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1.  Preemptive effects of a combination of preoperative diclofenac, butorphanol, and lidocaine on postoperative pain management following orthognathic surgery. 
Anesthesia Progress  2000;47(4):119-124.
The aim of the study was to investigate whether preemptive multimodal analgesia (diclofenac, butorphanol, and lidocaine) was obtained during sagittal split ramus osteotomy (SSRO). Following institutional approval and informed consent, 82 healthy patients (ASA-I) undergoing SSRO were randomly assigned to 1 of 2 groups, the preemptive multimodal analgesia group (group P, n = 41) and the control group (group C, n = 41). This study was conducted in a double-blind manner. Patients in group P received 50 mg rectal diclofenac sodium, 10 micrograms/kg intravenous 0.1% butorphanol tartrate, and 1% lidocaine solution containing 10 micrograms/mL epinephrine for regional anesthesia and for bilateral inferior alveolar nerve blocks before the start of surgery. Postoperative pain intensity at rest (POPI) was assessed on a numerical rating score (NRS) in the postanesthesia care unit (PACU) and on a visual analogue scale (VAS) at the first water intake (FWI) and at 24, 48, and 72 hours after extubation. POPI in the PACU was significantly lower in group P than in group C, whereas there were no significant differences at FWI, 24, 48, and 72 hours after extubation in both groups. Preemptive multimodal analgesia was not observed in this study.
PMCID: PMC2149035  PMID: 11432176
2.  Local anesthesia in the palate: a comparison of techniques and solutions. 
Anesthesia Progress  2000;47(4):139-142.
It was the purpose of the present investigation to determine if there were differences in soft-tissue anesthesia in the palate following infiltration and greater palatine nerve block anesthesia and to compare lidocaine with lidocaine plus epinephrine as palatal soft tissue anesthetics. Two studies using 10 volunteers were performed. In one trial, volunteers received a palatal infiltration opposite the second maxillary bicuspid on one side and a greater palatine nerve block on the other. Response to sharp probing and pain-pressure thresholds were measured on each side over a 1-hour census period. In the second trial, volunteers received 2% plain lidocaine as a palatal infiltration on one side and a similar infiltration of 2% lidocaine with 1:80,000 epinephrine on the other in a double-blind randomized fashion. Response to sharp probing was assessed over a 55-minute period. Data were analyzed using Student's paired t tests. The response to sharp probing and pressure-pain thresholds did not differ between palatal infiltration and greater palatine nerve block over the 1-hour period. Lidocaine with epinephrine provided longer lasting anesthesia than plain lidocaine following palatal infiltration (P < .001). Greater palatine nerve block and palatal infiltration provide similar soft-tissue anesthesia. Lidocaine with epinephrine produces longer-lasting soft-tissue anesthesia than plain lidocaine following palatal infiltration.
PMCID: PMC2149034  PMID: 11432180
3.  Clinical evaluation of inferior alveolar nerve block by injection into the pterygomandibular space anterior to the mandibular foramen. 
Anesthesia Progress  2000;47(4):125-129.
The conventional inferior alveolar nerve block (conventional technique) has potential risks of neural and vascular injuries. We studied a method of inferior alveolar nerve block by injecting a local anesthetic solution into the pterygomandibular space anterior to the mandibular foramen (anterior technique) with the purpose of avoiding such complications. The insertion angle of the anterior technique and the estimation of anesthesia in the anterior technique were examined. The predicted insertion angle measured on computed tomographic images was 60.1 +/- 7.1 degrees from the median, with the syringe end lying on the contralateral mandibular first molar, and the insertion depth was approximately 10 mm. We applied the anterior technique to 100 patients for mandibular molar extraction and assessed the anesthetic effects. A success rate of 74% was obtained. This is similar to that reported for the conventional technique but without the accompanying risks for inferior alveolar neural and vascular complications.
PMCID: PMC2149033  PMID: 11432177
4.  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
5.  Adverse reactions triggered by dental local anesthetics: a clinical survey. 
Anesthesia Progress  2000;47(4):134-138.
One hundred and seventy-nine patients completed a questionnaire focusing on adverse reactions to dental local anesthetics as manifested by 16 signs and symptoms. Twenty-six percent of the participants reported having at least 1 adverse reaction. It was found that most of the adverse reactions occurred within the first 2 hours following the injection of local anesthetics. Pallor, palpitations, diaphoresis, and dizziness were the most common adverse reactions reported in the study. The results pointed to a significant relationship between anxiety, gender, injection technique, and procedure with a higher incidence of adverse reactions.
PMCID: PMC2149031  PMID: 11432179
6.  Inferior alveolar nerve block by injection into the pterygomandibular space anterior to the mandibular foramen: radiographic study of local anesthetic spread in the pterygomandibular space. 
Anesthesia Progress  2000;47(4):130-133.
We studied the spread of local anesthetic solution in the inferior alveolar nerve block by the injection of local anesthetic solution into the pterygomandibular space anterior to the mandibular foramen (anterior technique). Seventeen volunteers were injected with 1.8 mL of a mixture containing lidocaine and contrast medium utilizing the anterior technique. The course of spread was traced by fluoroscopy in the sagittal plane, and the distribution area was evaluated by lateral cephalograms and horizontal computed tomography. The results indicate that the contrast medium mixture spreads rapidly in the pterygomandibular space to the inferior alveolar nerve in the subjects who exhibited inferior alveolar nerve block effect. We concluded that the anesthetic effect due to the anterior technique was produced by the rapid distribution of anesthetic solution in the pterygomandibular space toward the mandibular foramen, and individual differences in the time of onset of analgesia may be due to differences in the histologic perineural tissues.
PMCID: PMC2149029  PMID: 11432178
8.  Simulation technology in anesthesiology. 
Anesthesia Progress  2000;47(1):8-11.
PMCID: PMC2149012  PMID: 11212414
10.  Sevoflurane and isoflurane reduce oxygen saturation in infants. 
Anesthesia Progress  2000;47(1):3-7.
Volatile anesthetics are generally known to exert several influences on the respiratory system, but their direct effect on oxygen saturation as measured by pulse oximetry (SpO2) in infants remains unknown. In this study, 70 infants under 2 years of age who received general anesthesia were examined to determine the effects of several volatile anesthetics and nitrous oxide on SpO2. After endotracheal intubation, the subjects were ventilated using a Jackson-Rees circuit with oxygen, nitrous oxide, and either sevoflurane, enflurane, or isoflurane adjusted to twice the adult minimum alveolar concentration (MAC) for the agents when used in combination with 67% nitrous oxide. In all cases, the end-tidal carbon dioxide tension (PetCO2) was maintained within the same range (28-35 mm Hg). Significantly lower SpO2 values (paired t test, P < .05) were observed when the subjects were ventilated with oxygen, 67% nitrous oxide, and sevoflurane or isoflurane--but not with oxygen, 67% nitrous oxide, and enflurane--than when they were administered oxygen, 50% nitrous oxide, and the original concentration of each volatile anesthetic. These results suggest that sevoflurane and isoflurane have different effects from enflurane on gas exchange systems.
PMCID: PMC2149009  PMID: 11212413
11.  Clinical Evidence 
Anesthesia Progress  2000;47(1):12.
PMCID: PMC2149008
12.  IFDAS 
Anesthesia Progress  2000;47(1):13-25.
PMCID: PMC2149005
13.  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
14.  The hypoalgesic effect of 3-D video glasses on cold pressor pain: reproducibility and importance of information. 
Anesthesia Progress  2000;47(3):67-71.
The first aim of the study was to evaluate whether it was possible to manipulate the distraction effect induced by 3-D video glasses on the perceived pain and unpleasantness of the subjects by giving them different information about the expected effect. Second, the study aimed to determine the reproducibility of the effect. Forty-five students enrolled, 39 students participated in the study (24 women and 15 men, median age 23 years, range 19-28 years) because 6 did not show up for the first trial, and 37 completed the study because 2 subjects did not show up for the second trial. The subjects were randomized into 3 groups, balanced with respect to age and sex, that received different information about the effect of 3-D video on pain and unpleasantness: the first group received positive information, the second group received neutral information, and the third group received negative information. Once assigned to a group, there were no crossovers between the groups. A cold pressor stimulus was used to induce experimental pain, and the volunteers rated the intensity of pain and unpleasantness on 100-mm visual analogue scales. A new generation of video glasses were used in the study. Each volunteer was exposed to the cold pressor test in 2 randomized trials (video and control) after the information was given, and the 2 trials were repeated in a second session after 4 weeks. There was no significant difference in the effect of video glasses on perceived pain (P = .74) nor on the perceived unpleasantness (P = .84) among the 3 information groups. The data were therefore pooled. The results of the pooled data showed a significant effect of 3-D video on perceived pain (P = .03) but not on unpleasantness (P = .18). After 4 weeks, the study was repeated, and there were no significant changes in the effect of video glasses. The median visual analogue scale scores were reduced in both the video and the control trials compared with the first session.
PMCID: PMC2149026  PMID: 11432159
15.  Additional clinical observations utilizing bispectral analysis. 
Anesthesia Progress  2000;47(3):84-86.
Additional observations were made in the use of the bispectral (BIS) index with the use of ketamine and in performing general anesthesia without the use of local anesthesia in nonintubated patients. Twenty-five subjects undergoing extraction procedures in an outpatient setting were analyzed using bispectral analysis with ketamine and midazolam. Despite repeated injections of midazolam during the procedure, only transient decreases of the BIS occurred to the 80s, with a low value of 77 in all but 1 patient where ketamine was used. In comparison, values in the 50-70 range are typically seen immediately after the administration of sedative doses of midazolam, propofol, or methohexital. In the second study, once propofol anesthesia was initiated, BIS readings in the 30s were commonly seen in patients during their procedure. The lowest BIS level observed was 18. Bispectral analysis was useful to trend the present anesthetic state and adjust the dose of propofol accordingly. In no case was laryngospasm or total airway obstruction observed. In 1 case, partial airway obstruction secondary to retro-positioning of the tongue occurred with a subsequent decrease in oxygen saturation to 89%. This was rectified by repositioning the patient to alleviate the obstruction. Consistent with previous studies utilizing ketamine, BIS values are consistently higher when compared with other hypnotic agents. With the subsequent injection of midazolam, the BIS level did not decrease to anticipated levels. In the final study reviewed, when local anesthesia was not used during general anesthesia, bispectral analysis was a useful adjunct in helping maintain a steady state of general anesthesia in nonintubated patients undergoing third molar extractions. Bispectral analysis offers additional information on the depth of the hypnotic state and is useful in helping control the depth of anesthesia. A limitation of the index includes the inability to titrate the level of sedation induced by hypnotic agents such as midazolam when ketamine is concomitantly administered.
PMCID: PMC2149025  PMID: 11432161
17.  The use of bispectral analysis to monitor outpatient sedation. 
Anesthesia Progress  2000;47(3):72-83.
The bispectral (BIS) index has been used to interpret partial EEG recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. The author has evaluated BIS technology in determining the level of sedation in patients undergoing outpatient deep sedation. These experiences are outlined in this review article. Initially, the correlation of the BIS index with traditional subjective patient evaluation using the Observer's Assessment of Alertness and Sedation (OAA/S) scale was performed in 25 subjects. In a second study, the recovery profile of 39 patients where the BIS was used to monitor sedation was compared with a control group where the monitor was not used. A strong positive relationship between the BIS and OAA/S readings was found in the initial subjects. From the recovery study, it appears that use of the BIS monitor may help titrate the level of sedation so that less drugs are used to maintain the desired level of sedation. A trend to earlier return of motor function in BIS-monitored patients was also demonstrated. BIS technology offers an objective, ordinal means of assessing the depth of sedation. This can be invaluable in comparing studies of techniques. The BIS index provides additional information to standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. The trend to earlier return of motor function in BIS-monitored patients warrants further investigation.
PMCID: PMC2149022  PMID: 11432160
19.  Oral transmucosal fentanyl pretreatment for outpatient general anesthesia. 
Anesthesia Progress  2000;47(2):29-34.
The oral transmucosal formulation of fentanyl citrate (OTFC) has been reported to be an effective sedative, providing convenient and atraumatic sedation for children prior to general anesthesia or painful diagnostic procedures. Thirty-three young children (24-60 months of age) scheduled for outpatient general anesthesia for treatment of dental caries were enrolled in this randomized placebo-controlled clinical trial. To determine the effectiveness of the OTFC premedication, patient behavior was evaluated using three distinct outcome ratings. A sedation score rated behavior in the waiting room prior to OTFC as well as 10 minutes and 20 minutes after OTFC. A separation score rated the child's response to being separated from his/her parent or guardian for transport to the dental operatory. Finally, a cooperation score rated the child's acceptance of the mask induction. The OTFC formulation was well tolerated by most of the children in this study. Compared with the placebo oralet, the active OTFC improved behavior for separation from the parent (P < .05) and cooperation with the mask induction (P < .05). The duration of surgery and the time of recovery did not differ between placebo and active premedication. Side effects including respiratory and cardiovascular complications were reported more frequently in the active fentanyl group. Continuous monitoring of respiratory function is essential when using this unique and effective formulation of fentanyl for pediatric preanesthetic sedation.
PMCID: PMC2149014  PMID: 11881693
20.  Comparative study on anesthetic potency of dental local anesthetics assessed by the jaw-opening reflex in rabbits. 
Anesthesia Progress  2000;47(2):35-41.
The potency of 4 local anesthetics to dental pulp was compared. Drugs were 4% articaine with 12 microgram/mL epinephrine (A12), 4% articaine with 6 microgram/mL epinephrine (A6), 2% lidocaine with 12.5 microgram/mL epinephrine (L), and 3% propitocaine with 0.03 IU/mL felypressin (P). Local anesthetics were injected into the dental root of the mandibular incisor. Electromyogram (EMG) of the digastric muscle was measured during the jaw-opening reflex induced by electrical stimulation. The disappearance of the EMG wave was judged as positive evidence of anesthesia. The determination of ED50 of the anesthetic was made by probit analysis. The ED50 of the A12 was minimal in all the tested anesthetics throughout the entire course. The potency in the A6 was 2.8 times that of the L. The potency of the A12 at the 15-minute measurement was 3.8 times that of the A6. The ED50 of the P was higher compared with those of the other 3 groups. It was concluded that articaine showed quicker onset than lidocaine and propitocaine and that there was a need to increase the dosage to attain a quick onset or to extend the duration.
PMCID: PMC2149013  PMID: 11881694

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