure to pro-dysrhythmic factors related to oral surgical procedures such as local anesthetics, anxiety, and postoperative pain. Such risk can be handled by updated multidisciplinary management. In 2020, 3 male BrS patients needed oral surgical treatments at the Complex Unit of Odontostomatology of Aldo Moro University of Bari, Italy. Multidisciplinary individual risk assessment involved cardiologic hazard ratio stratification, event-free survival stratification, and 5-year average risk of ventricular dysrhythmias and sudden cardiac death for Brugada patients; American Society of Anesthesiologists physical status risk class; expected complexity and duration of the procedure; and anxiety score measured by the Modified Dental Anxiety Scale. The authors administered conscious sedation by intravenous diazepam to both a patient susceptible to vasovagal syncope needing tooth extraction with concomitant cystectomy (longer-lasting procedure) and to another who needed routine tooth extraction (brief procedure) but had a moderate dental anxiety score; the last 1 received local anesthesia alone due to his low anxiety, low susceptibility to vasovagal syncope, and need for routine tooth extraction. After positioning external biphasic defibrillator pads, 12-leads continuous electrocardiogram, and peripheral venous access, extractions were performed with local anesthesia by lidocaine 2% with epinephrine 1:100,000; acetaminophen was suggested for postoperative analgesia. No electrocardiographic changes occurred in the perioperative period. The current multidisciplinary individual risk assessment allowed us to detect each BrS patient's risk factors for major dysrhythmias and to adapt oral surgical and anesthesiologic protocols for safe targeted treatment.

Can visual inspection of the electrical activity of the diaphragm improve the detection of patient-ventilator asynchronies by pediatric critical care physicians?

BACKGROUND: Patient-ventilator asynchronies are challenging during pediatric mechanical ventilation. We hypothesized that monitoring the electrical activity of the diaphragm (EAdi) together with the "standard" airway opening pressure (Pao) and flow-time waveforms during pressure support ventilation would improve the ability of a cohort of critical care physicians to detect asynchronies in ventilated children. METHODS: We recorded the flow, Pao and EAdi waveforms in ten consecutive patients. The recordings were split in periods of 15 s, each reproducing a ventilator screenshot. From this pool, a team of four experts selected the most representative screenshots including at least one of the three most common asynchronies (missed efforts, auto-triggering and double triggering) and split them into two versions, respectively showing or not the EAdi waveforms. The screenshots were shown in random order in a questionnaire to sixty experienced pediatric intensivists that were asked to identify any episode of patient-ventilator asynchrony. RESULTS: Among the ten patients included in the study, only eight had EAdi tracings without artifacts and were analyzed. When the Eadi waveform was shown, the auto-triggering detection improved from 13% to 67% (P<0.0001) and the missed efforts detection improved from 43% to 95% (P<0.0001). The detection of double triggering, instead, did not improve (85% with the EAdi vs. 78% without the EAdi waveform; P=0.52). CONCLUSIONS: This single center study suggests that the EAdi waveform may improve the ability of pediatric intensivists to detect missed efforts and auto-triggering asynchronies. Further studies are required to determine the clinical implications of these findings.

Light Conscious Sedation in Patients with Previous Acute Myocardial Infarction Needing Exodontia: An Observational Study.

Aim This study evaluated a protocol of light conscious sedation for multimodal analgesia in patients with a clinical history of acute myocardial infarction requiring tooth extraction and to assess postoperative pain by using the quantity intake of acetaminophen as the indicator. Material and methods All 50 patients received preliminary anxiolysis via oral chlordemethyldiazepam administration. After 15 to 20 minutes, only patients reporting they were not fully relaxed received additional intravenous diazepam before tooth extraction. Acetaminophen 1000 mg was suggested as the preferred postoperative analgesic drug. Results The studied patients included 39 women and 11 men with a mean age of 69.4 ± 17.1 years. They were classified according to the American Society of Anesthesiologists Physical Status classification system as follows: 12 patients belonging to class II, 32 patient to class III, and the remaining six to class IV. Based on the Modified Dental Anxiety Scale, six patients were phobic and seven anxious. Nevertheless, intravenous conscious sedation was needed in 23 patients via diazepam. The first day after surgery, 76% of patients took acetaminophen, and 58% took acetaminophen the second day, with a mean two-day total intake of acetaminophen of 1020 ± 789 mg/day. Stratified statistical analysis was performed and revealed that 60.87% of patients receiving intravenous diazepam needed to take acetaminophen on the first day after dental extraction in contrast to the 88.89% of patients who did not receive intravenous diazepam (χ2 test; P = .021). Conclusions Our data suggest that anxiety related to dental procedures is widespread, although often unmentioned by patients. Moreover, the percentage of patients needing analgesics during the first 24 hours following surgery demonstrated that overall perioperative pain might be controlled by the light conscious sedation protocol for patients with previous acute myocardial infarction proposed in the current study.