Shionoya Yoshiki, Nakamura Eishi, Goi Takahiro, Nakamura Kiminari, Sunada Katsuhisa
Department of Dental Anesthesia, Nippon Dental University Hospital, Tokyo, Japan.
Department of Dental Anesthesiology, Nippon Dental University School of Life Dentistry, Tokyo, Japan.
Anesth Prog. 2019 Spring;66(1):37-41. doi: 10.2344/anpr-66-01-06.
Type II Arnold-Chiari malformation (ACM) is an abnormality in which the cerebellum, pons, and medulla oblongata are displaced downward into the spinal cord. Type II ACM is often complicated by respiratory depression, sleep-disordered breathing, and deglutition disorder as a result of medullary dysfunction and impairment of the lower cranial nerves. Bending and stretching of the neck is restricted, and anesthetic management is problematic in patients with the disorder. We performed dental treatment twice under intravenous sedation in a patient with intellectual disability with type II ACM complicated by hypercapnic respiratory failure. Propofol was used for the first sedation procedure. Repeated bouts of respiratory depression occurred on that occasion, so the airway was managed manually by lifting the jaw. However, aspiration pneumonitis occurred postoperatively. A combination of dexmedetomidine and midazolam was used for sedation on the second occasion, and the intervention was completed uneventfully without any respiratory depression. Our experience with this patient highlights the need for selection of an agent for intravenous sedation that does not require neck extension and has minimal effect on respiration in patients with type II ACM, who are at high risk of respiratory depression and pulmonary aspiration.
II型阿诺德-奇亚里畸形（ACM）是一种小脑、脑桥和延髓向下移位至脊髓的异常情况。II型ACM常因延髓功能障碍和下颅神经受损而并发呼吸抑制、睡眠呼吸紊乱和吞咽障碍。颈部的弯曲和伸展受限，患有该疾病的患者麻醉管理存在问题。我们对一名患有II型ACM并伴有高碳酸血症呼吸衰竭的智障患者在静脉镇静下进行了两次牙科治疗。第一次镇静程序使用了丙泊酚。那次出现了反复的呼吸抑制发作，因此通过抬起下颌进行手动气道管理。然而，术后发生了吸入性肺炎。第二次镇静时使用了右美托咪定和咪达唑仑的组合，干预顺利完成，没有出现任何呼吸抑制。我们对这名患者的经验凸显了在II型ACM患者中选择一种不需要伸展颈部且对呼吸影响最小的静脉镇静药物的必要性，这类患者有呼吸抑制和肺误吸的高风险。
