Cannabis is one of the most common psychoactive substances used worldwide, and its use is increasing. Modern products vary widely in tetrahydrocannabinol (THC) concentrations and usage routes, creating challenges for anesthesia providers. This review summarizes current evidence on the pharmacology, pharmacokinetics, physiologic effects, and perioperative considerations of cannabis to help guide safe anesthetic management of cannabis-using patients. Cannabis contains over 100 phytocannabinoids, chiefly psychoactive Δ9-THC and nonpsychoactive cannabidiol (CBD), which act on cannabinoid type-1 (CB1) and type-2 (CB2) receptors. Chronic use downregulates CB1 signaling, contributing to tolerance, dependence, and withdrawal. Cannabis exerts widespread physiologic effects, including neuropsychiatric complications, cardiovascular changes, respiratory issues, delayed gastric emptying, appetite stimulation, and reproductive endocrine disruption. Cannabis use has been associated with increased propofol requirements, possibly via cytochrome P450 enzyme induction and CB1 receptor downregulation. It may also alter responses to opioids, ketamine, and gabapentinoids, and chronic users often report higher postoperative pain. Cannabis use influences anesthetic dosing, airway and cardiovascular stability, and postoperative pain control. Thorough preoperative assessment, individualized anesthetic planning, and vigilant monitoring are essential, and further research is needed to establish evidence-based perioperative guidelines.

Remimazolam is an ultrashort-acting benzodiazepine approved for procedural sedation in 2020 by the US Food and Drug Administration; however, dosing information originating from the US is limited. No existing literature details infusion rates of remimazolam delivered by manually adjusted infusion pumps. This case report describes the administration of manually infused remimazolam to an 86-year-old man for the surgical extraction of third molars under procedural sedation. Following an initial dose of 4 mg delivered over 1 minute, the remimazolam infusion was titrated according to the patient's response from a starting rate of 15 mg/h to achieve deep sedation/general anesthesia. The maximum infusion rate was 30 mg/h, and a total dose of 14.1 mg of remimazolam was administered over 28 minutes. The surgery was successfully completed, the patient was satisfied with the anesthetic postoperatively, and he recovered and was discharged home without incident. Further studies are needed to fully characterize remimazolam infusions for a variety of patients using manually adjusted infusion pumps for use in the US.

Epilepsy and seizure activity in dental patients can pose difficult management and treatment considerations for dental professionals, especially for those utilizing sedation and general anesthesia in office-based settings. This 2-part review will provide an overview of current approaches to managing patients with seizure disorders in dental settings. The first part of this review focuses on categorization, identification, and management strategies for seizure disorders, including pharmacological treatment, surgical intervention, and other emerging therapies. The second part of this review will highlight treatment considerations for patients with seizure disorders undergoing sedation or general anesthesia for dental care, including the effects of sedatives and anesthetic agents on seizure activity, strategies for maintaining seizure control, and management of drug interactions.

To clarify the effects of remifentanil and remimazolam on the cardiovascular system, oral tissue blood flow, and oral tissue oxygen tension during general anesthesia in rabbits. Male Japanese white rabbits (body weight, 2.5 kg; N = 11) were treated with remimazolam at a dose of 1 mg/kg/h continuously. Measurements included blood pressure, heart rate, tissue blood flow (common carotid artery, tongue mucosal, mandibular bone marrow and masseter muscle), and tissue oxygen tension (mandibular bone marrow and masseter muscle). Remifentanil was then administered at 0.2 μg/kg/min and each measurement was collected again. The dose of remifentanil was increased to 0.4 μg/kg/min and each measurement was collected again. The same measurements were collected when remimazolam was administered at doses of 2 mg/kg/h and 4 mg/kg/h. Remimazolam administration did not significantly alter the parameters of each observation. Blood pressure, heart rate, and tissue blood flow (common carotid artery, tongue mucosal, mandibular bone marrow, and masseter muscle) decreased significantly in a dose-rate dependent manner under remifentanil administration, whereas tissue oxygen tensions (mandibular bone marrow and masseter muscle) were maintained. Remimazolam anesthesia in rabbits had minimal effects, but in combination with remifentanil, it produced remifentanil dose-dependent decreases in oral tissue blood flow as well as blood pressure and heart rate.

Previous studies have reported that the noise generated by dental equipment can interfere with the auscultation of respiratory sounds during sedation. Therefore, this study aimed to identify whether positing the acoustic sensor on the chest or cervical position would be least susceptible to interference from dental suction device noise, a prominent noise noted during respiratory sound monitoring during dental sedation. This prospective cohort study was conducted with 30 students. Sound intensity (dB) and frequency (kHz) levels from the dental suction were recorded from the cervical and chest regions under both oral and nasal breathing conditions and analyzed. The mean intensity of dental suction sounds was significantly lower in the chest region compared with the cervical region, regardless of the breathing condition (P < .001). Furthermore, in the chest region, the mean sound frequency during oral breathing was significantly lower than that during nasal breathing (P < .01). Our study suggests that monitoring respiratory sounds in the chest region can significantly reduce interference from noise generated by dental suction devices compared with monitoring at the cervical region.

Angiogenesis is associated with angiogenic therapy and wound healing processes. It is important for anesthesiologists to understand the effects of perioperative and long-term use of anesthetics on angiogenesis. This study aimed to determine the effects of ketamine on in vitro angiogenesis: the proliferation of human umbilical vein endothelial cells (HUVEC) and normal human diploid fibroblasts (NHDF), HUVEC migration, and in vitro capillary tube formation in cocultured HUVEC and NHDF. The effects of ketamine at concentrations of 1, 10, and 50 µM on the proliferation of HUVEC and NHDF for 48 hours were determined by using a water-soluble tetrazolium salt reagent. Quantitation of migration for 22 hours was achieved by measuring the fluorescence of migrating HUVEC exposed to ketamine using an angiogenesis system. The effects of ketamine on capillary tube formation with or without vascular endothelial growth factor (VEGF) were investigated in cocultured HUVEC and NHDF incubated for 3 and 10 days. Ketamine did not show any enhancing or suppressive effects on the in vitro proliferation of HUVEC and NHDF, HUVEC migration, or capillary tube formation in cocultured HUVEC and NHDF for either 3 or 10 days in the presence or absence of VEGF. Ketamine had no effects on in vitro angiogenesis using cultured HUVEC and NHDF. Ketamine can potentially be used as an anesthetic agent with no influence on angiogenesis.

We present a case of an infant patient with Robin sequence (Pierre Robin sequence; PRS) who underwent general anesthesia for a glossopexy procedure. Pediatric patients with PRS are prone to upper airway obstruction during general anesthesia induction and intubation difficulties due to micrognathia and glossoptosis. In this case, we facilitated mask ventilation by inserting a nasopharyngeal airway before induction and successfully intubated the patient using a 2-person technique that combined the use of a video laryngoscope and a flexible fiber-optic scope. This experience suggests that the use of appropriate devices can help ensure airway patency and enhance visualization and maneuverability during intubation.

We describe a case of profound bradyarrhythmia after sugammadex administration during ambulatory anesthesia. The patient was a 21-year-old man with autism spectrum disorder undergoing planned general anesthesia for dental treatment. After treatment completion, sugammadex was administered upon awakening, and sudden bradyarrhythmia appeared immediately. The patient's heart rate decreased to approximately 30 beats/min but quickly recovered to roughly 80 beats/min after the administration of intravenous atropine. Electrocardiography suggested sinoatrial block or sinus arrest. Although the exact mechanism is unknown, severe electrocardiographic changes can occur within a few minutes of sugammadex administration.

To evaluate the anesthetic efficacy of 4% articaine with 1:100,000 epinephrine via primary intraosseous (IO) injection with the QuickSleeper device vs inferior alveolar nerve block (IANB) for mandibular first molars diagnosed with symptomatic irreversible pulpitis (SIP). Sixty-four patients with a first mandibular molar with SIP were randomly divided into 2 groups: IO (n = 32) and IANB (n = 32). Each received either an IO injection with the 5th generation QuickSleeper device or a conventional IANB with 1.7 mL 4% articaine with 1:100,000 epinephrine. Success was defined as no/mild pain upon the access cavity preparation and initial filing. Injection pain, anesthetic onset, heart rate (HR) change, HR recovery time, and duration of anesthesia were also recorded and analyzed. The success rates were 40.6% for IANB and 81.2% for IO (P < .001). IO exhibited a significantly lower injection pain (P = .027), a shorter onset of action (P < .001), a greater heart rate increase (P < .001), a faster heart rate recovery time (P < .001), and a shorter duration of action (P < .001) vs IANB. Primary IO anesthesia using the fifth generation of the QuickSleeper device was more successful than IANB when using 4% articaine with 1:100,000 epinephrine to anesthetize mandibular first molars with SIP. The QuickSleeper device appeared to be a viable alternative to IANB for mandibular anesthesia.