Outcomes of a preoperative "bridging" strategy with glycoprotein IIb/IIIa inhibitors to prevent perioperative stent thrombosis in patients with drug-eluting stents who undergo surgery necessitating interruption of thienopyridine administration.

AIMS: Surgery after drug-eluting stent (DES) implantation may be associated with increased risk for perioperative stent thrombosis (ST). METHODS AND RESULTS: We evaluated the outcomes of 67 patients who underwent non-cardiac (n=51) or cardiac (n=16) surgery after DES implantation at our institution between 2008 and 2010 and who underwent preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor. Surgery occurred after a mean time of 13.9 ± 1.7 and 8.7 ± 2 months post stenting for non-cardiac (NCS) and cardiac surgery, respectively. Glycoprotein IIb/IIIa inhibitors were administered preoperatively for a mean of 7.1 ± 0.4 and 7.8 ± 0.7 days, respectively, then discontinued four to six hours before surgery. Most patients received aspirin through the perioperative period (33 NCS patients and 15 cardiac surgery patients). Clopidogrel was restarted as early as possible in the postoperative period. In the non-cardiac surgery group, two patients (3.9%, 95% confidence intervals 0.5% to 13.5%) suffered acute ST in the immediate postoperative period and four patients suffered major bleeding by the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) criteria. One cardiac surgery patient had probable ST one hour postoperatively. CONCLUSIONS: In spite of preoperative "bridging" with a glycoprotein IIb/IIIa inhibitor, postoperative stent thrombosis can still occur in patients with prior DES undergoing surgery requiring antiplatelet medication interruption.

Prolonged recovery associated with dexmedetomidine when used as a sole sedative agent in office-based oral and maxillofacial surgery procedures.

PURPOSE: Office-based oral and maxillofacial surgical procedures that require sedation are popular. Dexmedetomidine has the advantages of having a minimal effect on respiration and an antisialogogue effect that could make it a good choice for dental procedures. MATERIALS AND METHODS: We performed a prospective pilot study in which patients undergoing office-based oral and maxillofacial surgical procedures received dexmedetomidine as a sole sedative agent. The loading dose of dexmedetomidine (1 microg/kg infused over 10 minutes) was followed by a maintenance dose (0.2 to 0.8 microg/kg/hour) to achieve a Ramsay sedation score of 2 to 3. The demographic data were collected, and the pre- and intraprocedural vital signs and Ramsay sedation score were recorded every 5 minutes. The duration of the procedure, recovery time, and patient and surgeon satisfaction were documented. RESULTS: No statistically significant changes were found in the heart rate, respiratory rate, or oxygen saturation during the procedure when compared to baseline. However, we noticed a significant decrease in the heart rate at the end of the loading dose, and statistically significant change in the blood pressure between baseline and during the procedure (P < .05). The initial local anesthetic injections were recalled by 26% of the patients, and 73% had some recollection of the procedure. Nevertheless, the patient satisfaction score (range 1 to 10) was 8.6 +/- 2.3, and 86% of the patients would recommend this type of sedation. The surgeon satisfaction score (range, 1 to 5) was 3.9 +/- 1.3. The recovery time was prolonged (82.2 +/- 24.3 minutes) when compared with the total procedure time (44.6 +/- 27.9 minutes). CONCLUSIONS: Dexmedetomidine has demonstrated hemodynamic and respiratory stability when used as a sole sedative agent. Despite the discomfort on injection and the lack of reliable amnesic property, patient and surgeon satisfaction were high. However, the prolonged recovery time makes this drug unsuitable for busy office-based practices. We believe it should be reserved for patients with a high risk of respiratory complications (eg, obese patients or those with a history of sleep apnea).

Factors influencing oxygen store during denitrogenation in the healthy patient.

STUDY OBJECTIVE: To define the various factors that influence the rate of effective preoxygenation. DESIGN: Prospective, randomized study. SETTING: Procedure room in a teaching hospital. SUBJECTS: 14 ASA physical status I volunteers who performed 4 sessions of breathing in random order. Of these volunteers, 7 performed two extra sessions using vital capacity breathing, which were also completed in random order. INTERVENTIONS: Using the circle system, volunteers breathed with a mouthpiece and nose-clip until expired nitrogen reached 5%, using either a fresh gas flow of 5 L/min or 10 L/min or a system flushed with O(2). MEASUREMENTS: End-expired levels of O(2), nitrogen, and CO(2) were recorded. MAIN RESULTS: Minute ventilation, functional residual capacity, and age were significant factors for rate of denitrogenation. However, height and weight were not significant factors in predicting time to denitrogenation. At low flow rates, flushing with O(2) significantly decreased the time of denitrogenation. There appeared to be little clinical benefit of flushing with O(2) when a 10 L/min O(2) flow was used. CONCLUSIONS: A high gas flow rate appears critical to achieving rapid preoxygenation.

Dexmedetomidine as sole sedative for awake intubation in management of the critical airway.

We report a series of successful awake fiberoptic intubations in patients with critical (unstable, difficult) airways using the alpha(2)-agonist, dexmedetomidine. Dexmedetomidine has several desirable pharmacologic properties, including sedation, anxiolysis, hypnosis, analgesia, amnesia, antisialagogue effects, and a unique respiratory-sparing effect. Dexmedetomidine appears to be a useful agent for sedation during awake fiberoptic intubation in difficult airway patients.