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jtitle_s:("anesti Prog")
1.  Lidocaine toxicity. 
Anesthesia Progress  1998;45(1):38-41.
Local anesthetics are the most commonly used drugs in dentistry. The number of adverse reactions reported, particularly toxic reactions, are extraordinarily negligible. This article reports a case of lidocaine toxicity with its typical manifestation in a 37-yr-old healthy male. The toxic reaction followed transoral/transpharyngeal topical spraying of lidocaine preoperatively during preparation for general anesthesia. A review of dosages of the most commonly used local anesthetic drugs in dentistry and the management of a toxic reaction is presented. Clinicians need to be in a position to recognize and successfully manage this potential adverse reaction.
PMCID: PMC2148953  PMID: 9790008
2.  Erratum 
Anesthesia Progress  1998;45(1):44.
Images
PMCID: PMC2148949
3.  General anesthesia for the provision of dental treatment to adults with developmental disability. 
Anesthesia Progress  1998;45(1):12-17.
The management of the behavior of mentally challenged adults when providing required dental care is often a problem, whether in the dental office or in a hospital setting. Our institution has a designated program to provide required dental care to this group of patients. Because of the high incidence of poor cooperation, which may include aggressive antagonistic behavior, many of these patients are scheduled for dental care under general anesthesia with an incomplete preoperative medical assessment. The purpose of this study was to determine the impact and limitations that an incomplete medical assessment may present in the delivery of dental care under general anesthesia to these adults with developmental disability. After approval from the institutional review board, the medical records of 139 patients treated in this program between 1992 and 1994 were reviewed to determine the patient profiles, anesthesia management, and complications. The charts of these patients, who underwent dental and radiographic examination, scaling and prophylaxis, and restoration and extraction of teeth under general anesthesia, were reviewed. There were 149 procedures performed on these patients, some more than once. The mean age was 29.5 yr. Males predominated females by a ratio of 2:1. All had multiple diagnoses, medical problems, and medications. Twenty-three patients had Down's Syndrome, four had schizophrenia disorders, 42 had seizure disorders, 11 had hypothyroidism, seven had heart disease, and 14 had central nervous system and neuromuscular disorders. The remainder had a variety of diagnoses, including rare syndromes. One hundred had intravenous (i.v.), 25 had mask inhalation, and 24 had intramuscular ketamine (Ketalar) induction. Nasotracheal intubation was uneventful in 139 patients, five had difficult visualization of the larynx and intubation. Ten patients experienced intraoperative complications, including nonfatal ventricular arrhythmia, slight fall in blood pressure and hypertension (greater than 20% of preoperative value), and four individuals developed laryngospasm. In the Post Anesthetic Care Unit, five patients experienced minor airway problems resulting in a desaturation of oxygen to a level below 85%. Adults with developmental disabilities can be safely managed under general anesthesia for dental treatment in a hospital setting with minimal morbidity and without extensive preoperative investigations.
PMCID: PMC2148947  PMID: 9790004
5.  Pain following intravenous administration of sedative agents: a comparison of propofol with three benzodiazepines. 
Anesthesia Progress  1998;45(1):18-21.
The purpose of the present study is to compare the injection pain of propofol with that of benzodiazepines when used for intravenous sedation. In addition, we evaluated the efficacy of coadministering a small dose of 1% lidocaine (20 mg) to reduce the pain accompanying propofol injection. Intravenous propofol, diazepam, midazolam, or flunitrazepam were administered on separate occasions to volunteers and outpatients. The degree of injection pain was evaluated by the Visual Analog Scale (VAS) ruler. The efficacy of premixed lidocaine with propofol was also compared among the patients. The venous pain of propofol was significantly more intense than that of the three other drugs (P < 0.05). The injection pain of diazepam was more intense than that of midazolam (P < 0.05). Many patients reported no pain when propofol was coadministered with lidocaine. The addition of a small dose (20 mg) of lidocaine reduced the VAS pain score to comparable levels observed for benzodiazepines. Because injection pain might affect the patients' comfort during sedation, the addition of lidocaine to the propofol injection is deemed useful for intravenous sedation.
PMCID: PMC2148944  PMID: 9790005
6.  A double blind randomized comparison of oral trimeprazine-methadone and ketamine-midazolam for sedation of pediatric dental patients for oral surgical procedures. 
Anesthesia Progress  1998;45(1):3-11.
The safety and efficacy of an oral sedation technique for children having minor oral surgical procedures under local anesthesia were studied. One hundred healthy children between the ages of 2 and 7 yr received either a combination of midazolam (0.35 mg/kg) and ketamine (5 mg/kg) (Group A), or a combination of trimeprazine (3 mg/kg) and methadone (0.2 mg/kg) (Group B) 30 min preoperatively. Hemodynamic parameters, adverse reactions, postoperative recovery, and behavior were evaluated. More children were asleep, but rousable to verbal commands, 30 min after drug administration in Group A (40%) than in Group B (8%). Immediately before the dental procedure, 46% of children in Group A were asleep in contrast to 8% of children in group B. Significantly more children in Group A were awake, coughing, crying, and moving purposefully 30 and 60 min after admission to the recovery room. Two children (4%) in Group A vomited. Ten (20%) children in Group A hallucinated compared to none in Group B. The surgeon rated the procedure as good or very good in 94% of children in Group A compared to 78% in Group B. Our results show that the combination of midazolam and ketamine, administered orally, is a safe, effective, and practical approach to managing children for minor oral surgical procedures under local anesthesia.
PMCID: PMC2148942  PMID: 9790003
7.  Acute pain and use of local anesthesia: tooth drilling and childbirth labor pain beliefs among Anglo-Americans, Chinese, and Scandinavians. 
Anesthesia Progress  1998;45(1):29-37.
Differences in ethnic beliefs about the perceived need for local anesthesia for tooth drilling and childbirth labor were surveyed among Anglo-Americans, Mandarin Chinese, and Scandinavians (89 dentists and 251 patients) matched for age, gender, and occupation. Subjects matched survey questionnaire items selected from previously reported interview results to estimate (a) their beliefs about the possible use of anesthetic for tooth drilling and labor pain compared with other possible remedies and (b) the choice of pain descriptors associated with the use of nonuse of anesthetic, including descriptions of injection pain. Multidimensional scaling, Gamma, and Chi-square statistics as well as odds ratios and Spearman's correlations were employed in the analysis. Seventy-seven percent of American informants reported the use of anesthetics as possible remedies for drilling and 51% reported the use of anesthetics for labor pain compared with 34% that reported the use of anesthetics among Chinese for drilling and 5% for labor pain and 70% among Scandinavians for drilling and 35% for labor pain. Most Americans and Swedes described tooth-drilling sensations as sharp, most Chinese used descriptors such as sharp and "sourish" (suan), and most Danes used words like shooting (jagende). By rank, Americans described labor pain as cramping, sharp, and excruciating, Chinese used words like sharp, intermittent, and horrible, Danes used words like shooting, tiring, and sharp, and Swedes used words like tiring, "good," yet horrible. Preferred pain descriptors for drilling, birth, and injection pains varied significantly by ethnicity. Results corroborated conclusions of a qualitative study about pain beliefs in relation to perceived needs for anesthetic in tooth drilling. Samples used to obtain the results were estimated to approach qualitative representativity for these urban ethnic groups.
PMCID: PMC2148948  PMID: 9790007
8.  Perceived need for local anesthesia in tooth drilling among Anglo-Americans, Chinese, and Scandinavians. 
Anesthesia Progress  1998;45(1):22-28.
This study explored ethnic differences in perceptions of pain and the need for local anesthesia for tooth drilling among age- and gender-matched Anglo-American, Mandarin Chinese, and Scandinavian dentists (n = 129) and adult patients (n = 396) using a systematic qualitative research strategy. Semistructured qualitative interviews determined: (a) the relative frequency of use or nonuse of anesthetic for similarly specified tooth drilling, (b) the reasons for nonuse of anesthetic as reported by dentists about their patients, and (c) the distribution of reasons for not using anesthetic. American dentists (n = 51) reported that about 1% of their adult patients did not use anesthetic compared with 90% among Chinese (n = 31) and 37.5% among Scandinavian dentists (n = 40). Of patients, Americans (n = 112) reported 6% nonuse of anesthetic for tooth drilling compared with 90% of 159 Chinese and 54% of 125 Scandinavians. Reasons among Anglo-Americans and Scandinavians were similar (ranked): the sensation was tolerable, to avoid numb feelings afterwards, and fear of injections. Danish patients were an exception; the fact that they had paid extra and out-of-pocket for anesthetic ranked second. In contrast, Chinese dentists made their decisions not to use anesthetics because they explained drilling as only a suan or "sourish" sensation, whereas injections were described as "painful." It was concluded that ethnic pain beliefs and differences in health-care systems are powerful psychosocial variables that affect pain perception and the perceived need for anesthetic.
PMCID: PMC2148943  PMID: 9790006
9.  The Lifeblood of This Journal 
Anesthesia Progress  1998;45(1):1-2.
PMCID: PMC2148952  PMID: 19598714
10.  Change in pain threshold by meperidine, naproxen sodium, and acetaminophen as determined by electric pulp testing. 
Anesthesia Progress  1998;45(4):139-142.
The purpose of this study was to compare changes in pain threshold caused by meperidine, naproxen sodium, acetaminophen, and placebo. The change in pain threshold was measured by electric pulp testing. Acetaminophen elevated the pain threshold statistically significantly. Clinically, however, the superiority of acetaminophen is questionable. No elevation of the pain threshold occurred with narcotic drugs or with nonsteroidal anti-inflammatory drugs: our research shows that the electric pulp tests of patients who have taken these drugs preoperatively will have results similar to those of patients who have taken no drugs. We question the philosophy of administering these drugs for change in pain threshold at the levels used here preoperatively.
PMCID: PMC2148986  PMID: 10483385
11.  Anesthetic efficacy of a repeated intraosseous injection given 30 min following an inferior alveolar nerve block/intraosseous injection. 
Anesthesia Progress  1998;45(4):143-149.
To determine whether a repeated intraosseous (IO) injection would increase or prolong pulpal anesthesia, we measured the degree of anesthesia obtained by a repeated IO injection given 30 min following a combination inferior alveolar nerve block/intraosseous injection (IAN/IO) in mandibular second premolars and in first and second molars. Using a repeated-measures design, we randomly assigned 38 subjects to receive two combinations of injections at two separate appointments. The combinations were an IAN/IO injection followed approximately 30 min later by another IO injection of 0.9 ml of 2% lidocaine with 1:100,000 epinephrine and a combination IAN/IO injection followed approximately 30 min later by a mock IO injection. The second premolar, first molar, and second molar were blindly tested with an Analytic Technology pulp tester at 2-min cycles for 120 min postinjection. Anesthesia was considered successful when two consecutive readings of 80 were obtained. One hundred percent of the subjects had lip numbness with IAN/IO and with IAN/IO plus repeated IO techniques. Rates of anesthetic success for the IAN/IO and for the IAN/IO plus repeated IO injection, respectively, were 100% and 97% for the second premolar, 95% and 95% for the first molar, and 87% and 87% for the second molar. The repeated IO injection increased pulpal anesthesia for approximately 14 min in the second premolar and for 6 min in the first molar, but no statistically significant differences (P > 0.05) were shown. In conclusion, the repeated IO injection of 0.9 ml of 2% lidocaine with 1:100,000 epinephrine given 30 min following a combination IAN/IO injection did not significantly increase pulpal anesthesia in mandibular second premolars or in first and second molars.
PMCID: PMC2148985  PMID: 10483386
12.  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
16.  General anesthesia for disabled patients in dental practice. 
Anesthesia Progress  1998;45(4):134-138.
We reviewed the cases of 91 consecutive patients with disabilities who required general anesthesia at a tertiary referral center for dental treatment with a view to determining the factors that create difficulties in the anesthetic management. The more important of these are the special difficulties involved in making preoperative assessments of these patients and the difficulty in establishing monitoring. Other difficulties in anesthesia for these patients involve problems with gaining intravenous access, problems in determining when there has been adequate recovery from anesthesia, and problems in determining the degree of discomfort or pain the patients experience after dental treatment. Another potential hazard in this group of patients is the risk of drug interactions. We emphasize the need to train anesthetists in the care of disabled patients.
PMCID: PMC2148978  PMID: 10483384
19.  A Survey of Local Anesthesia Course Directors 
Anesthesia Progress  1998;45(3):91-95.
This study was designed to present local anesthesia course directors with detailed information that can be used in assessing and improving their courses. A questionnaire was mailed to the directors of local anesthesia courses in all dental schools in the United States and Puerto Rico. The results indicate that oral surgery/oral and maxillofacial surgery departments are involved in 89% of predoctoral local anesthesia courses and that a typical course has 15 hr of didactic and 5 hr of clinical instruction, with a 1:4 faculty:student ratio during the portion of clinical instruction that involves administering injections to classmates. Although an average course content can be derived from the data, the survey revealed quite a bit of diversity in terms of programs of instruction. The program designs, injections covered, instructional materials used, and protocols followed in the event of ineffective anesthetization all warrant consideration by those interested in the way in which instruction in local anesthesia occurs.
PMCID: PMC2148962  PMID: 19598720
Local anesthesia; Teaching, dental school
20.  Flunitrazepam Versus Placebo Premedication for Anxiety Control in General Dental Practice 
Anesthesia Progress  1998;45(3):96-102.
Our objective was to examine the performance of sublingual administration of the short- to intermediate-acting benzodiazepine flunitrazepam on patients with dental anxiety. The study was designed as a randomized double-blind, placebo-controlled crossover trial with nearly identical dental interventions performed on two separate occasions in 24 adult patients. Flunitrazepam (1 mg) significantly reduced anxiety and was well tolerated. With few exceptions, both the patients and the dentist clearly favored the session with flunitrazepam. Most patients also preferred the remaining part of the day when they had been premedicated with flunitrazepam. They were apparently not particularly troubled by being somewhat drowsy. Dizziness was not reported as a problem. Flunitrazepam appears to be an effective, safe, and recommendable alternative for premedication of anxious dental patients.
PMCID: PMC2148961  PMID: 19598721
Oral sedation; Benzodiazepine; Flunitrazepam; Dentistry
21.  How Good Are Your Anesthesia Records? 
Anesthesia Progress  1998;45(3):85-86.
PMCID: PMC2148960  PMID: 19598718
22.  Plasma Levels of 2% Lidocaine with 1:100,000 Epinephrine with Young Children Undergoing Dental Procedures 
Anesthesia Progress  1998;45(3):87-90.
Lidocaine levels were determined for 12 children, aged 55 to 150 mo, who received routine dental treatment, including multiple intraoral injections of 2% lidocaine (2.6 to 6.4 mg/kg) with 1:100,000 epinephrine. Peak plasma concentrations of lidocaine ranged from 0.7 to 3.8 μg/ml at 5 to 15 min postinjection. Generally accepted threshold concentrations for the onset of central nervous system toxicity are 5 to 10 μg/ml. In this study, no child approached these levels when given local anesthesia for dental procedures.
PMCID: PMC2148959  PMID: 19598719
Local anesthesia; Lidocaine; Child; Dental care; Plasma levels
23.  Influence of Minor Dental Surgery with and without Intravenous Sedation on Levels of Hormones Responsible for Volume Homeostasis in Elderly Hypertensive Patients 
Anesthesia Progress  1998;45(3):103-109.
Changes in the hormones responsible for volume homeostasis were observed before, during, and after minor dental surgery in 25 elderly hypertensive patients. These patients were divided into two groups. Group L patients were operated on using local anesthesia alone. Group LS patients were operated on using local anesthesia and intravenous sedation together. We found that plasma renin activity and aldosterone and vasopressin levels did not change intraoperatively in either group. We also found that intraoperative plasma human atrial natriuretic peptide (HANP) levels and systolic blood pressure were significantly elevated in group L and significantly decreased in group LS. Before local anesthesia was administered, HANP levels in both groups were already higher than the normal range in healthy adults. Therefore, these results suggest that increased HANP levels represent a compensatory response to offset further elevation of blood pressure. However, these increases did not seem to be sufficient to actually cause a decrease in blood pressure.
PMCID: PMC2148958  PMID: 19598715
Minor dental surgery; Hypertension; Elderly patient; Hormones; Volume homeostasis
24.  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
25.  A Clinical Evaluation of the Analgesic Efficacy of Preoperative Administration of Ketorolac and Dexamethasone Following Surgical Removal of Third Molars 
Anesthesia Progress  1998;45(3):110-116.
The purpose of this study was to compare the postoperative analgesic efficacy of the presurgical intravenous administration of a steroid (dexamethasone), a nonsteroidal anti-inflammatory drug (ketorolac), and a combination of the two medications. These drugs were administrated preoperatively, and their analgesic effects were assessed following the removal of four third molars using intravenous sedation (Fentany/Midazolam) and local anesthetic (2% lidocaine with 1:100,000 epinephrine). Thirty-four patients were randomly assigned to one of four groups: Group I (control), saline; Group II, 30 mg ketorolac; Group III, 8 mg dexamethasone; and Group IV, 30 mg ketorolac + 8 mg dexamethasone. Pain was assessed with the Heft-Parker graphic pain rating scale; the initial survey was completed preoperatively. The teeth were surgically removed by one of four oral and maxillofacial surgeons. Following surgery and initial recovery, the patients completed the second survey and were then admitted for overnight observation. The patients completed the remaining pain rating scales at 2-hr intervals for 12 hr. The last survey was completed at discharge (24 hr postoperatively). A postoperative narcotic analgesic was provided upon request (Tylenol 3). Pain data were assessed using one-way analysis of variance and the Duncan multiple range test (α = 0.05). At all postoperative intervals, the greatest pain scores were recorded in the control group. Statistically significant differences in pain scores were found at the 4-, 6-, 8-, and 10-hr postoperative intervals. At the 2-hr postoperative interval, pain had increased in all groups, but no differences were found among the groups. At the 4- and 6-hr interval, pain levels in Group I were significantly greater than those in Group II and Group IV, with Group III and IV not significantly different from Group II. At 10 hr, pain levels in the saline group were significantly greater than those in all the other groups. At all intervals, the only significant differences detected were found between the control group and the experimental groups; no significant differences were found at any point among any of the experimental groups. The relationship between the number of doses of narcotic medication taken postoperatively, and the preoperative intravenous regimen was assessed with a Kruskal-Wallis test. No significant difference was found among groups with respect to the need for postoperative pain medication (P > 0.05). Postoperative analgesia following third molar surgery was enhanced in the first 10 hr with the preoperative administration of ketorolac. The addition of dexamethasone did not improve the analgesic effect.
PMCID: PMC2148954  PMID: 19598716
Analgesic efficacy; Pain control; Nonsteroidal anti-inflammatory drugs; Steroids

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