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1.  Cerebrovascular Accident Under Anesthesia During Dental Surgery 
Anesthesia Progress  2014;61(2):73-77.
Stroke, or cerebrovascular accident (CVA), is a medical emergency that may lead to permanent neurological damage, complications, and death. The rapid loss of brain function due to disruption of the blood supply to the brain is caused by blockage (thrombosis, arterial embolism) or hemorrhage. The incidence of CVA during anesthesia for noncardiac nonvascular surgery is as high as 1% depending on risk factors. Comprehensive preoperative assessment and good perioperative management may prevent a CVA. However, should an ischemic event occur, appropriate and rapid management is necessary to minimize the deleterious effects caused to the patient. This case report describes a patient who had an ischemic CVA while under general anesthesia for dental alveolar surgery and discusses the anesthesia management.
PMCID: PMC4068093  PMID: 24932981
General anesthesia; Cerebrovascular event; Complication; Dentistry.
2.  Deliberate Hypotensive Anesthesia With the Rapidly Acting, Vascular-Selective, L-Type Calcium Channel Antagonist—Clevidipine: A Case Report 
Anesthesia Progress  2014;61(1):18-20.
Deliberate hypotension is an important technique for use in select anesthetics for procedures such as orthognathic surgery, specifically LeFort I maxillary osteotomy. We present a case report of an anesthetic involving deliberate hypotension for a 17-year-old female patient who presented for a LeFort I osteotomy, bilateral sagittal split of the mandible, and a genioplasty in order to correct a skeletal class III malocclusion. After reaching a steady-state general anesthetic, deliberate hypotension was induced solely with a bolus and subsequent continuous infusion of the ultrashort acting calcium channel blocker, clevidipine. The preoperative, intraoperative, and postoperative course and anesthetic management are discussed.
PMCID: PMC3975609  PMID: 24697821
Deliberate hypotension; Bolus infusion; Dental anesthesiology; Calcium channel antagonist; Orthognathic surgery; General anesthesia; Narcotics; Hemodynamics; IV agents; Hemostasis; Pain control; Post-operative pain management; PONV; Nasotracheal intubation; Anti-emetic prophylaxis; Maxillomandibular fixation
3.  Propofol Drip Infusion Anesthesia for MRI Scanning: Two Case Reports 
Anesthesia Progress  2013;60(2):60-66.
The magnetic resonance imaging (MRI) room is a special environment. The required intense magnetic fields create unique problems with the use of standard anesthesia machines, syringe pumps, and physiologic monitors. We have recently experienced 2 oral maxillofacial surgery cases requiring MRI: a 15-year-old boy with developmental disability and a healthy 5-year-old boy. The patients required complete immobilization during the scanning for obtaining high-quality images for the best diagnosis. Anesthesia was started in the MRI scanning room. An endotracheal intubation was performed after induction with intravenous administration of muscle relaxant. Total intravenous anesthesia via propofol drip infusion (4–7 mg/kg/h) was used during the scanning. Standard physiologic monitors were used during scan pauses, but special monitors were used during scanning. In MRI scanning for oral maxillofacial surgery, general anesthesia, with the added advantage of having a secured airway, is recommended as a safe alternative to sedation especially in cases of patients with disability and precooperative chidren.
PMCID: PMC3683882  PMID: 23763561
Magnetic resonance imaging (MRI); General anesthesia; Propofol drip infusion; Children; Developmental disability patients
4.  Continuous Veno-Venous Hemofiltration for Massive Rhabdomyolysis After Malignant Hyperthermia: Report of 2 Cases 
Anesthesia Progress  2013;60(1):21-24.
We present 2 cases of fulminant malignant hyperthermia (MH), complicated with massive rhabdomyolysis. The patients were successfully treated in the intensive care unit of our university teaching hospital, despite the lack of availability of dantrolene in our country, by early application of continuous veno-venous hemofiltration (CVVH). Both male patients developed fulminant malignant hyperthermia during anesthesia for oromaxillofacial surgery. CVVH was employed when the values of creatine phosphokinase (CPK), myoglobin (Mb), and lactate dehydrogenase (LDH) increased significantly. After emergency treatment and CVVH therapy, the values of CPK, Mb, and LDH in the blood plasma of the patients decreased significantly. The complications, including acute renal failure, disseminated intravascular coagulation, and acute respiratory distress syndrome were also treated without any obvious organ damage. Early detection and management are the keys to treat MH successfully. CVVH is a valuable therapeutic application in the initial/critical management of severe rhabdomyolysis. If these complications occur even with initial treatment with dantrolene, our experiences may be useful adjunctive treatments to consider.
PMCID: PMC3601726  PMID: 23506280
Malignant hyperthermia; Continuous veno-venous hemofiltration.
5.  Severe Intraoperative Bronchospasm Treated with a Vibrating-Mesh Nebulizer 
Anesthesia Progress  2012;59(3):123-126.
Bronchospasm and status asthmaticus are two of the most dreaded complications that a pediatric anesthesiologist may face. With the occurrence of severe bronchospasm and the inability to ventilate, children are particularly vulnerable to apnea and ensuing hypoxia because of their smaller airway size, smaller lung functional residual capacity, and higher oxygen consumption rates than adults. Nebulized medication delivery in intubated children is also more difficult because of smaller endotracheal tube internal diameters. This case demonstrates the potentially lifesaving use of a vibrating-mesh membrane nebulizer connected to the anesthesia circuit for treating bronchospasm.
PMCID: PMC3468290  PMID: 23050752
Asthma; Bronchospasm; Nasal intubation; Pediatric dental anesthesia; Vibrating-mesh; nebulizer
6.  Complicated Airway Due to Unexpected Lingual Tonsil Hypertrophy 
Anesthesia Progress  2012;59(2):82-84.
We report an unexpected failed laryngeal mask airway in a patient with unrecognized lingual tonsil hypertrophy (LTH). A 19-year-old obese woman presented for extraction of multiple teeth via intravenous general anesthesia. Surgery was interrupted due to a laryngospasm midway through the procedure. The laryngospasm required the existing laryngeal mask airway to be removed so the patient could be suctioned. Although it is unclear the extent of obstruction caused by LTH, the surgery had to be postponed due to the discovery of enlarged lingual tonsils, which prevented endotracheal intubation. One reason for unexpected difficult airways is attributed to LTH. It is recognized that LTH is more common in patients with obstructive sleep apnea; however, LTH also has an increased prevalence in obese children with prior palatine tonsillectomies or adenoidectomies. Unexpected LTH can complicate general anesthesia by making placement of a laryngeal mask airway difficult. Thus, further research needs to be conducted to gain a deeper understanding on how to reduce the risks presented by LTH during sedation surgeries.
PMCID: PMC3403586  PMID: 22822995
Lingual tonsil hypertrophy; Endotracheal intubation; Laryngospasm; Anesthesia; Sedation; Complication; Intubation
7.  Dual Bougie Technique for Nasotracheal Intubation 
Anesthesia Progress  2012;59(2):85-86.
We read with great interest the anesthetic technique of using a gum elastic bougie (GEB) for nasal intubation in a recent issue of Anesthesia Progress. The authors recommend the use of GEB for the first attempt of nasotracheal intubation in patients with a difficult airway. We agree that this is an excellent alternative. We also have found an excellent variation of this method that utilizes a double bougie technique for insertion of a nasotracheal tube if the difficult airway can be secured initially with an orotracheal tube.
PMCID: PMC3403587  PMID: 22822996
Dual bougie technique; Nasotracheal intubation
8.  Anesthetic Considerations for Masticatory Muscle Tendon-Aponeurosis Hyperplasia: A Report of 24 Cases 
Anesthesia Progress  2012;59(2):87-89.
Masticatory muscle tendon-aponeurosis hyperplasia (MMTAH) is a new disease entity characterized by limited mouth opening due to contracture of the masticatory muscles, resulting from hyperplasia of tendons and aponeuroses. In this case series, we report what methods of airway establishment were conclusively chosen after rapid induction of anesthesia. We had 24 consecutive patients with MMTAH who underwent surgical release of its contracture under general anesthesia. Rapid induction of anesthesia with propofol and rocuronium was chosen for all the cases. In 7 cases, intubation using the Macintosh laryngoscopy was attempted; however, 2 of those cases failed to be intubated on the first attempt. Finally, intubation using the McCoy laryngoscopy or fiber-optic intubation was alternatively used in these 2 cases. In 7 cases, the Trachlight was used. In the remaining 10 cases, fiber-optic intubation was used. Limited mouth opening in patients with MMTAH did not improve with muscular relaxation. “Square mandible” has been reported to be one of the clinical features in this disease; however, half of these 24 patients lacked this characteristic, which might affect a definitive diagnosis of this disease for anesthesiologists. An airway problem in patients with MMTAH should not be underestimated, which means that other intubation methods rather than direct laryngoscopy had better be considered.
PMCID: PMC3403588  PMID: 22822997
Masticatory muscle tendon-aponeurosis hyperplasia; Square mandible; Difficult airway management
9.  Oral Mucosal Injection of a Local Anesthetic Solution Containing Epinephrine Enhances Muscle Relaxant Effects of Rocuronium 
Anesthesia Progress  2012;59(1):18-21.
The purpose of this study was to examine how submucosal injection of a clinically relevant dose of a lidocaine hydrochloride solution containing epinephrine affects the muscle relaxant effects of rocuronium bromide. Sixteen patients scheduled for orthognathic surgery participated in this study. All patients were induced with fentanyl citrate, a target-controlled infusion of propofol and rocuronium bromide. Anesthesia was maintained by total intravenous anesthesia. After nasotracheal intubation, an infusion of rocuronium bromide was started at 7 µg/kg/min, and the infusion rate was then adjusted to maintain a train of four (TOF) ratio at 10 to 15%. The TOF ratio just prior to oral mucosal injection of a 1% lidocaine hydrochloride solution containing 10 µg/mL epinephrine (LE) was taken as the baseline. TOF ratio was observed for 20 minutes, with 1-minute intervals following the start of injection. Mean epinephrine dose was 85.6 ± 18.6 µg and mean infusion rate of rocuronium bromide was 6.3 ± 1.6 µg/kg/min. TOF ratio began to decrease 2 minutes after the injection of LE, reached the minimum value at 3.1 ± 3.6% 12 minutes after the injection, and then began to recover. We conclude that oral mucosal injection of LE enhances the muscle relaxant effects of rocuronium bromide.
PMCID: PMC3309297  PMID: 22428970
Rocuronium; Lidocaine with epinephrine; Muscle relaxant effects
10.  Transient Delayed Facial Nerve Palsy After Inferior Alveolar Nerve Block Anesthesia 
Anesthesia Progress  2012;59(1):22-27.
Facial nerve palsy, as a complication of an inferior alveolar nerve block anesthesia, is a rarely reported incident. Based on the time elapsed, from the moment of the injection to the onset of the symptoms, the paralysis could be either immediate or delayed. The purpose of this article is to report a case of delayed facial palsy as a result of inferior alveolar nerve block, which occurred 24 hours after the anesthetic administration and subsided in about 8 weeks. The pathogenesis, treatment, and results of an 8-week follow-up for a 20-year-old patient referred to a private maxillofacial clinic are presented and discussed. The patient's previous medical history was unremarkable. On clinical examination the patient exhibited generalized weakness of the left side of her face with a flat and expressionless appearance, and she was unable to close her left eye. One day before the onset of the symptoms, the patient had visited her dentist for a routine restorative procedure on the lower left first molar and an inferior alveolar block anesthesia was administered. The patient's medical history, clinical appearance, and complete examinations led to the diagnosis of delayed facial nerve palsy. Although neurologic occurrences are rare, dentists should keep in mind that certain dental procedures, such as inferior alveolar block anesthesia, could initiate facial nerve palsy. Attention should be paid during the administration of the anesthetic solution.
PMCID: PMC3309298  PMID: 22428971
Inferior alveolar nerve block; Facial nerve palsy
11.  Nasal Foreign Body: An Unexpected Discovery 
Anesthesia Progress  2011;58(3):121-123.
Nasal foreign bodies may result from the abundant availability of tiny objects in our society and a curious child exploring his or her nasal cavities. An inserted object that is not witnessed or retrieved can remain relatively asymptomatic or cause local tissue damage and potentially yield more serious consequences. An unusual case of a young child who presented for dental rehabilitation under general anesthesia is described. Immediately prior to the nasotracheal intubation, an unanticipated foreign body was detected and safely removed before any injury occurred. This case report discusses the presentation and pathophysiology of nasal foreign bodies. Moreover, applicable suggestions are provided to aid in the prevention and management of the unexpected discovery of a nasal foreign body after the induction of general anesthesia.
PMCID: PMC3167155  PMID: 21882987
12.  Transient Cardiac Arrest in Patient With Left Ventricular Noncompaction (Spongiform Cardiomyopathy) 
Anesthesia Progress  2011;58(1):22-25.
Left ventricular noncompaction (LVNC), also known as spongiform cardiomyopathy, is a severe disease that has not previously been discussed with respect to general anesthesia. We treated a child with LVNC who experienced cardiac arrest. Dental treatment under general anesthesia was scheduled because the patient had a risk of endocarditis due to dental caries along with a history of being uncooperative for dental care. During sevoflurane induction, severe hypotension and laryngospasm resulted in cardiac arrest. Basic life support (cardiopulmonary resuscitation) was initiated to resuscitate the child, and his cardiorespiratory condition improved. Thereafter, an opioid‐based anesthetic was performed, and recovery was smooth. In LVNC, opioid‐based anesthesia is suggested to avoid the significant cardiac suppression seen with a volatile anesthetic, once intravenous access is established. Additionally, all operating room staff should master Advanced Cardiac Life Support/Pediatric Advanced Life Support (including intraosseous access), and more than 1 anesthesiologist should be present to induce general anesthesia, if possible, for this high‐risk patient.
PMCID: PMC3265263  PMID: 21410361
Left ventricular noncompaction; Spongiform cardiomyopathy; General anesthesia; Laryngospasm; Cardiac arrest; Dental treatment; Heart disease
13.  General Anesthesia for a Child With Landau-Kleffner Syndrome, a Case Report 
Anesthesia Progress  2010;57(3):109-111.
Landau-Kleffner syndrome is a rare, epileptiform disorder with a pathognomonic sudden aphasia, epilepsy, and electroencephalographic abnormalities. It was first described in 1957. No case reports are included in the anesthesia literature. This case report describes a 9-year-old male who was treated for dental caries while under intubated general anesthesia. The case was successful and uneventful, with multiple precautions taken to prevent seizures or other complications. The authors hope that this report will provoke communication and additional case reports.
PMCID: PMC3315276  PMID: 20843226
Auditory agnosia: Aphasia; Landau-Kleffner syndrome; General anesthesia; Dental
14.  Negative Pressure Pulmonary Edema After Oral and Maxillofacial Surgery 
Anesthesia Progress  2009;56(2):49-52.
Negative pressure pulmonary edema (NPPE) following upper airway obstruction (UAO) has been reported in several clinical situations. The main cause of NPPE is reported to be increased negative intrathoracic pressure. We present a case of NPPE that occurred after general anesthesia for plate removal after jaw deformity surgery. After completion of the surgery, administration of inhaled anesthetics was stopped and the patient opened his eyes on verbal command. Immediately after extubation, the patient stopped breathing and became cyanotic. Acute UAO following laryngospasm was suspected. Soon after reintubation, pink, frothy fluid came out of the endotracheal tube, and a tentative diagnosis of NPPE was made. Continuous positive airway pressure was applied. In addition, furosemide and dexamethasone were administered. By the next day, the symptoms had almost disappeared.
PMCID: PMC2699692  PMID: 19642719
Negative pressure pulmonary edema; Upper airway obstruction; Continuous positive airway pressure
15.  Review and Management of the Dental Patient With Long QT Syndrome (LQTS) 
Anesthesia Progress  2009;56(2):42-48.
Long QT syndrome (LQTS) is a unique cardiovascular condition, with both congenital and acquired forms that afflict patients. These patients show a lengthening of the repolarization phase of the cardiac cycle, which can be best visualized on an electrocardiogram (ECG). The ECG changes can include QT interval (the time between the start of the Q wave and the end of the T wave, as seen on an ECG) and T wave abnormalities, as well as progression to torsades de pointes and ventricular fibrillation. The ECG changes are most commonly elicited by physical activity, emotional stress, and certain medications. This condition represents a challenge for the oral and maxillofacial surgeon. Patients with LQTS must receive proper medical management and a controlled and anxiety-free surgical environment. The purpose of this article was to present a review of LQTS and provide recommendations for effective surgical management. Additionally, a case report of a patient with LQTS, treated by one of the authors, has been included.
PMCID: PMC2699691  PMID: 19642718
Long QT syndrome; Torsades de pointes; Ventricular fibrillation
16.  Use of Masseteric and Deep Temporal Nerve Blocks for Reduction of Mandibular Dislocation 
Anesthesia Progress  2009;56(1):9-13.
A patient presented with a unilateral dislocated condyle that was resistant to reduction by simple manual manipulation because of elevator muscle spasm and severe muscle and temporomandibular joint pain. A technique involving a masseteric nerve block and a temporal nerve block was used, allowing a quick, safe, and minimally painful reduction. The method used for delivering these nerve blocks is described here.
PMCID: PMC2662506  PMID: 19562887
Masseteric nerve block; Deep temporal; Temporomandibular joint dislocation; TMJ reduction; TMJ subluxation; Open lock
17.  Perioperative Management of Obstructive Sleep Apnea With Nasal Continuous Positive Airway Pressure 
Anesthesia Progress  2008;55(4):121-123.
The high risks associated with general anesthesia in obstructive sleep apnea syndrome (OSAS) patients have been reported. Many authors have suggested that the intraoperative administration of opioids and sedatives should be limited or avoided because these drugs selectively impair muscle activity in the upper airway. We report the case of an OSAS patient who was managed with nasal continuous positive airway pressure (NCPAP) and treated safely in spite of the use of conventional anesthetic and analgesic agents typically used for patients without OSAS. She had little pain during the perioperative period. It is suggested that NCPAP is an effective treatment for not only preventing airway obstructive apnea but for allowing the administration of anesthetic and analgesic drugs without major complications.
PMCID: PMC2614650  PMID: 19108596
Obstructive sleep apnea syndrome; NCPAP; Perioperative management
18.  Delirium During Intravenous Sedation With Midazolam Alone and With Propofol in Dental Treatment 
Anesthesia Progress  2006;53(3):95-97.
A 62-year-old man visited our clinic for dental implantation under intravenous sedation. He demonstrated increased psychomotor activity and incomprehensible verbal contact during intravenous sedation. Although delirium caused by midazolam or propofol in different patients has been reported, the present case represents a delirium that developed from both drugs in the same patient, possibly because of the patient's smaller tolerance to midazolam and propofol.
PMCID: PMC1693665  PMID: 17175823
Delirium; Midazolam; Propofol; Dental treatment
19.  Foreign Body Obstruction Preventing Blind Nasal Intubation 
Anesthesia Progress  2006;53(2):49-52.
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.
PMCID: PMC1614215  PMID: 16863390
Foreign body obstruction; Intubation
20.  Uvular Edema Secondary to Snoring Under Deep Sedation 
Anesthesia Progress  2006;53(1):13-16.
A 57-year-old male with a documented history of obstructive sleep apnea with loud snoring received deep intravenous sedation with midazolam, fentanyl, ketamine, and propofol infusion and a left interscalene brachial plexus nerve block for a left biceps tendon repair. Loud snoring during the case was noted. On the second postoperative day, he was observed to have significant uvular edema. After due consideration of the various elements in the differential diagnosis, it was concluded that negative pressure trauma from deep snoring during the sedation was the most likely etiology.
PMCID: PMC1586864  PMID: 16722279
Uvular edema; Obstructive sleep apnea; Deep sedation; Negative pressure edema
21.  Anesthetic Management of a Patient With Sturge-Weber Syndrome Undergoing Oral Surgery 
Anesthesia Progress  2006;53(1):17-19.
This case involves a possible complication of excessive bleeding or rupture of hemangiomas. Problems and anesthetic management of the patient are discussed. A 35-year-old man with Sturge-Weber syndrome was to undergo teeth extraction and gingivectomy. Hemangiomas covered his face and the inside of the oral cavity. We used intravenous conscious sedation with propofol and N2O-O2 to reduce the patient's emotional stress. It was previously determined that stress caused marked expansion of this patient's hemangiomas. Periodontal ligament injection was chosen as the local anesthesia technique. Teeth were extracted without excessive bleeding or rupture of hemangiomas, but the planned gingivectomies were cancelled. Deep sedation requiring airway manipulation should be avoided because there are possible difficulties in airway maintenance. Because this was an outpatient procedure, propofol was selected as the sedative agent primarily because of its rapid onset and equally rapid recovery. Periodontal ligament injection with 2% lidocaine containing 1 : 80,000 epinephrine was chosen for local anesthesia. Gingivectomy was cancelled because hemostasis was challenging. As part of preoperative preparation, equipment for prompt intubation was available in case of rupture of the hemangiomas. The typically seen elevation of blood pressure was suppressed under propofol sedation so that expansion of the hemangiomas and significant intraoperative bleeding was prevented. Periodontal ligament injection as a local anesthetic also prevented bleeding from the injection site.
PMCID: PMC1586859  PMID: 16722280
Sturge-Weber syndrome; Hemangioma; Mental retardation; Anesthetic management; Oral surgery
22.  Benzocaine-induced Methemoglobinemia 
Anesthesia Progress  2005;52(4):136-139.
A case is reported in which a patient developed methemoglobinemia-induced cyanosis while under general anesthesia during surgery for multiple fascial space infections. The cause of methemoglobinemia was 20% benzocaine spray used for local anesthesia before intubation. Acutely developing methemoglobinemia is infrequently encountered in clinical practice. When confronted with cyanosis in the absence of cardiac or pulmonary disease, one must seriously consider the diagnosis of methe-moglobinemia. The etiology of methemoglobinemia, the causative agents, the diagnosis, and the emergency treatment required are discussed.
PMCID: PMC1586795  PMID: 16596913
Methemoglobinemia; Benzocaine; Cyanosis
23.  Tiagabine May Reduce Bruxism and Associated Temporomandibular Joint Pain 
Anesthesia progress  2005;52(3):102-104.
Tiagabine is an anticonvulsant gamma-aminobutyric acid reuptake inhibitor commonly used as an add-on treatment of refractory partial seizures in persons over 12 years old. Four of the 5 cases reported here indicate that tiagabine might also be remarkably effective in suppressing nocturnal bruxism, trismus, and consequent morning pain in the teeth, masticatory musculature, jaw, and temporomandibular joint areas. Tiagabine has a benign adverse-effect profile, is easily tolerated, and retains effectiveness over time. Bed partners of these patients report that grinding noises have stopped; therefore, the tiagabine effect is probably not simply antinociceptive. The doses used to suppress nocturnal bruxism at bedtime (4–8 mg) are lower than those used to treat seizures.
PMCID: PMC1586785  PMID: 16252740
Pain; Tiagabine; Bruxism; Trismus
24.  Intraoperative Damage and Correction of Pilot Balloon During Orthognathic Surgery 
Anesthesia Progress  1997;44(1):38-39.
A case of intraoperative damage to the nasotracheal tube pilot balloon and its correction is discussed.
PMCID: PMC2148856  PMID: 9481980
Maxillofacial; Surgery; Nasotracheal tube
25.  Reflex Bronchospasm-Induced Acute Massive Pulmonary Collapse 
Anesthesia Progress  1988;35(6):244-246.
Acute massive pulmonary collapse following reflex bronchospasm is described in a patient undergoing general anesthesia. The authors suggest that a chest radiograph should be taken as routine procedure after the onset of airway constriction during anesthesia.
PMCID: PMC2167770  PMID: 3270991

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