Anaesthetic Assesment for Dental Patients Flashcards
Difference between pain and anxiety
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
3 ways in which pain and anxiety can be managed
Increasing in
Risks?
LA
IVS
GA
With increasing risk, cost and inconvenience
Complications rare
Risks increase for with medical conditons
IVS definition and advantages and disadvantages
- 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
GA advantages and disadvantages
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
Fasting and GA
- 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
Indications for GA
- 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
How to assess fitness for surgery
- Risks associated with GA depend on a number of factors
- ASA grading is a tool that helps clinician assess the risk of GA
ASA 1
Fit and Well
Healthy
Non smoking
Minimal alcohol intake
ASA 2
Mild disease No effect on daily living Slightly increased risk Current smoker Social alcohol drinker Obesity (30
ASA 3
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)
ASA 4
- 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
ASA 5
- Moribund patient
- Not likely to survive without an operation
- Ruptured aortic aneurysm
- Intra-cranial bleed
- Isochemic bowel
- Multiple organ failure
ASA 6
Declared brain dead
Awaiting organ transplant
What indications are suitable for day surgery
- 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
What are the contraindications for Day surgery
- 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
Temporary conditions that are contra-indicated to surgery
- Colds
- Flu
- Sore throat
- Those undergoing medical investigations should wait for a diagnosis
Obesity and GA
- <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
Pregnancy and GA/IVS/LA
-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
Age and GA/IVS
- 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)
Operation time and relavance to type of pain/anxiety relief provided
- 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
Indications of sedation instead of LA
- 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
Indications of Ga over sedation
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
Key points when considering GA
- Take a thorough med history
- ASA?
- Anxiety?
- BMI?
- Home support
- Treatment duration
- Previous GA complications
- Focus on risk/benefit
- Ask anaesthetist if any doubt
Hypertension and Anaesthesia: problems and management
Problems
- Bleeding
- Risk of MI and stroke
Management
- 170/110mmHg treat as normal
- Above this, consider IVS and/or discuss with GP
Angina and Anaesthesia: risk and management
Risk:
- Angina Attack
- MI
Management:
-GTN available
Cardiovascular Disease examples and anaesthesia
- 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
Asthma and Anaesthesia
- 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
COPD and Anaesthesia
-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
Renal Disease and Anaesthesia
- 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
Liver Disease and Anaesthesia: risk and management
-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
Diabetes and Anaesthesia: risks and recommendations
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
Anticoagulation drugs and Anaesthesia
Risks and management
-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
Haematological conditions and management
Haemophilia
Von Willebrands
Thrombocytopenia
Management:
- Liase with patient’s haematologist
- Platelets >50 *10^9 /L
- Local haemostatic measures
- Tranexamic Acid use
- No NSAIDs
Steroids risks and management
Risk:
Addisonian crisis
May delay healing
Management
- No increase dose on the day of surgery
- But GA anaesthetist may provide extra steroid support
