SummaryWe studied 411 children aged 3-10 years who were referred for dental treatment. They were randomly allocated to have inhalation conscious sedation with either sevoflurane ⁄ nitrous oxide mixture or nitrous oxide alone. Dental treatment was satisfactorily completed in 215 ⁄ 241 children who were given sevoflurane ⁄ nitrous oxide mixture (89%) compared with 89 ⁄ 170 who were given nitrous oxide alone (52%) (Chi square 70.3, p < 0.0001). All children remained conscious and responsive to verbal contact throughout the treatment and in the recovery room. No adverse side-effects were recorded in either group and there were no significant differences in oxygen saturation, heart rate, recovery profile, or time to discharge home between the groups. The study concluded that, for every 100 children treated with sevoflurane ⁄ nitrous oxide mixture, 37 children would be saved a general anaesthetic if given combined sevoflurane and nitrous oxide mixture rather than nitrous oxide alone. The use of sevoflurane in low concentrations 0.1-0.3% to supplement nitrous oxide and oxygen for inhalation conscious sedation is safe, practical, and significantly more effective than nitrous oxide alone in children having dental treatment.

SummaryFailure of dental treatment due to anxiety is a common problem in children. The aim of this study was to establish whether the use of a combination of intravenous midazolam with inhalation agents (nitrous oxide alone or in combination with sevoflurane) was any more likely to result in successful completion of treatment than midazolam alone. A further aim was to evaluate the clinical viability of these techniques as an alternative to general anaesthesia. In total, 697 children too anxious for management with relative analgesia and requiring invasive dental procedure for which a general anaesthetic would usually be required, were recruited and randomly assigned to one of three groups given the following interventions: group 1 -a combination of inhaled medical air and titrated intravenous midazolam, group 2 -a combination of inhaled 40% nitrous oxide in oxygen and titrated intravenous midazolam, and group 3 -a combination of an inhaled mixture of sevoflurane 0.3% and nitrous oxide 40% in oxygen with titrated intravenous midazolam. The primary outcome measure was successful completion of the intended dental treatment with a co-operative child responsive to verbal commands. In group 1, 54% (94 ⁄ 174 children) successfully completed treatment. In group 2, 80% (204 ⁄ 256 children) and in group 3, 93% (249 ⁄ 267 children) completed treatment. This difference was significant at the 1% level. Intravenous midazolam, especially in combination with inhaled nitrous oxide or sevoflurane and nitrous oxide, are effective techniques, with the combination of midazolam and sevoflurane the one most likely to result in successful treatment.

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SummaryWe studied 128 patients undergoing nasal intubation to see whether the nostril side used influenced peri-operative nasal complications. In the apparently normal nostril, there is no significant difference between either nostril in difficulty of intubation ( p . 0.8). Similarly, there is no significant difference in the incidence of bleeding at intubation ( p . 0.2), at extubation ( p . 0.5) and once the patient has returned to recovery ( p . 0.1). Postoperative nostril patency is also similar between groups ( p . 0.85). Standard teaching of nasal intubation recommends that, in the first instance, the right nostril should be used when patency appears equal on both sides of the nose [1]. This is because the tracheal tube is designed such that the flat side of the bevel is on the left side of the tip. However, there is no evidence that the risk of trauma to the nose, or difficulty with intubation, is any greater using the left nostril. Many case reports of potentially serious complications of nasal intubation have in fact involved the right nostril [2±4].Our study aimed to elucidate whether the left nostril was more difficult to intubate than the right and whether the complications, in terms of bleeding and postoperative nostril patency, were different between the two sides. MethodAfter approval from the Hospital Research Ethics Committee, we studied 128 patients who were undergoing elective dental surgery that required nasal intubation. Patients were ASA classification 1 or 2. They had no history of nasal disease, including epistaxis, no coagulation problems, and were not taking medication likely to increase bleeding. None of the group had hypertensive disease. Patients were not studied if there was apparent unilateral decrease in nostril patency, determined by breathing through each nostril individually.A standard anaesthetic technique was used. Premedication with diclofenac 100 mg rectally was given up to 30 min before surgery. Induction and maintenance of anaesthesia was performed using a combined propofol (500 mg)/alfentanil (2 mg) infusion, with atracurium 0.3 mg.kg 21 given to facilitate intubation. Ventilation throughout anaesthesia was provided using an oxygen/ nitrous oxide mixture.The nostril side for intubation was chosen randomly and no vasoconstrictor spray was used. Intubation was performed using a Portex`Ivory' cuffed nasotracheal tube lubricated with water-soluble jelly. A tube with an internal diameter of 6.5 mm was used for men and 6 mm for women. The tube was passed through either nostril with the slant of the bevel facing to the left. The ease of passing the tube through the nostril was noted. Once the tip of the tube had passed into the oropharynx, direct laryngoscopy was performed and the presence of blood in the pharynx was noted. This was classified as either (1) blood absent, (2) blood staining on the cuff only (mild bleeding) or (3) blood pooling on the posterior pharyngeal wall (severe bleeding). The tube was then passed into the trachea under direct vision, the cuff was inflated ...

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