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The effect of flumazenil on the recovery time of dental patients sedated with diazepam
1238 Reprint requests Hoglandssjukhuset,
CURRENT LITERATURE
to Dr Jarhult: Department S-575 00 Eksjo, Sweden.
of Surgery,
Postanginal Sepsis. Shapiro J, Fried MP, Strome M. Head Neck Surg 11:164, 1989 Septicemia following pharyngitis, called postanginal sepsis, is a process in which infection spreads via tonsillar veins or lymphatic channels to the internal jugular vein. There, a thrombophlebitis can occur that can release septic emboli, which produce varying symptoms depending on the endpoint of embolization. This article reviews the English language literature relating to postanginal sepsis and presents three new cases. The authors found that the average length of time between the onset of sore throat and the development of systemic septic symptoms was 9 days (range 0 to 22 days). The neck examination was usually abnormal, with the most common symptom being pain along the anterior border of the sternocleidomastoid muscle. The most common organisms found on positive blood culture were Fusobacteria. The most frequent problem due to systemic emboli was pulmonary involvement with infiltrates and pleural effusions. Other signs and symptoms of postanginal sepsis include high spiking fevers, chills, malaise, and leukocytosis. Useful studies on patients with postanginal sepsis included neck ultrasound or CT scan looking for abscess cavities. The mortality rate since the induction of penicillin is 8%. Management of a patient with suspected postanginal sepsis includes obtaining a history of antecedent pharyngitis. A careful neck and oropharyngeal examination should be performed. If the neck is tender a CT scan should be ordered, along with blood cultures. Most of the organisms likely to cause postanginal sepsis are sensitive to penicillin or clindamycin. The discovery of an abscess should prompt surgical exploration for drainage and possible ligation and resection of any thrombosed portions of the internal jugular vein. In most cases recovery is prolonged.-J.R. HUMP Reprint requests MA 02115.
to Dr Shapiro: 333 Longwood Ave, Boston,
Comparison of Pulse Oximeters: Effects of Vasoconstriction and Venous Engorgement. Wilkins CJ, Moores M, Hanning CD. Br J Anaesth 62:439, 1989 Pulse oximetry is an emerging standard for anesthetic monitoring. Although accurate under steady-state conditions, detection may be impaired in the presence of vasoconstriction (CNSTR) or venous congestion (CONG). This study compared the accuracy of five pulse oximeters under these conditions. Oximeters tested were: Ohmeda 3700, Novametric 500, Criticare Systems Inc. model 501, Accusat (Datascope Corp), and Lifestat 1600 (Physiocontrol Corp). Ten healthy volunteers had finger probes from each machine placed in a randomly assigned manner, and a Biox III oximeter was applied to the subjects’ ears for safety monitoring. Each subject was twice given a hypoxic gas mixture (10% oxygen, 90% nitrogen) to breathe for 2 minutes with control desaturation values recorded. A blood pressure cuff was inflated to 40 mm Hg on the upper arm to induce venous congestion, and two episodes of hypoxia induced as before. To induce vasoconstriction, a cooled, water-filled plastic bag was placed over the forearm for 10 minutes, and again hypoxia induced. All data were recorded on a calibrated chart re-
corder. Time for detection of desaturation was not significantly different among all oximeters in either control, CNSTR, or CONG groups. All oximeters had significant increases in detection time of two to three times the control value when CNSTR or CONG conditions were present, causing a mean delay of 150 seconds to detection of hypoxic insult. Of all the units tested, the Novametrix failed to detect the maximum desaturation that occurred under CNSTR or CONG conditions. The same unit failed to give an alarm of poor quality signals while other units gave clear warning under CNSTR or CONG conditions. The authors warn that presence of a normal pulse signal does not imply that perfusion is adequate for detection of hypoxia. They state that new versions of several oximeters were introduced after the study began (including Novametrix) and may perform differently than those tested.-J. DEMBO Reprint requests to Dr Wilkins: University Department of Anaesthesia, General Hospital, Gwendolen Rd, Leicester LES 4PW, England.
The Effect of Flumazenil on the Recovery Time of Dental Patients Sedated With Diazepam. Young ER, Kestenberg SH, Toal CB. Anesth Prog 36:46, 1989 Diazepam, which is used widely for sedation in dentistry, has a long half-life that may cause prolonged sedation. Flumazenil is an imidazobenzodiazepine that antagonizes the effects of benzodiazepines by binding to the same receptors. This study examined the efficacy of flumazenil in shortening the recovery following diazepam sedation. Twenty-one healthy young men undergoing restorative dentistry were randomly assigned to receive flumazenil or placebo. Each group was sedated with diazepam 0.15 mg/kg intravenously, and local anesthetic was given. Fifteen minutes after the diazepam dose, flumazenil 0.015 mg/kg or placebo vehicle was given IV in doubleblind fashion. Psychomotor function was tested presedation and postsedation at S-minute intervals using the Trieger test, digit-symbo1 substitution (DSS), Romberg test, and an independent assessment by the dentist, nurse, and patient. Significant differences between groups included better performance on the Trieger test and DSS only at 5 and 10 minutes; after 15 minutes no differences were noted. The authors attribute these tindings to the natural cessation of diazepam effects after 15 minutes. They conclude that, although flumazenil was useful in improving psychomotor performance during the immediate postsedation period, it cannot be recommended for routine use following benzodiazepine sedation.-J. DEMBO Reprint requests to Dr Young: Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada.
The Correlation of Specific Variables of Tumor Differentiation With Response Rate and Survival in Patients With Advanced Head and Neck Cancer Treated With Induction Chemotherapy. Ensley JF, Kish JA, et al. Cancer 63: 1487, 1988 Conventional tumor grading correlates poorly with the biological response and survival rates in patients with advanced squamous cell cancers of the head and neck (SCCHN) treated with cisplatinum combinationinduction therapy. Because conventional grading may be
CURRENT LITERATURE
to Dr Jarhult: Department S-575 00 Eksjo, Sweden.
of Surgery,
Postanginal Sepsis. Shapiro J, Fried MP, Strome M. Head Neck Surg 11:164, 1989 Septicemia following pharyngitis, called postanginal sepsis, is a process in which infection spreads via tonsillar veins or lymphatic channels to the internal jugular vein. There, a thrombophlebitis can occur that can release septic emboli, which produce varying symptoms depending on the endpoint of embolization. This article reviews the English language literature relating to postanginal sepsis and presents three new cases. The authors found that the average length of time between the onset of sore throat and the development of systemic septic symptoms was 9 days (range 0 to 22 days). The neck examination was usually abnormal, with the most common symptom being pain along the anterior border of the sternocleidomastoid muscle. The most common organisms found on positive blood culture were Fusobacteria. The most frequent problem due to systemic emboli was pulmonary involvement with infiltrates and pleural effusions. Other signs and symptoms of postanginal sepsis include high spiking fevers, chills, malaise, and leukocytosis. Useful studies on patients with postanginal sepsis included neck ultrasound or CT scan looking for abscess cavities. The mortality rate since the induction of penicillin is 8%. Management of a patient with suspected postanginal sepsis includes obtaining a history of antecedent pharyngitis. A careful neck and oropharyngeal examination should be performed. If the neck is tender a CT scan should be ordered, along with blood cultures. Most of the organisms likely to cause postanginal sepsis are sensitive to penicillin or clindamycin. The discovery of an abscess should prompt surgical exploration for drainage and possible ligation and resection of any thrombosed portions of the internal jugular vein. In most cases recovery is prolonged.-J.R. HUMP Reprint requests MA 02115.
to Dr Shapiro: 333 Longwood Ave, Boston,
Comparison of Pulse Oximeters: Effects of Vasoconstriction and Venous Engorgement. Wilkins CJ, Moores M, Hanning CD. Br J Anaesth 62:439, 1989 Pulse oximetry is an emerging standard for anesthetic monitoring. Although accurate under steady-state conditions, detection may be impaired in the presence of vasoconstriction (CNSTR) or venous congestion (CONG). This study compared the accuracy of five pulse oximeters under these conditions. Oximeters tested were: Ohmeda 3700, Novametric 500, Criticare Systems Inc. model 501, Accusat (Datascope Corp), and Lifestat 1600 (Physiocontrol Corp). Ten healthy volunteers had finger probes from each machine placed in a randomly assigned manner, and a Biox III oximeter was applied to the subjects’ ears for safety monitoring. Each subject was twice given a hypoxic gas mixture (10% oxygen, 90% nitrogen) to breathe for 2 minutes with control desaturation values recorded. A blood pressure cuff was inflated to 40 mm Hg on the upper arm to induce venous congestion, and two episodes of hypoxia induced as before. To induce vasoconstriction, a cooled, water-filled plastic bag was placed over the forearm for 10 minutes, and again hypoxia induced. All data were recorded on a calibrated chart re-
corder. Time for detection of desaturation was not significantly different among all oximeters in either control, CNSTR, or CONG groups. All oximeters had significant increases in detection time of two to three times the control value when CNSTR or CONG conditions were present, causing a mean delay of 150 seconds to detection of hypoxic insult. Of all the units tested, the Novametrix failed to detect the maximum desaturation that occurred under CNSTR or CONG conditions. The same unit failed to give an alarm of poor quality signals while other units gave clear warning under CNSTR or CONG conditions. The authors warn that presence of a normal pulse signal does not imply that perfusion is adequate for detection of hypoxia. They state that new versions of several oximeters were introduced after the study began (including Novametrix) and may perform differently than those tested.-J. DEMBO Reprint requests to Dr Wilkins: University Department of Anaesthesia, General Hospital, Gwendolen Rd, Leicester LES 4PW, England.
The Effect of Flumazenil on the Recovery Time of Dental Patients Sedated With Diazepam. Young ER, Kestenberg SH, Toal CB. Anesth Prog 36:46, 1989 Diazepam, which is used widely for sedation in dentistry, has a long half-life that may cause prolonged sedation. Flumazenil is an imidazobenzodiazepine that antagonizes the effects of benzodiazepines by binding to the same receptors. This study examined the efficacy of flumazenil in shortening the recovery following diazepam sedation. Twenty-one healthy young men undergoing restorative dentistry were randomly assigned to receive flumazenil or placebo. Each group was sedated with diazepam 0.15 mg/kg intravenously, and local anesthetic was given. Fifteen minutes after the diazepam dose, flumazenil 0.015 mg/kg or placebo vehicle was given IV in doubleblind fashion. Psychomotor function was tested presedation and postsedation at S-minute intervals using the Trieger test, digit-symbo1 substitution (DSS), Romberg test, and an independent assessment by the dentist, nurse, and patient. Significant differences between groups included better performance on the Trieger test and DSS only at 5 and 10 minutes; after 15 minutes no differences were noted. The authors attribute these tindings to the natural cessation of diazepam effects after 15 minutes. They conclude that, although flumazenil was useful in improving psychomotor performance during the immediate postsedation period, it cannot be recommended for routine use following benzodiazepine sedation.-J. DEMBO Reprint requests to Dr Young: Faculty of Dentistry, University of Toronto, Toronto, Ontario, Canada.
The Correlation of Specific Variables of Tumor Differentiation With Response Rate and Survival in Patients With Advanced Head and Neck Cancer Treated With Induction Chemotherapy. Ensley JF, Kish JA, et al. Cancer 63: 1487, 1988 Conventional tumor grading correlates poorly with the biological response and survival rates in patients with advanced squamous cell cancers of the head and neck (SCCHN) treated with cisplatinum combinationinduction therapy. Because conventional grading may be