RISK ASSESSMENT

In principle, if there is any medical condition which may be improved, (e.g.

pulmonary disease, hypertension, cardiac failure, chronic bronchitis, renal
disease), surgery should be postponed and appropriate therapy instituted.

There has been great interest recently in quantifying factors preoperatively

which correlate with the development of postoperative which correlates with the
development of postoperative morbidity and mortality.

AS A grading

The ASA grading system was introduced originally as a simple description of the
physical state of a patient. Despite its apparent simplicity, its remains one of the
few prospective descriptions state of a patient. Despite its apparent simplicity, it
remains one of the few prospective descriptions of the patient which correlate with
the risk of anaesthesia and surgery. It is extremely useful and should be applied to
all patients who present for surgery.

The ASA Physical Status Scale .

Class I A normally healthy individual
Class II A patient with mild systemic disease
Class III A patient with severe systemic disease that in not incapacitating.
Class IV A patient with incapacitating systemic disease that is a constant
threat to life
Class V A moribund patient who is not expected to survive 24 h with or
without operation.
Class E Added as a suffix for emergency operation .
Mortality rates after anaesthesia and surgery for each. ASA physical status-
emergency and elective cases. .

ASA rating Mortality rate (%) .

I 0.1
II 0.2
III 1.8
IV 7.8
V 9.4 .

Cardiovascular disease

Myocardial infarction

The majority of preoperative infarctions occur on the third day after surgery, and
50% are silent. The mortality associated with preoperative is 40-60%.

It is accepted generally that the development of preoperative reinfarction is related

closely to the time interval between the first MI and surgery, and the an interval of
6 months or less is associated with the highest incidence of reification.

It is still recommended that a myocardial infarction within 6 months of proposed

surgery is a contraindication to elective anaesthesia and surgery, unless the risks of
postponing surgery outweigh the likelihood of preoperative infarction.

Hypertension

Arterial pressure increases with age, and on admission to the ward there is often
some degree of hypertension associated with anxiety. The arterial pressure should
therefore be measured at regular intervals in the preoperative period in order to
assess the resting baseline level.

The view that a diastolic pressure in excess of 110 mmHg is associated with an
increased risk of myocardial ischemia.

Thus, patients who present preoperatively with a diastolic arterial pressure in

excess of 110 mmHg should receive antihypertensive treatment. As several days or
weeks may be required to stabilise the cardiovascular system, surgery should be
postponed for 2-3 weeks.

Multifactorial assessment of risk

Goldman and his colleagues have examined by multivariate analysis a number of

risk factors in patients undergoing non-cardiac surgery and produced a risk index
for the development of life-threatening cardiovascular complications in the
preoperative period. The Goldman-cardiac Rick Index' has been shown in several
studies to provide a reasonable prognostic indication of the risk of developing
cardiac complications postoperatively.

Goldman's index of cardiac risk in non-cardiac procedures .

Risk factor Points
3rd heart sound or jugular venous distension 11
MI in preceding 6 months 10
Rhythm other than sinus or premature atrial contractions 7
Abdominal, thoracic, or aortic operation 3
Age > 70 years 5
Important aortic stenosis 3
Emergency operation 4
Poor condition as defined by any one of: 3
Pao2 <8 kPa
Paco2 > 6.5 kPa
K+ < 3.0 mmol/litre
HCO3 < 20 mmol/litre
urea < 7.5 mmol/litre
creatinine > 270 mol/litre
SGOT abnormal
chronic liver disease .
5 points or less - cardiac mortality 0.2 %.
6-25 points - cardiac mortality 2%.
> 25 points - cardiac mortality 56%.

Pulmonary disease

Patients at risk or developing postoperative pulmonary complications include

smokers, those with pre-existing lung disease, the obese, and those undergoing
thoracic and abdominal surgery.

Age

It is generally agreed that the elderly are subject to increased risks of anaesthesia
and surgery. This is largely because of the association between many diseases of
the cardiovascular or respiratory systems and age, and also because routine clinical
evaluation often fails to detect cardio respiratory dysfunction in geriatric patients.

Predication of risk factors in general

Factors which are of greatest importance in predicting the development of

postoperative morbidity and mortality include, in decreasing order of importance:

1. Clinical assessment - ASA greater than 3.

2. Cardiac failure.
3. Cardiac failure.
4. Pulmonary disease.
5. Pulmonary abnormalities confirmed by X-ray.
6. ECG abnormalities.

Common causes for postponing surgery.

1. Acute upper respiratory tract infection (common cold).
2. Existing medical disease (cardiac, respiratory, endocrine, etc.) which is not
under optimum control.
3. Emergency surgery for which the patient has not been resuscitated
adequately. Postponenement may be necessary for only 1-2h to permit
 restoration of circulating blood volume. This important principle may be
breached if hemorrhage is extensive and continuous.
4. Recent ingestion of food. In general, anaesthesia for elective surgery should
not be undertaken within 4-6 h of ingestion of food or liquids.
5. Failure to obtain informed consent. Consent is invalid of obtained after the
patient has received premedicant drugs.
6. Drug therapy. It is unwise to proceed to anaesthesia if the patient is
receiving drug therapy which is not under optimum control.

PREOPERATIVE THERAPY

Respiratory disease
In patients with respiratory disease who are regarded as fit for surgery, chest
physiotherapy should be started preoperatively. In addition, sputum should be
obtained for bacteriological examination and culture to determine optimum
antibiotic therapy in the event of postoperative chest infection.

Asthma

Chest physiotherapy should be started preoperatively. If severe asthma is present,

instruction may be required in the use of appropriate bronchodilators, e.g.
salbutamol by inhaler.

Cardiovascular disease

Subacute bacterial endocarditis

For those at risk or developing subacute bacterial endocarditis, prophylactic

antibiotics are required.

Hypertension

In patients who are found to be hypertensive on admission, regular measurement

of arterial pressure should be undertaken. If the diastolic pressure decreases below
110 mmHg, it is reasonable to proceed with surgery. If the patient is a known
hypertensive receiving therapy, adjustment of the dosage of antihypertensive may
be required.

It is essential that antihypertensive therapy be continued throughout the

postoperative period Many -blocking drugs have a relatively short half-life, and if
a patient is receiving such therapy it may be preferable to change to a drug with a
long duration of action, such a atenolol or nadolol. It bowel function is likely to
remain disturbed for several day postoperatively, it may be necessary to use an i.v.
infusion of atenolol 2-6 mg/h or labetalol 2-5-10 mg/h.

Diabetic management

Obstructive jaundice

This is associated with the hepatorenal syndrome and bleeding problems. To

minimise the risk of renal failure, an i.v. infusion should be started on the night
before surgery. Glucose 5% should be infused at a rate of 100ml/h. In addition,
mannitol 20g should be given just before or at induction of anaesthesia, Vitamin K
may be prescribed in a dose of 10 mg daily preoperatively, and postoperatively for
3 days.

Blood transfusion requests

Blood is an expensive commodity and blood transfusion carries very small but
finite risks of incompatibility reactions and transmission of infection. Blood should
therefore be used only if absolutely necessary. The object of transfusion is to
ensure that the postoperative hemoglobin concentration does not decline to less
than 10g/dl. Thus the amount of blood ordered from the blood transfusion service
depends upon both the patient's preparative hemoglobin concentration does not
decline to less than 10g/dl. Thus the amount of blood ordered from the blood
transfusion service depends upon both the patient's preoperative hemoglobin
concentration and the extent of surgery:
PURPOSE OF PREOPERATIVE EVALUATION OF A PATIENT

1. To obtain pertinent information about the patient's medical history and

physical as well as mental condition.

2. To determine about the need for a medical consolation and the king of
investigation required.

3. To educate the patient about anaesthesia, preoperative care, pain treatments,

in the hope of reducing anxiety and thereby facilitating recovery.

4. To choose the anaesthetic plan to be followed, guided by the risk factors,

uncovered by medical history.

5. To obtain informed consent.

The ultimate goal of preoperative medical assessment of a patient is to

reduce the morbidity of anaesthesia, as well as surgery.

Two functions of preoperative evaluation are closely related. Acquisition of

a pertinent medical history and information about physical and medical conditions
which affect all the decisions about testing, consultation and discussion of care
plans with the patient.
Routine Preoperative Anaesthetic Evaluation
History
1. Current problems.
2. Other known problems.
3. Treatment/medicines for the problems: dose, duration and effectiveness.
4. Current drugs use: reasons, dose duration, effectiveness and side effects.
5. H/o drug allergies.
6. H/o use of tobacco (smoking or smokeless or alcohol) quantity and
duration.
7. Prior anesthetic exposure: type, any adverse effects.
8. General health and review of organ system.
 i. Cardiovascular system (hypertension, heart disease, angina, activity
level).
ii. Respiratory system (cough, cold, sputum, asthma, upper respiratory tract
infection).
iii. Central nervous system (headache, dizziness, visual disturbances,
stroke, seizures-epilepsy).
iv. Gastrointestinal system (nausea, vomiting, reflux, diarrhoea, weight
change).
v. Renal system (abnormal function).
vi. Hepatic system (jaundice, hepatitis).
vii.Endocrine system (diabetes mellitus, thyroid dysfunction,
pheochromocytoma).
viii. Heamatologic system (excessive bleeding anemia, any particular
blood disorder or dyscrasias).
ix. Musculoskeletal system back or joint pain, arthritis).
x. Reproductive system (menstrual history, pregnancy).
Physical Examination
It broadly includes the following:
1. Vital signs
2. Airway
3. Heart
4. Lungs
5. Extremities
6. Neurologic examination.

Pulse rate and blood pressure should be checked. If there is rise in BP from the
normal values (120-140 mm Hg 60-80 mm Hg in adult), The patient might need
treatment to bring it to normal value.

The oral cavity should be inspected closely for the presence of caries, caps, loose
teeth or dentures and particularly protruding upper incisors. The extent of mouth
opening is assessed together with the degree of flexion of the cervical spine and
extension of the atlanto-occipital joint. Micrognathia, a large tongue, limited range
of movement of the TMJ or cervical spine, or a short neck suggest that difficulty
may be encountered in endotracheal intubation.
Many congenital or acquired deformities can affect the airway, jaw opening, neck
movement etc.
Dentist should always be cognizant of the importance of the patients cardiac status
while performing pre-anesthetic evaluation. Episodes of marked hypertension
ischemic changes on ECG and the combination of hypotension and tachycardia are
associated with an increased incidence of post operative myocardial infarction.
Auscultation of the chest should be done for dry or wet sounds.
In physical examination, one should not forget to examine skin and mucous
membrane for pallor to find out anemia,jaundice in case of impaired function liver
function and hepatitis, petechiae seen in blood dyscrasias, physical trauma and
subacute bacterial endocarditis.

LABORATORY TESTS
Determination of hemoglobin and haematocrit values, total and differential
white blood cell count and urinalysis.
A Chest X-ray, electrocardiogram and blood chemistry (glucose, blood urea
nitrogen and electrolytes).
Patients with a history of a bleeding disorder should have test for the
estimation of bleeding time, prothrombin time and partial thromboplastin time.
More sophisticated test such as liver or pulmonary function test, arterial blood gas
analysis, computer tomography or magnetic resonance imaging may be indicated
after history and physical examination. Blood sugar ,serum electrolytes and
creatinine/blood urea,nitrogen,are also included in routine tests.
SPECIFIC MANAGEMENT PROBLES
Patients with diabetes
Most well-controlled patients with diabetes mellitus present no great management
problem for either ambulatory or inpatient oral and maxillofacial surgery, although
established odontogenic infection often requires more aggressive care in the
diabetic and may also alter glucose tolerance.
It is important to know whether onset was juvenile or adult whether control
is by diet alone, oral hypoglycemic drugs, single-dose long acting insulin, or long-
acting and short acting insulin; whether the patient has episodes of hypoglycemia
manifested as insulin shock; whether the patient has ever been in diabetic coma;
whether the patients tests his urine regularly and with what results; and whether
any complications of diabetes area present.
The stress of anesthesia causes increased glucose intolerance causes
increased glucose intolerance. Since hypoglycemia all methods of management,
for either the ambulatory or the hospitalized patient, are promulgated on attempts
to prevent hypoglycemia. The patient having a single extraction with local
anesthesia should be treated soon after mealtime, preferably in the morning,
regardless of the method by which his diabetes is controlled. Some source of
glucose must be available to treat hypoglycemia. Ambulatory patients undergoing
a general anesthetic and requested not to eat or drink prior to the procedure my
require the following modifications: if they are taking oral hypoglycemics twice a
day, the prior evening's does as well as the morning does is omitted. They are
treated early in the morning. As soon as oral intake is reestablished, they should eat
and take their morning does of medication and thereafter return to their normal
regimen. Patients taking a single morning does of long-acting insulin may take half
their dose before coming to the office even though they have not eaten. After the
procedure, as soon as adequate oral intake is reestablished, the remaining daily
dose of insulin should be taken.
Hospitalization of the oral surgical patent with diabetes mellitus permits
closer monitoring of blood glucose levels and the provision of continuous glucose
via intravenous infusion. For the adequately controlled diabetic, whose control is
by did alone or NPH or lente insulin, surgery should be done early in the day.
Intravenous 5% or 10% glucose in water is administered and half the usual dose of
long acting insulin insulin is given at the time the infusion is begun.

Prophylaxes for dental and surgical procedures of the upper respiratory tract
All dental procedures Surgery or
that are likely to result Instrumentation of
in gingival bleeding the respiratory tract
Most congenital heart disease; Regimen A or B Regimen A or B
rheumatic or other acquired
valvular heart disease; idiopathic
hypertrophic subaorbic stenosis,
mitral valve prolapse syndrome
with mitral insufficiency
Prosthetic heart valves Regimen B Regimen B
Antibiotic Prophylaxis
Regimen A
(penicillin)
Potential-oral combined
Adults : Aqueous crystalline penicillin
G (1000.00 units intramuscularly)
mixed with procaine penicillin G
(600,000 units intramuscularly)
Give 30 minutes-1 hour prior to
procedure, then give peniclillin V
(formerly called phenoxy methyl
penicilln) 500mg orally 6 hours for
8 doses.
Children : Aqueous crystalline
penicillin G (30,000 units/kg
intramuscularly) mixed with
procaine penicillin G (600,000
Unit intramuscularly). Timing of
doses for children is the same as
for adults. For children less than
60 pounds the dose of penicillin V
is 250 mg orally every 6 hours for
8 doses.
Oral
Adults : Penicillin V (20gm orally 30
minutes-1 hour prior to the
procedure then 500 mg orally
every 6 hours for 8 doses)
Children : Penicillin V (2.0 gm orally
30 minutes-1hour prior to
procedure, then 500 mg orally
every 6 hours for 8 doses for
children less than 60 poundes, use
1.0 gm orally 30 minutes-1 hour
prior to the procedure, then 250
mg orally every 6 hours for 8
doses)
For patients allergic to penicillin:
use either vancomycin (see regimen
B) or use Adults :
Erythromycin (1.0 gm orally 1-2
hours prior to the procedure, then
500 mg orally every 6 hours for 8
doses.)
Children : Erythromycin (20mg/kg
orally 1-2 hours prior to the
procedure, then 10 mg/kg every 6
hours for 8 doses.)
Regimen B
(penicillin plus streptomycin)
Parenteral-oral combined
Adult s : Aqueous crystalline penicillin
G (1000.00 units intramuscularly)
mixed with procaine penicillin G
(600,000 units intramuscularly)
plus streptomycin (1 gm
intramuscularly), Give 30
minutes-1 hour prior to procedure,
then penicillin V 500mg orally 6
hours for 8 doses.
Children : Aqueous crystalline
penicillin G (30,000 units/kg
intramuscularly) mixed with
procaine penicillin G (600,000
Unit intramuscularly) plus
streptomycin (20mg/kg
intramuscularly) Timing of doses
for children is the same as for
adults. For children less than 60
pounds the dose of penicillin V is
250 mg orally every 6 hours for 8
doses.
For patients allergic to penicillin:
Adults : Vancomycin (1gm
intravenously over 30 minutes to 1
hour). Start initial vancomycin
infusion -1 prior to procedure,
then erythromycin, 500 mg orally,
every 6 hours for 8 doses.
Children : Vancomycin (20mg/kg
intravenously over 30 minutes-1
hour) Timing of doses for children
is same as for adults.
Erythromycin dose is 10 mg/kg
every 6 hour for 8 doses.