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Human Disease > Anaesthetic Assesment for Dental Patients > Flashcards

Anaesthetic Assesment for Dental Patients Flashcards

1
Q

Difference between pain and anxiety

A

Pain

  • Defense reaction associated with actual or perceived threats
  • Condition of avoidance
  • Perception

Anxiety

  • Also a defense reaction
  • Ranges from apprehension to terror
  • When fear is unreasonably excessive, it can be described as a phobia
  • Barrier to dental care
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2
Q

3 ways in which pain and anxiety can be managed
Increasing in
Risks?

A

LA
IVS
GA
With increasing risk, cost and inconvenience
Complications rare
Risks increase for with medical conditons

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3
Q

IVS definition and advantages and disadvantages

A
  • Technique in which the use of a drug produces a state of depression of the CNS enabling tx to be carried out
  • Verbal contact with the patient is maintained throughout the period of sedation
  • Drugs and techniques are used to provide conscious sedation

Advantages:

  • Conscious sedation lower mortality than GA
  • Reflexes on the upper airway are maintained

Disadvantages:

  • Still caries a risk
  • some dispute over starvation
  • Regurgitation of the gastric contents is rare and the risk of aspiration is even rarer
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4
Q

GA advantages and disadvantages

A

Advantages:

  • No muscular activity therefore it is easy to complete the procedure
  • Pt has no recollection of the procedure

Disadvantages:

  • Risk of mortality and morbidity
  • GA should only be prescribed if clinically justified
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5
Q

Fasting and GA

A
  • Possible to bring up gastric contents and aspirate into the respiratory system
  • Mendelsons Syndrome
  • Aspiration pneumonia

No more solid food 6 hours prior to surgery
No more liquids (clear), non-particulate/carbonated 4 hours prior to surgery

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6
Q

Indications for GA

A
  • Repeated failed LA
  • Failed sedation
  • Extensive surgery/prolonged
  • Surgery would be extremely unpleasant (operation of maxillary sinus which is supplied by a lot of nerves that cannot be anaesthetised)
  • Patient cannot remain still for examples in Parkinsons
  • Extreme anxiety/phobia

Always discuss alternative methods for pain and anxiety management
Ensure the patient is fit for surgery

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7
Q

How to assess fitness for surgery

A
  • Risks associated with GA depend on a number of factors

- ASA grading is a tool that helps clinician assess the risk of GA

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8
Q

ASA 1

A

Fit and Well
Healthy
Non smoking
Minimal alcohol intake

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9
Q

ASA 2

A 
Mild disease 
No effect on daily living 
Slightly increased risk 
Current smoker 
Social alcohol drinker 
Obesity (30
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10
Q

ASA 3

A 
Systemic Disease
Affects daily living 
Poorly controlled DM or BP 
Poorly controlled Asthma/COPD
Morbid obesity >40 
Alcohol/drug dependancy 
Dialysis/kidney disease 
Controlled cardiac disease (stable angina)
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11
Q

ASA 4

A
  • Severe systemic disease
  • Constant threat to life
  • CVA, TIA
  • Heart failure
  • Unstable angina
  • Recent MI
  • Sepsis
  • Advanced lung disease

GA should be avoided in these patients as they have a much higher risk

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12
Q

ASA 5

A
  • Moribund patient
  • Not likely to survive without an operation
  • Ruptured aortic aneurysm
  • Intra-cranial bleed
  • Isochemic bowel
  • Multiple organ failure
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13
Q

ASA 6

A

Declared brain dead

Awaiting organ transplant

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14
Q

What indications are suitable for day surgery

A
  • Fit and Well (ASA 1/2/3)
  • BMI reasonable (<40)
  • Procedure is short (<2 hours)
  • Low bleeding risk
  • Patient has a suitable escort and adequate home support
  • Adequate mouth opening
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15
Q

What are the contraindications for Day surgery

A
  • Unstable systemic disease (ASA 4)
  • Limited mouth opening
  • No escort/home support
  • Obesity (>40BMI)
  • Surgery likely to last >2 hours
  • Patient unwilling to have GA
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16
Q

Temporary conditions that are contra-indicated to surgery

A
  • Colds
  • Flu
  • Sore throat
  • Those undergoing medical investigations should wait for a diagnosis
17
Q

Obesity and GA

A
  • <40 suitable
  • Can result in:
  • Hypertension
  • Difficulties with airway management
  • Poor ventilation and intubation
  • DVT risk increases
  • Increase dose of anaesthetic drugs and delayed recovery
  • Difficult to canulate
18
Q

Pregnancy and GA/IVS/LA

A

-GA is contraindicated in
Early preggers due to risk of foetal development
Late preggers due to risk to mother due to uterus placement on chest and abdominal veins

  • IVS is also contraindicated
  • LA ideally only in 2nd and 3rd trimesters
19
Q

Age and GA/IVS

A
  • No upper age limit
  • Biological age of patient should be assessed
  • ASA classification is helpful
  • IVS Be careful in the elderly (provide low dose and double the time it takes to give it- go slow and low)
20
Q

Operation time and relavance to type of pain/anxiety relief provided

A
  • If <30 mins then defo LA
  • If >30 mins but <1h, then in some cases LA is tolerable, but can also use IVS
  • Based on the individual
21
Q

Indications of sedation instead of LA

A
  • Operation time >30 mins <1h
  • History of failed LA
  • Simple complex surgical procedure
  • Multiple routine surgical extractions
  • More difficult access
  • Anxious/phobic patients
  • Gag reflex
  • No medical contraindications
  • Adult escort available
22
Q

Indications of Ga over sedation

A

If same indications as iv sedation, then you can do day stay sedation (<1 hour operation time)

If operation time > 1 hour, difficult intubation, medical contraindication to day stay GA, BMI >40, no medical contraindications to GA or no adult escort available, then in-patient GA

23
Q

Key points when considering GA

A
  • Take a thorough med history
  • ASA?
  • Anxiety?
  • BMI?
  • Home support
  • Treatment duration
  • Previous GA complications
  • Focus on risk/benefit
  • Ask anaesthetist if any doubt
24
Q

Hypertension and Anaesthesia: problems and management

A

Problems

  • Bleeding
  • Risk of MI and stroke

Management

  • 170/110mmHg treat as normal
  • Above this, consider IVS and/or discuss with GP
25
Q

Angina and Anaesthesia: risk and management

A

Risk:

  • Angina Attack
  • MI

Management:
-GTN available

26
Q

Cardiovascular Disease examples and anaesthesia

A
  • Cardiac defects
  • Valve replacements
  • Previous endocarditis
  • Hypertrophic cardiomyopathy
  • Heart failure
  • Rhythm disturbances
  • On going cardiac ischaemia (MI/angina)
  • Antibiotic cover may be needed
  • Refer to cardiologist
27
Q

Asthma and Anaesthesia

A
  • Reversible airway limitation caused by bronchial inflammation
  • Assess disease severity: recent admissions, last attack, inhalers

Management:

  • ask about NSAID tolerance
  • May need an anaesthetic review if poorly controlled
28
Q

COPD and Anaesthesia

A

-Poorly reversible airflow limitation that is persistent and progressive lung inflammation

Ask patient how managed and last hospital admission

Management:

  • GA and IVS are best avoided
  • NSAIDs are avoided
29
Q

Renal Disease and Anaesthesia

A
  • Can affect haemostasis (thrombocytopenia)
  • Increased activity of drugs excreted through the kidney
  • Dialysis:
  • Dental extractions on the day off
  • When the heparin has worn off
30
Q

Liver Disease and Anaesthesia: risk and management

A

-Alcohol-induced liver cirrhosis and viral hepatitis

Risk:

  • Increased bleeding risk
  • Impaired drug metabolism

Management:

  • Blood investigations
  • Liase with GP or relevant consultant
  • Avoid IVS (BDZ metabolism maybe impaired)
  • No NSAIDs
31
Q

Diabetes and Anaesthesia: risks and recommendations

A

Risk:

  • Hypoglycaemic emergency
  • Delayed healing

Recommendations:

  • Establish management and stability of disease
  • HBA1c (glycosylated HB)
  • Pre-op: blood glucose should be taken
  • Treat first on the list (for GA)
  • Consider post-operative antibiotics
  • May need a sliding scale/admissions
32
Q

Anticoagulation drugs and Anaesthesia

Risks and management

A

-Warfarin and NOAC should not be stopped

Risks:
-Post operative bleeding

Management:

  • INR check pre-op <4
  • NOAC: no ability to monitor levels
  • Local haemostatic measures
  • NO NSAIDs
33
Q

Haematological conditions and management

A

Haemophilia
Von Willebrands
Thrombocytopenia

Management:

  • Liase with patient’s haematologist
  • Platelets >50 *10^9 /L
  • Local haemostatic measures
  • Tranexamic Acid use
  • No NSAIDs
34
Q

Steroids risks and management

A

Risk:
Addisonian crisis
May delay healing

Management

  • No increase dose on the day of surgery
  • But GA anaesthetist may provide extra steroid support

Human Disease (19 decks)

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