JDSA JOURNAL ABSTRACTS

Abstract

Akiko Shiki, Yukio Ishikura, Katsuya Ogata2009;37(1):7-14We provided flunitrazepam for behavioral management during dental treatment in cerebral palsy (CP) patients. In order to elucidate the relationship between physical condition and the effective dose of flunitrazepam in behavioral management, regression analysis was performed on categories of physical difficulty to dental treatment as independent variables and on effective doses of flunitrazepam in behavioral management of CP patients as dependent variables.Subjects and Methods: The subjects were 24 CP patients who were classified in 3 groups: A1, A2 and R (Table 1) according to the type of amenability to dental treatment. Patients in group A did not show resistant behavior such as head shaking, and were further classified in A1 and A2 according to jaw control ability. Group A1 (Adaptable 1; 8 patients) included patients who could hardly open their mouth and keep their jaw position. Group A2 (Adaptable 2; 8 patients) included patients who had a marked clenching or mouth opening reflex, which made the treatment impractical. Group R (Rejective; 8 patients) included patients who showed resistant behavior by powerful movements of their head or extremities.In order to determine the minimum effective dose of intravenously administered flunitrazepam, an increasing-dose challenge was performed in 3 steps in each group: 0.015, 0.02 and 0.03 mg/kg in groups A1 and A2; and 0.02, 0.03 and 0.04 mg/kg in group R. The third level dose, or 2 mg, was the maximum dose. In group A, the injection was terminated when the patient's rigidity disappeared, even if the whole dose had not been injected. The judgment of whether or not the dose was effective or ineffective was made 20 minutes after the injection, and based on scores related to respiration, behavior and complications (Table 2) during the 20 minutes. If the dose was judged to be effective, the study on the patient was concluded. Regression analysis was performed on the data shown in Table 3.Results: The resulting correlation coefficient of 0.73 was significant (p<0.01). The Multiple R value was 0.53 (Table 3). The characteristics of the problems after the administration of flunitrazepam in each group have been described and are shown in Figures 1 and 2.Conclusion: The results suggest that the category of amenability to dental treatment contributes to the level of the effective dose of flunitrazepam in behavioral management of CP patients.Ogata Dental ClinicKenji Murata, Yasuhiko Kato, Tomomi Kohara, Mari Umemura, Motoko Ishikawa, Hideyuki Matsui, Hisako Kishimoto*, and Junichiro Kotani2009;37(1):15-19.We report two cases who developed intractable convulsion and unconsciousness in patients undergoing dental treatment who were diagnosed with conversion disorder.Case 1 was a 31-year-old female diagnosed with conversion disorder and epilepsy, who was dependent on medical treatment and drugs. For this patient, we performed tooth extractions over several different sessions under intravenous sedation. She often developed unconsciousness and convulsions with hyperventilation during and after the treatment, although her state of consciousness was not correlated with the dosage of the sedative drug employed. To find out whether convulsion was due to epilepsy or conversion disorder, we assessed the state of consciousness by using a bispectral index (BIS) monitor. Although the results of such monitoring are not completely reliable, we considered them useful for diagnosing epilepsy in this case.Two years later, she had several dental treatments under intravenous sedation, and we were able to complete the dental treatment without any complication of convulsion or loss of consciousness. However, the patient developed several episodes of hyperventilation.Case 2 was a 26-year-old female who developed convulsions and unconsciousness during dental treatment, which was not ameliorated by administration of diazepam and phenobarbital. The patient was transported to a nearby hospital, where she received an intravenous administration of midazolam, which stopped the convulsions. They also conducted cerebral CT scan and electroencephalogram examinations, but no abnormalities were recognized. The patient was then admitted to a psychiatry department of a hospital, where she was diagnosed with conversion disorder. After being discharged, we performed a number of dental treatments without any complications, which made us believe that the steroids and isoniazid drugs that have been taken by the patient may have accounted at least in part for the convulsion.From our experience in the above cases, we conclude that it is difficult to fully assess the various degrees of conversion disorder in patients undergoing dental treatment. In case 1, we performed dental treatment with intravenous sedation, but the symptoms were difficult to control the first time. In order to elucidate the consciousness state of the patient and diagnose whether the convulsions were due to epilepsy, the BIS monitor was useful. In case 2, we found that in order to effectively diagnose and treat patients with conversion disorder, it is important to consider the possible side effects caused by commonly used drugs taken by these kind of patients as well as their environmental and psychological state and background.Department of Anesthesiology, Osaka Dental University*Kishimoto Dental ClinicYukiko Otsubo, Masahiro Kemmochi*, Yumiko Matsuura*, Hideki Mamiya*, Tatsuya Ichinohe*, and Yuzuru Kaneko37(1):20-24.Rhabdomyolysis is derived from skeletal muscle cell disruption. The disrupted muscle cells release several intracellular substances such as creatine phosphokinase (CK), lactate dehydrogenase (LDH), myoglobin and potassium into the interstitial space and serum. The main causes of rhabdomyolysis include direct muscular injury, strenuous exercise, seizure, infection, hyperthermia, drugs, and endocrinopathies.We report a case of rhabdomyolysis with creatine phosphokinase (CK) elevation and myogloblinuria after general anesthesia. A 37-year-old male patient who had undergone sagittal splitting ramus osteotomy (SSRO) under general anesthesia using propofol, vecuronium bromide and fentanyl was scheduled for plate removal one year after the first surgery. At the general anesthesia for SSRO surgery, there was no apparent problem except slight CK elevation (302 IU/l).Preoperative evaluation at this time showed similar results that CK was slightly elevated (366 IU/l). Anesthesia was induced with fentanyl citrate, atropine sulphate and propofol. Muscle relaxation was facilitated with rocuronium bromide and nasotracheal intubation was performed. Anesthesia was maintained with air, oxygen and sevoflurane. The course of anesthesia was uneventful. At emergence, the patient complained of muscle pain at both femoral regions. However, its intensity was gradually decreased. The urine color immediately after arrival at the recovery room in the ward was normal. However, five hours after surgery, dark reddish brown urine without high fever was observed. In addition, CK value was elevated. Therefore, rhabdomyolysis was suspected. We performed urethral catheterization and fluid loading was started. Time course of urine output was recorded. The peak CK and myoglobin level was 66,432 IU/l and more than 3,000 ng/ml, respectively. However, no critical complication such as acute renal failure was developed. These data were improved from the first postoperative day and the patient was discharged on the fifth postoperative day. Although the cause of this case was unclear, this appeared to be a case of rhabdomyolysis that developed after general anesthesia.Department of Anesthesiology, National Defense Medical College*Department of Dental Anesthesiology, Tokyo Dental CollegeNaotaka Kishimoto, Shingo Sugioka, Kayoko Hashimoto, Yuki Kan, Hideyuki Matsui, Yoko Nunotani, Yoko Hakumoto, Yasuhiko Kato, Yoshihiro Momota, Yasushi Sakuma, and Junichiro Kotani2009;37(1):25-29Remifentanil is a very short-acting and selective μ opioid receptor agonist, which has been considered effective for relatively short surgical procedures. Although the efficacy and safety of remifentanil combined with general anesthetics have been widely reported, there are only a few reports regarding oral and maxillofacial surgery. We evaluated the use of remifentanil combined with sevoflurane or propofol for general anesthesia, and compared the difference in anesthesia recovery and postoperative pain between the two groups. One hundred-two general anesthetic cases at the Osaka Dental University Hospital that received general anesthesia with remifentanil between January and July 2007 were divided in two groups: air, oxygen and sevoflurane anesthesia group (AOS), and air, oxygen and propofol anesthesia (AOP) group. The AOS group and the AOP group were retrospectively analyzed and compared postoperatively regarding time to extubation, postoperative nausea and vomiting (PONV), postoperative analgesia, sore throat, and the administration of analgesics. No significant difference was observed between the AOS group and AOP group (Table 1–3); except that the frequency of a postoperative sore throat was lower in the AOS group (Table 4). PONV and shivering are considered to be common complications, but the frequency of these complications is low. Although PONV and shivering are frequently caused by the administration of general anesthetics, these were probably ameliorated by the use of dexamethasone and aggressive heating, respectively. The short duration of action after the administration of remifentanil, which is a major property of the drug, can be a disadvantage in postoperative pain management.In the present study, early postoperative regional pain was frequently observed. The results suggest the importance of active pain control in the early postoperative period, even in low invasive oral and maxillofacial surgery where local anesthesia has a rapid action.Department of Anesthesiology, Osaka Dental University