18 Surgery for the compromised patient
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This chapter offers guidance and general principles for dealing with patients who are suffering from a disorder that might affect their treatment. It is not possible to deal with every situation or disease state. Drug interactions and adverse effects are not described in detail.
Patients presenting for treatment may be compromised in a variety of ways—financially, socially, psychologically or medically. An ability to identify patients who are disadvantaged is an important clinical skill. Observation of the patient when they are first seen, and an ability to ask appropriate questions during the interview, will provide most of the information required.
Important factors include the patient’s general appearance and demeanour, and whether they are accompanied when they attend the surgery. These factors become increasingly important when the patient is elderly.
During the history-taking procedure, in addition to the standard medical enquiries (see Ch. 2) it is important to explore the patient’s attitude to previous treatment, and their probable responses to planned treatment. It is also advisable to assess whether the patient is unusually anxious or shows evidence of any other departures from normal behaviour. Discussions regarding the patient’s social background should identify, particularly for older patients, whether they live alone or have family support.
When surgery is contemplated, it is in response to a patient’s clinical complaint. However, it is important to ensure that the problem is given appropriate priority within the patient’s general, social and health care, so that the treatment recommended is relevant and is seen by the patient to be acceptable and desirable.
For the compromised patient the likely outcome must be considered against the risks and consequences of the surgery’a treatment plan which may be routine and sensible for a healthy patient may need to be modified considerably when dealing with an elderly or sick patient.
In the general practice environment, short episodes of treatment are usually tolerated well but extensive, prolonged surgical procedures are not recommended.
Patients who are psychologically vulnerable and who may become confused when treatment is described to them should be encouraged to discuss the proposals with a family member or friend whilst in the surgery. It is often beneficial to arrange a second appointment specifically for this purpose. It is also important not to increase anxiety by emphasizing unlikely risks, particularly if the treatment proposed is essential. If the surgery is part of a longer-term treatment plan, then the patient’s ability to complete the whole course (physically and financially) must be confirmed.
A patient’s aftercare must also be taken into account. The recovery period will require an adjustment for the patient in terms of daily activities and diet, and support at home (from partner, relatives or friends) is an important factor. For patients who are unwell, the effects of their illness, including their medications, on wound healing and the prescription of drugs required to aid recovery are additional important factors to take into account.
Before finalizing a surgical treatment plan which is appropriate and specific for the patient, they will have been assessed:
When the history is documented, a detailed medical enquiry (often obtained initially from a questionnaire completed by the patient) will have identified whether the patient has had, or is suffering from, any significant disease. It is important to remember that even if the patient has been seen at the practice for many years, the history must be checked before arranging any surgery.
Patients may be suffering from diseases of which they are unaware and the surgeon must take into account the patient’s social status when interpreting the medical history; for example, an overweight, middle-aged man who consumes alcohol should be considered a possible risk for a degree of liver dysfunction. Also, with increasing age, patients may suffer from undiagnosed cardiovascular (cardiores-piratory) disorders such as hypertension and ischaemic heart disease.
Once a disease state has been identified, there must be some attempt to categorize the illness, so that planned surgery is based on a systematic approach rather than a ‘one-off’ judgement.
As well as identifying the disease some attempt should be made to assess its severity. For example, the length of time the patient has suffered from the problem and the effect it has on their life and mobility are helpful measures. Direct enquiries about whether the patient has been hospitalized (and when and how often) and how the patient is managed (whether by their practitioner or with regular outpatient visits to a hospital specialist unit) will also assist.
The assessment scale first introduced by the American Society of Anesthesiologists (see Ch. 3) has provided a basis for similar classifications, such as scales for the severity of congestive heart failure or for severity of cardiopulmonary disease. This type of grading may be helpful in the assessment of a patient’s general medical status. A suggested system is given below.
Using a grading system to assess the patient’s medical and social status provides a framework for planning the best way and location to undertake the required surgery.
In general terms, most dentoalveolar surgery could be provided in the practice environment, under local anaesthesia, using premedication or sedation when beneficial. It would be wise to be extremely cautious with some patients in this group if general anaesthesia is contemplated, e.g. elderly people or patients with suspected risk factors.
Most of these patients could be managed in the practice environment, given sensible responses to the medical history and medications required (e.g. antibiotic cover for valvular disease). In some patients (e.g. epileptic patients) the positive prescription of sedation would assist in management.
It is unwise to undertake surgery when a patient has an acute upper respiratory tract infection. Emergency surgery can be provided, but treatment would have to be of limited duration, because of respiratory difficulty and the possibility of the patient coughing during the procedure. Some diagnostic problems can arise when acute maxillary sinusitis develops associated with infection of the upper respiratory tract.
An elective general anaesthetic should not be provided when a patient has an acute respiratory infection.
Lower respiratory tract infections are commonly acute exacerbations of bronchitis. These infections cause cough, fever, breathlessness and malaise, and it is highly unlikely that a patient would attend for treatment whilst in this condition: a patient with pneumonia would be too ill to consider surgical treatment. If emergency treatment is required whilst the patient has an acute infection, it should be directed at relieving pain and be of minimal duration, under local anaesthesia.
Chronic obstructive airways disease is usually due to chronic bronchitis, in which viscous mucus accumulates in the airways. A chronic cough is usually present, and the inability to clear the mucus from the lung structures results in frequent secondary infections and may be associated with emphysema. This type of lung disorder is nearly always associated with chronic hypoxia. Patients with more severe disease cannot tolerate lengthy procedures and are extremely uncomfortable if treated supine.
Surgical procedures that can be reasonably completed in about 20–30 minutes under local anaesthesia may be undertaken in the general practice environment with the patient sitting, not supine. Intravenous sedation should be used only with carefully selected patients because, once the patient is reclined, hypoxaemia and reduced respiratory function from the disease will cause difficulties in breathing, which are exacerbated by sedation. The use of supplementary oxygen during sedation is helpful, but the patient must be monitored carefully and continuously.
Asthma is common; it is valuable to assess the severity of the disease before planning treatment. Patients who have been hospitalized with an episode of asthma or who take systemic steroids on a regular basis should be considered as severe asthmatics and unsuitable for sedation or general anaesthesia, except in hospital. Patients suffering from milder asthma, which is controlled with inhalers, are usually suitable for management in general practice. An asthma attack can be precipitated by stress, so it is important to plan treatment in a sympathetic way to avoid anxiety from undue waiting before surgery and, where necessary, to use premedication (oral benzodiazepines are useful). Treatment under local anaesthesia is usually safe; patients should have with them their usual medications and use their inhaler before treatment.
Drug sensitivities are common, and opiates are best avoided (but are rarely indicated for pain control following oral surgery). Some asthmatic patients are sensitive to the non-steroidal analgesics (NSAIDs), the use of which can initiate bronchospasm or a severe asthma attack. It is important to enquire whether the patient reacts adversely to aspirin, ibuprofen or similar drugs. Fortunately, most asthmatics can take NSAIDs safely and should not be denied these valuable analgesics.
This is most frequently reported in the history as angina (crushing central chest pain, associated with myocardial ischaemia), with the patient having been prescribed drugs to relieve the symptoms. Angina may be accompanied by hypertension and some degree of heart failure—the patient should be examined for evidence of either. Mild angina does not preclude surgery being carried out in general practice, but frequent severe attacks, unstable angina and angina at rest are more worrying and the patient would be better managed in hospital. The severity of ischaemic heart disease may be judged by the distance that the patient can walk on the flat without having to stop because of chest pain, their ability to climb stairs and the frequency with which they take medication such as sublingual nitrate sprays to relieve pain.
Angina is best prevented by good patient management, including adequate pain control. Premedication and sedation are extremely useful. It is useful to advise the patient to take their spray or tablet used to alleviate angina as a prophylactic measure before surgery commences.
The use of lidocaine (lignocaine) with adrenaline (epinephrine) will provide the most profound pain control and is therefore the drug of choice. It is, as usual, important to use an aspirating system and to inject slowly. Occasionally a small, transient increase in heart rate will be induced, but this is rarely of clinical significance.
When a patient has suffered a myocardial infarction, any surgery should be deferred for at least 3 months if possible, and treatment requiring general anaesthesia for at least 6 months. Emergency treatment within these periods is best provided in hospital, where local anaesthesia and sedation are likely to be selected.
Hypertension is associated with increasing age and increased peripheral arterial resistance. Mild degrees of hypertension are common and are often undiagnosed. Some patients are ‘controlled’ with diuretics (necessitating the assessment of potassium levels before significant surgery or general anaesthesia). Hypertension may be secondary to other disease states (e.g. renal or endocrine) and this should be revealed when the history is taken.
Patients who have been hypertensive for years may well have heart failure or angina; if either is known to exist, the patient must be considered more prone to complications during or after surgical treatment.
Pain and anxiety must be avoided in hypertensive patients to prevent increases in blood pressure before and during surgery. Good pain control (local anaesthesia using lidocaine (lignocaine) with adrenaline (epinephrine)), with premedication for the obviously anxious, is essential, and intravenous sedation is valuable during surgery. Lidocaine (lignocaine) 2% with adrenaline (epinephrine) 1:80 000 is the most effective local anaesthetic currently available and, although systemic effects of the adrenaline (epinephrine) can be demonstrated, there is no evidence that moderate doses have any serious harmful effect in hypertensive patients.
Intravenous sedation is valuable for most hyper-tensives, as it reduces the risk of increasing blood pressure from anxiety and discomfort. For obviously anxious hypertensive patients, premedication should be considered.
This is a consequence of other disorders, mainly valvular disease, ischaemic heart disease or hypertension. Even when heart failure appears to be controlled, it should be taken as an indication of cardiovascular ‘wear and tear’.
Patients suffering from left-sided heart failure develop pulmonary oedema, with dyspnoea and a cough. Ankle oedema may be apparent. When right-sided failure is also present, further respiratory embarrassment may occur due to congestion of abdominal organs, and more obvious peripheral (ankle) oedema will be evident.
Surgery can be undertaken for a patient with heart failure, but prolonged treatment should be avoided. Stress can induce an increased sense of respiratory difficulty; if the patient is supine, dyspnoea can be exacerbated, so patients are best managed semi-reclined or sitting upright.
Patients with heart failure can be difficult to manage although those who appear to be well controlled and live a relatively active life can be treated in the practice. Local anaesthesia will be regarded as perfectly safe, but intravenous sedation might precipitate respiratory difficulties and patients requiring sedation might be more appropriately managed in hospital. Similarly patients with poorly controlled disease, with evident breathlessness and oedema, will be better managed within the hospital environment.
Heart failure can interfere with vascular perfusion of the liver and, consequently, drug metabolism. A limiting factor in planning surgery is therefore a restriction in the dose of local anaesthetic solution that can be used. This further dictates that only short procedures should be undertaken at each visit.
If there is turbulence in flow within the heart there is a risk of bacteria from the bloodstream settling on the endocardium and causing infective endocarditis. A bacteraemia will result from most invasive surgical procedures in the mouth (such as tooth extraction). Therefore it is necessary to identify patients who are at risk of endocarditis and provide appropriate prophylactic measures at the time of surgery. Detailed guidance from the Working Party of the Society for Antimicrobial Chemotherapy is published in the British National Formulary.
Disorders of coagulation are the most significant in daily practice. Although the congenital coagulation defects are usually identified when the history is taken, some others may only be revealed during the examination or suspected from the history (e.g. secondary to liver disease). Interference with platelet function is a feature of the NSAIDs and aspirin. Patients commonly take ‘over-the-counter’ drugs of these types.
If the history reveals episodes of troublesome or serious haemorrhage following previous surgery, or if examination reveals unusual purpura or bruising, then the patient should be fully investigated before surgery is undertaken.
Patients who may be considered likely to have a mild haemorrhagic disorder (perhaps due to other disease) or who have been taking analgesics should be treated cautiously, with limited surgery being provided in the first instance. Management under local anaesthesia, preferably avoiding deep (block) injections, with sedation if required, is acceptable, but attention to haemostasis with adequate postoperative care and follow-up is essential. Inferior dental block injections rarely seem to cause bleeding at the injection site for those therapeutically anticoagulated. However, for patients with a severe clotting defect such as haemophilia there is a risk of a substantial haematoma developing.
Those patients who have identified coagulation or platelet defects will require contemporaneous assessment and replacement therapy and should, therefore, be managed in hospital. Once there has been replacement therapy there is no need to withhold block injections.
Many patients are taking anticoagulant drugs and if a patient volunteers a relevant history, then positive enquiry into anticoagulant treatment should be undertaken.
Patients on anticoagulation therapy will carry with them a record of their drug treatment and INR assessments. If minor procedures are planned (e.g. the extraction of one or two teeth or a biopsy) then it is reasonable to proceed if the INR value on the day of surgery is no greater than 3, with strict attention to postoperative haemostasis (using a resorbable material in the socket and sutured into place). The surgical removal of teeth, and greater numbers of extractions, can be carried out with an INR of up to 4, provided that, in addition to the local measures, tranexamic acid mouthwashes are prescribed.
If the INR is greater than 4, then modification of the anticoagulant regimen will be required, in collaboration with the physician controlling the patient’s anticoagulation. The treatment should be undertaken in hospital. There is variation between hospitals in recommended values of INR for particular procedures.
Problems arise with postoperative care. The use of NSAIDs is undesirable in these patients and pain control must be provided using paracetamol in the outpatient setting. If surgery is likely to induce significant pain, the patient is probably best managed in hospital, where opioids can be used. The prescription of antibiotics can also interfere with anticoagulation control, necessitating frequent reassessment.
The general management of diabetic patients in the dental practice is acceptable, provided that the usual protocols are adopted—that patients are encouraged to take their drugs and meals at normal times before their treatment, which must be provided at sensible times (preferably in the morning). Difficulties arise when general anaesthesia is required and patients must be starved—in these circumstances management in hospital is essential.
Problems can arise postoperatively because of interference with wound healing and secondary infection. For this reason, antibiotics are usually prescribed following surgery in and around the mouth.
Patients who suffer from milder forms of diabetes (controlled by diet alone, or sometimes with oral hypoglycaemics) can usually be managed well within the practice environment, but patients who are insulin-dependent can be a greater risk.
It is unwise to provide intravenous sedation for insulin-dependent diabetics unless the practice has the ability to check blood sugar levels before treatment, and immediately if any difficulty with managing the level of consciousness arises.
Remember that patients who have suffered from diabetes for many years may have other diseases as a consequence (e.g. cardiovascular or renal).
The disorders that are relatively common are osteoarthrosis and rheumatoid arthritis. The severity of these disorders should be noted when the patient is first examined and a history is taken.
Problems with mobility might well interfere with the patient’s ability to seek advice or return to the practice if problems arise after surgical treatment. These potential restrictions must be considered when surgery is planned; family support is invaluable.
When planning a surgical procedure for a patient with severe rheumatoid arthritis it is necessary to ensure that the patient can be maintained comfortably in an appropriate position, that the mouth can be opened sufficiently widely for the anticipated duration of the procedure and that care is taken to support the neck—particularly if the patient is sedated.
Outpatients with these disorders usually take NSAIDs. The possibility of anaemia and interference with postoperative haemostasis must be taken into account. In addition, patients with severe rheumatoid arthritis may well be on steroid therapy.
The most common neurological problem presenting in younger patients is epilepsy. Many patients are well controlled but are taking a variety of medications, some of which (e.g. valproate) may cause haemorrhagic tendency. Provided the well-known aspects of management are adopted (preventing anxiety and irritating ‘stroboscopic’ lighting defects), epileptic patients can be managed well under local anaesthesia. The use of local anaesthetics is not contraindicated: there is no evidence that local anaesthetic agents provoke epilepsy. Less well-controlled patients benefit from sedation during surgery.
In older patients with neurological diseases, difficulties of management arise primarily in people with Parkinson’s disease, or those who have had significant strokes.
A patient with Parkinson’s disease may appear expressionless and be uncommunicative. It is important that the treatment is discussed with the carer as well as the patient—the patient may be upset and anxious if he or she is not apparently involved in the debate. There may be postural problems and rigidity, making management in the dental chair quite difficult. Problems of rigidity or tremor are frequently overcome using intravenous sedation, although it is preferable to plan the first episode of treatment to be ‘minimal’, to see whether sedation is helpful to the individual patient.
Patients who have suffered a cerebrovascular accident might have significant impairment with mobility and communication. This can increase difficulties with oral hygiene, particularly if there is facial paralysis, and postoperative wound care will require additional attention. Patients may well be hypertensive (this should be investigated) and have other features of cardiovascular disease; they may well also be on anticoagulants. All of these factors make their management in the general practice environment quite inconvenient although, if the patient is mobile, their families usually welcome maintenance of local, normal dental care. In more severe cases it is preferable to carry out surgery in hospital.
Many patients are taking prescribed medications but, when the history is obtained, it is important to enquire about other drug use, in particular over-the-counter medications and recreational drugs. Information about drugs may provide an insight into the patient’s health that was not revealed during the history. It is important to assess the potential difficulties that might arise during management because of drug treatments or interactions. There are some well-known problems, but new adverse reactions and interactions continue to be reported. It is important to consult up-to-date publications regarding new drugs and their effects (e.g. BNF).
The importance of the pharmacological aspects of treatment should be considered systematically:
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Answers on page 271.