General Anesthesia Management Research Articles

Case Report: Dental treatment under general anesthesia and dental management of a child with congenital ichthyosis

Case Report: Dental treatment under general anesthesia and dental management of a child with congenital ichthyosis

Evaluating Large Language Models in Dental Anesthesiology: A Comparative Analysis of ChatGPT-4, Claude 3 Opus, and Gemini 1.0 on the Japanese Dental Society of Anesthesiology Board Certification Exam.

Purpose Large language models (LLMs) are increasingly employed across various fields, including medicine and dentistry. In the field of dental anesthesiology, LLM is expected to enhance the efficiency of information gathering, patient outcomes, and education. This study evaluates the performance of different LLMs in answering questions from the Japanese Dental Society of Anesthesiology Board Certification Examination (JDSABCE) to determine their utility in dental anesthesiology. Methods The study assessed three LLMs, ChatGPT-4 (OpenAI, San Francisco, California, United States), Gemini 1.0 (Google, Mountain View, California, United States), and Claude 3 Opus (Anthropic, San Francisco, California, United States), using multiple-choice questions from the 2020 to 2022 JDSABCE exams. Each LLM answered these questions three times. The study excluded questions involving figures or deemed inappropriate. The primary outcome was the accuracy rate of each LLM, with secondary analysis focusing on six subgroups: (1) basic physiology necessary for general anesthesia, (2) local anesthesia, (3) sedation and general anesthesia, (4) diseases and patient management methods that pose challenges in systemic management, (5) pain management, and (6) shock and cardiopulmonary resuscitation. Statistical analysis was performed using one-way ANOVA with Dunnett's multiple comparisons, with a significance threshold of p<0.05. Results ChatGPT-4 achieved a correct answer rate of 51.2% (95% CI: 42.78-60.56, p=0.003) and Claude 3 Opus 47.4% (95% CI: 43.45-51.44, p<0.001), both significantly higher than Gemini 1.0, which had a rate of 30.3% (95% CI: 26.53-34.14). In subgroup analyses, ChatGPT-4 and Claude 3 Opus demonstrated superior performance in basic physiology, sedation and general anesthesia, and systemic management challenges compared to Gemini 1.0. Notably, ChatGPT-4 excelled in questions related to systemic management (62.5%) and Claude 3 Opus in pain management (61.53%). Conclusions ChatGPT-4 and Claude 3 Opus exhibit potential for use in dental anesthesiology, outperforming Gemini 1.0. However, their current accuracy rates are insufficient for reliable clinical use.These findings have significant implications for dental anesthesiology practice and education, including educational support, clinical decision support, and continuing education. To enhance LLM utility in dental anesthesiology, it is crucial to increase the availability of high-quality information online and refine prompt engineering to better guide LLM responses.

The anesthetic management of a child with ohtahara syndrome and severe stridor: a case report

BackgroundOhtahara syndrome is a progressive developmental and epileptic encephalopathy that manifests in the early infantile period. This rare condition is characterized by intractable seizures, psychomotor retardation, and poor prognosis. To date, there are a handful of case reports regarding the anesthetic management of children with Ohtahara syndrome. However, limited reports exist of patients with Ohtahara syndrome who present with difficult airways. This report describes our airway findings and general anesthetic management of a pediatric patient with Ohtahara syndrome undergoing diagnostic bronchoscopy for severe inspiratory stridor.Case presentationA 14-month-old, 9 kg, male patient with Ohtahara syndrome presented with a year-long history of severe inspiratory stridor and was scheduled for bronchoscopy with lavage. On exam, the patient had noisy breathing, was non-verbal with developmental delay, and had poor head control with significant central hypotonia. The patient was induced with ketamine and general anesthesia was maintained with propofol. Bronchoscopic evaluation was completed uneventfully and revealed a diagnosis of laryngotracheomalacia. The patient’s breathing was maintained spontaneously throughout the procedure and no seizures were noted. In the post anesthesia care unit, the patient’s respiratory and cardiovascular function were stable.ConclusionsThis report documents the unusual finding of severe inspiratory stridor in a 14-month-old child diagnosed with Ohtahara syndrome and our anesthetic management during their diagnostic bronchoscopy. Currently, documentation of complex airway pathology present in patients with Ohtahara syndrome is limited and should be further evaluated. This will assist pediatric anesthesiologists as these patients may require careful preoperative assessment, thoughtful airway management, and surgical alternatives on standby.

Remimazolam for general anesthesia in a patient with aortic stenosis and severe obesity undergoing transcatheter aortic valve implantation

IntroductionThere is currently limited research on the clinical use of remimazolam in severely obese patients. In this report, we describe the anesthesia management of transcatheter aortic valve implantation (TAVI) in a severely obese patient using remimazolam.Case descriptionA 76-year-old woman (height 1.54 m; total body weight 104 kg; body mass index 43.9 kg/m2) was scheduled for TAVI via the femoral artery approach for aortic valve stenosis. Preoperative echocardiography showed an aortic valve peak flow of 4.0 m/s and an effective orifice area of 0.75 cm2. Anesthesia induction was performed with a bolus dose of 100 μg fentanyl, 15 mg remimazolam, 60 mg rocuronium, and a continuous infusion of remifentanil at 0.4 mg/h. Intraoperatively, remimazolam was administered at a rate of 35 mg/h. General anesthesia management was completed without any complications, although the patient required temporary catecholamine and inhalation anesthesia assistance due to hemodynamic changes.ConclusionOwing to its pharmacological advantages, remimazolam may be an option for anesthesia induction and maintenance in severely obese patients with unstable circulation.

Dental treatment outcomes in Thai children treated for severe early-childhood caries under general anaesthesia and non-pharmacological behaviour management: a retrospective study

PurposeThe aim of this study was to compare dental-treatment outcomes, oral-hygiene improvement, and patient co-operation during follow-up visits between children treated under general anaesthesia (GA) and non-pharmacological behaviour management (NP).MethodsThis retrospective study reviewed the dental chart records of healthy patients less than 71-month-old with severe early childhood caries (S-ECC) from 2008 to 2020 with at least a 6-month follow-up. The demographical data, dental-treatment outcomes, oral-hygiene status, and patient behaviour at the follow-up visits were analysed by the Mann–Whitney U test, Pearson’s Chi-square, Fisher’s exact test, Friedman test, and Wilcoxon test with a significance level of 0.05.ResultsThis study included 210 GA cases and 210 age-matched control NP cases. The GA group had a significantly higher caries experience, lower patient co-operation, poorer oral hygiene, and higher number of complex dental treatment than the NP group at baseline (p < 0.001). The number of children who had incomplete dental treatment under non-pharmacological behaviour management was higher than the GA group. After treatment, the number of new carious teeth in the NP group was significantly higher than in the GA group only at the 6-month follow-up. However, there was no significant difference in treatment failure, oral-hygiene improvement, and patient behaviour between groups.ConclusionAlthough patients in the GA group had higher dental and behaviour problems than the NP group, the overall dental-treatment outcomes, including oral hygiene and behaviour improvement, were not significantly different between groups Therefore, regular follow-up and preventive treatment in the maintenance phase are essential for children with severe early-childhood caries.

Development and Validation of the SCAN-Score to Indicate General Anesthesia for Dental Care in Children.

Background: General anesthesia is an approach used to address behavior issues in pediatric dentistry. This indication often relies on the practitioner's discretion rather than objective criteria. We developed SCAN-score to assist pediatric dentists in the case of doubt to indicate general anesthesia for uncooperative children. The study aims were to assess the validity of the SCAN-score, which aims to indicate general anesthesia or chairside management for dental care. Methods: A retrospective study was performed on children aged between 2 and 10 years who received dental care. The SCAN-score combined three item scales (age, need of care, behavior) and three additional factors: communication barriers, permanent teeth caries, and local anesthesia contraindications. Mean scores were estimated. An ROC curve was constructed with sensitivities and specificities obtained. Results: The study included 284 children, with 154 treated through chairside methods and 130 treated under general anesthesia. The mean score was 5.6 ± 2.8 in the chairside management group and 12.9 ± 1.9 in the general anesthesia group. The sensitivity of the score (cutoff at 10) was 0.99, and the specificity was 0.94. The estimate of the ROC is 0.994. Conclusions: The SCAN-score appears to be an excellent tool to support the practitioner's decision to refer to general anesthesia care.

General anesthesia for maternal surgery during pregnancy: dogmas, myths and evidence, a narrative review

Up to 1% of pregnant women require general anesthesia and maternal non-obstetric surgery during pregnancy, of which urgent abdominal procedures are most commonly indicated. This narrative review summarizes several dogmas and myths on the management of general anesthesia during pregnancy and the corresponding evidence. While historical studies found delayed gastric emptying during pregnancy, recent evidence concluded that gastric emptying remains nearly normal during the entire pregnancy until the onset of labor. To correctly estimate the aspiration risk, gastric ultrasound should be increasingly performed. Based on the available evidence, the application of cricoid pressure should be discouraged during rapid sequence induction of pregnant women. A cuffed endotracheal tube is traditionally recommended, but laryngeal masks have been used in &gt; 9000 patients undergoing cesarean section without observation of aspiration. All material to manage a difficult airway should be available as difficult intubation remains an ongoing concern in obstetrics. Risk factors for difficult intubation are nonobstetric in nature. Due to the lack of evidence for hemodynamic management, it is not possible to make an evidence-based recommendation. We recommend to adhere to the expert opinion of maintaining maternal blood pressure close to the normal physiologic value by using (15°-)30° left lateral tilt position, intravenous fluids and noradrenaline or phenylephrine. Most recent clinical observational studies suggested to consider laparoscopic over open surgery as a standard treatment for abdominal surgery. While animal studies observed impaired fetal brain development after prenatal anesthesia exposure, this could not be confirmed by an observational clinical study.

General Anaesthesia Management in a Patient Diagnosed with Kabuki Syndrome and Review of the Literature

General Anaesthesia Management in a Patient Diagnosed with Kabuki Syndrome and Review of the Literature

Ultrasound-Guided Dorsal Penile Nerve Block in Children: An Anatomical-Based Observational Study of a New Anesthesia Technique.

Dorsal penile nerve block stands out as one of the commonly employed regional anesthetic techniques in children. Despite the large body of experience, failure rates are still significant. We included 20 children (median (SD) age of 73 (31) months) scheduled for circumcision without general anesthesia and secondary airway manipulation in a consecutive case series. Under ultrasound guidance and utilizing an in-plane needle guidance technique, the dorsal penile nerve block was administered with slight sedation, and spontaneous respiration was maintained in all cases. To investigate the underlying anatomy for dorsal penile nerve blockade, we dissected three cadavers. The primary study endpoint was the success rate of surgical blockade, meaning that the surgical procedure could be performed without additional general anesthesia and invasive airway management. The secondary endpoint was the requirement of analgesics until discharge from the post-anesthesia care unit. The primary endpoint was successfully met in all patients according to our strict definition without additional general anesthesia or airway manipulation. In addition, no child received analgesics until discharge from the recovery room. The anatomical investigation clarified the specific anatomy as baseline knowledge for an ultrasound-guided dorsal penile nerve blockade and enabled successful performance in 20 consecutive children where penile surgery was possible in light sedation without additional airway manipulation.

Management of General Anesthesia in Difficult Airway: A Case Report

When dealing with clinical disorders known as difficult airways, airway management during general anesthesia still presents challenges. A cross-sectional study done in Indonesia in 2016 found that 28 out of 250 patients receiving general anesthesia had respiratory problems. The existing algorithm must be properly and effectively managed in order to resolve this issue. This case report discusses a 14-month-old pediatric patient with right preauricular lymphoma who will undergo tumor biopsy surgery using general anesthesia. The size of the tumor mass that has grown and covered the patient's airway makes it difficult to manage the airway during general anesthesia, making intubation impossible. To overcome this, bagging was carried out by improvising the technique of reversing the position of the mask cover on the patient during the operation. The patient can be saved and allowed to go home after treatment. Appropriate management during perioperative especially related to airway management will produce good results for patient health and safety. With this case report, hopefully it can add knowledge and an alternative ventilation technique if you encounter a similar case.&#x0D; &#x0D; Keywords: difficult airway, general anesthesia, lymphoma preauricular

Anesthetic management with remimazolam in very elderly patients undergoing hybrid surgery of transcatheter aortic valve implantation plus off-pump coronary artery bypass grafting: report of two cases

BackgroundRemimazolam is a short-acting benzodiazepine with small circulatory depression. We used remimazolam for general anesthesia management in two very elderly patients undergoing hybrid surgery of transcatheter aortic valve implantation (TAVI) plus off-pump coronary artery bypass grafting (OPCABG).Case presentationA 96-year-old man (case 1) and a 92-year-old woman (case 2) had complex coronary artery disease (CAD) and severe aortic stenosis (AS) and were scheduled for TAVI plus OPCAB. Anesthesia in both patients was induced with 6 mg/kg/h remimazolam and fentanyl and maintained with 0.3 mg/kg/h and 0.5 mg/kg/h remimazolam and fentanyl, respectively. Although catecholamines were required, we successfully maintained circulation during the induction of anesthesia and the procedures of OPCAB and TAVI. Both patients were discharged without complications.ConclusionRemimazolam can be a useful option for safe general anesthesia in very elderly patients when performing hybrid surgery.

General Anesthetic Management for Foramen Magnum Decompression and Tonsillectomy in a Patient with Arnold-Chiari Malformation Type 1: A Case Report

Arnold-Chiari Malformation Type 1 (ACM-1) is a neuroanatomical anomaly leading to unique anesthesia challenges. We detail the anesthetic management of a 35-year-old female with ACM-1 undergoing foramen magnum decompression and tonsillectomy. Her obesity and tonsillectomy history posed postoperative risks, requiring specialized care. After surgery, she was monitored in the intensive care unit for 24 hours under sedation, then successfully extubated. She was discharged two weeks later without complications. Proper management of ACM-1 patients demands expert collaboration, thorough assessment, and tailored anesthesia planning for surgical safety and success.

General anesthetic management in two patients with an anaphylaxis history cholinergic urticaria

BackgroundCholinergic urticaria is triggered by an increased body temperature after exercise, passive warming, or emotional stresses. The anesthetic management used for two patients with an anaphylaxis history after cholinergic urticaria is described.Case presentationPatient 1: A 34-year-old female was scheduled for a right-side thyroidectomy. At 27 years old, she experienced post-exercise anaphylaxis and repeated episodes of hives following exercise, sunbathing, mental stresses, and the consumption of spicy foods. Patient 2: A 35-year-old female was scheduled for a laparoscopic ovarian cystectomy. At 19 years old, she experienced anaphylaxis after a long bath and then hives after hot showers, bicycle riding, and long walks. For both patients, intraoperative passive warming was not performed to prevent excessive warming, and prophylactic antiemetics and multimodal analgesia were used to minimize their perioperative stresses.ConclusionCareful anesthetic management is necessary to prevent anaphylaxis during anesthesia in a patient with a history of cholinergic urticaria.

Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage.

Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3days after the onset of symptoms. Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.

Tanı Konulmamış Nöromüsküler Hastalığı Olan Gebenin Acil Sezaryen için Anestezi Yönetimi

A 30 year-old ASA II pregnant woman with an undiagnosed neuromuscular disease at 41 weeks of gestation was admitted to our hospital. Neurological examination is normal except lower extremity weakness that has been ongoing for the last 10 years. In this case report, we aimed to discuss general anesthesia management for emergency cesarean section of this particular pregnant woman.

A prospective observational study of recall of discomfort on tracheal extubation after general anaesthesia

BackgroundTracheal extubation is a critical stage in the management of general anaesthesia during which serious complications may occur. Immediately before extubation, patients often exhibit signs that suggest that they are awake and experiencing discomfort. There is concern that patients may retain such memories of the extubation process. However, previous studies have not examined patient recall of extubation in detail. We therefore investigated the frequency of recall of discomfort during extubation, as well as first orientation to place, and other recollections upon emerging from general anaesthesia. MethodsIn a prospective observational study, 818 patients were interviewed during routine post-anaesthesia rounds on the day after general anaesthesia. The primary outcome was the proportion of patients recalling discomfort during extubation. The secondary outcome was the location of orientation to place upon emerging from general anaesthesia. ResultsRecall of discomfort during extubation was uncommon, at 1.1% (n=9; 95% confidence interval [CI]: 0.5–2.1%). Only 3.1% of patients recalled the extubation process at all (n=25; 95% CI: 2.0–4.5%). The first orientation to place was most commonly in transit to a ward, in 41% of cases (n=337; 95% CI: 38–45%). ConclusionsRecall of discomfort during extubation appears to be rare, and the great majority of patients may not retain any memory of the extubation process. This information may be used to reassure patients and guide extubation practices for anaesthetists. Clinical trial registrationUMIN Clinical Trials Registry (UMIN000046136).

Effects of qCON and qNOX-guided general anaesthesia management on patient opioid use and prognosis: a study protocol

IntroductionThe adverse effects of general anaesthetic drugs (especially opioids) cannot be ignored. However, current nociceptive-monitoring techniques still lack consistency in guiding the use of opioids. This trial will study the...

Management of general anaesthesia in a patient with beta thalassaemia major

Management of general anaesthesia in a patient with beta thalassaemia major

Clinical Improvement and Tumor Regression in Parturient With a Brain Tumor and Intracranial Bleeding After C-Section with General Anesthesia

Brain tumors and intracranial bleeding are rare cases in pregnancy. Anesthesia management for a C-section with comorbidity remains challenging. We presented a 33-year-old woman (34–36 weeks pregnant) with the complaint of weakness in her right extremities, blurred vision, and ptosis of her left eye from a month before hospitalization. The brain computed tomography (CT) revealed a mass at the left parasellar region with a bleeding component and cerebral edema accompanied by subfalcine herniation. We conducted general anesthesia for cesarean delivery in a patient with a brain-protective technique. Brain CT revealed a decrease in the mass size and neither intracranial bleeding nor cerebral edema. In conclusion, general anesthesia management provided a good outcome in a parturient with a brain tumor and intracranial bleeding that underwent C-section. The mechanism of clinical improvement and tumor regression is unclear and requires further research, but it is believed that it is related to pregnancy hormones.

Prediction of Postoperative Pulmonary Complications in Patients Undergoing Functional Endoscopic Sinus Surgery: A Cohort Study

Introduction: Considering the pathophysiology of nasal obstruction, changes in certain parameters such as Peripheral Blood Eosinophil Count (PBEC), bedside pulmonary function test, Peak Expiratory Flow Rate (PEFR), and Electrocardiography (ECG) may have some correlation with postoperative pulmonary complications such as upper airway obstruction, loss of pharyngeal muscle tone, and postobstructive pulmonary oedema. Aim: To observe and analyse the changes in PBEC, bedside pulmonary function test, PEFR, and ECG in patients undergoing Functional Endoscopic Sinus Surgery (FESS). Materials and Methods: A prospective cohort study was conducted at Bharati Hospital, Pune, Maharashtra, India over a two-year duration from December 2020 to October 2022. A total of 50 patients aged above 18 years undergoing FESS surgery were included in the study. The statistical analysis was performed using the Chi-square test and student’s t-test. After thorough preoperative evaluation, the aforementioned predictors were recorded. General anaesthesia management for FESS surgery was done according to the standard protocol. Vigilant intraoperative monitoring of vital parameters including peak airway pressure and plateau pressure was performed. After shifting the patients to the recovery room, they were observed for: 1) Hypoxia; 2) Hypercarbia; 3) Laryngospasm; 4) Bronchospasm; and 5) Pulmonary oedema. Results: A total of 50 patients aged between 18 years and 65 years with the mean age was 41.7±15.4 years were included in the study, with 32 males and 18 females. Only 24% of the study population showed postoperative hypoxia, while the rest of the complications were not observed in any patient. Changes in eosinophil count, PEFR, and ECG did not have any correlation with postoperative hypoxia and were statistically insignificant. Bedside pulmonary function tests, including the Sabrasez breath-holding test and the Sabrasez single breath count test, showed changes in 30% and 76% of patients, respectively. Forced Expiratory test change was seen in 72% of patients. Among these, 19.4% showed hypoxia. Out of the 12 cases showing postoperative hypoxia, seven had a disease duration of less than six months. Conclusion: The Sabrasez breath-holding test and Sabrasez single breath count are good predictors for postoperative hypoxia in patients undergoing FESS surgery. Shorter duration of nasal obstruction also showed postoperative hypoxia.