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Orbital infections
658
CURRENT LITERATURE
cular unit. Anesthesia and evaluation were administered by the authors. Patients were premedicated with meperidine and atropine one hour prior to induction using midazolam and fentanyl. Maintenance of anesthesia was achieved by infusion of the induction agents. The patients also received suxamethonium and pancuronium for intubation. Ventilation was controlled with ambient air in oxygen (Fi02 = 0.4). Recovery time was recorded as patients received either flumazenil or placebo. Patients were scored for sedation, cooperation, comprehension, orientation, and amnesia. Evaluation took place before injection of trial solutions and at selected time intervals afterwards. One patient was excluded due to a broken ampule from the blinded samples. The results indicated that the median dose of flumazenil (0.1 mglmL) was 8 mL (range 2 to 20 mL) and of placebo (isotonic saline) was 8 mL (range 2 to 20 mL). The median recovery time was eight minutes (range 2 to 22 minutes) on flumazenil versus 19.5 minutes (range 2 to 360 minutes) on placebo. The authors point out that the doses of medication for anesthesia were small, and that larger doses may affect recovery. However, they conclude that flumazenil was able to reverse total IV anesthesia using midazolam and fentanyl to a clinically significant degree.-M.L. O'NEIL Reprint requests to Dr Klausen: Department of Anaesthesia, Aalborg Hospital, DK-9000 Aalborg, Denmark.
Total Intravenous Anaesthesia With Midazolam and Flumazenil in Outpatient Clinics. A Comparison With Isoflurane or Thiopentone. Raeder IC, Hole A, et al. Acta Anaesthesiol Scand 31:634, 1987 Intravenous anesthetic induction agents provide rapid general anesthesia. Most are associated with side effects that include long recovery time. Theoretically, inhalation anesthetics provide short recovery due to rapid elimination but are associated with complications, including prolonged induction. Midazolam is suitable induction and
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Continued from page 554
total intravenous (IV) anesthetic agent at the appropriate dosages. Its prolonged recovery period may be counteracted with the benzodiazepine antagonist flumazenil. Four different anesthetic regimens were compared on the basis of intra- and post-operative patient function and well-being. One hundred patients scheduled to undergo outpatient gynecologic procedures were randomly divided into four parallel groups. They were evaluated postoperatively in a double-blind manner. The anesthesia varied based on administration and dosages of alfentanil, rnidazolam, thiopentone (thiopental), nitrous oxide and oxygen, isoflurane, placebo (isotonic saline), and flumazenil. All anesthesia was administered by the same anesthesiologist. The patients were evaluated based on induction time, recovery time, cooperation, wakefulness, amnesia, reaction, tranquility, alertness, and side effects. Evaluation was accomplished by direct observation and testing or by questionnaire. Thiopentone followed by midazolam at induction dosages showed the shortest induction times. Isoflurane and nitrous oxide groups took longer and were less predictable for induction. The authors report induction and procedure amnesia for all groups. Recovery time varied for all groups. Patients receiving flumazenil were fully awake and cooperative within two minutes after administration, but were unable to perform difficult and time-consuming tests from 15 to 420 minutes postoperatively as adequately as isoflurane or thipentone patients. The authors conclude that all anesthetic methods were satisfactory with regard to surgery, anesthesia and postoperative periods. Patients receiving flumazenil were awake most rapidly after anesthesia, whereas placebo patients were most drowsy during the first two hours postoperatively. Total IV anesthesia with midazolam, alfentanil, and single-dose flumazenil reversal seems to be a safe and promising technique in short procedures.-M.L. O'NEIL Reprint requests to Dr Raeder: Anestesiavd, Baerum Sykehus, N-1316 Baerum Sykehus, Norway.
LETTERS TO THE EDITOR
Dr Wishan is to be commended for his work in an area that we feel is important in the counseling and planning for orthognathic surgery patients. Changes in this field are rapid and compelling, and we look forward to seeing the reports and data from Drs Wishan and Conover. DAVID M. SARVER, DMD, MS Birmingham, Alabama ORBITAL INFECTIONS
To the Editor:-I would like to comment on the article "Orbital Infections" (O'Ryan F, Diloreto D, Barber HD, et al: J Oral MaxiIlofac Surg 46:991, 1988). In the accompanying case report, the degree of courage of the operating surgeon, in my opinion, exceeds his or her clinical judgment. The patient at the time of his last surgery apparently had empyema of the frontal and sphenoid sinuses, empyema of the right ethmoid andmaxillary sinuses, right orbital subperiosteal abscess, and loss of vision of the right eye. He had an oral temperature of
I03.3°F, and was showing rapid deterioration in mental status. An ophthalmologic consultation was obtained. However, there was no indication of either a neurosurgicalor ENT evaluation. Fortunately, the patient recovered. This was a critically ill patient with a complex problem. To take a patient with rapidly deteriorating neurologic status to surgery without a neurosurgical evaluation is poor judgment in spite of what the CT report stated. Furthermore, to perform sinus surgery on a patient with a pansinusitis without consulting an otolaryngologist also represents poor judgment. If this type of thought process and patient management is what is generally taught today, we need to reevaluate our educational process. The welfare of the patient must be our first consideration. I have been in the profession for 28 years, including training, and I can assure you that I get all the help I can muster in the management of patients such as the one described. WILLIAM N. SMITH, MD, DDS EI Centro, California
CURRENT LITERATURE
cular unit. Anesthesia and evaluation were administered by the authors. Patients were premedicated with meperidine and atropine one hour prior to induction using midazolam and fentanyl. Maintenance of anesthesia was achieved by infusion of the induction agents. The patients also received suxamethonium and pancuronium for intubation. Ventilation was controlled with ambient air in oxygen (Fi02 = 0.4). Recovery time was recorded as patients received either flumazenil or placebo. Patients were scored for sedation, cooperation, comprehension, orientation, and amnesia. Evaluation took place before injection of trial solutions and at selected time intervals afterwards. One patient was excluded due to a broken ampule from the blinded samples. The results indicated that the median dose of flumazenil (0.1 mglmL) was 8 mL (range 2 to 20 mL) and of placebo (isotonic saline) was 8 mL (range 2 to 20 mL). The median recovery time was eight minutes (range 2 to 22 minutes) on flumazenil versus 19.5 minutes (range 2 to 360 minutes) on placebo. The authors point out that the doses of medication for anesthesia were small, and that larger doses may affect recovery. However, they conclude that flumazenil was able to reverse total IV anesthesia using midazolam and fentanyl to a clinically significant degree.-M.L. O'NEIL Reprint requests to Dr Klausen: Department of Anaesthesia, Aalborg Hospital, DK-9000 Aalborg, Denmark.
Total Intravenous Anaesthesia With Midazolam and Flumazenil in Outpatient Clinics. A Comparison With Isoflurane or Thiopentone. Raeder IC, Hole A, et al. Acta Anaesthesiol Scand 31:634, 1987 Intravenous anesthetic induction agents provide rapid general anesthesia. Most are associated with side effects that include long recovery time. Theoretically, inhalation anesthetics provide short recovery due to rapid elimination but are associated with complications, including prolonged induction. Midazolam is suitable induction and
a
Continued from page 554
total intravenous (IV) anesthetic agent at the appropriate dosages. Its prolonged recovery period may be counteracted with the benzodiazepine antagonist flumazenil. Four different anesthetic regimens were compared on the basis of intra- and post-operative patient function and well-being. One hundred patients scheduled to undergo outpatient gynecologic procedures were randomly divided into four parallel groups. They were evaluated postoperatively in a double-blind manner. The anesthesia varied based on administration and dosages of alfentanil, rnidazolam, thiopentone (thiopental), nitrous oxide and oxygen, isoflurane, placebo (isotonic saline), and flumazenil. All anesthesia was administered by the same anesthesiologist. The patients were evaluated based on induction time, recovery time, cooperation, wakefulness, amnesia, reaction, tranquility, alertness, and side effects. Evaluation was accomplished by direct observation and testing or by questionnaire. Thiopentone followed by midazolam at induction dosages showed the shortest induction times. Isoflurane and nitrous oxide groups took longer and were less predictable for induction. The authors report induction and procedure amnesia for all groups. Recovery time varied for all groups. Patients receiving flumazenil were fully awake and cooperative within two minutes after administration, but were unable to perform difficult and time-consuming tests from 15 to 420 minutes postoperatively as adequately as isoflurane or thipentone patients. The authors conclude that all anesthetic methods were satisfactory with regard to surgery, anesthesia and postoperative periods. Patients receiving flumazenil were awake most rapidly after anesthesia, whereas placebo patients were most drowsy during the first two hours postoperatively. Total IV anesthesia with midazolam, alfentanil, and single-dose flumazenil reversal seems to be a safe and promising technique in short procedures.-M.L. O'NEIL Reprint requests to Dr Raeder: Anestesiavd, Baerum Sykehus, N-1316 Baerum Sykehus, Norway.
LETTERS TO THE EDITOR
Dr Wishan is to be commended for his work in an area that we feel is important in the counseling and planning for orthognathic surgery patients. Changes in this field are rapid and compelling, and we look forward to seeing the reports and data from Drs Wishan and Conover. DAVID M. SARVER, DMD, MS Birmingham, Alabama ORBITAL INFECTIONS
To the Editor:-I would like to comment on the article "Orbital Infections" (O'Ryan F, Diloreto D, Barber HD, et al: J Oral MaxiIlofac Surg 46:991, 1988). In the accompanying case report, the degree of courage of the operating surgeon, in my opinion, exceeds his or her clinical judgment. The patient at the time of his last surgery apparently had empyema of the frontal and sphenoid sinuses, empyema of the right ethmoid andmaxillary sinuses, right orbital subperiosteal abscess, and loss of vision of the right eye. He had an oral temperature of
I03.3°F, and was showing rapid deterioration in mental status. An ophthalmologic consultation was obtained. However, there was no indication of either a neurosurgicalor ENT evaluation. Fortunately, the patient recovered. This was a critically ill patient with a complex problem. To take a patient with rapidly deteriorating neurologic status to surgery without a neurosurgical evaluation is poor judgment in spite of what the CT report stated. Furthermore, to perform sinus surgery on a patient with a pansinusitis without consulting an otolaryngologist also represents poor judgment. If this type of thought process and patient management is what is generally taught today, we need to reevaluate our educational process. The welfare of the patient must be our first consideration. I have been in the profession for 28 years, including training, and I can assure you that I get all the help I can muster in the management of patients such as the one described. WILLIAM N. SMITH, MD, DDS EI Centro, California