PubMed Health⌕ Search

Biomedical subjects

N A Sandler

Publications and source records attributed to N A Sandler.

18 recordsLinked to original sources
PubMed2001

Assessment of recovery in patients undergoing intravenous conscious sedation using bispectral analysis.

PURPOSE: The Bispectral Index (BIS) has been recently shown to objectively predict the level of sedation in patients undergoing conscious sedation. It was the goal of this study to directly compare the recovery profile of patients where the BIS was used to monitor sedation with a control group where the monitor was not used. PATIENTS AND METHODS: Forty patients undergoing third molar extractions under intravenous conscious sedation were randomly assigned to 2 groups. In both groups, induction of sedation was performed using a standard dose of fentanyl (1.5 microg/kg) and midazolam (0.05 mg/kg). Propofol was then given in 10 to 20 mg boluses until a clinically desirable sedation level was achieved. In 1 group, the BIS was then monitored continually during surgery using a microcomputer (Aspect-1050 Monitor, Aspect Co, Natick, MA) and recorded at 5-minute intervals. The anesthetist (N.A.S.) provided additional propofol boluses to maintain a BIS level of 70 to 80. In the other group, the BIS sensor was applied, but the monitor was not used. In this group, the sedation was modified, and additional propofol was given based solely on the anesthetist's subjective assessment of the desired level of sedation (Observer's Assessment of Alertness/Sedation [OAA/S] scale level 2 to 3). Additional boluses of 1 mg of midazolam were given during the procedure if patients required repeated boluses of propofol at less than 5-minute intervals to maintain the desired sedation level (BIS level of 70 to 80 or OAA/S level of 2 to 3). These additional midazolam boluses, as well as the time of the last sedative dose (propofol or midazolam) were recorded to study the effect of these factors on recovery. RESULTS: Of the 40 patients initially included in the study, 1 subject in the BIS-monitored group was excluded due to the loss of intravenous access at initiation of the case. For the remaining 39 subjects, 19 were assessed objectively using the BIS monitor, whereas 20 were assessed subjectively using the OAA/S scale. The BIS cases were slightly longer in duration than the OAA/S cases, lasting an average of 26 minutes versus 22 minutes. This difference was statistically nonsignificant (P =.19). Less propofol was used in the BIS cases, with an average of 98 mg for BIS cases versus 106 mg for OAA/S cases (P =.59). The total dose in mg/kg/min was significantly less in the BIS group (0.054 mg/kg/min) than in the OAA/S group (0.074 mg/kg/min; P =.0082). There was no significant difference in the amount of midazolam administered after induction between the 2 groups (P =.60). The surgeon, who was blinded to whether the monitor was used, ranked the third molar extractions more difficult in the BIS group (P =.05). However, patients in the BIS group were on average more cooperative, with better maintenance of muscle tone. The difference in these parameters were nonsignificant (P =.15 and .092, respectively). A positive Romberg test was obtained earlier in BIS patients, although this difference was nonsignificant (P =.097). The straight-line test was completed significantly sooner in BIS patients (P =.013). There was no significant difference between the BIS and OAA/S groups in perceptual speed (P =.55) or computation (P =.32). There was essentially no difference between groups in patient-assessed comfort or recall of the procedure. There were also no notable differences in anesthesia complications, return to activities of daily life, or pain medication use between the 2 groups. CONCLUSIONS: The BIS provides additional information for standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. It appears that use of the BIS monitor can help to titrate the level of sedation so that less drugs are used to maintain the desired level. The trend toward an earlier return of motor function in BIS-monitored patients warrants further investigation.

Adult↗
PubMed2000

The use of bispectral analysis in patients undergoing intravenous sedation for third molar extractions.

PURPOSE: The bispectral (BIS) index has been used to interpret electroencephalogram (EEG) recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. It was the purpose of this project to assess the usefulness of BIS technology in determining the level of sedation in patients undergoing third molar extraction under conscious sedation. PATIENTS AND METHODS: Twenty-five subjects undergoing third molar extraction in an outpatient setting were analyzed. The EEG activity was recorded continually during surgery using a microcomputer (Aspect-1050 Monitor; Aspect Co, Natick, MA) with real-time bispectral data obtained by EEG skin electrodes through a frontotemporal montage. The Observer's Assessment of Alertness and Sedation (OAA/S) scale was used to subjectively assess the level of sedation observed by the anesthetist before initiating the sedation procedure and then at 5-minute intervals until the end of the procedure. The BIS level was simultaneously recorded. The initial sedation was accomplished using a standard dose of midazolam (0.05 mg/kg) and fentanyl (1.5 microg/kg) followed by a 10- to 30-mg bolus of propofol until a level of sedation at which the patient's eyes were closed and he or she was responsive only to vigorous stimulation or repeated loud calling of their name (OAA/S level of 1 to 2). Local anesthesia was then administered. Additional doses of sedative medication (midazolam or propofol) were given during the procedure to maintain the desired level of sedation (an OAA/S level of 2 to 3). The time and dose of the drug given were recorded. The level of sedation based on a single anesthetist's interpretation (OAA/S) and the BIS readings were then compared. RESULTS: A strong positive relationship between the BIS index and OAA/S readings was found (P < .0001). Pairwise comparisons of mean BIS index and its corresponding OAA/S level were significantly different from each other (P < .003) except for OAA/S levels 2 and 3 (P = .367). CONCLUSION: BIS technology offers an objective, ordinal means of assessing the depth of sedation. There was a strong relationship between the objective BIS values and subjective assessment (OAA/S scale) of the depth of anesthesia. This can be invaluable in providing an objective assessment of sedation in oral and maxillofacial surgery where it may be difficult to determine the level of sedation clinically.

Adolescent↗
PubMed2000

The use of bispectral analysis to monitor outpatient sedation.

The bispectral (BIS) index has been used to interpret partial EEG recordings to predict the level of sedation and loss of consciousness in patients undergoing general anesthesia. The author has evaluated BIS technology in determining the level of sedation in patients undergoing outpatient deep sedation. These experiences are outlined in this review article. Initially, the correlation of the BIS index with traditional subjective patient evaluation using the Observer's Assessment of Alertness and Sedation (OAA/S) scale was performed in 25 subjects. In a second study, the recovery profile of 39 patients where the BIS was used to monitor sedation was compared with a control group where the monitor was not used. A strong positive relationship between the BIS and OAA/S readings was found in the initial subjects. From the recovery study, it appears that use of the BIS monitor may help titrate the level of sedation so that less drugs are used to maintain the desired level of sedation. A trend to earlier return of motor function in BIS-monitored patients was also demonstrated. BIS technology offers an objective, ordinal means of assessing the depth of sedation. This can be invaluable in comparing studies of techniques. The BIS index provides additional information to standard monitoring techniques that helps guide the administration of sedative-hypnotic agents. The trend to earlier return of motor function in BIS-monitored patients warrants further investigation.

Adolescent↗
PubMed2000

Additional clinical observations utilizing bispectral analysis.

Additional observations were made in the use of the bispectral (BIS) index with the use of ketamine and in performing general anesthesia without the use of local anesthesia in nonintubated patients. Twenty-five subjects undergoing extraction procedures in an outpatient setting were analyzed using bispectral analysis with ketamine and midazolam. Despite repeated injections of midazolam during the procedure, only transient decreases of the BIS occurred to the 80s, with a low value of 77 in all but 1 patient where ketamine was used. In comparison, values in the 50-70 range are typically seen immediately after the administration of sedative doses of midazolam, propofol, or methohexital. In the second study, once propofol anesthesia was initiated, BIS readings in the 30s were commonly seen in patients during their procedure. The lowest BIS level observed was 18. Bispectral analysis was useful to trend the present anesthetic state and adjust the dose of propofol accordingly. In no case was laryngospasm or total airway obstruction observed. In 1 case, partial airway obstruction secondary to retro-positioning of the tongue occurred with a subsequent decrease in oxygen saturation to 89%. This was rectified by repositioning the patient to alleviate the obstruction. Consistent with previous studies utilizing ketamine, BIS values are consistently higher when compared with other hypnotic agents. With the subsequent injection of midazolam, the BIS level did not decrease to anticipated levels. In the final study reviewed, when local anesthesia was not used during general anesthesia, bispectral analysis was a useful adjunct in helping maintain a steady state of general anesthesia in nonintubated patients undergoing third molar extractions. Bispectral analysis offers additional information on the depth of the hypnotic state and is useful in helping control the depth of anesthesia. A limitation of the index includes the inability to titrate the level of sedation induced by hypnotic agents such as midazolam when ketamine is concomitantly administered.

Airway Obstruction↗
PubMed1999

The use of maxillary sinus endoscopy in the diagnosis of orbital floor fractures.

PURPOSE: The goal of the current study was to evaluate the ability to diagnose the presence of an inferior orbital wall fracture through the use of a transantral endoscopy technique at bedside. PATIENTS AND METHODS: Seven trauma patients with initial axial computed tomography (CT) scan findings consistent with an orbital floor fracture were studied. Before endoscopy, the patients underwent a coronal CT scan with 3-mm cuts for later comparison with the endoscopic findings. The surgeon performing the endoscopy procedure was blinded to the results of the coronal CT scan. Visual acuity, intraocular pressure, and measurement for enophthalmos were performed before endoscopy. The endoscopic procedure was performed at the bedside using local anesthesia. A trocar was used in the canine fossa to gain access to the maxillary sinus. A 30 degrees and then a 70 degrees endoscope were introduced through the trocar to evaluate the integrity of the orbital floor (ie, maxillary sinus roof). The degree of mucosal injury of the orbital floor and the presence of blood or orbital contents in the sinus were recorded. The ophthalmologic examination was repeated after completion of endoscopy. RESULTS: The endoscopic procedure was able to be completed in all patients. There was no change in the ophthalmologic examination in any patient as a result of endoscopy. In six of the seven patients studied, the endoscopic findings correlated with the need for surgical intervention to repair the orbital floor predicted on the basis of coronal CT scan. This was determined by the degree of injury to the orbital floor and the presence of hematoma, exposed bone, or fat. In the remaining case, endoscopy was not diagnostic for the presence of a fracture because only ecchymosis of the orbital floor was noted. CONCLUSIONS: The ability to perform endoscopy under local anesthesia at the bedside is useful in those trauma patients whose concomitant injuries may prohibit other diagnostic modalities.

Adolescent↗
PubMed1999

Subjective and objective assessment of the temporalis myofascial flap in previously operated temporomandibular joints.

PURPOSE: This study evaluated the subjective and objective findings in patients who had undergone temporomandibular joint (TMJ) reconstruction with a temporalis myofascial flap. All joints had previously been reconstructed with alloplastic, allogeneic, or autogenous material. PATIENTS AND METHODS: Twenty-three consecutive patients who underwent 28 temporalis myofascial flap procedures were assessed subjectively and objectively preoperatively and at an average of 36 months postoperatively. Panoramic radiographs, magnetic resonance imaging (MRI), or coronal computed axial tomography scans (CT scans) were performed on all patients preoperatively to evaluate for joint disease. A visual analog scale (VAS) was used to assess pain preoperatively and postoperatively. Patients also reported their use of pain medication, ability to function, diet, complications, and overall satisfaction. Preoperative and postoperative objective assessment consisted of an evaluation of range of motion, deviation on opening, joint noise on function, and cosmesis. RESULTS: On preoperative radiographic examination, 24 of 28 joints showed signs of bony degeneration, including cortical erosion, condylar flattening, and joint space alterations. Four joints showed evidence of ankylosis. The average preoperative maximal interincisal opening (MIO) was 23.7 mm, and the postoperative average was 32.3 mm (P<.05). Preoperatively, all patients displayed one or more objective clinical signs of joint disease such as joint noise on function, deviation on opening, limited mouth opening (less than 20 mm), or limited excursions (less than 2 mm). Postoperatively, 65% displayed one or more of these signs, a significant reduction (P<.05). Preoperatively, the average pain score was 8.2 on the VAS, and postoperatively the average pain score was 3.4 (P<.0005). Fifteen patients used less pain medication postoperatively, 7 used the same amount, and 1 patient used more. Thirteen patients were very satisfied with the overall results of the surgery, 4 were satisfied, and 4 were not satisfied. Two patients were satisfied with their increased function but were not satisfied with their pain reduction. All were satisfied with their cosmetic appearance. Minor complications after the procedure included 3 patients who had preauricular paresthesia and 1 who had an intraoperative dura mater exposure without sequelae. Two patients had postoperative superficial suture infections, and 2 noted hearing changes that were found to be clinically insignificant by audiologic examination. CONCLUSION: The temporalis myofascial flap is an autogenous graft that has the advantages of close proximity to the temporomandibular joint, minimal surgical morbidity, and successful clinical results. It was found to be a valuable option for TMJ reconstruction in joints in which alloplastic, allogeneic, or autogenous materials have previously been placed unsuccessfully.

Adult↗
PubMed1998

Correlation of inflammatory cytokines with arthroscopic findings in patients with temporomandibular joint internal derangements.

PURPOSE: The goal of this study was to evaluate the presence of the inflammatory cytokines interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) within the superior temporomandibular joint (TMJ) space in patients with internal derangements and to compare these values with the pathologic findings seen arthroscopically. PATIENTS AND METHODS: Thirty patients with symptomatic TMJ dysfunction and clinical and imaging evidence of internal derangements of the TMJ were evaluated. Before entering the superior joint space with the arthroscope, 2 mL sterile saline was injected and, after 30 seconds of equilibration, was aspirated for analysis. The surgeon then performed diagnostic arthroscopy. The degree of synovitis, degeneration, percent condylar roofing, and any pathologic changes, such as perforations, were recorded. The level of total protein in each sample was ascertained, as well as the levels of IL-1 beta, IL-6, and TNF-alpha. RESULTS: Of 30 samples tested, three were discarded because of failure to gain access into the superior joint space. Of the 27 remaining samples, IL-6 showed the closest correlation with the level of acute synovitis demonstrated arthroscopically. Two of the higher IL-6 levels (167 and 324 pg/microg protein) were seen with patients with a significant disc perforation. In patients with a high degree of vascularity, IL-6 was found to be between 0 to 581 pg/microg protein with an average of 80 pg/microg protein and a median value of 43 pg/mg. These values significantly correlated with the degree of vascularity (P < or = .02). This is in comparison with the 10 remaining patients, who showed significantly fewer vascular changes arthroscopically. In these patients, the range of IL-6 was 0 to 35 pg/microg protein, with an average of 19 pg/microg protein and a median value of 14.5 pg/microg. These values significantly correlated with the smaller degree of vascularity (P < or = .02). In seven patients, the role of nonsteroidal antiinflammatory drug (NSAID) use resulted in decreased levels of IL-6, which has been noted in previous studies. In patients with higher rated redundancy of the synovial tissue, the average IL-6 level was 92 pg/microg protein, whereas the median value was 44 pg/microg protein. In patients with little or no redundant synovial tissue, an average IL-6 level of 22 pg/microg protein was present. The median value in these same joints was 15 pg/microg protein. These IL-6 values significantly correlated with the degree of redundancy (P < or = .03). The degree of degenerative change (chondromalacia, fibrillation), disc displacement (roofing), and the presence or absence of adhesions did not significantly affect the levels of IL-6 within the patients studied. The presence of IL-1 beta and TNF-alpha was not found to correlate with the arthroscopic findings in the superior joint space. CONCLUSIONS: The presence of IL-6 correlated with the degree of acute synovitis. IL-1 beta and TNF-alpha were not found in significant levels within the superior joint space. These findings correlated with those reported by other investigators. The production of IL-6 by synovial cells and its role in TMJ disease warrants further investigation.

Adolescent↗
PubMed1998

Comparison of propofol and methohexital continuous infusion techniques for conscious sedation.

PURPOSE: Methohexital and propofol have been shown to be effective agents for continuous intravenous infusion to produce conscious sedation during oral surgical procedures. The current study was conducted to compare these techniques for intraoperative cardiopulmonary stability, patient cooperation, amnesia, comfort, recovery time, and postoperative nausea and vomiting. METHODS: Seventy ASA Class I or Class II patients between the ages of 18 and 40 years, scheduled for surgical extraction of impacted third molars, were entered into the study. Thirty-five patients were assigned to group A (methohexital) and 35 were assigned to group B (propofol). Intravenous sedation was accomplished using premedication with 1.5 microg/kg of fentanyl and 0.05 mg/kg of midazolam followed by the continuous infusion of methohexital or propofol at a rate of 50 microg/kg/min. The infusion was then titrated to 100 microg/kg/min to accomplish a level of sedation in which the eyes were closed and the patients were responsive to verbal commands. Subjects were monitored for variability of heart rate, blood pressure, oxygen saturation, amnesia, comfort, cooperation, nausea and vomiting, and recovery time based on cognitive, perceptual, and psychomotor tests. RESULTS: There was no statistical difference between the two medication groups except for heart rate, which was found to increase by 11 beats/min for group A and only three beats/min in group B. CONCLUSION: A continuous infusion technique using either methohexital or propofol (50 to 100 microg/kg/min) was found to be safe and effective, with no clinically significant differences in cooperation, cardiopulmonary stability, recovery time, amnesia, comfort, and the incidence of nausea or vomiting. However, the cost-effectiveness of methohexital is superior to that of propofol.

Adolescent↗
PubMed1996

Economic analysis and its application to oral and maxillofacial surgery.

PURPOSE: Recent clinical publications have increasingly emphasized comparison of cost with benefits in such areas such as drug therapies, surgical procedures, and prophylaxis regimes within certain populations. In the past, cost analysis was based principally on the comparative market price of new treatment compared with standard therapy. Benefits were assessed solely in terms of objective clinical and imaging improvement. Now, issues such as quality of life, early return to occupation, and subjective symptoms of pain and discomfort caused by a treatment are also being critically evaluated. Addressing these latter issues, however, is often complicated and expensive. This article reviews some terms and principles of cost analysis, cost effectiveness, and cost-benefit analysis. Examples are given of recent attempts to quantify costs and benefits for individuals, hospitals, health organizations, and society as a whole. Guidelines are suggested concerning how these studies can be applied to oral and maxillofacial surgery.

Cost of Illness↗
PubMed1995

Differential diagnosis of jaw pain in the elderly.

While many diseases are marked by pain in the mandible or maxilla, a number of these conditions appear to be more prevalent in people 65 years and older. People in this age group often have a number of medical problems and take a variety of medications, so clear-cut diagnosis of jaw pain can be difficult. Memory deficits or concomitant somatic complaints can further complicate the diagnosis. This article presents a differential for jaw pain in the elderly and reports on a pertinent case.

Aged↗