Kawaai Hiroyoshi

Kudoh Kanae

Suzuki Fumihiko

Tanaka Katsunori

Tomita Shu

Yamazaki Shinya

Suzuki, Fumihiko

13853

Tomita, Shu

13854

Kudoh, Kanae

13855

Tanaka, Katsunori

13856

Kawaai, Hiroyoshi

13857

Yamazaki, Shinya

13858

Ohu University Repository / 奥羽大学学術機関リポジトリ

Emergency　Treatment　of　Massive　Hemorrhage　afterUpper　Third　Molar　Extraction:A　Case　ReportFumihiko SUZUKI,Shu TOMITA,Kanae KUDOHKatsunori TANAkA,Hiroyoshi KAWAAI and Shinya YAMAZAKITooth extraction is ar utine dental reatment, and massive hemorrhage r r ly oc-curs in it. In the present case, mergency treatment was performed to stop massivehemorrhage aft r upper third molar extraction. The patient was a50-year-old femalewith hypertension who underwent an upper third molar extraction a  adental clinic.Since massive hemorrhage continued after tooth extraction, the patient wasaken toour hospital. General anesthesia was elected because hemostasis under local anesthe-sia was difficult, hema omas were present i  the buccal mucosa and soft palate,and arespiratory risk waspredicted. Awakenasotracheal fiberoptic in ubation was electedbecause mask ventilation was difficult. Since thegreater palatine art ry wasnot in-jured, it was assumed that the hemorrhagic pointwas present i  abranch of the ptery-goid plexus. Thetracheal tube was left or espiratory management after reatment,and removed on postoperative day 2after complete hemostasis was confirmed. It is im-portant to evaluate the necessity of general anesthesia for hemostatic treatment inconsideration of the cause and volume of massive hemorrhage.Key words hemorrhage,pterygoid plexus,emergency treatmentIntroductionTooth extraction is a routine dental treat-ment. Hemorrhage after tooth extraction is afrequent complication, but massive hemorrhagerarely occurs. The cause ofmassive hemorrhageafter tooth extraction is roughly divided intosystemic causes, such as hemophilia 1,2) andanti-thrombotic therapy 3),and local causes due toinjury of the surrounding tissue 4,5). In this pa-tient, we performed emergency treatment formassive hemorrhage aft r the upper third mo-lar extraction.Case descriptionThe patient wasa50-year-old female, 153cm in height and 52kg in weight,with hyper-tension. She underwent the upper right thirdmolar extraction a  ade tal clinic, and massivehemorrhage occurred after extraction. The max-illary tuberosity was partially attached to theextracted tooth(Fig.1). The dentist attemptedhemostasis, but hemorrhage continued. Th  pa-tient was urgently taken toOHU UniversityHospital. On arrival, the blood pressure was171/113 mmHg;pulse, 85 beats/min; respira-tory ate, 20 breaths/min; and percutaneous ar-受付:平 成28年7月14日,受理:平成28年11月1日奥羽大学歯学部口腔外科学講座歯科麻酔学分野Division of Dental Anesthesiology, Department ofOral Surgery, Ohu University School fDentistryFig.1 Extracted ooth with apart of maxillary tuberosityterial blood oxygen saturation, 98%. On bloodtesting, the red blood cell count (334×104/μ?),hemoglobin　level　(10.8g/d?),　and　 hematocrit(31.5%)　were　decreased,　and　the　platelet　count(16.3×104/μ?),　thrombin　test　value　(11.5　sec-onds),　prothrombin time international normal-ized ratio (1.05), prothrombin time percentageactivity(94.2%), and activated partial thrombo-plastin time (24.0 seconds) were normal. Hem-orrhage could not be stopped by hemostatictreatment under local anesthesia. During thisperiod, hematomas appeared and rapidly ex-panded in the buccal mucosa and soft palate. Anoral surgeon of our hospital considered that in-hibition of hemorrhage under local anesthesiawas impossible, and selected hemostatic treat-ment under general anesthesia to avoid airwayobstruction by the expanding hematoma.After standard monitoring, general anesthe-sia was introduced by the intravenous adminis-tration of midazolam(1mg), propofo1 (0.5μg/m?by　target　controlled　infusion),　and　remifentanil(0.5μg/kg/min)　under　oxygen　inhalation(6?/min)(Fig.2).　Two　minutes　later,　the　dose　of　con-tinuous　remifentanil　infusion　was　decreased　to0.1μg/kg/min.　Since an oral surgeon continuedpressure hemostasis of the region around theupper third molar with his finger and gauze,bag ventilation and oral tracheal intubation us-ing a laryngoscope were difficult. Thus, nasotra-cheal fiberoptic intubation was performed. Gen-eral anesthesia was maintained with propofol(1.0μg/m?　by　target　controlled　infusion)　andremifentani1　(0.15μg/kg/min)　under　oxygen(1?/min)　and　air　(3?/min)　inhalation.　Temporaryhemostasis　was　achieved,　but　hemorrhage　re-curred　when　 the　blood　pressure　rose　in　theawakening　process,　for　which　general　anesthe-sia　was　resumed.　The　greater　palatine　arterywas　not　injured,　and　hemorrhage on the distalside of the extraction site was confirmed. Afterpressure hemostasis, the extraction socket wascovered with a hemostatic agent, and the woundwas sutured. The tracheal tube was not removedbecause of the risk of airway obstruction by thehematoma. After hemostatic treatment, a singledose of propofol(30+20mg) and continuous dex-medetomidine(0.7μg/Kg/h)　were　administeredfor　sedation,　and　a　single　dose　of　fentanyl　wasadministered(50+20+30μg)　 for　postoperativeFig.2　Anesthesia　recordanalgesic　treatment.　The　 patient　was　 trans-ferred　to　an　ICU.　The　 tracheal　tube　was　re-moved　after　confirming complete hemostasis onpostoperative day 2.DiscussionThe most important focus of this case was toidentify the cause of the massive hemorrhage.The systemic causes of massive hemorrhage in-clude a hemorrhagic predisposition 1,2) and anti-thrombotic therapy 3), and the local causes in-clude hemorrhage from the extraction socketand injury of the surrounding tissue 4～6).　Theblood　coagulation　system　of　this　patient　wasnormal,　and　the　patient　had　received　no　anti-thrombotic　 therapy.　Accordingly,　systemiccauses　were　 excluded.　Regarding　 the　localcause,　hemorrhage　was　observed　on　the　distalside　of　the　extraction　site.　It　was　 consideredthat　the　cause　of　the　bleeding　is　an　iniury　of　thegreater　palatine　artery,　the　descending　palatineartery,　the　posterior　superior　alveolar　artery,　orthe　pterygoid　plexus 4). Subsequently, it was as-sumed that the hemorrhagic point was presentin the pterygoid plexus because the bleedingwas not a pulsatile. There have been severalcase reports of complications associated withthe pterygoid plexus after upper third molarextraction5,6). Shah and Bridgman 5) reportedfracture of the maxillary tuberosity and pulsat-ing massive hemorrhage after extraction of theupper right second molar. Their patient requiredgeneral anesthesia for the control of massivehemorrhage and removal of fractured bone frag-ments, similarly to our patient. Warburton andBrahim6) reported infraorbital hematoma thatappeared 2 days after extraction of the upperbilateral third molars, and discussed communi-cation of the pterygoid plexus with the infraor-bital structure in the infratemporal fossa. It isimportant toconsider complications of upperthird molar extraction associated with the pter-ygoid plexus and confirm the anatomical mor-phology ofthe maxillary tuberosity. The appro-priate operation of tooth extraction tools i alsonecessary.The blood loss was estimated from the bodyweight (Wt) (kg) and hemoglobin level (Hb)(g/d?)　of　the　patient　using　the　equation　below:Bleeding　Wt×0.7 pre-bleeding Hb ×　(pre　-bleeding　Hb　-　post　-bleeding　Hb)On　the　assumption　that　the　hemoglobinlevel before tooth extraction was 14 g/d?,　theblood　loss　was　calculated　asfollows：Bleeding=52×　0.7/14×（　14-10.8)=8.32dl(832m?)This　is　useful　to　judge　the　necessary　volumeof　blood　transfusion,　although　it　is　an　estimate.The　indication　of　blood　transfusion　is　more　thana　30%　loss　of　the　circulating　blood　7)　or　a　6　g/d?　orlower　hemoglobin　level　9）.　The circulating　bloodof　this　patient　was　estimated　to　be　36.4d?　(52　kgx　0.7d?).　If　the　blood　loss was 8.32d?, 22.9% ofthe circulating blood was lost. The hemoglobinlevel of the patient was 10.8 g/d?. Accordingly,blood transfusion was unnecessary for this pa-tient. However, the blood loss was greater than20% of the circulating blood, and so the infusionof colloid solution was necessary.Awake nasotracheal fiberoptic intubation wasselected because hemorrhage continued, tra-cheal intubation under laryngoscopic direct vi-sion was difficult, and there was a risk of caus-ing hemorrhage from the soft palatal hematomaby laryngoscope operation. Midazolam andremifentanil were intravenously administeredbecause awake intubation without sedation isintolerable for patients. Several studies sug-gested that midazolam and remifentanil re-duced pain during awake nasotracheal fiberop-tic intubationg 9,10).In conclusion, it is mportant o judge whethergeneral anesthesia is necessary fo  hemostatictreatment in consideration of the cause and vol-ume of massive hemorrhage.The authors declare noconflict of interest a sociatedwith this manuscript.1)2)3)4)5)6)7)8)9)10)ReferencesOrlian, A. I. and Karmel, R. : Postoperativebleeding in an undiagnosed hemophilia A pa-tient : report of case. J. Am, Dent. Assoc.118;583-584 1989.Laguna, P. and Klukowska,A.:Managementof oral bleedings with recombinant factor VⅡain children with haemophilia A and inhibitor.Haemophilia 11;2-4 2005.Brooks,A.s.: Delayed complications of toothextraction i patients taking warfarin, antibi-otics, and other medications. J. Oral Maxillo-fac. Sung. 69;977-979 2011.Kawahara,I.,Hamada,T.,Kanno,K.,Kon,H.,Takada,S.and Ohno,T.:A case of hemor-rhage after extraction of the upper third molarrequiring an emergency operation to achievehemostasis. Jpn. J. Oral Diag. 27;48-512014.Shah,N.and Bridgman,J.B.: An extractioncomplicated by lateral and medial pterygoidtethering of a fractured maxillary tuberosity.Br.Dent.J. 198;543-544 2005.Warburton, G. and Brahiin, J. S.: Intraorbitalhematoma after emoval of upper third molara case report. J. Oral Maxillofac. Surg. 64;700-704 2006.American college of surgeons, committee ontrauma. : Advanced trauma life supportcourse manual. American College of Surgeons,Chicago, 1989.ASA Task Force. : Practice guidelines forblood component therapy. Anesthesiology 84;732-747 1996.Machata, A. M., Gonano, C., Holzer, A.,Andel,D.,Spiss,C.K.,Zimpfer,M.and Illievich,U.M.: Awake nasotracheal fiberoptic intuba-tion: patient comfort, intubating conditions,and hemodynamic stability during conscioussedation with remifentanil. Anesth. Analg. 97;904-908 2003.Song,J.W.,Kwak,Y.L.,Lee,J.W.,Chang,C.H.,Kim,H.S.and Shim,Y.H.:The optimaleffect site concentration of remifentanil incombination with intravenous midazolam ndtopical lidocaine forawake fibreoptic nasotra-cheal intubation in patients undergoing cervi-cal spine surgery. Minerva Anestesiol. 78521-526 2012.著 者 へ の 連 絡 先:鈴 木 史 彦,(〒963-8611)郡 山 市 富 田 町字 三 角 堂31-1 奥 羽 大 学 歯 学 部 口 腔 外 科 学 講 座 歯 科 麻 酔学 分 野Reprint requests: Fumihiko SUZUKI, Division fDentalAnesthesiology, Department of Oral Surgery, OhuUniversity School of Dentistry31-1 Misumido, Tomita, Koriyama, 963-8611, Japan

Emergency Treatment of Massive Hemorrhage after Upper Third Molar Extraction: A Case Report

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Emergency Treatment of Massive Hemorrhage after Upper Third Molar Extraction: A Case Report

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