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1.  Three Newly Approved Analgesics: An Update 
Anesthesia Progress  2013;60(4):178-187.
Since 2008, three new analgesic entities, tapentadol immediate release (Nucynta) diclofenac potassium soft gelatin capsules (Zipsor), and bupivacaine liposome injectable suspension (EXPAREL) were granted US Food and Drug Administration (FDA) approval to treat acute pain. Tapentadol immediate-release is a both a mu-opioid agonist and a norepinephrine reuptake inhibitor, and is indicated for the treatment of moderate to severe pain. Diclofenac potassium soft gelatin capsules are a novel formulation of diclofenac potassium, which is a nonsteroidal anti-inflammatory drug (NSAID), and its putative mechanism of action is through inhibition of cyclooxygenase enzymes. This novel formulation of diclofenac allows for improved absorption at lower doses. Liposomal bupivacaine is a new formulation of bupivacaine intended for single-dose infiltration at the surgical site for postoperative analgesia. Bupivacaine is slowly released from this liposomal vehicle and can provide prolonged analgesia at the surgical site. By utilizing NSAIDs and local anesthetics to decrease the transmission of afferent pain signals, less opioid analgesics are needed to achieve analgesia. Since drug-related adverse events are frequently dose related, lower doses from different drug classes may be employed to reduce the incidence of adverse effects, while producing synergistic analgesia as part of a multimodal analgesic approach to acute pain.
doi:10.2344/0003-3006-60.4.178
PMCID: PMC3891458  PMID: 24423420
Liposomal bupivacaine; Tapentadol; Diclofenac potassium soft gelatin capsules; Analgesics
2.  Environmental Implications of Anesthetic Gases 
Anesthesia Progress  2012;59(4):154-158.
For several decades, anesthetic gases have greatly enhanced the comfort and outcome for patients during surgery. The benefits of these agents have heavily outweighed the risks. In recent years, the attention towards their overall contribution to global climate change and the environment has increased. Anesthesia providers have a responsibility to minimize unnecessary atmospheric pollution by utilizing techniques that can lessen any adverse effects of these gases on the environment. Moreover, health care facilities that use anesthetic gases are accountable for ensuring that all anesthesia equipment, including the scavenging system, is effective and routinely maintained. Implementing preventive practices and simple strategies can promote the safest and most healthy environment.
doi:10.2344/0003-3006-59.4.154
PMCID: PMC3522493  PMID: 23241038
Volatile anesthetics; Environmental pollution; Greenhouse warming potential; Ozone depletion potential
3.  Perioperative Management of the Glucose-6-Phosphate Dehydrogenase Deficient Patient: A Review of Literature 
Anesthesia Progress  2009;56(3):86-91.
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common enzymatic disorder of red blood cells in humans. It is estimated that about 400 million people are affected by this deficiency.1 The G6PD enzyme catalyzes the first step in the pentose phosphate pathway, leading to antioxidants that protect cells against oxidative damage.2 A G6PD-deficient patient, therefore, lacks the ability to protect red blood cells against oxidative stresses from certain drugs, metabolic conditions, infections, and ingestion of fava beans.3 The following is a literature review, including disease background, pathophysiology, and clinical implications, to help guide the clinician in management of the G6PD-deficient patient. A literature search was conducted in the following databases: PubMed, The Cochrane Library, Web of Science, OMIM, and Google; this was supplemented by a search for selected authors. Keywords used were glucose-6-phosphate dehydrogenase (G6PD) deficiency, anesthesia, analgesia, anxiolysis, management, favism, hemolytic anemia, benzodiazepines, codeine, codeine derivatives, ketamine, barbiturates, propofol, opioids, fentanyl, and inhalation anesthetics. Based on titles and abstracts, 23 papers and 1 website were identified. The highest prevalence of G6PD is reported in Africa, southern Europe, the Middle East, Southeast Asia, and the central and southern Pacific islands; however, G6PD deficiency has now migrated to become a worldwide disease. Numerous drugs, infections, and metabolic conditions have been shown to cause acute hemolysis of red blood cells in the G6PD-deficient patient, with the rare need for blood transfusion. Benzodiazepines, codeine/codeine derivatives, propofol, fentanyl, and ketamine were not found to cause hemolytic crises in the G6PD-deficient patient. The most effective management strategy is to prevent hemolysis by avoiding oxidative stressors. Thus, management for pain and anxiety should include medications that are safe and have not been shown to cause hemolytic crises, such as benzodiazepines, codeine/codeine derviatives, propofol, fentanyl, and ketamine. The authors of this article make 5 particular recommendations: (1) Anyone suspected of G6PD deficiency should be screened; (2) exposure to oxidative stressors in these individuals should be avoided; (3) these patients should be informed of risks along with signs and symptoms of an acute hemolytic crisis; (4) the clinician should be able to identify both laboratory and clinical signs of hemolysis; and finally, (5) if an acute hemolytic crisis is identified, the patient should be admitted for close observation and care.
doi:10.2344/0003-3006-56.3.86
PMCID: PMC2749581  PMID: 19769422
Glucose-6-phosphate dehydrogenase; G6PD; Blood disease; Blood deficiency; G6PD deficiency; G6PD management; Favism; Hemolysis; Hemolytic crisis; Anemia
4.  Dental anesthesia management of methemoglobinemia-susceptible patients: a case report and review of literature. 
Anesthesia Progress  2004;51(1):24-27.
A healthy but slightly pale 24-year-old female patient with a history of "turning blue" following dental procedures performed under local anesthesia claimed allergies to sulfa drugs, aspirin, Benadryl, and "all caines." The patient also acknowledged mild cyanosis after extreme exertion, Native American ancestry, and a 1996 diagnosis of methemoglobinemia following administration of a sulfa drug. Previous medical and dental records were reviewed. Restoration of several teeth and extraction of 2 third-molar teeth were completed under general anesthesia. Anesthesia was induced with propofol, nasotracheal intubation was accomplished with succinylcholine, and anesthesia was maintained with desflurane in oxygen supplemented by meperidine without local anesthesia. Vital signs, including pulse oximetry, remained stable, and the patient was dismissed after a 2-hour recovery/observation period. The patient experienced no postoperative complications. This case report provides a review of literature and clinical guidelines for management of methemoglobinemia-susceptible patients.
PMCID: PMC2007462  PMID: 15106687
5.  Pathogenesis of postoperative oral surgical pain. 
Anesthesia Progress  2003;50(1):5-17.
Pain is a major postoperative symptom in many oral surgical procedures. It is a complex and variable phenomenon that can be influenced by many factors. Good management of oral surgical pain requires a detailed understanding of the pathogenesis of surgical pain. This article aims at reviewing postoperative pain from a broad perspective by looking into the nociception, neuroanatomy, neurophysiology, and neuropharmacology of pain. Therapeutic recommendations are made after reviewing the evidence from the literature for maximizing the efficacy of pain management techniques for oral surgical pain.
PMCID: PMC2007420  PMID: 12722900
6.  Maximizing the safety of nonsteroidal anti-inflammatory drug use for postoperative dental pain: an evidence-based approach. 
Anesthesia Progress  2003;50(2):62-74.
This article reviews the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative dental pain. An evidence-based approach is used to evaluate the clinical studies to date on the safe use of these drugs in dental patients. No drugs are without adverse effects or are perfectly safe, but their safe use in clinical practice would entail maximizing the therapeutic efficacy and minimizing the adverse effects. Therapeutic recommendations are made after reviewing the evidence for the safe use of NSAIDs in postoperative dental pain.
PMCID: PMC2007429  PMID: 12866802
7.  Paradoxical reactions to benzodiazepines in intravenous sedation: a report of 2 cases and review of the literature. 
Anesthesia Progress  2002;49(4):128-132.
Paradoxical reactions to benzodiazepines have been thoroughly reported since the introduction of this type of drug. The mechanism of benzodiazepine action is through the gamma-aminobutyric acid receptors. Properties of benzodiazepine include sedation, anxiolysis, amnesia, anticonvulsion, and muscle relaxation. Unfortunately, adverse paradoxical reactions can be stimulated by benzodiazepines and are difficult to predict and diagnose. Two cases of paradoxical reactions associated with the use of intravenous midazolam are presented, and the management of this complication and its different etiologies are reviewed. The relationship of the paradoxical reaction to alteration of the cholinergic homeostasis, serotonin levels, the role of genetics, and gamma-aminobutyric acid receptor configuration is discussed.
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PMCID: PMC2007411  PMID: 12779114
8.  Corticosteroids and oral surgery. 
Anesthesia Progress  2001;48(4):130-132.
PMCID: PMC2007382  PMID: 11724221
10.  Anesthetic considerations for orthognathic surgery with evaluation of difficult intubation and technique for hypotensive anesthesia. 
Anesthesia Progress  2000;47(4):151-156.
Orthognathic surgery is carried out to improve facial appearance and/or to improve malocclusion. Usually, patients are young and healthy. However, they may have airway problems. Reinforced silicone low-pressure, high-volume endotracheal tubes and p-xylometazoline (Otrivin) for nasal vasoconstriction reduces problems due to the endotracheal tubes. A head-up position with ventilator and monitoring equipment at the foot end helps the surgeons as well as the surgery. Surgeons may be the cause of endotracheal tube problems. Bleeding is a major problem that may be encountered and is reduced by induced hypotension. During osteotomies, severe bradycardia may occur and may even lead to cardiac arrest. In the early postoperative period, bleeding may be a problem. Later ulceration at the tip of the nose and on the buttocks may be seen if preventive measures are not carried out.
PMCID: PMC2149032  PMID: 11432182
11.  The effects of cigarette smoking on anesthesia. 
Anesthesia Progress  2000;47(4):143-150.
Cigarette smoke contains over 4000 substances, some of which are harmful to the smoker. Some constituents cause cardiovascular problems, increasing the blood pressure, heart rate, and the systemic vascular resistance. Some cause respiratory problems, interfering with oxygen uptake, transport, and delivery. Further, some interfere with respiratory function both during and after anesthesia. Some also interfere with drug metabolism. Various effects on muscle relaxants have been reported. Risk of aspiration is similar to that of nonsmokers, but the incidence of postoperative nausea and vomiting appears to be less in smokers than in nonsmokers. Even passive smoking effects anesthesia. Best is to stop smoking for at least 8 weeks prior to surgery or, if not, at least for 24 hours before surgery. Anxiolytic premedication with smooth, deep anesthesia should prevent most problems. Monitoring may be difficult due to incorrect readings on pulse oximeters and higher arterial to end tidal carbon dioxide differences. In the recovery period, smokers will need oxygen therapy and more analgesics. It is time that anesthesiologists played a stronger role in advising smokers to stop smoking.
PMCID: PMC2149030  PMID: 11432181
12.  Ketamine: review of its pharmacology and its use in pediatric anesthesia. 
Anesthesia Progress  1999;46(1):10-20.
The management of the uncooperative pediatric patient undergoing minor surgical procedures has always been a great challenge. Several sedative techniques are available that will effectively alleviate anxiety, but short of general anesthesia, no sedative regimen is available that will enable treatment of the uncooperative child. Ketamine produces a unique anesthetic state, dissociative anesthesia, which safely and effectively enables treatment of these children. The pharmacology, proposed mechanisms of action, and clinical use of ketamine (alone and in combination with other agents) are reviewed and evaluated.
PMCID: PMC2148883  PMID: 10551055
13.  Huntington's disease: review and anesthetic case management. 
Anesthesia Progress  1998;45(4):150-153.
Huntington's disease is a dominantly inherited progressive autosomal disease that affects the basal ganglia. Symptoms appear later in life and manifest as progressive mental deterioration and involuntary choreiform movements. Patients with Huntington's disease develop a progressive but variable dementia. Dysphagia, the most significant related motor symptom, hinders nutrition intake and places the patient at risk for aspiration. The combination of involuntary choreoathetoid movements, depression, and apathy leads to cachexia. Factors of considerable concern to the anesthesiologist who treats patients with Huntington's disease may include how to treat frail elderly people incapable of cooperation, how to treat patients suffering from malnourishment, and how to treat patients with an increased risk for aspiration or exaggerated responses to sodium thiopental and succinylcholine. The successful anesthetic management of a 65-yr-old woman with Huntington's disease who presented for full-mouth extractions is described.
PMCID: PMC2148983  PMID: 10483387
15.  Patient-Controlled Sedation 
Anesthesia Progress  1998;45(3):117-126.
Patient-controlled sedation was utilized in patients aged 15 to 85 yr who were undergoing surgery under local or regional anesthesia. Midazolam, propofol, and methohexitone were used, either by themselves or in combination with fentanyl or alfentanil. Sedation was mild to moderate in the majority of patients, and operating conditions were good. The sedation method provided patients the ability to control the sedation and to vary the degree of sedation according to the environment and to the stress of the procedure. Sedation of the elderly, which tends to be problematic, was made easy using this method, and the elderly patients appeared to enjoy the option. The problems encountered were oversedation, respiratory depression, pain during injection, and postural hypotension.
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PMCID: PMC2148957  PMID: 19598717
Patient-controlled sedation; Review
16.  Violent emergence from anesthesia: is it a pharmacological or psychological reaction? 
Anesthesia Progress  1997;44(4):142-143.
A violent emergence from deep sedation is an uncommon reaction in the daily practice of anesthesia in the oral and maxillofacial surgery office. We present a case of a 22-yr-old male with a severe violent emergence from deep sedation that we attribute to a psychological rather than a pharmacological cause. A differential diagnosis is discussed, as are methods of treatment.
PMCID: PMC2148935  PMID: 9481958
17.  Pulmonary edema following postoperative laryngospasm: case reports and review of the literature. 
Anesthesia Progress  1997;44(3):110-116.
Pulmonary edema that follows upper airway obstruction may occur in a variety of clinical situations. The predominant mechanism is forced inspiration against a closed or occluded glottis, inducing large intrapleural and transpulmonary pressure gradients favoring the transudation of fluid from the pulmonary capillaries into the interstitium. Postanesthetic laryngospasm has been implicated as the most frequent cause of this syndrome in adults. Risk factors for development of postlaryngospasm pulmonary edema include difficult intubation; nasal, oral, or pharyngeal surgical site; and obesity with obstructive apnea. The syndrome is recognized by development of hypoxia shortly (1-90 min) after a laryngospasm. A chest radiograph will reveal a symmetric bilateral infiltrate with normal heart size. Cardiogenic pulmonary edema and aspiration must be ruled out. Treatment is directed at correction of hypoxia with supplemental oxygen and use of diuretics (furosemide). Occasionally patients may require intubation.
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PMCID: PMC2148924  PMID: 9481972
18.  Oxygen desaturation in a child receiving a combination of ketamine and midazolam for dental extractions. 
Anesthesia Progress  1997;44(2):68-70.
A combination of 0.35 mg/kg midazolam and 5 mg/kg ketamine, administered orally for pediatric sedation, resulted in a severe decreases in blood oxygen saturation postoperatively. The patient, a 2-yr-old child, did not respond to command or mild physical stimulation in the recovery room 60 min after receiving the drugs. The benzodiazepine antagonist, flumazenil (0.01 mg/kg), was administered intravenously to reverse the action of midazolam. No adverse effects were observed thereafter, and the postoperative recovery was uneventful. Combining different classes of drugs may result in less variability in patients response, but there is a greater potential for drug-induced side effects and drug interactions.
PMCID: PMC2148828  PMID: 9481964
19.  Anesthetic management of a patient with Bartter's syndrome undergoing orthognathic surgery. 
Anesthesia Progress  1997;44(2):71-75.
Bartter's syndrome is a rare disorder characterized by severe hypokalemic alkalosis, marked elevation in plasma renin activity, pressor insensitivity to angiotensin II, and normal or low values of plasma sodium, plasma chloride, and blood pressure. Many of the clinical features and biochemical abnormalities appear to be secondary to chronic hypokalemia. We managed a 22-yr-old man requiring orthognathic surgery for correction of facial asymmetry under general anesthesia.
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PMCID: PMC2148826  PMID: 9481965
21.  Vasoconstrictor agents for local anesthesia. 
Anesthesia Progress  1995;42(3-4):116-120.
PMCID: PMC2148913  PMID: 8934977
22.  Dental anesthesia and pediatric dentistry. 
Anesthesia Progress  1995;42(3-4):95-99.
PMCID: PMC2148908  PMID: 8934972
23.  Flumazenil in dentistry. 
Anesthesia Progress  1995;42(3-4):121-125.
PMCID: PMC2148898  PMID: 8934978
24.  Induced hypotension during anesthesia with special reference to orthognathic surgery. 
Anesthesia Progress  1995;42(2):41-58.
Since Gardner first used arteriotomy during anesthesia to improve visibility in the surgical field, various techniques and pharmacological agents have been tried for the same purpose. With reports documenting the spread of acquired immune deficiency syndrome through blood transfusions, prevention of homologous blood transfusions during surgery has also become a major concern. Induced hypotension has been used to reduce blood loss and thereby address both issues. In orthognathic surgery, induced hypotension during anesthesia has been used for similar reasons. It is recommended that hypotensive anesthesia be adjusted in relation to the patient's preoperative blood pressure rather than to a specific target pressure and be limited to that level necessary to reduce bleeding in the surgical field and in duration to that part of the surgical procedure deemed to benefit by it. A mean arterial blood pressure (MAP) 30% below a patient's usual MAP, with a minimum MAP of 50 mm Hg in ASA Class I patients and a MAP not less than 80 mm Hg in the elderly, is suggested to be clinically acceptable. Various pharmacological agents have been used for induced hypotension during orthognathic surgery. In addition, there are many drugs that have been used in other types of surgery that could be used in orthognathic surgery to induce hypotension. Recent reports using control groups do not show significant differences in morbidity and mortality attributable to induced hypotension during anesthesia. Appropriate patient evaluation and selection, proper positioning and monitoring, and adequate fluid therapy are stressed as important considerations in patients undergoing induced hypotension during orthognathic surgery.
PMCID: PMC2148853  PMID: 8934953
25.  Preemptive analgesia: the prevention of neurogenous orofacial pain. 
Anesthesia Progress  1995;42(2):36-40.
Chronic neurogenous pain is often an extremely difficult condition to manage. In the orofacial region, trauma from injury or dental procedures may lead to the development of severe neuralgic pains and major distress to the patient. Clinical and experimental evidence suggests that the use of adequate preemptive regional anesthesia, systemic analgesia, and the avoidance of repeated, painful stimuli may reduce the incidence of this problem.
PMCID: PMC2148850  PMID: 8934952

Results 1-25 (99)