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Management of post-hyperventilation apnea during dental treatment under monitored anesthesia care with propofol.

Kobayashi M, Kurata S, Sanuki T, Okayasu I, Ayuse T - Biopsychosoc Med (2014)

Bottom Line: A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure.We subsequently successfully provided her with monitored anesthesia care with propofol.This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

View Article: PubMed Central - PubMed

Affiliation: Department of Dental Anesthesiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki-shi, 852-8588 Japan.

ABSTRACT
Although hyperventilation syndrome generally carries a good prognosis, it is associated with the risk of developing severe symptoms, such as post-hyperventilation apnea with hypoxemia and loss of consciousness. We experienced a patient who suffered from post-hyperventilation apnea. A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure. We subsequently successfully provided her with monitored anesthesia care with propofol. Monitored anesthesia care with propofol may be effective for the general management of patients who have severe hyperventilation attacks and post-hyperventilation apnea. This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

No MeSH data available.


Related in: MedlinePlus

Time course of the second episode. Propofol anesthesia after midazolam premedication was used for general management.
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Related In: Results  -  Collection

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Fig2: Time course of the second episode. Propofol anesthesia after midazolam premedication was used for general management.

Mentions: A female 17-year-old (height 154 cm, weight 56.4 kg) was scheduled for dental treatment (root canal treatment for an infected lower second molar) under regional anesthesia at the dental office of a university hospital. Since she had previously experienced hyperventilation attacks, not only during dental treatment but also in other situations, such as during bus rides, she was prescribed benzodiazepines (alprazolam) and paroxetine hydrochloride hydrate by a psychiatrist for a diagnosis of hyperventilation syndrome. There was no other medical history other than the psychological aspects. During the root canal treatment, the patient had a hyperventilation attack after experiencing pain. After fifteen minutes of therapeutic treatment using the rebreathing method with a paper bag did not alleviate her symptoms, our team dental anesthesiologist was asked to support her respiratory condition. As shown in Figure 1, after confirming sustained hyperventilation of respiratory rate 50 ~ 60 breaths/minute with desaturation to 92% associated with blood pressure 130/83 mmHg and pulse rate 115 beats/minute, we decided to provide low dose 2 l/min of oxygen supplementation using a bag-valve-mask instead of using the paper bag. With this, although her oxygen saturation improved to 100%, hyperventilation continued for 20 minutes. Confirming sustained hyperventilation, we decided to administer midazolam intravenously, as generally recommended in the treatment algorithm for hyperventilation syndrome [6]. However, we decided to decrease the dose of intravenous administration of midazolam to 0.5 mg, to minimize the risk of unpredictable changes in respiratory function. Immediately after injection of midazolam the hyperventilation subsided, with her respiratory rate improving to 20 breaths/minute. However, she then lost consciousness and developed complete apnea, resulting in significant desaturation to 88 ~ 76%. We tried to treat her with artificial ventilation using a bag-valve-mask with supplementation of a higher dose of 5 ~ 7 l/min oxygen. Two minutes after continuous mask ventilation of 8 ~ 10 counts/min to treat the complete apnea associated with unconsciousness and cyanosis, she regained consciousness and began to breathe at a respiratory rate of 15 breaths/minute. Her blood pressure was 120/80 mmHg and pulse rate was 72 beats/minute. We continuously monitored her respiratory condition for ne hour until full recovery from the symptoms. Thereafter, we informed the patient and her mother about the episode of severe hyperventilation attack and post-hyperventilation apnea during the dental treatment and recommended that she undergo further such treatments under monitored anesthesia, care with spontaneous breathing.


Management of post-hyperventilation apnea during dental treatment under monitored anesthesia care with propofol.

Kobayashi M, Kurata S, Sanuki T, Okayasu I, Ayuse T - Biopsychosoc Med (2014)

Time course of the second episode. Propofol anesthesia after midazolam premedication was used for general management.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4260203&req=5

Fig2: Time course of the second episode. Propofol anesthesia after midazolam premedication was used for general management.
Mentions: A female 17-year-old (height 154 cm, weight 56.4 kg) was scheduled for dental treatment (root canal treatment for an infected lower second molar) under regional anesthesia at the dental office of a university hospital. Since she had previously experienced hyperventilation attacks, not only during dental treatment but also in other situations, such as during bus rides, she was prescribed benzodiazepines (alprazolam) and paroxetine hydrochloride hydrate by a psychiatrist for a diagnosis of hyperventilation syndrome. There was no other medical history other than the psychological aspects. During the root canal treatment, the patient had a hyperventilation attack after experiencing pain. After fifteen minutes of therapeutic treatment using the rebreathing method with a paper bag did not alleviate her symptoms, our team dental anesthesiologist was asked to support her respiratory condition. As shown in Figure 1, after confirming sustained hyperventilation of respiratory rate 50 ~ 60 breaths/minute with desaturation to 92% associated with blood pressure 130/83 mmHg and pulse rate 115 beats/minute, we decided to provide low dose 2 l/min of oxygen supplementation using a bag-valve-mask instead of using the paper bag. With this, although her oxygen saturation improved to 100%, hyperventilation continued for 20 minutes. Confirming sustained hyperventilation, we decided to administer midazolam intravenously, as generally recommended in the treatment algorithm for hyperventilation syndrome [6]. However, we decided to decrease the dose of intravenous administration of midazolam to 0.5 mg, to minimize the risk of unpredictable changes in respiratory function. Immediately after injection of midazolam the hyperventilation subsided, with her respiratory rate improving to 20 breaths/minute. However, she then lost consciousness and developed complete apnea, resulting in significant desaturation to 88 ~ 76%. We tried to treat her with artificial ventilation using a bag-valve-mask with supplementation of a higher dose of 5 ~ 7 l/min oxygen. Two minutes after continuous mask ventilation of 8 ~ 10 counts/min to treat the complete apnea associated with unconsciousness and cyanosis, she regained consciousness and began to breathe at a respiratory rate of 15 breaths/minute. Her blood pressure was 120/80 mmHg and pulse rate was 72 beats/minute. We continuously monitored her respiratory condition for ne hour until full recovery from the symptoms. Thereafter, we informed the patient and her mother about the episode of severe hyperventilation attack and post-hyperventilation apnea during the dental treatment and recommended that she undergo further such treatments under monitored anesthesia, care with spontaneous breathing.

Bottom Line: A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure.We subsequently successfully provided her with monitored anesthesia care with propofol.This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

View Article: PubMed Central - PubMed

Affiliation: Department of Dental Anesthesiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki-shi, 852-8588 Japan.

ABSTRACT
Although hyperventilation syndrome generally carries a good prognosis, it is associated with the risk of developing severe symptoms, such as post-hyperventilation apnea with hypoxemia and loss of consciousness. We experienced a patient who suffered from post-hyperventilation apnea. A 17-year-old female who suffered from hyperventilation syndrome for several years developed post-hyperventilation apnea after treatment using the paper bag rebreathing method and sedative administration during a dental procedure. We subsequently successfully provided her with monitored anesthesia care with propofol. Monitored anesthesia care with propofol may be effective for the general management of patients who have severe hyperventilation attacks and post-hyperventilation apnea. This case demonstrates that appropriate emergency treatment should be available for patients with hyperventilation attacks who are at risk of developing post-hyperventilation apnea associated with hypoxemia and loss of consciousness.

No MeSH data available.


Related in: MedlinePlus