靶控输注异丙酚和异丙酚复合瑞芬太尼镇静在小儿埋伏多生牙拔除手术中应用的比较

目的 对靶控输注异丙酚和异丙酚复合瑞芬太尼2种镇静方法在小儿埋伏多生牙拔除手术中的应用进行比较。方法 将60例接受上前牙区埋伏多生牙拔除术的患儿随机分为2组：异丙酚组（P组,n=30）和异丙酚复合瑞芬太尼组（PR组,n=30）。P组：滴定法靶控输注异丙酚至改良OAA/S评分3分时进行手术。PR组：靶控输注瑞芬太尼目标浓度为1 ng·mL^-1,滴定法靶控输注异丙酚至改良OAA/S评分3分时进行手术。采用Houpt行为治疗效果评分评估2组患儿术中配合情况,记录2组患儿心率、血压、血氧饱和度、呼吸频率和Narcotrend指数（NI）,以及相关并发症、不良反应及药物输注情况。结果 Houpt行为治疗效果评分PR组优于P组（P<0.05）。血氧饱和度、呼吸频率PR组低于P组（P<0.05）,心率、血压及NI值2组无统计学差异（P>0.05）。呼吸抑制和顺行性遗忘的发生率,PR组高于P组（P<0.05）。结论 在小儿埋伏多生牙拔除术中,靶控输注异丙酚和靶控输注异丙酚复合瑞芬太尼镇静这2种方法都是安全有效的。在吸氧状态下,靶控输注异丙酚复合瑞芬太尼镇静优于异丙酚镇静。     

Patient-controlled sedation with propofol in minor oral surgery.

PURPOSE: We sought to evaluate the benefits of patient-controlled sedation with propofol for minor oral surgery. PATIENTS AND METHODS: After instructions were given on how to use the technique, 28 male and 24 female patients sedated themselves during minor oral surgery with titrating 18-mg bolus doses of propofol with a lockout period of 1 minute. RESULTS: Surgery lasted from 5 to 29 minutes; 28 patients were moderately and 17 were deeply sedated. Seven patients were oversedated. All of those who were oversedated responded to commands within 1 minute of being unresponsive and continued to obtain increments of propofol. Vital signs were stable in all patients even during oversedation. Eighteen patients were talkative, and 17 complained of pain along the vein. Operating conditions were good in 38, fair in 12, and poor in 2. The majority, 48 patients, were relaxed, and 47 were willing to undergo the sedation technique again. Ten had total, 22 had partial, and 20 had no amnesia. CONCLUSIONS: Relaxed patients, good operating conditions, and quick recovery of oversedated patients without unstable vital signs provide evidence that propofol has favorable pharmacokinetic and pharmacodynamic properties for patient-controlled sedation. This study also highlights the importance of close monitoring of patients during patient-controlled sedation.     

Comparison of a bolus of fentanyl with an infusion of alfentanil during target-controlled propofol infusion in third molar extraction under conscious sedation.

PURPOSE: This study was designed to compare hemodynamic changes, respiratory depression, and patient satisfaction between a bolus of fentanyl and an infusion of alfentanil during target-controlled propofol infusion in third molar extraction under conscious sedation. PATIENTS AND METHODS: Forty patients were randomly assigned to receive either a bolus of fentanyl (n = 24) or an infusion of alfentanil (n = 16) in combination with target-controlled propofol infusion. Hemodynamic changes, respiratory depression, sedation, and cooperation scores were recorded during surgery and patient satisfaction scores were assessed after surgery. RESULTS: Changes in mean blood pressure, heart rate, or oxygen saturation within and between the groups were not significant throughout the procedure. There were no significant differences in sedation, cooperation, and patient satisfaction scores between the 2 groups. CONCLUSION: Because there was no difference in hemodynamic variables and patient satisfaction scores between a bolus of fentanyl and an infusion of alfentanil during target-controlled propofol infusion, both combinations are suitable for conscious sedation in third molar extraction.     

Patient maintained propofol sedation for dental surgery

AIM: This study evaluated a system for patients to operate a target-controlled infusion (TCI) of propofol for sedation. PARTICIPANTS: 50 healthy adults, undergoing minor oral surgical procedures under local anaesthesia. METHODS: Following instructions, patients were allowed to control their own sedation to comfortably undergo surgery. Outcome Measures: Operating conditions, degree of sedation, vital signs and patients' assessment of the technique. RESULTS: Operating conditions were described as good in 47 patients and fair in 3. Optimal sedation was provided at a median target blood concentration of 2 mcg/ml (range1-3mcg/ml). 30 were sedated moderately, 16 deeply and 4 mildly. None were oversedated. The vital signs were stable in all patients. 30% of patients had injection pain and 28% became talkative. Patient satisfaction was high with 86% feeling adequately relaxed and 92% willing to use it again. 14 patients had complete and 22 had partial amnesia for the procedure. CONCLUSIONS: This technique combines the benefits of target-controlled infusion with patient-controlled feedback and produces safe dental sedation.     

Moderate intravenous sedation for office-based full face laser resurfacing using a continuous infusion propofol pump.

PURPOSE: The purpose of this study was to compare the anesthetic requirements and hemodynamic and oxygenation variables involved between the bolus midazolam/fentanyl intravenous sedation-analgesia technique, and the same technique combined with continuous-infusion propofol. PATIENTS AND METHODS: This was a retrospective chart analysis of 41 consecutive patients undergoing full-face carbon dioxide laser resurfacing with either bolus midazolam/fentanyl (n = 15) or midazolam/fentanyl with continuous propofol infusion anesthesia (n = 26) techniques. Data recorded were noninvasive baseline and intraoperative hemodynamic measurements at 5-minute intervals for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), pulse pressure (PP), pulse (P), and rate-pressure product (RPP), respiratory rate (RR), and oxygen saturation (SpO2). Data collected were reported as mean values with standard deviation. Statistical analyses were performed with the Student's t test and found statistically significant for P < .05. RESULTS: Statistically significant decreases in averages were seen in SBP (P < .001), DBP (P = .02), MAP (P = .004), P (P < .00l), RPP (P < .00l), and RR (P < .001), but not PP (P = .4) and SpO2 (P = .08) in the midazolam/fentanyl/continuous propofol infusion group compared with the midazolam/fentanyl only group. Changes from baseline were statistically significant only for MAP (P = .04), but statistically insignificant for all other measurements, SBP (P = .7), DBP (P = .4), P (P = .95), PP (P = .97), RPP (P = .6), RR (P = .6), and SpO2 (P = .4). Statistically significant smaller amounts of midazolam (P = .01) and fentanyl (P < .001) were used in the midazolam/fentanyl/continuous propofol infusion pump group. Length of procedure was statistically insignificant between groups (P = .4). Conclusion The addition of a continuous propofol pump maintained hemodynamic and oxygenation values close to baseline, while decreasing the amount of respiratory depressing opiates administered and without affecting the length of the procedure.     

Teaching oral surgery to undergraduate students: a pilot study using a Web-based practical course

The Internet has been used in oral surgery teaching mainly to deliver learning material across the World Wide Web and to make use of online interactivity resources in everyday surgical practice, such as by e-mails, discussion groups, and chats. The aim of this paper is to describe and evaluate a Web-based practical course on oral surgery principles, which was applied to undergraduate students. This course was investigated as a distance learning simulation in which the student would be performing surgical activities at home, and the teacher and the school environment would be absent. A Web site was created containing the course material. For this study, the students participated in the Web-based course in a multimedia lab equipped with computers and Internet, internal sound system and TV circuits. In the event of significant mistakes by students, the TV circuit could be used to show the correct procedure for all the participants at the same time. Microcameras were used to monitor the student's actions during the Internet use. Students' impressions were determined by a questionnaire. Computer manipulation with ease and antiergonomic postures were observed. We concluded that distance learning courses with practical modules must be considered as a special type of educational modality, with reference to the relationship between the student and the computer.     

不同镇静药对口腔颌面外科术后留置气管导管患者的镇静作用

目的: 探讨不同镇静药对口腔颌面外科术后留置经鼻腔气管导管患者的镇静作用及其可能的不良反应。方法: 将60例口腔颌面外科术后留置经鼻腔气管导管患者按随机数字表法为3组,每组20例。患者入ICU后,各组患者均采用氢吗啡酮镇痛,分别采用咪达唑仑、丙泊酚和右美托咪定镇静,分别记录入ICU镇静前(T₀)和镇静开始后30 min(T₁)、1 h(T₂)、2 h(T₃)、6 h(T₄)、12 h(T₅)和拔管后10 min(T₆)各时间点Ramsay镇静评分和BPS镇痛评分以及生命体征;记录各组患者不良反应发生率。采用SPSS 19.0软件包对数据进行统计学分析。结果: 咪达唑仑、右美托咪定和丙泊酚Ramsay评分差异无统计学意义(P>0.05)。在T₃、T₄、T₅时,右美托咪定组BPS评分均显著低于咪达唑仑组和丙泊酚组(P<0.05)。3组患者低血压发生率差别无统计学意义(P>0.05);心动过缓发生率右美托咪定组显著高于与丙泊酚和咪达唑仑组(P<0.05);右美托咪定组和丙泊酚组患者并发躁动的人数显著低于咪达唑仑组(P<0.05)。结论: 右美托咪定和咪达唑仑、丙泊酚均能满足ICU患者的镇静需要,且右美托咪定具有一定的镇痛作用,可减少ICU患者躁动发生率。     

异丙酚靶控输注用于口腔颌面外科盲探插管麻醉的效果评价

目的:观察异丙酚靶控输注(TCI)用于口腔颌面外科盲探插管麻醉的效果。方法:将80例口腔颌面外科气道困难病例等分为4组,均采用盲探气管插管新技术插管。插管前,组Ⅰ、组Ⅱ、组Ⅲ给予芬太尼4μg/kg,并分别按1.0μg/ml、1.5μg/ml、2.0μg/ml的靶血药浓度实施异丙酚TCI;组Ⅳ仅给予芬太尼4μg/kg。所有患者均用局麻药完善气管内表面麻醉,观察比较4组插管的麻醉效果。结果:组Ⅱ和组Ⅲ的Ramsay镇静评分较用药前明显上升,插管中其分值也显著高于其他组(P<0.05);插管中,组Ⅱ和组Ⅲ的MAP、HR稳定;组Ⅰ和组Ⅳ显著上升(P<0.05);插管中,4组RR均明显下降,其中,以组Ⅲ最为明显(P<0.05),但4组的SpO2、PETCO2均无显著变化;4组的血浆PRL和血浆AⅡ插管后较插管前均有不同程度的明显上升,组Ⅳ升幅明显高于组Ⅲ(P<0.05)。结论:异丙酚靶控输注有助于完善盲探插管麻醉,在控制合适靶血药浓度的前提下,这种方法是安全可行的。     

TCI异丙酚镇静在牙科畏惧症小儿拔牙术的应用

目的:观察56例牙科畏惧症小儿行拔牙手术时采用靶控输注(target controlled infusion,TCI)异丙酚镇静的效果,探讨靶控输注镇静剂方式在牙科畏惧症小儿拔牙时的安全性及适用性.方法:56例牙科畏惧症拔牙小儿静脉TCI异丙酚,血浆靶控浓度设定为1.5μg/ml,测定镇静后拔牙时小儿心率(HR)及脉搏氧(SpO2),并测量镇静值,与拔牙前测量值进行比较.结果:小儿在拔牙时的HR轻度下降,SpO2在实施TCI镇静剂前后无显著变化,小儿均处于中度镇静状态,Ramsay镇静评分5.2±0.8,镇静评分前后比较有显著意义.结论:TCI镇静技术用于小儿牙科畏惧症拔牙术具有良好的镇静效果,对呼吸及循环系统无明显影响,适用于小儿拔牙术中畏惧症的控制和治疗.     

New method of sedation in oral surgery

Local anesthesia, the well-known method of sedation, usually is insufficient for dental implantation and the augmentation of the alveolar ridge, because the operations last for 1 to 2 hours and patients may experience fear and strain. This article examines a new complex sedation method using ketorolac, midazolam, and a local anesthetic 4% solution of articaine hydrochloride and epinephrine (Septanest) in combination with a vasoconstrictor. This method was applied to 67 patients operated on for dental implantation with screw implants or for the alveolar ridge augmentation with biocompatible materials. The control group, which consisted of 20 patients, received local anesthesia with articaine-epinephrine only. Most of the control patients were found to have experienced fear and strain during the aforementioned surgical procedures; their blood pressure and pulse rate increased, and more than half of them experienced pain. No disorders of hemodynamics or the psychoemotional status of the patients were observed during sedation with ketorolac, midazolam, and articaine-epinephrine. Furthermore, anterograde amnesia was determined for the 80% of the patients in the test group.     

Bolus dose with continuous infusion of midazolam as sedation for outpatient surgery.

This double-blind, randomised, cross-over trial in 41 patients for 3rd molar surgery compared the safety, amnesic properties and psychomotor recovery between a bolus injection of midazolam and a bolus injection followed by continuous infusion of midazolam. The latter showed good safety and better amnesia to events during the procedure, but prolonged the recovery time.     

Intravenous or rectal diazepam for outpatient sedation in minor oral surgery

In a randomized cross-over study on sedation in outpatient oral surgery, intravenous and rectal administration of diazepam were compared. The mean dose for intravenous diazepam was 0.22 mg X kg-1 (range 0.15-0.38) and for rectal diazepam 0.58 mg X kg-1 (range 0.50-0.71). The determining factors for the patients' preference for sedation method, apprehension, effect produced by the sedative, recovery from sedation and the postoperative course were studied. The patients preferred the session in which they experienced stronger effect, regardless of the route of administration. Patient preference for sedation method did not differ when optimal dose regimens were used, and a preset dose of 10 mg rectal diazepam did not produce the desired effect. Apprehension was significantly higher prior to and during the first operation than the second operation, and all patients recovered from sedation within 2 1/2 hours after the administration.     

Remifentanil for use during conscious sedation in outpatient oral surgery.

PURPOSE: Remifentanil is a new, short-acting opioid that is similar pharmacodynamically to currently available opioids but differs in its pharmacokinetics. In the present study, we compared the use of remifentanil with the use of meperidine during intravenous conscious sedation for third molar surgery. PATIENTS AND METHODS: Forty patients who were scheduled for the removal of impacted third molars were randomly assigned to undergo 1 of 2 intravenous conscious sedation techniques. For both groups, 50:50 nitrous oxide oxygen were administered via nasal hood, and midazolam was titrated to Verril's sign. Twenty patients each then received either remifentanil 0.05 microgram/kg/min or meperidine 50 mg. Both patients and surgeons were blinded to the narcotic that was used. Blood pressure, heart rate, and oxygen saturation were determined before sedation and every 5 minutes during surgery. Recovery was measured using serial Trieger tests every 5 minutes after surgery. Patient and surgeon satisfaction of the quality of sedation was measured with a visual analog scale. RESULTS: Peak heart rate (91 beats/min for remifentanil vs 107 beats/min for meperidine, P <.01) and peak systolic blood pressure (131 mm Hg for remifentanil vs. 142 mm Hg for meperidine, P <.05) were significantly lower for the remifentanil group. Although there was a trend toward increased surgeon satisfaction with remifentanil (86 of 100 with remifentanil vs. 73 of 100 with meperidine), it was not found to be statistically significant. Likewise, other physiologic parameters were not found to be statistically significant. CONCLUSIONS: The lower peak heart rate and systolic blood pressure levels indicate that remifentanil may allow for less fluctuation in cardiovascular parameters. This could prove beneficial in patients with cardiovascular compromise.     

A comparative study of sevoflurane sedation with nitrous oxide sedation for dental surgery

This study compares the use of inhalation sedation using sevoflurane (group S) with inhalation sedation using nitrous oxide (group N) in patients undergoing bilateral extraction of third molar teeth under local anaesthesia. The study was designed as a cross-over study. Seventeen ASA I, day surgery patients were studied. Patients were randomly allocated to receive either 8 l/min 50% nitrous oxide in oxygen (group N) or same flow of 1% sevoflurane (group S) for the first procedure. Each patient then had the alternate method of sedation for the second procedure. There were no significant differences between the methods in patient co-operation and surgeon's satisfaction with sedation. Psychomotor tests were comparable in both groups. The patients were significantly more sedated in the group S compared to group N (P=0.004). Significantly more patients complained of an unpleasant odour group S (P<0.01) but none withdrew from the study for this reason. No adverse cardiorespiratory effects resulted from sevoflurane or nitrous oxide sedation. Both methods gave good amnesia during the procedure. There was high acceptance of both methods and the patients rated the technique as equally satisfactory. We conclude that inhalation sedation with sevoflurane is a suitable alternative method to nitrous oxide sedation.     

Comparison of remifentanil with fentanyl for deep sedation in oral surgery.

PURPOSE: The aim of this study was to compare recovery for oral surgery patients given a deep sedation regimen of midazolam, propofol, and remifentanil with a standard control of fentanyl in place of remifentanil. MATERIALS AND METHODS: This investigation was designed as a randomized, prospective, single-blinded controlled study. Group 1, the control, received midazolam 0.03 mg/kg, fentanyl 1 microg/kg, and propofol initially at 140 microg/kg/min. Group 2 received midazolam 0.03 mg/kg, remifentanil: propofol (1:500) given at an initial propofol infusion rate of 40 microg/kg/min. Outcome measures included time to response to verbal command, Aldrete score = 9, Postanesthesia Discharge Scoring System = 7, and assessment by the Digit Symbol Substitution Test. RESULTS: Forty-seven subjects were entered in the study. Baseline findings were homogenous between the 2 groups. Subjects in group 2 recovered earlier (P < .005) and required less propofol for both the induction (0.8 +/- 0.4 versus 1.2 +/- 0.6 mg/kg; mean +/- SD, P < .01) and maintenance of deep sedation (46 +/- 9 versus 131 +/- 17 microg/kg/min; P < .005). There were minor differences in vital signs. CONCLUSIONS: This study demonstrated that this remifentanil regimen provided significantly more rapid recovery and used significantly less propofol compared with the fentanyl regimen.     

A preliminary study on oxygen saturation levels of patients during periodontal surgery with and without oral conscious sedation using diazepam

BACKGROUND: Stress and anxiety alter respiratory rate and thereby alter oxygen saturation in the blood. Management of psychological stress in the dental office may help maintain blood gas homeostasis. One method of stress management is through the use of preoperative oral sedation. METHODS: The study population consisted of 13 patients scheduled to receive two quadrants of periodontal surgery at two different appointments. A randomized split-mouth crossover design was used with one quadrant of surgery involving preoperative oral sedation (diazepam) and local anesthetic, and the second using local anesthetic only. Oxygen saturation was monitored by pulse oximetry, which recorded the number of times saturation dropped below 95% in a given time period. Data were recorded at 5 time periods: 1) baseline; 2) from time of anesthetic administration to 20 minutes into surgery; 3) 21 to 40 minutes; 4) 41 to 60 minutes; and 5) 61 to 80 minutes into the surgery. Data were analyzed by a two-factor repeated measures ANOVA. The two within-group factors were treatment group and time. RESULTS: Results indicated no significant interaction between time and treatment (P > .05). However, data for groups over time suggested a trend supporting an interaction. The eta2 value of 0.124 suggested a moderate effect favoring the diazepam treatment. No significant difference was noted for the main effect of treatment and time. However, the eta2 value of 0.24 for treatment effect (diazepam versus no diazepam) suggested a meaningful difference between groups. Similarly the eta2 value of 0.135 for time suggested a moderate effect over time within-subjects. CONCLUSIONS: This study indicates that diazepam given orally in adult dosages does not cause significant respiratory depression, and is generally safe for those healthy patients who may require slight to mild sedation during periodontal surgery.