PRE -OPERATIVE MEDICAL ASSESSMENT OF DENTAL PATIENT
Author:

Dr. Altaf H Malik

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Co authors:

Dr. Ajaz A Shah

Associate Professor and Head,

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Dr. Suhail Latoo

Lecturer

Department of Oral Pathology and Microbiology,

Govt. Dental College, Srinagar.

Dr. Manzoor Ahmad Malik

J & K Health Services, SDH Banipora

Dr. Rubeena Tabasum

Resident

C.D Hospital, Srinagar.

Dr. Shazia Qadir

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

INTRODUCTION

Knowledge regarding the patient’s medical condition is of utmost importance in patient management and care pre and post surgically. A detailed medial history will give the practitioner all the necessary. Relevant information regarding the patient’s general condition as well as physical status

PHYSICAL STATUS CLASSIFICATION SYSTEM

In 1962, the American Society of Anesthesiologist adopted the ASA physical classification system. This system identifies the medical risk to a patient undergoing a surgical procedure. The classification system is as follows:

ASA I: A patient without systemic disease; a normal, healthy patient

ASA II: A patient with mild systemic disease

ASA III: a patient with sever systemic disease that limits activity, but is not incapacitating

ASA IV: a patient with incapacitating systemic disease that is a constant threat to life

ASA V: A moribund patient not expected to survive 24 hours with or without surgery.

ASA E: Emergency operation of any kind, E precedes the ASA number, indicating the patient’s physical status.

CARDIAC DISEASE.

Although all types of cardiac diseases are at high-risk of serious complications when undergoing surgical procedures under general anesthesia, certain conditions like unstable angina, congestive cardiac failure , valvular septal defects, and myocardial infarction increase the risk four folds. A history of bypass, angioplasty or valve replacement is of significant importance. Although cardia disease is not an absolute importance. Although cardiac disease is not an absolute contraindication, the surgeon should weigh the benefits against the risks before deciding the choice of anesthesia.

Preoperative Investigations
1. Routine chest radiograph-posteroanterior view. 2. Electrocardiogram Echocardiogram
4 Stress test
Blood investigations like lipid profile and bleeding time, clotting time and prothrombin time and index in case the patient is on long-term anticoagulants
Preoperative medications

If the patient is a case of rheumatic heart disease or has undergone valve replacements, a suitable antibiotic prophylaxis must be given. If the patient is on injection penidura every three weeks, the surgery should be scheduled immediately after the scheduled dose to reduce the risk of infective endocarditis. Patients on long term anticoagulant therapy should discontinue the anticoagulants at least 4 to 5 days prior to surgery with the physician’s consent. If discontinuation of oral anticoagulant therapy is not advisable, the patient should be shifted to intravenous anticoagulants like heparin. The patient’s bleeding time and clotting item is checked on the day of surgery after omission of the anticoagulant.

Intra and Postoperative management
All the patients should be monitored intra and postoperatively by means of ECG, pulse oximeter, and arterial line. A central venous pressure (CVP) cut down may be performed if necessary. The patient should be maintained on intravenous cardiac drugs till oral feeds are given Fluid overload should be voided, especially in cases of congestive cardiac failure. The fluid volume can be judged by the CVP.
HYPERTENSION

Hypertension is considered to be the elevation of the blood pressure above 140/190 mm of mercury.

Uncontrolled hypertension can have the following surgical and anesthetic complications.
It reflects on the cardia status of the patient, thereby increasing the an aesthetic complications It reflects on the cardiac status of the patient, thereby increasing the anesthetic risk to the patient. It causes excessive bleeding from the operation site, thereby complicating the surgical procedure as well as significant blood loss for the patient.
Preoperative investigations
Chest radiograph-poster anterior view for detecting cardiac enlargement. ECG USG of the kidneys Opthalmic evaluation for pailledema and retinal haemorrhage.
Renal function tests (Blood urea nitrogen serum creatinine and serum electrolyte).

Preoperative Medication and Management

The patient’s blood pressure should be monitored and controlled within the normal permissible limits prior to the surgical procedure. If the patient is on antihypertensive, the morning dose of medication prior to surgery must be given with sips of water.

Intra and Postoperative Management.
The blood pressure should be monitored continuously intra and postoperatively. The patient’s cardiac status should also be monitored on the ECG machine and on the pulse oximeter. Antihypertensive must be continued intra and postoperatively. If the patient is on diuretics, the patient must be supplemented postoperatively with intravenous potassium supplements. If the procedure is performed under local anaesthesia, then local aneasthetic without adrenaline or bupivacaline, which does not have any significant effect on the cardiac status, is to be used.
RESPIRATORY DISEASE

Respiratory disease can be categorized obstructive and infiltrative pulmonary diseases. Obstructive pulmonary disease includes chronic obstructive pulmonary conditions like, asthma, chronic bronchitis, pneumothorax and emphysema. Infiltrative disease is inclusive of diseases that cause inflammatory changes in the alveolar walls. Any respiratory disease is first characterized by dyspnea.

The patient with decrease in the pulmonary reserve poses a great risk for procedures under general anaesthesia. The patients should be asked for a thorough history of beedi/cigarette as well as past history of tuberculosis. If the patient is suffering from tuberculosis, then details of his / her drug regimen and duration of treatment is asked. From the surgeons point of view the most important aspect is the patient’s respiratory reserve and his ability to tolerate general anaesthesia. If the patients treated under local anaesthesia, the broncho- dilator inhaler should be kept ready for use in case of an emergency.

Preoperative Investigations
Routine chest radiograph posteroanterior view. Pulmonary function tests. Blood investigations like arterial blood gases. Sputum AFB / culture. Bronchoscopy, if required
The patient should be counseled to discontinue beedi / cigarette smoking prior to the procedure. Any acute infection should be treated by antibiotics. The patient should be on bronchodilators pre, intra and postoperatively. The patient must carry his / her inhaler with him / her for use in case of an emergency.

Intra and Postoperative Management
Arterial blood gas monitoring should also be carried out intra and postoperatively. Avoid fluid overload Blood loss should be replaced by whole blood or packed cells to avoid decrease in the oxygen carrying capacity of blood.
RENAL DISEASES

Patients with renal disease like renal failure, acute glomerulonephritis, and nephrotic syndrome pose a significant surgical risk. Disturbances in the renal function leads to changes in the acid base balance, serum calcium and phosphorous levels, fluid retention, and electrolyte concentration. A patient with chronic infection may develop sepsis postoperatively. These patients also have associated hypertension secondary to fluid retention and anaemia.

Preoperative investigations.
Renal profile-blood urea nitrogen, serum cretinine, serum electrolytes. Creatinine clearance test. Serum calcium and phosphorous. Urine analysis-physical and microscopic. USG of the kidneys. Renal Doppler studies. Radionuclide scanning for renal clearance time
Intra and Postoperative Management
Fluid balance, acid-base balance and electrolyte balance must be closely monitored. Renal profile tests must be performed intra as well as postoperatively. Blood replacement is done by washed packed cells. Potassium overload during fluid replacement is to be avoided. The patient should be covered with broad-spectrum antibiotics to prevent sepsis. As most antibiotics are excreted through the kidneys, only a few have been proved safe for use. Amoxycillin, doxycycline and minocycline are a few recommended antibiotics.
MANAGEMENT OF RENAL TRANSPLANT PATIENT

1. Renal transplant patient’s come under American society of Anaesthsiologist Risk category III (Requiring medical consultation)

2. Stressed Reduction:

Patient should obtain proper rest the night before.

Appointments should be kept short.

Barbiturates and Benzodiazepins can be used in normal amounts.

Nitrous oxide-oxygen combination is an excellent anxiolytic.

Maintain a non-threatening environment.

Morning appointment.

Consultation with the patient’s physician for the need of additional steroids.

Steroids dose can be doubled the day before on the day of, 2 days after dental procedure.

Graft survival -> 90% at one year with overall mortality rate 5%

Patients need to immuno suppressed with a corticosteroid plus steroid sparing drug (azathioprin) cyclosprim to prevent raft rejection.

Treatment:

Those with symptoms of Cronic Renal Failure Treatment like CRF

Immuno suppressed-> steroid + antibiotic prophylaxis.

Hepatitis common- patient kept away from source of infection

Candidiasis.- Topical nistatin, amphoterecin, miconazole

Patients on immunosuppressive therapy with renal transplantation have a risk of developing malignant disease, (lymphoma, skin, cervical and lips cancer) leukoplakia, kaposis sarcoma

Drugs that can be used in Renal transmutation patients

SaferDrugs- Cloxoacillin, Penicillin, Minocycline, Erythromycin,

Refampicin, Lignocaine. Chloralhydrate,Diazepam

Fairly Safe- Ampicicilin,amoxicillin,Benzylpencillin cotrimazole,

metronidozole,codein, Barbiturates, Phenothiazins.

Less safe- Aminoglycosites cephalosporin, pracetamol, acetoaminophin,

pethidine, opiods, antihistamins,

Avoid Drugs Tetracyclin , sulphonaimides, NSAID’s and Aspirin

HEPATIC DISEASE

Preoperative Investigations
Liver enzymesSGOT (serum glutamic oxaloacetic transaminise),
SGPT (serum glutamic pyruvic transaminse).
Total bilirubin, direct and indirect bilirubin. Serum albumin. Serum alkaline phosphates. Bleeding time and clotting time. Prothrombin time and index. USG liver. Australia antigen test.
Intra and Postoperative Management
Avoid unaesthetic gases that are metabolized in the liver, like halothane. Correction of coagulation deficiencies by IV vitamin K, fresh frozen plasma transfusions. Careful intra and postoperative management of blood volume, cardiac output, urine volume and co0mposition. Potassium supplementation during fluid replacement. Appropriate precautions and sterilization techniques to prevent transmission of disease in a carried of viral hepatitis.
DIABETES MELLITUS

Diabetes mellitus is caused by an absolute or relative deficiency of insulin in the body can be classified into type 1(insulin dependent) and type 2 (insulin dependent). Type 1 is more commonly seen in young patients and type 2 in adults. A patient can be classified as a diabetic when his fasting glucose levels are constantly above 140mg/dl.

The nature of problems faced by the surgeon during the management of a know diabetic patient are as follows.
Optimal blood sugar levels are to be maintained during the procedure as well as postoperatively to prevent hypoglycemia or hyperglycemia and ketoacidosis. Both the conditions may be life-threatening to the patient. The patient is prone to infections and has to be given adequate pre and postoperative broad-spectrum antibiotic coverage to prevent infections. The patient may have additional systemic complications like renal failure, cardiac disorders, and ophthalmic problems and generalized vascular disease due to long-standing diabetes.
For surgical purpose a diabetic can be classified in three groups:
Sugar levels controlled by diet and oral hypoglycemic. Sugar levels controlled by insulin. “Brittle diabetes”, usually of juvenile onset, whose metabolic needs is labile and have sequel of long-standing disease such as renal failure, retinopathy, and generalized vascular disease.
Elective surgeries can be usually performed without complications in the first two types. In the third type, although the management remains same, amore rigid control is to be exercised intra and postoperatively.

Preoperative Investigations
Routine chest radiograph-posteroanterior view. Electrocardiogram Blood investigations like:
a. Blood sugar fasting and postprandial

b. Glucose tolerance test

c. Renal profile (BUN, SC,SE)
Urine sugar.
If the patient is on oral hypoglycemics, he/she must be shifted to insulin on the day of surgery. The general principle for the management of the patient under general anaesthesia is to provide at least 200gm of carbohydrate with adequate insulin to cover this need.

Sugar Levels and Insulin Dose

Sugar Levels (mg %) Insulin dose

80 120 Plain 5% dextrose (D)

120-180 4 units in 5% dextrose

180-250 8 units in 5% dextrose

250-300 14 units in 5% dextrose

300 and above 14 units in normal saline

Intra and Postoperative Management
Check the patient’s blood and urine sugar levels on the morning of surgery with the help of hemoglucose strips and urostrips or glucometer. Prepare a sliding insulin scale to be followed intraoperatively based on the patient’s sugar levels. Pre and postoperative broad spectrum antibiotic coverage. Intra and postoperative close monitoring of the bold and urine sugar levels. Prevents the patient from going into ketoacidosis or hypoglycemia.
Signs of hypoglycemia: The patent is apprehensive restless, agitated, the skin is moist and pale and there is tachycardia. The patient then lapses in to coma.

Treatment : In a conscious patient, ora carbohydrates are given to collect the glucose levels. In an unconscious patient IV administration of 50% glucose solution restores consciousness in 5 to 10 minutes or 1mg glucogon IM restores consciousness in 15 minutes.

Signs of diabetic ketoacidosis : Vomiting, tachypnea, Kussmaul (deep, rapid breathing at regular intervals) breathing, dehydration and circulatory collapse.

Treatment: Administration of insulin to normalize body metabolism and restoration of body fluids and electrolytes.

6.Shift the patient at the earliest possible to his regular oral feeds and antidiabetic medications.

THYROID DISORDERS

Patients having disorders can be broadly divided in to 3 groups hypothyroid, euthyroid and hyperthyroid. Out of these euthyroid patients pose no risk for any surgical procedures. In both hypo and hyperthyroidism, elective surgery is best postponed till the patient is euthyroid.

The sense of hypothyrodism are water and mucopolysacharide retention, slowing of metabolic process leading to bradycardia, constipation, letheargy and hypothermia. Untreated hypothyroid patients respond poorly to stress and proceed in myxedema coma.

Hyperthyrodism leads to a hypermetabolic state in the body resulting in catabolic state with tachycardia, diarrhea and heat intolerance. If this patient is subjected to stress, he goes in to what is known as “thyroid storm”, which is a state of metabolic hyperactivity lasting for 24 to 48 hours. It is a severe exacerbation of the signs and symptoms of hyperthyroidism and is usually accompanied by hyperpyrexia. The condition is life-threatening and requires control of hyperpyrexia, tachycardia and cardiac failure.

Preoperative investigations

1 Thyroid hormone levels T3, T4, TSH

2 Serum electrolytes

3 Serum proteins

4 Radionuclide thyroid scan to study the gland.

Intra and post operative management.

1. Monitor the Hormone levels intra and postoperatively

2. Continuous monitoring of vital parameters, blood pressure, pulse and

Temperature.

3. Check for signs and symptoms of hypo / hyperthyroidism

4. Continuous monitoring of cardiac function, especially during thyroid crisis. Infuse thyroid hormone if the patient shows signs of hypothyroidism.

5. If the patient is in a thyroid storm, treat by cooling the patient, intravenous, infusion of glucose and IV fluids, glucose and corticosteroids

6. Use narcotic agents and anesthetic medications judiciously in hypothyroid patients as they can have a profoundly depressing effect.

ADRENAL DISEASE.

Two common adrenal disorders that have to be dealt with during surgical procedures are cushings syndrome (overproduction ) and addisons disease (under production)

The symptoms of cushings syndrome are diabetes, sodium and water retention, potassium excretion, hypertension and fat redistribution. the patient also has a tendency to osteoporosis, poor wound healing and purpura formation. During surgery attention must be paid in maintaining optimum levels of carbohydrates in the body, sodium and potassium ion levels and the blood pressure. There may be postoperative problems of bleeding and delayed wound healing.

Underproduction can occur due to adrenal suppression due to exogenous steroids or due to a disease of adrenal origin (Addison’s disease).Usually any patient who has received steroids for longer than two weeks within a year prior to surgery should be considered as a candidate for adrenal insufficiency.

Preoperative investigations

1.Renal profile.

2.Serum electrolytes.

3.Fasting Blood Sugar.

4.Platletcount.

5.Coagulation profile.

Patients with adrenal insufficiency should be supplemented with adequate exogenous steroids prior to procedure to help the patient combat with stress

Intra and Postoperative Management.

1.Continuous monitoring of the vital sings.

2. Adequate intravenous corticosteroid supplementation to prevent adrenal crisis.

3. Maintain fluid and electrolyte balance.

4. Monitor blood sugar levels.

NEUROLOGICAL DISORDERS

Neurological disorders can be categorized into patients with cerebrovascualar disorders, seizure disorders and patients with head injury. the main factors of consideration in these patients is to maintain adequate cerebral perfusion intra and postoperatively and to control any seizure episode during this period. Patients with seizure disorders usually do not pose a great problem for intra operative management except for cases of status asthamaticus, where there can be life-threatening complications. The surgeon should weigh the risks and benefits infarcts, aneurysms, and areteriovenous malformations are very high-risk candidates and are absolute contraindications for surgical procedures.

Preoperative investigations

1.Routine skull radiographs-posteroanterior and lateral views.

2.CT scan/MRI brain.

3.EEG.

4.Liver function tests.

If the patient is an epileptics, adequate control of seizure episodes must be achieved prior to the surgical procedure. The anticonvulsant must be continued till the morning of the surgery. The morning dose is given with sips of water.

Intra and Postoperative Management

1.The patient should be given intravenous anti-convulsants intraoperatively.

2.Postoperatively the patient should be shifted to his normal dose of anticonvulsants at the earliest possible.

3.Throughout the procedure, hypotension/hyoxia is to be avoided and an adequate cerebral perfusion is to be maintained.

DISORDERS OF THE HAEMOPOLETIC SYSTEM

Disorders of the haemopoietic system can be grouped into anaemias, leucocyte disorders and coagulation factor abnormalities(haemophilia).Anamias include iron deficiency anemia, thalassaemia, sickle cell anaemia; and leucocyte disorders include leucocytosis and agranulocytosis.

Any disturbance in the haemopoietic system

1. Predisposes the patient to prolonged bleeding during any surgical procedure, which cannot be controlled by routine hemostatics.

2. May cause severe internal bleeding due to blunt injury following intubation, a condition if unnoticed may pose a life-threatening complication.

3.Leukemic and thalassemic patients may be on repeated blood transfusions and may have liver disorder due to excessive deposits of hemosiderin.

4.the rate of postoperative infection and delayed wound healing is also very high, especially in agranulocytosis, leukemia and anaemia.

Preoperative investigations.

1.Complete blood count

2.Bleeding time and clotting time.

3.Prothrombin time and index

4.Partial thromboplastin time.

5.Coagulation factor level assay (in case of factor abnormalities).

6.Platlet count

7.Haemoglobin.

8.Liver function tests

Prior to the procedure, the patient’s blood counts must be built up to the normal values by transfusion of whole blood, packed cells, plasma or plasma components and clotting factors. For a hemophiliac, the factor VIII level should be raised to at least 50 to 70 percent prior to the procedure. Once the blood levels are normal, the patient can be treated as a normal patient with regards to surgical kept ready for transfusion intraoperatively, if required. In case of leukemics, the patient should be covered with broad-spectrum antibiotics pre and postoperatively.

Intra and Postoperative management

1. Avoid undue trauma to the tissues during any procedure performed.

2. Avoid entering deep tissue spaces blindly, thereby preventing any internal bleeding.

3. Complete hemostasis must be achieved prior to wound closure.

4. Intraoperative transfusion of blood/blood products, if found necessary.

5. Monitoring of hemoglobin, complete blood counts intra and postoperatively.

6. Maintain adequate blood volume throughout the procedure and at the same time avoid cardiac overload.

7. Monitor the vital parameters closely for any changes in the fluid volume indicated by the pulse and blood pressure.

8. Postoperatively the patient may be maintained on systemic oral coagulants like vitamin K for 3-5 days.

9. Cover the patient with adequate broad spectrum antibiotics.

10. Avoid medications that can exacerbate the underlying condition, especially in agranculocytosis.

In view of the rise in blood borne transmission of diseases like AIDS, hepatitis B and hepatitis C, the government has made it compulsory for testing of all the three viruses before storing the blood in the blood bank. But the decision to transfuse blood and blood products must still be made judiciously weighing the risks and benefits.

Management of a Hemophiliac Patient

Classically hemophilia is of two types, hemophilia A (factor VIII deficiency) and haemophilia B (factor IX deficiency).The disorder is a sex-linked recessive trait.Approximatley 50 percent of the female offspring’s are carriers of the disorder and 50 percent of the male offspring’s have the clotting disorder. these patients have the clotting disorder. These patients have a tendency to bruise easily and prolonged bleeding.

The successful management of a hemophiliac is dependent on the adequate maintenance of the antihaemophilic globulin. The normal AHG level is 50 to 100 percent. In a hemophiliac, for good hemostasis, the factor level must be 20 percent above normal, though a normal level is also acceptable.

Thromboplastin regeneration time not only determines the factor VIII deficiency but also distinguishes it from factor IX deficiency. Factor VIII replacement can be provided through blood, plasma, fresh frozen plasma, and cryoprecipitate. The latter is the replacement choice as it offers only the deficient factor.

Management

1. Build up factor VIII level to 50 to 70 percent.

2. Avoid injecting into deep tissue spaces, i.e. avoid block techniques. Use infiltration anaesthesia.

3. Traumatic extraction surgical procedure.

4. Avoid unnecessary trauma to the soft tissues, avoid suturing, if not required.

IMMUNOCOMPROMISED PATIENTS

Immunocompromised patients can be grouped into patients having deficiency in cell mediated, humoral immunity, neutorphils complements, patients on immunosuppressive drugs like chemotherapeutic agents and steroids and patients suffering from long-standing debilitating conditions like diabetes and nutritional deficiencies.

These patients are highly susceptible to infections and must be given

broad-spectrum antibiotic coverage for the same.

Preoperative investigations.

Complete blood count

Liver function tests

Renal function tests

Serum proteins

Blood sugar levels.

Urine analysis.

Routine chest radiograph.

Intra and Postoperative Management

The management will vary according to the condition the patient is suffering from. Usually it is almost impossible to correct the causative factor and the treatment is usually supportive only.

Constant monitoring of the vital parameters.

Broad spectrum antibiotic coverage.

While handling HIV infected patients, special care must be exercised to prevent the transmission of the disease.

AUTOIMMUNE DISORDERS

The group of autoimmune disorders includes systemic lupus erythematosus, scleroderma, collagen disorders rheumatoid arthritis, Shjogren’s syndrome, polyartertis nodosa,etc. These patients may have significant cardiac, renal and bone marrow impairment, which may contraindicate elective surgery. The patients, whenever possible must be operated during their remission phase. A few of these patients may be on long-term corticosterioid therapy, therefore, precautions to prevent adrenal insufficiency must be taken.

A few of these patients have loss of flexibility in the joints, especially the thoracic cage and neck joints, thereby posing problems in intubation and ventilation. In posing problems in intubation and ventilation. In scleroderma, the patients have a restricted oral opening as well as restricted expansion of the chest wall.

Patients with collagen disorders may also have delayed postoperative wound healing.

PREGNANCY AND LACTATION.

Every female patient in the childbearing age must be asked for history of pregnancy of missed menstrual cycles. Great care must be taken when dealing with the pregnant patient since the surgeon has to treat not only the mother but also prevent any undue harm to the fetus. It is safe to perform procedures under local anaesthesia in the second trimester. In the first trimester, there is a risk of stress related abortion as well as teratogenicity, while in the third trimester there is a risk of stress induced while in the third trimester there is a risk of stress induced early labor. General anaesthesia is a contraindication in the third trimester, unless it is a life saving emergency the third trimester, unless it is a life saving emergency procedure. In the first and second trimesters care must be taken to avoid fetal anoxia.

Again, the risks and benefits must be weighed prior to the procedure, The mother should be fully explained about the risks before performing any procedure. The mother should be fully explained about the risks before performing any procedure. teratogenic drugs like tetracyclines,salicylates, and chloramphenicol are best avoided. Amoxycillin, cloxacillin, ampicillin and paracetamol can be safely prescribed.

CONCLUSION

Concluding this chapter, a few points need to be highlighted, which will define a basic protocol to be followed during the management of a medically compromised patient.

A through knowledge of the patient’s medical background must be obtained.

The surgeon should also have knowledge about the medications taken by the patient and the regularity of the patient in taking the same.

A written consent for the surgical procedure has to be obtained from a specialist in the field prior to the procedure.

Adequate and necessary preoperative investigations must be performed.

The patient should be explained about the risks and benefits of the procedure with regards to his general condition and a witnessed written consent for the procedure, as well as high-risk consent should be obtained from the patient.

The operation theater must be well-equipped with functional life support systems and an updated emergency trolley in case of an emergency. The same applies to the postoperative recovery room.

The decision of whether or not to operate lies with the surgeon and he/she must make his/her choice judicious weighing the pros and cons with respect to surgical benefits and anesthetic risks


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