Different Aspects of General Anesthesia in Pediatric Dentistry: A Review

Context:Most child population is able to undergo dental treatment in the conventional setting. However, some children fail to cope with in-office conscious state and cannot respond to usual management modalities. This review aims to discuss the topic further. Evidence Acquisition: A computerized search in databases PubMed, MEDLINE, EMBASE, Google Scholar and Google were performed using dental general anesthesia related keywords. Original and review English-written articles that were limited to child population were retrieved without any limitation of publication date. The suitable papers were selected and carefully studied. A data form designed by author was used to write relevant findings. Results: Preoperative oral examination and comprehensive evaluation of treatment needs is only possible after clinical and radiographic oral examination. Effective collaboration in dental GA team should be made to minimize psychological trauma of children who undergo dental GA. Before conducting comprehensive dental treatment under GA, the general health of the child and the success rate of procedures provided needs to be accurately evaluated. It is noteworthy that determination of the optimal timing for GA dental operation is of great importance. Providing safety with pediatric dental rehabilitation under GA is critical. Conclusions: Besides criteria for case selection of dental GA, some degree of dental practitioner’s judgment is required to make decision. Pre- and post-operative instructions to parents or caregiver decrease the risk of complications. However, trained resuscitation providers, careful monitoring and advanced equipment minimize adverse outcomes.

Analgesia epidural con bupivacaína en el trabajo de parto en multíparas del Hospital Vicente Corral Mosoco 1995-1996

Con el objeto de valorar la eficacia y los efectos de la analgesia peridural lumbar con bupivacaina en la madre durante el parto el recién nacido, se realizó un estudio clínico experimental con una muestra de 60 multíparas dividido en 2 grupos de 30 cada uno: el primero recibió analgesia peridural con bupivacaína en concentraciones al 0.125 por ciento en el primer periodo y 0.25 por ciento en el segundo periodo del parto, y el otro que constituyó el grupo control que no recibió analgesia. Ambos grupos tuvieron cracterísticas similares en cuanto a edad, paridad, altura de fondo uterino, dilatación. El alivio del dolor fue estadísticamente significativo en comparación con el grupo control [p<0.001] tanto en el periodo de dilatación como en el expulsivo. La dosis media utilizada en el primer período del parto fue de 25.3 mgs. La duración del periodo de dilatación en el grupo con peridural fue menor con relación al grupo control [p<0.001]; igualmente fue menor en el periodo expulsivo aunque no estadísticamente significativo. En cada grupo el 3.3 por ciento terminó en cesárea. Durante el periodo expulsivo no se utilizó fórceps. No hubo diferencia estadística en la forma y tipo de alumbramiento en los dos grupos. El apgar en un minuto fue mejor en el grupo con epidural que en el control [p<0.005]. No hubo diferencia estadística a los 5 y 10 minutos. En el 6.8 por ciento de pacientes se presentó dolor dorso-lumbar en el puerperio, cefalea pulsátil en el 3.4 por ciento. En el resto [89.7 por ciento] no se presentó efecto alguno. El 100 por cien de los 29 pacientes que terminaron su parto por vía vaginal estivieron satisfechas con la analgesia peridural

Developing a model of technology appropriation: A Marxian perspective

This paper explores the philosophical origins of appropriation of Information Systems (IS) using Marxian and other socio-cultural theory. It provides an in-depth examination of appropriation and its application in extant IS theory. We develop a three-tier model using Marx’s foundational concepts and from this generate four propositions that we test in an empirical example of IS in anesthesia. Using Marxian theory, this paper seeks common ground among existing theories of technology appropriation in IS research. This work contributes to IS research by (1) opening philosophical discussions on appropriation and the human ↔ technology nexus, (2) drawing on these varying perspectives to propose a general conceptualization of technology appropriation and (3) providing a starting point towards a general causal model of technology appropriation.

Drugs and neurotransmitters

This eChapter has an introduction to pharmacology and drug nomenclature followed by a detailed discussion of routes of administration starting with oral administration (with absorption from the gastrointestinal tract, and first pass liver metabolism. This is followed by a discussion of rectal, sublingual and injection routes of administration(intravenous, intra-arterial, subcutaneous, intramuscular, intrathecal and epidural). Then the topical, pulmonary and intraosseus routes of administration are considered.

The clinical effectiveness of interventions to assist perioperative temperature management for women undergoing Cesarean Section : a systematic review

Background Women undergoing Cesarean Section (CS) are vulnerable to the adverse effects associated with perioperative core temperature drop, in part due to the tendency for CS to be performed under neuraxial anesthesia, blood and fluid loss, and vasodilation. Inadvertent perioperative hypothermia (IPH) is a common condition that affects patients undergoing surgery of all specialties and is detrimental to all age groups, including neonates. Previous systematic reviews on IPH prevention largely focus on either adult or all ages populations, and have mainly overlooked pregnant or CS patients as a distinct group. Not all recommendations made by systematic reviews targeting all adult patients may be transferable to CS patients. Alternative, effective methods for preventing or managing hypothermia in this group would be valuable. Objectives To synthesize the best available evidence in relation to preventing and/or treating hypothermia in mothers after CS surgery. Types of participants Adult patients over the age of 18 years, of any ethnic background, with or without co-morbidities, undergoing any mode of anesthesia for any type of CS (emergency or planned) at healthcare facilities who have received interventions to limit or manage perioperative core heat loss were included. Types of intervention(s) Active or passive warming methods versus usual care or placebo, that aim to limit or manage core heat loss as applied to women undergoing CS were included. Types of studies Randomized controlled trials (RCTs) that met the inclusion criteria, with reduction of perioperative hypothermia a primary or secondary outcome were considered. Types of outcomes Primary outcome: maternal core temperature measured during the preoperative, intraoperative and postoperative phases of care Secondary outcomes: newborn core temperature at birth, umbilical pH obtained immediately after birth, Apgar scores, length of Post Anesthetic Care Unit (PACU) stay, maternal thermal comfort. Search strategy A comprehensive search was undertaken of the following databases from their inception until May 2012: ProQuest, Web of Science, Scopus, Dissertation and Theses PQDT (via ProQuest), Current Contents, CENTRAL, Mednar, OpenGrey, Clinical Trials. There were no language restrictions. Methodological quality Retrieved papers were assessed for methodological quality by two independent reviewers prior to inclusion using JBI software. Disagreements were resolved via consultation with the third reviewer. An assessment of quality of the included papers was also made in relation to five key quality factors. Data collection Two independent reviewers extracted data from the included papers using a previously piloted customized data extraction tool. Results 12 studies with a combined total of 719 participants were included. Three broad intervention groups were identified; intravenous (IV) fluid warming, warming devices, leg wrapping. IV fluid warming, whether administered intraoperatively or preoperatively, was found to be effective at maintaining maternal (but not neonatal) temperature and preventing shivering, but does not improve thermal comfort. The effectiveness of IV fluid warming on Apgar scores and umbilical pH remains unclear. Warming devices, including forced air warming and under body carbon polymer mattresses, were effective at preventing hypothermia and reduced shivering, however were most effective if applied preoperatively. The effectiveness of warming devices to improve thermal comfort remains unclear. Preoperative forced air warming appears to aid maintenance of neonatal temperature, while intraoperative forced air warming does not. Forced air warming was not effective at improving Apgar scores and the effects for umbilical pH remain unclear. Conclusions Intravenous fluid warming, by any method, improves maternal temperature and reduces shivering for women undergoing CS. Preoperative body warming devices also improve maternal temperature, in addition to reducing shivering.

Birth control : to what extent do women report being informed and involved in decisions about pregnancy and birth procedures?

Background: Health policy, guidelines, and standards advocate giving patients comprehensive information and facilitating their involvement in health-related decision-making. Routine assessment of patient reports of these processes is needed. Our objective was to examine decision-making processes, specifically information provision and consumer involvement in decision-making, for nine pregnancy, labour, and birth procedures, as reported by maternity care consumers in Queensland, Australia. Methods: Participants were women who had a live birth in Queensland in a specified time period and were not found to have had a baby that died since birth, who completed the extended Having a Baby in Queensland Survey, 2010 about their maternity care experiences, and who reported at least one of the nine procedures of interest. For each procedure, women answered two questions that measured perceived (i) receipt of information about the benefits and risks of the procedure and (ii) role in decision-making about the procedure. Results: In all, 3,542 eligible women (34.2%) completed the survey. Between 4% (for pre-labour caesarean section) and 60% (for vaginal examination) of women reported not being informed of the benefits and risks of the procedure they experienced. Between 2% (epidural) and 34% (episiotomy) of women reported being unconsulted in decision-making. Over one quarter (26%) of the women who experienced episiotomy reported being neither informed nor consulted. Conclusions: There is an urgent need for interventions that facilitate information provision and consumer involvement in decision-making about several perinatal procedures, especially those performed within the time-limited intrapartum care episode.

Understanding the abnormal brain activity in epilepsy as a potential predictor of the onset of an epileptic seizure

The Brain Research Institute (BRI) uses various types of indirect measurements, including EEG and fMRI, to understand and assess brain activity and function. As well as the recovery of generic information about brain function, research also focuses on the utilisation of such data and understanding to study the initiation, dynamics, spread and suppression of epileptic seizures. To assist with the future focussing of this aspect of their research, the BRI asked the MISG 2010 participants to examine how the available EEG and fMRI data and current knowledge about epilepsy should be analysed and interpreted to yield an enhanced understanding about brain activity occurring before, at commencement of, during, and after a seizure. Though the deliberations of the study group were wide ranging in terms of the related matters considered and discussed, considerable progress was made with the following three aspects. (1) The science behind brain activity investigations depends crucially on the quality of the analysis and interpretation of, as well as the recovery of information from, EEG and fMRI measurements. A number of specific methodologies were discussed and formalised, including independent component analysis, principal component analysis, profile monitoring and change point analysis (hidden Markov modelling, time series analysis, discontinuity identification). (2) Even though EEG measurements accurately and very sensitively record the onset of an epileptic event or seizure, they are, from the perspective of understanding the internal initiation and localisation, of limited utility. They only record neuronal activity in the cortical (surface layer) neurons of the brain, which is a direct reflection of the type of electrical activity they have been designed to record. Because fMRI records, through the monitoring of blood flow activity, the location of localised brain activity within the brain, the possibility of combining fMRI measurements with EEG, as a joint inversion activity, was discussed and examined in detail. (3) A major goal for the BRI is to improve understanding about ``when'' (at what time) an epileptic seizure actually commenced before it is identified on an eeg recording, ``where'' the source of this initiation is located in the brain, and ``what'' is the initiator. Because of the general agreement in the literature that, in one way or another, epileptic events and seizures represent abnormal synchronisations of localised and/or global brain activity the modelling of synchronisations was examined in some detail. References C. M. Michel, G. Thut, S. Morand, A. Khateb, A. J. Pegna, R. Grave de Peralta, S. Gonzalez, M. Seeck and T. Landis, Electric source imaging of human brain functions, Brain Res. 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Supply, demand, and equilibrium in the market for CRNAs

This study determined the current trends in supply, demand, and equilibrium (ie, the level of employment where supply equals demand) in the market for Certified Registered Nurse Anesthetists (CRNAs). It also forecasts future needs for CRNAs given different possible scenarios. The impact of the current availability of CRNAs, projected retirements, and changes in the demand for surgeries are considered in relation to CRNAs needed for the future. The study used data from many sources to estimate models associated with the supply and demand for CRNAs and the relationship to relevant community and policy characteristics such as per capita income of the community and managed care. These models were used to forecast changes in surgeries and in the supply of CRNAs in the future. The supply of CRNAs has increased in recent years, stimulated by shortages of CRNAs and subsequent increases in the number of CRNAs trained. However, the increases have not offset the number of retiring CRNAs to maintain a constant age in the CRNA population. The average age will continue to increase for CRNAs in the near future despite increases in CRNAs trained. The supply of CRNAs in relation to surgeries will increase in the near future.

Flupirtine enhances the anti-hyperalgesic effects of morphine in a rat model of prostate bone metastasis

Objective Current treatments for cancer pain are often inadequate, particularly when metastasis to bone is involved. The addition to the treatment regimen of another drug that has a complementary analgesic effect may increase the overall analgesia without the necessity to increase doses, thus avoiding dose-related side effects. This project investigated the synergistic effect of the addition of the potassium channel (KCNQ2–3) modulator flupirtine to morphine treatment in a rat model of prostate cancer-induced bone pain. Design Syngeneic prostate cancer cells were injected into the right tibia of male Wistar rats under anesthesia. This led to expanding tumor within the bone in 2 weeks, together with the concurrent development of hyperalgesia to noxious heat. Paw withdrawal thresholds from noxious heat were measured before and after the maximum non-sedating doses of morphine and flupirtine given alone and in combinations. Dose-response curves for morphine (0.13–5.0 mg/kg ip) and flupirtine (1.25–10.0 mg/kg ip) given alone and in fixed-dose combinations were plotted and subjected to an isobolographic analysis. Results Both morphine (ED50 = 0.74 mg/kg) and flupirtine (ED50 = 3.32 mg/kg) caused dose-related anti-hyperalgesia at doses that did not cause sedation. Isobolographic analysis revealed that there was a synergistic interaction between flupirtine and morphine. Addition of flupirtine to morphine treatment improved morphine anti-hyperalgesia, and resulted in the reversal of cancer-induced heat hyperalgesia. Conclusions These results suggest that flupirtine in combination with morphine may be useful clinically to provide better analgesia at lower morphine doses in the management of pain caused by tumors growing in bone.

Back to normal: A retrospective, cross-sectional study of the multi-factorial determinants of normal birth in Queensland, Australia

Background Currently, care providers and policy-makers internationally are working to promote normal birth. In Australia, such initiatives are being implemented without any evidence of the prevalence or determinants of normal birth as a multidimensional construct. This study aimed to better understand the determinants of normal birth (defined as without induction of labour, epidural/spinal/general anaesthesia, forceps/vacuum, caesarean birth, or episiotomy) using secondary analyses of data from a population survey of women in Queensland, Australia. Methods Women who birthed in Queensland during a two-week period in 2009 were mailed a survey approximately three months after birth. Women (n=772) provided retrospective data on their pregnancy, labour and birth preferences and experiences, socio-demographic characteristics, and reproductive history. A series of logistic regressions were conducted to determine factors associated with having labour, having a vaginal birth, and having a normal birth. Findings Overall, 81.9% of women had labour, 66.4% had a vaginal birth, and 29.6% had a normal birth. After adjusting for other significant factors, women had significantly higher odds of having labour if they birthed in a public hospital and had a pre-existing preference for a vaginal birth. Of women who had labour, 80.8% had a vaginal birth. Women who had labour had significantly higher odds of having a vaginal birth if they attended antenatal classes, did not have continuous fetal monitoring, felt able to ‘take their time’ in labour, and had a pre-existing preference for a vaginal birth. Of women who had a vaginal birth, 44.7% had a normal birth. Women who had a vaginal birth had significantly higher odds of having a normal birth if they birthed in a public hospital, birthed outside regular business hours, had mobility in labour, did not have continuous fetal monitoring, and were non-supine during birth. Conclusions These findings provide a strong foundation on which to base resources aimed at increasing informed decision-making for maternity care consumers, providers, and policy-makers alike. Research to evaluate the impact of modifying key clinical practices (e.g., supporting women׳s mobility during labour, facilitating non-supine positioning during birth) on the likelihood of a normal birth is an important next step.

Inadvertent hypothermia after procedural sedation and analgesia in a cardiac catheterisation laboratory: A prospective observational study

Objective To identify the prevalence of and risk factors for inadvertent hypothermia after procedures performed with procedural sedation and analgesia in a cardiac catheterisation laboratory. Design Single-centre, prospective observational study. Setting Tertiary care private hospital in Australia. Participants A convenience sample of 399 patients undergoing elective procedures with procedural sedation and analgesia were included. Propofol infusions were used when an anaesthetist was present. Otherwise, bolus doses of either midazolam or fentanyl or a combination of these medications was used. Interventions None Measurements and main results Hypothermia was defined as a temperature <36.0° Celsius. Multivariate logistic regression was used to identify risk factors. Hypothermia was present after 23.3% (n=93; 95% confidence interval [CI] 19.2%-27.4%) of 399 procedures. Sedative regimens with the highest prevalence of hypothermia were any regimen that included propofol (n=35; 40.2%; 95% CI 29.9%-50.5%) and the use of fentanyl combined with midazolam (n=23; 20.3%; 95% CI 12.9%-27.7%). Difference in mean temperature from pre to post-procedure was -0.27°C (Standard deviation [SD] 0.45). Receiving propofol (odds ratio [OR] OR 4.6 95% CI 2.5-8.6), percutaneous coronary intervention (OR 3.2 95% CI 1.7-5.9), body mass index <25 (OR 2.5 95% CI 1.4-4.4) and being hypothermic prior to the procedure (OR 4.9; 95% CI 2.3-10.8) were independent predictors of post-procedural hypothermia. Conclusions A moderate prevalence of hypothermia was observed. The small absolute change in temperature observed may not be a clinically important amount. More research is needed to increase confidence in our estimates of hypothermia in sedated patients and its impact on clinical outcomes.

Postprocedural effects of gastrointestinal endoscopy performed as a day case procedure in children : implications for patient and family education

A prospective design that included a survey tool, nursing care records, and telephone interview was used to determine postprocedural effects experienced by children and families following gastrointestinal endoscopy performed as a day procedure. One hundred twenty-one children attending a pediatric gastroenterology unit for endoscopy under general anesthesia participated in the study. Physical symptoms, day care/school attendance, behavioral issues, and economic factors in the 72 hours post procedure were identified. Over half the children (n = 69, 57%) experienced pain in the hospital post procedure. Pain was reported by 73 children (60%) at home on the day of the procedure, by 55 children (45%) on Day 1 post procedure, and by 37 children (31%) on Day 2 post procedure. The throat was the most common site of pain. Nausea or vomiting was experienced by 37 children (31%) at some time following their procedure but was not associated with procedure type, age, or fasting time. Over half the children (n = 53, 51%) who usually attended day care or school did not attend the day following their procedure. Twenty-four parents (40%) who would normally have worked on the day after the procedure did not attend employment. These findings have been used to improve the preprocedural information and discharge management of patients treated in a pediatric gastroenterology ambulatory setting. © The Society of Gastroenterology Nurses & Associates 2007. All Rights Reserved.

Esophageal stricture in children: Fiber-optic endoscopy and dilatation under fluoroscopic control

We made a retrospective analysis of the efficacy and complication rate of 268 esophageal dilatation procedures performed under fluoroscopic control using the fiber-optic endoscope in 45 children with esophageal stricture. Antegrade and retrograde stricture dilatation was performed under general anesthetic, mainly as an outpatient procedure. Thirty-six children had an esophageal stricture following tracheoesophageal fistula and/or esophageal atresia repair, and nine children had severe corrosive stricture of the esophagus following lye ingestion. The procedure was well tolerated and effective. © 1992 Raven Press, Ltd., New York.

Restorative treatment practices and dentist-related factors

This study aimed at elucidating real-life aspects of restorative treatment practices. In addition, dentists' views and perceptions of and variation in restorative treatment practices with respect to dentist-related factors were evaluated. Reasons for placement and replacement of restoration, material selection, posterior restoration longevity, and the use of local anesthesia were assessed on two cross-sectional data sets. Data from the Helsinki Public Dental Service (PDS) included details on 3057 restorations performed by dentists (n=134) during routine clinical work in 2001. The other PDS data from Vantaa were based on 205 patient records of young adults containing information on 1969 restorations investigated retrospectively from 1994-1996 backwards; 51 dentists performed the restorations. In addition, dentists’ self-reported use of local anesthesia and estimates of restoration longevity were investigated by means of a nationwide questionnaire sent to 592 general dental practitioners selected by systematic sampling from the membership list of the Finnish Dental Association in 2004. All data sets included some background information on dentists such as gender, year of birth or graduation, and working sector. In PDS in 2001, primary caries was the reason for placement of restoration more often among patients aged under 19 years than among older patients (p<0.001). Among patients over 36 years of age, replacements represented the majority. Regarding dentist-related factors, replacements of restorations were made by younger dentists more frequently than by older dentists (p<0.001). In PDS in 1994-1996, the replacement rate of posterior restorations was greater among female dentists than among male dentists (p=0.01), especially for amalgams (p=0.008). The mean age of replaced posterior restoration among young adults was 8.9 (SD 5.2) years for amalgam and 2.4 (SD 1.4) years for tooth-colored restorations, the actual replacement rate for all existing posterior restorations being 7% in PDS in 1994-1996. Of all restorative materials used, a clear majority (69%) were composites in PDS in 2001. Local anesthesia was used in 48% of cases and more frequently for older patients (55%) than for patients aged under 13 years (35%) (p<0.001). Younger dentists more often used local anesthesia for primary restoration than did the older dentists (p<0.001), especially for primary teeth (p=0.005). Working sector had an impact on dentists’ self-reported use of local anesthesia and estimates of restoration longevity; public sector dentists reported using local anesthesia more frequently than private sector dentists for Class II (p=0.04) and for Class III restorations (p=0.01). Private sector dentists gave longer estimates of posterior composite longevity than public sector dentists (p=0.001). In conclusion, restorative treatment practices seem to vary according to patient age and also dentist-related factors. Replacements of restorations are common for adults. For children, clear underuse of local anesthesia prevails.