Abstract

We present a case of prolonged lower limb movement disorder following general anesthesia in a female patient in her early forties. She presented with vigorous, regular synchronous, rhythmic, and jerky movements during the immediate postoperative period lasting around forty minutes. Her past anesthetic history suggests varying degrees of postoperative movement disorders. Our patient was on long-term hydroxyzine for her skin condition. She had uneventful anesthetics before the prescription of hydroxyzine for her skin condition. All post-anesthetic dystonic events were reported while she was on hydroxyzine. Dystonic reactions during the perioperative period are rare and mostly occur during induction and emergence, which usually be transient. Our patient had prolonged lower limb dystonia resulting in severe muscular pain and lethargy for a few days. Further, she once developed transient aphasia and prolonged dysphonia following total intravenous anesthesia. This clinical finding could be a part of spasmodic laryngeal dystonia, which has not been reported previously. We correlate this rare postoperative dystonic reaction with propofol and possibly with the concurrent use of hydroxyzine.

As differential diagnosis can widely vary, the correlation of clinical findings with movement disorders is important for the diagnosis. Alterations of anesthetic techniques avoiding propofol and holding hydroxyzine are advisable in such rare clinical situations. Early diagnosis of perioperative movement disorders will prompt specific treatments, such as anticholinergic medications, for dystonia.

Introduction

We report a case of prolonged dystonia on multiple occasions in a patient following general anesthesia. Movement disorders are rare during the perioperative period. However, transient movement disorders have been reported during induction and emergence from general anesthesia [1,2]. Severe and prolonged dystonic reactions following general anesthesia are rare, especially in patients with no other risk factors, and are frequently misinterpreted as convulsions.

Voice changes can be due to Laryngeal dystonia [3]; however, it has not been reported following general anesthesia. Our patient previously had aphasia and dysphonia following total intravenous anesthesia in the past which can be a presentation of laryngeal dystonia. Although hydroxyzine can rarely cause movement disorders [4], dystonia in patients on hydroxyzine has never previously been reported following general anesthesia. Even though not conclusive, we try to correlate dystonia as a possibility of concurrent use of hydroxyzine in our patient.

Case Presentation

A female patient in her early forties presented to us with severe sciatica pain for primary posterior fusion and decompression in the lumbar region. She had a medical history of chronic pain and skin psoriasis and had undergone a total of eight surgical procedures, including hand surgeries, arthroscopic shoulder surgeries, posterior decompression in the lumbar region, and partial gastrectomy as an emergency surgery in the past.

The patient experienced abnormal movements in her lower limbs during most of her postoperative periods. These were described as vigorous, painful, involuntary movements of the lower limbs lasting for a couple of hours. The use of midazolam and magnesium transiently reduced her signs and symptoms.

A year ago, she received total intravenous anesthetics for hand surgery, where she experienced aphasia for a couple of hours and dysphonia lasting for a couple of months. Dysphonia was explained as a stuttering and difficulty in controlling her voice with excessive loudness. She had no sore throat or structural anomaly on endoscopy. Her CT and MRI brain were essentially normal at that time and her symptoms as functional expressive dysphasia after referring to a neurologist.

She had no history of any movement disorders in the past except during the emergence of anesthetics. She had no family history of movement disorders or problems that could relate to anesthetics. She was on hydroxyzine for her skin condition as a long-term medication and took bisacodyl, co-codamol, lansoprazole, and methotrexate as regular medications.

On examination, she weighed 101 kg (BMI 38 kg/m²), was euthermic, and did not appear anxious. Her heart rate was 78 beats per minute, and her cardiovascular and respiratory systems were unremarkable. Apart from a foot drop on her left side, her neurological examination was normal. Her laboratory investigations, including electrolytes, were also normal.

Anesthesia was induced with 200 mg of propofol and 60 mg of rocuronium. During the 40 minutes of operative time, her vital parameters remained within normal ranges, and she was euthermic. Anesthesia was maintained with sevoflurane in oxygen and air. The patient received 4 mg of ondansetron, 6.6 mg of dexamethasone, a total of 15 mg of morphine, 1 g of paracetamol, 40 mg of parecoxib, 1 g of magnesium, and 1 mg of intrathecal morphine intraoperatively. After tracheal extubation, the patient was sent to the recovery area.

When she was fully awake, her legs began exhibiting regular, synchronous, rhythmic, and jerky movements. They were vigorous enough to cause her body to move or slide down the bed. The movements occurred in clusters of 4 to 5 jerks every 10 to 15 seconds. Her torso was also involved, with her abdominal and erector spinae muscles experiencing intermittent spasms. The patient’s lower limb muscles were spastic. She received 2 mg of midazolam, which transiently relieved her symptoms for about 2 to 3 minutes. The patient complained of severe pain in her lower limbs and was subsequently administered an additional 10 mg of morphine intravenously. No other abnormal movements or body positions were noted. She was fully conscious and cooperative throughout. Her heart rate increased to 140 beats per minute and remained above 120 beats per minute. The highest body temperature recorded was 36.8 °C.

After 40 minutes of dystonic movements, she was moved into an assisted sitting position with both legs hanging down, where complete cessation of her symptoms was noted. She experienced excessive sweating and muscle pain for a couple of hours, which were treated symptomatically.

The patient was discharged home on the second day, and no further abnormal movements were reported. She felt weak and fatigued for the following few days. Successive follow-up visits were carried out, and after multidisciplinary meetings with the anesthetic, acute medical, and specialist neurology teams, an anesthetic alert was raised and detailed communication was forwarded to her family physician. We suggested avoiding propofol and withholding hydroxyzine for at least three preoperative days in the future.

Discussion

Dystonia is considered a movement disorder classically present with sustained muscle contractions and repetitive or patterned movements in varying body parts. It often produces a twisting posture and interestingly follows a task-specific movement, frequently called a sensory trick. Among the other hyperkinetic movement disorders like chorea, myoclonus, akathisia, tics, and tremors, our patient’s signs and symptoms tallied with dystonic movement disorder. She presents with this movement disorder only after anesthetics, therefore, it can be considered as a dystonic reaction to anesthetics or as a complex interaction of anesthetic with medication she is already on.

Sustained or patterned contractions of agonist and antagonistic muscles in limbs, trunk, and neck result in involuntary movements and twisting posture. She presented with lower limb dystonia; however, she suffered from dysphonia following anesthetics in the past, which can be a form of adductor laryngeal spasmodic dystonia resulting in voice tremors and affecting loudness of the voice. Further, spasticity in the neck and facial muscles could result in life-threatening airway emergencies with upper airway obstruction. To our knowledge, this is the first case report describing laryngeal dystonia following anesthetic.

Dystonic reactions during the perioperative period are rare and mostly occur during induction and emergence, which usually be transient [1,2]. The majority of the cases of perioperative movement disorders were correlated to propofol or antiemetic agents such as metoclopramide or ondansetron. In our case, ondansetron had been used without any ill effects previously. Propofol was used as the induction agent in all her previously reported dystonic events and, on one occasion, as part of total intravenous anesthesia, where severe lower limb dystonia and aphasia were reported.

A clear pattern of worsening severity and duration of the dystonic reaction after each anesthetic was noted in our case, and such a graded response following anesthesia has been described previously.

Even though the pathophysiology of dystonia is not clearly understood, several mechanisms have been described by various authors. The classic description is an imbalance between inhibitory dopaminergic and excitatory cholinergic systems in the basal ganglia. Recent research suggests that dystonia is a motor circuit disorder rather than a simple neurochemical imbalance confined to the basal ganglia. Further, studies involving tonic vibration reflex stimulus suggest that muscle spindle afferent pathways carry kinaesthetic inputs to the cerebellum [5]. Sensory inputs are directed to the basal ganglia and mainly to the striatum via the thalamus. These pathways could explain the sensory elements of dystonia.

A compartment model in the striatum could explain some of the findings related to our patient’s presentation. Striosomes and matrices are considered neurochemically distinct compartments in the striatum (Figure 1). Of that, a much larger compartment, the matrix, comprises direct excitatory and indirect inhibitory neurons [5]. Excitatory outputs mediate via dopamine 1 (D1) receptors and indirect inhibitory outputs involve D2 receptors. Neurons in the ribosome get inputs from the limbic system. Cholinergic neurons influence the activation of striosomes. These ribosomal neurons have inhibitory projections into substantia nigra pars compacta (SNc) which act via gamma-aminobutyric acid (GABA) receptors. Outputs from SNc have feedback into striosome and matrix mediated via dopamine. It activates predominantly the direct pathway of matrix via D1 receptors giving rise to an excitatory motor response.

Figure 1: Three compartmental model of basal ganglia circuit with direct and indirect motor outputs.

Source: [5].

GABA, gamma-aminobutyric acid; SNc, substantia nigra pars compacta

Various extrapyramidal side effects have been reported about the use of propofol. The mechanism of such movement disorders is largely unknown but commonly relates to an imbalance of cholinergic and dopaminergic effects in basal ganglia. Propofol is known to inhibit fatty amide hydrolase, which metabolizes the endocannabinoid anandamide (AEA). This leads to a significant increase in the whole brain content of AEA following propofol administration [6]. The endocannabinoid system has a fundamental role in the control of movements. Therefore, changes in the endocannabinoid system could partly explain the effects on movement disorders after propofol administration.

Hydroxyzine is a first-generation antihistamine that acts as an H1 receptor inverse agonist. It is commonly used in the treatment of itchiness, insomnia, motion sickness, and anxiety. Further, it has an antagonistic effect on D2 receptors. That could result in an inhibition of the indirect inhibitory pathway at the striatum, resulting predominance of excitatory direct motor output. There are cases of dystonia following hydroxyzine administration in the literature [4], and involuntary motor activities reported in hydroxyzine (ATARAXTM) product information. Studies have shown that long-term prescription of hydroxyzine can cause tardive dyskinesia [7].

Our patient was on hydroxyzine for her skin condition as a long-term medication. The patient had undergone a few general anesthetics without dystonic reactions before taking the treatment with hydroxyzine. However, since starting on hydroxyzine, she subsequently had dystonic reactions after each general anesthetic she had undergone. It is unclear how hydroxyzine interacts with general anesthetics, and we could not find previously published cases highlighting such interaction.

Acute dystonia is commonly treated with anticholinergic medications such as benztropine and procyclidine. Symptoms generally improve within 10 to 30 minutes. Intravenous benzodiazepines are effective in acute dystonic reactions.

Conclusions

Movement disorders during the perioperative period are rare and transient. Atypical presentations of dystonic reactions can occur in the form of laryngeal dystonia and dysphonia. Even though postoperative dystonic reactions are commonly attributed to propofol and antiemetic medications, we conclude that they can be related to other dopamine antagonists like hydroxyzine. Therefore, detailed patient history, consideration of possible drug interactions, and correlation of clinical findings with movement disorders are all important for the diagnosis. Alterations of anesthetic techniques avoiding propofol and holding hydroxyzine are advisable in such rare clinical situations. Early diagnosis of perioperative movement disorders will prompt specific treatments, such as anticholinergic medications for acute postoperative dystonia.

References

1. Ananthanarayan C, Blight K: Dystonic reaction after anesthesia. Can J Anaesth. 2001, 48:101. 10.1007/BF03019825
2. Patel M, Park BL: Acute dystonic reaction in the upper extremity following anesthesia. Cureus. 2022, 14:e31166. 10.7759/cureus.31166
3. Simonyan K, Berman BD, Herscovitch P, Hallett M: Abnormal striatal dopaminergic neurotransmission during rest and task production in spasmodic dysphonia. J Neurosci. 2013, 33:14705-14. 10.1523/JNEUROSCI.0407-13.2013
4. Gunduz S,Karacayir N, Ozkan M: Hydroxyzine induced dystonia. Austin Pediatr. 2016, 3:1026.
5. Kaji R, Bhatia K, Graybiel AM: Pathogenesis of dystonia: is it of cerebellar or basal ganglia origin?. J Neurol Neurosurg Psychiatry. 2018, 89:488-92. 10.1136/jnnp-2017-316250
6. Patel S, Wohlfeil ER, Rademacher DJ, et al.: The general anesthetic propofol increases brain N-arachidonylethanolamine (anandamide) content and inhibits fatty acid amide hydrolase. Br J Pharmacol. 2003, 139:1005-13. 10.1038/sj.bjp.0705334
7. Clark BG, Araki M, Brown HW: Hydroxyzine-associated tardive dyskinesia. Ann Neurol. 1982, 11:435. 10.1002/ana.410110423

Abstract

The challenge in bimaxillary surgery lies in significant intraoperative bleeding, prompting various strategies to minimize blood loss. Among the methods considered for controlling intraoperative bleeding, hypotensive anesthesia and the use of piezosurgical instruments (Osada, Tokyo, Japan) have been explored. However, hypotensive anesthesia may have adverse effects on cardiac function, and surgical time is likely to be prolonged when using piezosurgical instruments. This study retrospectively examined whether the combined use of hypotensive anesthesia and piezosurgical instruments reduces intraoperative bleeding and whether the combination impacts cardiac function. The combination of hypotensive anesthesia and piezosurgical instruments significantly reduced intraoperative bleeding. Furthermore, the combination was associated with a significantly higher incidence of tachycardia, particularly with the use of nicardipine. Additionally, the combination significantly lengthened the duration of the surgery and may have increased the burden on cardiac function. Landiolol was effectively employed to manage tachycardia. When selecting hypotensive anesthesia as a means to limit bleeding, proactive preparation and preventive small-dose administration of landiolol could be beneficial in managing the potential occurrence of tachycardia.

Introduction

Orthognathic surgery is a well-established method for correcting dentofacial deformities, often necessitating bimaxillary surgery [1]. Bimaxillary surgery, which combines mandibular and maxillary osteotomies, allows for the alteration of the occlusal plane and the three-dimensional repositioning of the jaws. Many of the patients undergoing bimaxillary surgery are healthy young adults with minimal systemic complications [2]. However, in recent years, there has been an increasing incidence of elderly patients undergoing bimaxillary surgery, potentially making perioperative management more challenging [3].

Bimaxillary surgery can be associated with significant blood loss and the need for transfusion, emphasizing the growing importance of exploring alternative measures with minimal adverse effects to reduce intraoperative hemorrhage [2,4].

One approach to mitigating blood loss during bimaxillary surgery involves the use of hypotensive anesthesia [1]. Hypotensive anesthesia is a technique in which blood pressure is intentionally lowered during surgery to reduce bleeding and improve surgical field visibility [1,5]. While its potential for reducing intraoperative bleeding has been recognized, studies examining its efficacy specifically in bimaxillary surgery have produced conflicting findings [1]. Moreover, concerns regarding vital organ hypoperfusion during hypotensive anesthesia have been raised in other studies [1,5]. Notably, cardiovascular complications significantly contribute to postoperative morbidity and mortality following non-cardiac surgeries [6]. These complications extend hospital stays, escalating healthcare costs, and constitute a leading cause of perioperative mortality [7]. Elderly patients, in particular, exhibit a higher prevalence of coronary artery disease, amplifying the risk of cardiac events during the perioperative period [8].

Piezoelectric instruments utilize ultrasonic microvibrations of 60-200 μm/s at frequencies of 24-29 kHz to cut mineralized tissue while leaving soft tissue unharmed. These instruments provide an alternative strategy for bleeding management, albeit with potential challenges such as prolonged surgical duration [9]. Further investigation is warranted to understand their impact on increased bleeding and cardiac function in relation to the extended surgical time. Both hypotensive anesthesia and piezoinstruments are being explored as distinct approaches, and a comprehensive, sequential evaluation of both methods is unprecedented in the existing literature.

Therefore, the aim of this study was to investigate whether the combination of hypotensive anesthesia and piezosurgical instruments affects blood loss during bimaxillary surgery while ensuring intraoperative safety. Particular attention was paid to changes in circulatory function during surgery to assess whether the combination of hypotensive anesthesia and piezosurgical instruments imposes undue cardiac stress.

Materials & Methods

This study received approval from the Ethics Committee of the Defense Medical University Hospital, Japan Permit Number, 4859. Data were collected from the medical records of 30 patients who underwent bimaxillary surgery between 2015 and 2023. To be included in the study sample, patients had to meet the following criteria: they were classified as having American Society of Anesthesiologists (ASA) physical status I or II and had no significant systemic illnesses, such as severe cardiovascular, respiratory, renal, or hepatic diseases, which were excluded from the ASA categorization. Examples of excluded conditions include uncontrolled hypertension, severe asthma, chronic obstructive pulmonary disease, and advanced diabetes mellitus. Additionally, preoperative electrocardiogram (ECG) examinations confirmed the absence of waveform patterns suggestive of severe ischemic heart disease in all patients, who were aged between 18 and 80 years and included both males and females.

In all cases, continuous monitoring of patients’ vital signs, including electrocardiography, pulse oximetry, temperature probe, and capnography, was conducted during surgery and the recovery period. A transducer connected to an indwelling arterial catheter was used to continuously monitor mean arterial pressure (MAP) in subjects during surgery. In hypotensive anesthesia, the target MAP was set between 50 and 65 mmHg.

The anesthesia induction technique was uniform across all cases, with an induction dose of propofol administered at 2 to 2.5 mg/kg. Fentanyl at 1 μg/kg was used to suppress intubation responses. Rocuronium at 0.6 mg/kg was administered as a muscle relaxant. All patients received cefmetazole 1 g or cefazolin 1 g immediately after induction, and the same antimicrobial agent in the same dose was administered every three hours.

The primary anesthesia maintenance agents included propofol, sevoflurane, and desflurane. Remifentanil at 0.2 to 0.35 μg/kg/minute was administered for analgesia maintenance. In the hypotensive anesthesia group, medications such as nicardipine, a calcium channel blocker, or alprostadil alfadex, a prostaglandin E1 preparation, were continuously infused to maintain the target MAP and bolus dose as needed.

All patients underwent a Le Fort I osteotomy and a bilateral sagittal split osteotomy (BSSO). Xylocaine 2% with 1:80,000 epinephrine was used for local infiltration anesthesia of the lower jaw and upper jaw. Firm fixation of bone segments was achieved using plates and screws, with no intermaxillary fixation applied postoperatively. Piezosurgical instruments were used in all cases in the hypotensive anesthesia group (Osada, Tokyo, Japan). Dexamethasone 6.6 mg or betamethasone 2 mg was administered before the conclusion of surgery in all cases. No transfusions were administered to any of the patients.

Intravenous fluid, urine output, and blood loss were measured. Intravenous fluid measurements were taken and recorded by the anesthesia team, while urine output and blood loss were measured by nurses and recorded by the anesthesia team. To measure intraoperative blood loss, a consistent method was applied to all cases. It involved subtracting the volume of saline used for irrigation during suctioning, both during washing and cutting, from the total volume in the suction canister. Additionally, the increase in weight of the gauze used (1 g = 1 ml) was added to determine the amount of blood loss. Furthermore, preoperative and postoperative day one blood tests were conducted, and using the Hct value, the estimated perioperative blood loss was calculated according to the equation proposed by Gross [10].

Statistical analysis was performed using GraphPad Prism 8 (MDF, Boston, USA). The two anesthesia groups were compared using a one-way analysis of variance (ANOVA), with unpaired t-tests used as post hoc tests for age and BMI. Fisher’s exact test was employed for the analysis of sex, while the Mann-Whitney U test was used for other variables. Fisher’s exact test was also utilized for the analysis of the occurrence of intraoperative tachycardia and the use of hypotensive agents. All values are presented as the mean ± standard deviation (± SD). Statistical significance was defined as p < 0.05.

Results

An overview of the data is presented in Tables 1, 2, and Figure 1. There were no significant differences between the two groups in terms of age, BMI, or fluid replacement. The operative and anesthetic times were significantly longer in the hypotensive anesthesia group compared to the normal anesthesia group. Additionally, the urinary output in the hypotensive anesthesia group was significantly lower than in the normal anesthesia group. Concerning blood loss, the hypotensive anesthesia group exhibited significantly less bleeding compared to the normal anesthesia group. The estimated perioperative blood loss calculated from Hct values in preoperative and postoperative day one blood tests did not show a significant difference between the two groups.

Figure 1: Comparisons of the outcome variables.

HA: Hypotensive anesthesia, NA: Normal anesthesia, *p < 0.05 (Mann-Whitney U test).

The hypotensive anesthesia group had a significantly higher incidence of tachycardia compared to the normal anesthesia group. Among the six cases where nicardipine was used, tachycardia occurred in three cases, suggesting a tendency for tachycardia to occur when nicardipine was used. No cases of tachycardia occurred when alprostadil alfadex was used. In the four cases where tachycardia occurred, adequate analgesia was confirmed before the administration of landiolol, and heart rate control was excellent in all cases.

As for postoperative complications, only one case of postoperative infection was observed in the hypotensive anesthesia group, and no other significant complications, except for nerve damage, were noted in either group.

Discussion

Bimaxillary surgery involves various innovations to minimize blood loss, including the use of induced hypotensive anesthesia, ultrasonic cutting instruments, tranexamic acid, and local anesthesia [2,4].

In bimaxillary surgery, induced hypotensive anesthesia is administered using inhaled anesthetics, intravenous drug therapy, or a combination of both, taking advantage of the blood pressure-lowering effects of agents such as propofol and sevofluran [11,12]. Maintaining the desired hypotension during bimaxillary surgery can often be challenging, and in such cases, the concurrent use of drugs such as nicardipine, nitroprusside, labetalol, nitroglycerin, diltiazem, and prostaglandin E1 derivatives may be necessary [1,13,14]. Among these drugs, nicardipine is commonly used due to its affordability, accessibility, and ease of use [13]. Additionally, the use of piezosurgical instruments in bimaxillary surgery minimizes soft tissue damage and intraoperative blood loss but may extend surgical time, which is a drawback [4,15]. The extension of surgical time in bimaxillary surgery is known to significantly increase relative intraoperative blood loss [15]. In this study, the combination of hypotensive anesthesia and piezosurgical instruments resulted in significantly longer surgical times, likely attributed to the use of piezosurgical instruments, but did not result in increased blood loss. From these findings, it is suggested that the extension of surgical time with piezosurgical instruments may not be associated with an increase in intraoperative blood loss. This study used propofol and sevoflurane as maintenance anesthetics, and in cases where the target hypotension was not achieved, alprostadil alfadex (a prostaglandin E1 derivative) was used. The MAP was maintained at 50-70 mmHg during hypotensive anesthesia, which was consistent with values reported in other studies [1,16].

In this study, the hypotensive anesthesia group had significantly less blood loss compared to the normal anesthesia group, suggesting that the combination of hypotensive anesthesia and piezosurgical instruments was effective in reducing blood loss. While visual estimation is the most widely used method for measuring blood loss during surgery, it is not always accurate, especially in cases of hidden bleeding [17]. In such cases, several formulas using blood test results are used to estimate blood loss [17,18]. In this study, preoperative and postoperative hematocrit values were used to estimate blood loss, with the result that there was no significant difference in the estimated blood loss between the normal and hypotensive anesthesia groups. This outcome may be attributed to the fact that both groups received equivalent volume infusions; however, the normal anesthesia group exhibited a higher urinary output, resulting in an elevated postoperative hematocrit value, consequently leading to a lower calculated blood loss.

Hypotensive anesthesia, particularly in non-cardiac surgery patients, has been associated with adverse effects when the MAP falls below 60-70 mm Hg, even for short durations [19]. Prolonged maintenance of the MAP below 65 mmHg during surgery is known to increase the risk of organ dysfunction, with longer durations associated with higher postoperative mortality rates and organ dysfunction incidence [20]. Furthermore, a threshold estimated to cause a gradual increase in the odds of myocardial injury is reported to be a MAP of 65 mmHg during surgery [21]. It is recommended to maintain the MAP above 65 mmHg during surgery, especially after induction [22]. To avoid increasing oxygen consumption and causing ischemia in the unprepared heart, it is crucial to maintain a balance between myocardial oxygen supply and demand, which is best achieved by avoiding hypotension, tachycardia, and hypertension [23]. Maintaining cardiac output is particularly important for non-cardiac surgery patients [24]. The use of nicardipine has been associated with a relatively high incidence of reflex tachycardia, occurring in 17.2% of cases over a short period of time [13]. In this study, nicardipine was continuously administered for a relatively long period, leading to increased myocardial oxygen consumption and potentially a higher risk of circulatory dysfunction.

Beta-blockers are the preferred agents for managing tachycardia-induced arrhythmias, but their use can increase side effects such as stroke and severe bradycardia in low-risk patients, potentially worsening patient outcomes [25]. Among beta-blockers, esmolol and landiolol are short-acting, beta-1 selective agents, have no bronchoconstrictive effects, have very short half-lives, and provide rapid onset, allowing for continuous intravenous infusion and excellent adjustability [26]. Esmolol may be risky in cases with unstable hemodynamics due to its blood pressure-lowering effect, while landiolol effectively lowers heart rate without lowering blood pressure, making it favorable for rate control [27]. The landiolol group had a significantly higher rate of returning to sinus rhythm compared to the diltiazem group, with a lower incidence of hypotension and bradycardia, indicating safety [28]. Preventive landiolol administration has been suggested to be effective in preventing tachycardia in non-cardiac surgery cases [29,30]. However, there have been no reports of landiolol administration for intraoperative tachycardia in orthognathic surgery. In this study, landiolol was administered for the management of tachycardia, resulting in early improvement in circulatory function. Therefore, the administration of landiolol may be effective for patients undergoing orthognathic surgery who present with tachycardia.

Limitations of this study include the inability to discern the individual impacts of hypotensive anesthesia and the use of piezosurgical instruments, as they were employed concurrently. Consequently, it remains unclear which factor primarily contributed to the observed reduction in blood loss. Additionally, this study, being retrospective and relatively small in scale with a sample size of 30 patients, is inherently constrained by its methodology. Variations in anesthesia methods and hypotensive techniques further introduce potential confounding variables, both known and unknown. Moreover, the absence of a universally accepted gold standard for accurately calculating blood loss and estimating total blood volume necessitated the adoption of the formula proposed by Gross, which, while widely utilized, does not fully address the challenge of precise measurement in this context.

Conclusions

The combination of hypotensive anesthesia and piezosurgical instruments during bimaxillary surgery effectively reduced blood loss. However, tachycardia may occur during hypotensive anesthesia, especially when nicardipine is used, and may lead to a strain on cardiac function. The study demonstrated the effectiveness of landiolol in managing tachycardia. For patients undergoing orthognathic surgery who present with tachycardia, the preparation and preventive use of landiolol may be beneficial.

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