Spontaneous tension pneumothorax following outpatient general anesthesia

A case is reported in which a spontaneous tension pneumothorax developed after outpatient general anesthesia with a nitrous oxide oxygen mixture. The patient was not intubated or ventilated with positive pressure on the airway. The pneumothorax could be attributed to either a postanesthetic coughing episode, the administration of nitrous oxide, which may have caused already present apical blebs to increase in size to the point of rupture, or both.     

Benzocaine-induced methemoglobinemia during general anesthesia

A case is reported in which a patient developed cyanosis under general anesthesia due to methemoglobinemia. The cause of the methemoglobinemia was benzocaine applied topically to the pharynx and trachea. When confronted with cyanosis in the absence of cardiac or pulmonary disease, one must seriously consider the diagnosis of methemoglobinemia. Supplemental oxygen should be administered and methylene blue given intravenously. If possible, determination of arterial blood gases should be made to obtain the methemoglobin concentration. Finally, all medical and dental personnel using benzocaine should be aware of the recommended dose and the possible complications of overdosage.     

Hypoxemia during outpatient general anesthesia

A high incidence of arterial oxygen desaturation during outpatient general anesthesia was found when patients were continuously monitored with the ear oximeter. The incidence of hypoxemia is minimized by the use of supplemental oxygen.     

Continuous transcutaneous O2 and CO2 monitoring during conscious sedation for oral surgery

Continuous transcutaneous oxygen and carbon dioxide monitoring during conscious sedation using diazepam, fentanyl, and methohexital indicates that hypoxia occurs in all patients maintained on room air; 36% of the patients maintained on room air showed a decrease in transcutaneous oxygen of greater than 20 mg Hg. Although the use of supplemental O2 prevented hypoxia, the combination of diazepam, fentanyl, and methohexital depressed all of the patient's carbon dioxide chemoreceptors, resulting in a rise in carbon dioxide in the oxygen-supplemented patients as well as in the patients who were maintained on room air. The need for supplemental oxygen in patients sedated with diazepam, fentanyl, and methohexital is clearly established.     

Parapharyngeal pack for oral surgery

A parapharyngeal pack that is kind to oral tissue, highly absorbent, and autoclavable is presented for use in minor oral surgery procedures under sedation and amnesic techniques.     

Blood pressure fluctuations in hypertensive patients during oral surgery

The lability of blood pressure during oral surgical procedures and the effects of antihypertensive drugs on this lability have not been investigated sufficiently to evaluate potential medical risks. The purpose of this study was to accurately evaluate blood pressure fluctuations during oral surgical procedures in three groups of patients: normotensive patients; stratum I hypertensive patients not taking medication; and stratum I hypertensive patients taking antihypertensive medication. Blood pressure measurements were recorded by an American Heart Association certified technician at baseline, immediately prior to surgery, during administration of the local anesthetic, during the surgical procedure, and 15 minutes after surgery. Analysis of variance indicated that the blood pressure fluctuations (systolic and diastolic) among these five intervals were not statistically significant for any of the groups. The clinical significance of the above findings is that stratum I hypertensive patients experience minimal fluctuations in blood pressure that are no greater than those in normotensive patients and, therefore, may present no greater clinical risk during the dental stress associated with certain oral surgical procedures.     

Electroencephalographic monitoring during general anesthesia

This paper presents a concise review of the recent advances in the field of electroencephalographic monitoring during administration of general anesthetics. It presents the history and background of this technique and describes the principles of electroencephalographic monitoring and its mathematical analysis. It concludes with a discussion of the techniques currently available for the display of the electroencephalogram as a monitoring tool and describes current clinical applications.     

Clinical assessment of etomidate for outpatient general anesthesia: a preliminary evaluation

Etomidate, a nonnarcotic, nonbarbiturate hypnotic agent, was assessed in a group of 20 patients requiring general anesthesia for outpatient oral surgical procedures. Changes in mean blood pressure, heart rate, and transcutaneous oxygen tension (PtcO2) were examined following the intravenous administration of etomidate for the induction and maintenance of general anesthesia. Clinical evidence of pain on injection, myoclonic muscle activity, apnea, nausea, and emesis were documented. A postoperative questionnaire evaluated levels of amnesia and acceptance of the drug by the patient and surgeon. No significant (P less than 0.05) change in PtcO2 occurred during etomidate infusion; however, a statistically significant but clinically insignificant change did occur in mean blood pressure and heart rate. Although myoclonic muscle activity, pain on injection, and nausea and vomiting were documented, the subjective evaluation of this agent by patient and surgeon was favorable.     

The use of the fibrin adhesion system for local hemostasis in oral surgery

In 144 patients with bleeding disorders and in 11 patients with normal coagulation, 517 wound sealings were performed using the fibrin adhesion system (FAS) with the primary object of local hemostasis. Excellent results were obtained in patients with bleeding disorders caused by impaired thrombocyte function or anticoagulant therapy. Replacement therapy or the withdrawal of anticoagulant medication was thereby avoided. Ultimate hemostasis in patients with hemophilia was achieved by fibrin sealing in combination with low-dose replacement therapy with clotting factor concentrates. Though the risk of hepatitis transmission cannot be completely ruled out, the advantages, such as excellent tissue tolerance, complete resorption, and a wide spectrum of practical uses, speak in favor of the use of this physiologic tissue adhesive.     

Neurohumorally induced cardiac dysrhythmias during nitrous oxide-oxygen-thiopental anesthesia

Barbiturate, nitrous oxide, and oxygen are commonly used by the oral and maxillofacial surgeon to anesthetize the ambulatory oral surgery patient. The authors report three cases of ventricular dysrhythmia occurring from surgical stimulation during nitrous oxide-oxygen-thiopental anesthesia. These dysrhythmias were most likely mediated via direct neural stimulation of cardiac sympathetic nerves. Concomitant with adrenergic stimulation, a rise in the arterial plasma norepinephrine level was documented, along with an increase in the rate-pressure product. Immediate recognition and treatment of ventricular dysrhythmia is mandatory to preclude further serious cardiovascular complications or death.     

The use of fibrin sealant in oral and maxillofacial surgery

A fibrin sealing system is described and its application in various oral and maxillofacial surgical procedures is discussed. The system produces hemostasis, promotes wound healing, and serves as a tissue adhesive.     

General anesthesia for the pediatric patient

The pediatric patient is not physiologically and anatomically a small adult. Comparisons and specific distinctions are presented with emphasis on the anesthetic management of children in the office. Modifications of the Bain circuit with a nasal inhaler have simplified the problem of waste gas scavenging and assisted ventilation.     

Use of scopolamine for dental anesthesia and analgesia techniques

A review of the English literature on the pharmacologic effects of scopolamine is presented and indications for the current use of the drug in dental anesthesia and analgesia are evaluated. The authors conclude that the role of scopolamine in the production of conscious sedation for outpatient dental surgery should be reevaluated in the light of contemporary findings.     

A modified auriculotemporal nerve block for regional anesthesia of the temporomandibular joint

A technique for producing regional auriculotemporal nerve analgesia is described. Undesirable side effects have been minimized by avoiding facial nerve branches and blood vessels, and injection at the site of the nerve trunk.     

Postoperative nutritional supplementation for the orthognathic surgery patient

Twenty-four orthognathic surgery patients were studied to determine the impact of a high-calorie liquid supplement on preventing or minimizing catabolism commonly associated with surgery. The experimental group of 12 subjects, chosen at random, consumed blenderized foods ad libitum and a high-calorie dietary supplement providing a minimum of 50% of energy requirements. The remaining 12 subjects consumed only blenderized foods and served as the control group. The nutritional status of all patients was assessed one day before surgery and on Day 7 of the first, third, and sixth postoperative week. In general, nutrient intake in the experimental group remained similar to that before surgery, whereas intake in the control group decreased significantly, particularly at the one-week postoperative evaluation. It was concluded that the addition of a high-calorie liquid supplement to the dietary regimen of orthognathic surgery patients helped maintain nutrient intake at a level comparable to that before surgery. This resulted in better maintenance of body weight and somatic protein compartments compared with the control group.     

Preoperative nutritional supplementation for the orthognathic surgery patient

Orthognathic surgery patients were studied to determine the nutritional adequacy of a high-calorie liquid supplement. The supplements were given for one month before surgery in an attempt to achieve a 5% weight gain and/or for six weeks after surgery to approximate 50% of the estimated caloric requirements of the patients. It was concluded that preoperative supplementation to achieve weight gain before surgery is of no apparent value. However, balanced nutrient intake can be achieved for patients when supplementation is given postoperatively at a level of 50% of estimated caloric requirements, and can result in improved nitrogen retention and protein sparing.