BDS 13002 Pre-Assessment & Safe Patient Selection PDF

NEWGIZA UNIVERS ITY BDS 13002 Pre-Assessment, Consent & Safe Patient Selection Aims NEWGIZA UNIVERS ITY The aim of this lecture is to introduce pre-ass...

NEWGIZA UNIVERS ITY BDS 13002 Pre-Assessment, Consent & Safe Patient Selection Aims NEWGIZA UNIVERS ITY The aim of this lecture is to introduce pre-assessment as an integral part of safe sedation practice and highlight the role it plays in reducing complications and ensuring safety through appropriate patient selection. The aim is also to explore the impact of common medical co-morbidities on the delivery of safe conscious sedation. Objectives On completion of this lecture, the student should be able to: Define pre-assessment and describe its different components. Explain the role of pre-assessment in the context of the patient journey through an episode of sedation. Summarise the possible outcomes following pre-assessment including the features that would identify a patient as 'safe’ for dental chair sedation. Identify clinical features that impact sedation for common conditions: chronic obstructive pulmonary disease (COPD), coronary artery syndrome (CAS), atrial fibrillation (AF) and Type 1 & 2 Diabetes Mellitus.  NEWGIZA UNIVERS What is pre-assessment? ITY Pre-assessment is the process in which clinicians and patients work together to select tests, treatments, management and/or support packages based on clinical evidence& the patients’ informed preferences. Inform risks & Reduce risk of Optimise concerns. Manage mortality/ patient’s expectations. morbidity recovery Advise how to prepare & attend.  NEWGIZA UNIVERS ITY Sedation providers must work not only to optimize patients prior to the procedure but should also act as gatekeepers for procedural safety. The saying “an ounce of prevention is worth a pound of cure” encapsulates the pre-sedation mindset. The main objective for the sedation provider during pre-procedural assessment is to answer the question: is this patient optimized for the procedure or not?  NEWGIZA UNIVERS Components of Pre- ITY assessment Proceed Consent, Info & History Examination Investigation Decline Advice History Examination Baseline observations Anaesthetic history: Previous anaesthesia? Complications? FHx? Anxiety examination CVS/RS assessment if indicated Past medical Airway assessment history Drug history & allergies History Social history Components of Pre-assessment NEWGIZA UNIVERS ITY History The process of constructing a successful sedation plan starts with a careful, targeted history focusing on a few critical domains. Pre-assessment should, wherever possible, include consultation of previous records.  NEWGIZA UNIVERS ITY The Medical History Previous anaesthetics/ Anaesthetic History sedation? For what surgeries? Any complications related to the anaesthetic/sedation? Any airway difficulties? Any family history of anaesthetic problems?  NEWGIZA UNIVERS ITY The Medical History A brief history Previous of the anaesthetics/ reason for presenting for sedation? surgery. History of Presenting For what surgeries? Complaint This does not need to be explored in great depth Any complications as related the sedationist. to the anaesthetic/sedation? Pay attention for clues about thingsdifficulties? Any airway related to sedation (e.g. fractured tooth post RTC Any family – fractured history of arm preventing anaesthetic cannula problems? also?)  NEWGIZA UNIVERS ITY The Medical History A Anybrief Previous history ongoing orofsignificant the anaesthetics/ reason sedation? past for presenting medical history for surgery. What For whatcondition? surgeries? This does not need to be How explored in great depth Any complications is it managed? as related Past Medical History the sedationist. to the Is anaesthetic/sedation? management effective? Pay attention for clues Does about itthings Any airway impactrelated difficulties? sedation?to sedation (e.g. fractured tooth it post Any family Can RTC – fractured be optimised? history of arm preventing anaesthetic cannula problems? also?)  NEWGIZA UNIVERS ITY The Medical History Any A brief Previous history ongoing allergies? ofsignificant the anaesthetics/ orReaction reason sedation? past type? for presenting medical Severity?history for surgery. What For what surgeries?(Px & condition? medications OTC)? This does not need to be How explored in great depth Any complications is it managed? as related Compliant? the sedationist. to the Is anaesthetic/sedation? management effective? Drug History Effective? Pay attention for clues Does about itthings Any airway related difficulties? impact sedation?to Vigilance sedation (e.g.for fractured anticoagulants tooth it post Any family Can RTC –&fractured history be optimised? of oral arm preventing anaesthetic hypogylcemics cannula problems? also?)  NEWGIZA UNIVERS ITY The Medical History Who Any A allergies? will brief Previous be history Reaction with of pt thefor 24h anaesthetics/ Any ongoing or significant type?procedure? post reason Severity? sedation? for presenting for past medical history surgery. Will What For ptmedications what besurgeries? (Px & able to manage What condition? basic OTC)? This activities does afterto be not need sedation explored or require in great Any complications How is it managed? depth as related additional Compliant? the to support? sedationist. the anaesthetic/sedation? Is management effective? How Effective? will pt getfor Pay attention to/from clues dental about clinicdifficulties? things Any airway Does it impact on day of related sedation? to Social History sedation? Vigilance (e.g. sedation for fractured Can anticoagulants tooth Any post RTC family it be –&fractured history optimised? oral of Does hypogylcaemics arm pt drive? preventing anaesthetic cannula problems? also?)  NEWGIZA UNIVERS ITY The Medical History A Enquire Any Whobrief Previous specifically allergies? will be historywithof ptabout: Reaction the anaesthetics/ for 24h Any ongoing or significant reason Hypertension type? post Severity? procedure? sedation? for presenting for past surgery.medical history Asthma / airway disease ForChest What Will what bepain ptmedications able/ angina (Px & to manage surgeries? What condition? This Hx of OTC)? basic “heart activities does attack” not needafterto be explored Hx complications Any of stroke sedation or require in great depth as related How is it managed? the toEpilepsy Compliant? additional the support? sedationist. anaesthetic/sedation? IsDiabetes management effective? PayBloodwillborne Effective? Howattention pt get viruses forto/from clues Does dental about Any clinicdifficulties? things airway it impact on day of related sedation? to including If screening Vigilance (e.g. sedation? sedation for fractured for Can domestic Any it violence, anticoagulants tooth post family be RTC history optimised? include –&fractured oral of it Systems Enquiry arm here. hypogylcaemics Does pt drive? preventing anaesthetic cannula problems? also?)  NEWGIZA UNIVERS ITY Chronic Obstructive Airways Disease (COPD) Chronic inflammatory lung disease causing obstructed airflow from the lungs. Caused by long-term exposure to irritant gases or particulate matter (e.g. smoke). S&S include SOB, wheeze, mucoid sputum and cough. Treated with bronchodilators, inhaled & systemic steroids, phosphodiesterase inhibitors, theophylline, antibiotics & oxygen therapy.  NEWGIZA UNIVERS ITY COPD & Sedation ASA classification very important – some will be ASA 2, some ASA 3. Increased risk of breathing difficulty during sedation and more difficult to ventilate. Increased risks with sedation but also with anaesthesia. Only consider suitable for sedation if good long-term control demonstrated. Refer for anaesthetic opinion if any doubt.  NEWGIZA UNIVERS ITY Coronary Artery Syndrome Episodes of myocardial ischaemia caused by plaque in the coronary arteries obstructing blood flow to the myocardium Stable angina  unstable angina  myocardial infarction May have had angioplasty and be on antiplatelet therapy. Consider postponing treatment if 40 are classified as ASA III and are therefore unsuitable for primary care conscious sedation.  Airway Assessment NEWGIZA UNIVERS ITY Although BMI is important, the dental practitioner should also consider the distribution of a patient's body fat. Those who have a thick neck or appear to be ‘top-heavy’ may be at greater risk of airway problems due to increased distribution of adipose tissue around the upper airway. As a result, a high BMI with predominant weight distribution around the lower abdomen and hips may be less concerning than patients with weight centered around the upper body. A neck circumference over 40 cm (16 inches) may be associated with an increased likelihood of OSA. This can be easily assessed by asking for an individual's collar size, or using a flexible tape measure. Airway Assessment NEWGIZA UNIVERS ITY Cervical spine mobility Assessment of a patient's cervical spine mobility will allow the practitioner to assess how easily a patient's airway can be opened with maneuvers such as a head tilt chin lift. This can be simply performed by checking for full range of movement when the patient moves their head side to side and up and down. Cervical spine range of movement should be more than 90 degrees (anterior plus posterior flexion) to ensure easy intubation.  Airway Assessment NEWGIZA UNIVERS ITY Dentition Removable dental prostheses may present a risk to the airway. The presence or absence of these should be recorded during the sedation pre-assessment. Prostheses should be removed prior to sedation to minimize risk of displacement and airway obstruction, particularly if poorly fitting. Airway Assessment NEWGIZA UNIVERS ITY Dentition Where appropriate, practitioners may wish to consider methods of airway protection, such as rubber dam. Another consideration is that the edentulous may be more difficult to ventilate in an emergency due to the loss of cheek and lip support resulting in a poor mask seal. Airway Assessment NEWGIZA UNIVERS ITY Mouth opening, inter-incisor distance: Mouth opening is central to airway management and intubation. Adequacy of mouth opening should be assessed in all patients. An inter-incisor distance: Normal distance 5cm or three finger breadths. ‹ 3cm: difficult intubation ‹ 2cm: possibility of difficult supra-glottic device (LMA) insertion. Airway Assessment NEWGIZA UNIVERS ITY Mandibular protrusion An inability for a patient to bite their upper lip, or place their lower incisors in front of their upper incisors are non-reassuring features. Grade C is rare but diagnostic for difficult intubation. Grade B however has poor positive predictive value (PPV) Position of lower teeth in relation to the upper Class Lower incisors can be placed in front of upper incisors A Lower incisors can be placed in line with the upper incisors B Lower teeth cannot be placed in line with the upper C incisors Airway Assessment NEWGIZA UNIVERS ITY Thyro-mental distance The thyromental distance is that measured between the thyroid notch and the mental prominence when the head is fully extended. A distance less than 6 cm has been cited as a risk factor for difficult mask ventilation and difficulty in placing supra-glottic airway devices.  NEWGIZA UNIVERS Airway Assessment ITY STERNOMENTAL DISTANCE The sternomental distance (SMD) is defined as the distance between the mentum and sternum with the head fully extended and the mouth closed. The threshold value of less than 12.5-13.5cm is used to predict a higher incidence of difficult intubation. Evaluate NEWGIZA UNIVERS ITY 3-3-2 Rule Airway Assessment NEWGIZA UNIVERS ITY The Modified Mallampati score The Modified Mallampati score classifies the visibility of oropharyngeal structures when the patient opens their mouth maximally and extrudes their tongue. The greater the score, the more difficult the airway is potentially considered to be (score 3&4). The Modified NEWGIZA UNIVERS ITY Mallampati score Structures visible Class Faucial pillars, soft palate and uvula visible I Faucial pillars and soft palate visible Uvula obscured by II tongue Only soft palate is visible III Soft palate not visible IV  NEWGIZA UNIVERS Components of Pre- ITY assessment Proceed Consent, Investigatio History Examination n Info & Advice Decline History Examination Baseline observations Anaesthetic history: Previous anaesthesia? Complications? FHx? Anxiety examination CVS/RS assessment if indicated Past medical Airway assessment history Drug history & allergies Social history Investigation Investigations NEWGIZA UNIVERS ITY Review available laboratory test results Order additional laboratory tests guided by a patient’s medical condition, physical examination, and the likelihood that the results will affect the management of sedation/analgesia. Evaluate results of these tests before sedation is initiated. Start with tests based on surgical grade & age. Add tests not yet done as indicated by disease severity.  NEWGIZA UNIVERS Investigatio ITY ns with tests based on surgical grade & age. Start For grade 2 (intermediate procedures): U&E s Glucos Urin Age CXR ECG FBC INR crea e e t < 16 16- 60 61- 80 Adapted from The Oxford Handbook of Anaesthesia >80 Investigations NEWGIZA UNIVERS ITY ASA grades ASA 1 patients: Most ASA 1 patients do not need most investigations prior to sedation for dental procedures. ASA 2 & 3 patients: - CVS disease: ASA2 : ECG ASA3 : ECG & (Urea, creat & electrolytes) - Renal disease: ASA 2: (Urea, creat & electrolytes) ASA3 : (Urea, creat & electrolytes), FBC & ECG  Proceed or Decline? NEWGIZA UNIVERS ITY Deciding whether to proceed with sedation or decline a patient is the sole decision of the person administering the sedation. When making this decision, the seditionist should consider their own abilities in the context of patient Proceed Decline factors, the operation & the team/environment they will work with. It is important to strike a balance between having confidence in your ability as a seditionist & knowing your  NEWGIZA UNIVERS Components of Pre- ITY assessment Proceed Consent, Examina Investigat History ion Info & tion Advice Decline History Examination Investigation Consent, Anaesthetic Baseline Blood tests Information & Advice observations history: Previous anaesthesia? Complications? FHx? Urinalysis Inform Anxiety CVS/RS patient examination assessment if they are high risk & implications of if indicated Past medical Airway Pregnancy assessment test history (repeat on day of procedure) thishistory & allergies Drug ECG/Echo Imaging Social history Manage their expectations of the intra- & post- operative periods Gain informed consent to administer  Consent, Information & Advice NEWGIZA UNIVERS ITY Consent Information Advice What to expect both during & Consent to Smoking after the administer cessation. procedure. sedation/ Medications Any points of risk anaesthesia. management. or concern. Consent for Fasting Likely or adjunct guidelines. significant techniques (e.g. Post-operative complications airway care arising from management). requirements. sedation/ anaesthesia.  Understanding the NEWGIZA UNIVERS ITY terms Consent is the ongoing, voluntary, informed decision of a person with capacity to make that decision to Consent accept a test, examination or treatment on the basis of an explanation of a clinician. Capacity is a person’s ability to make their own decision on a matter. It requires they can understand Capacity relevant information, retain it, and weigh up the different possible outcomes. Complications are medical problems that arise Complication during disease or as a result of intervention or treatment.  Consent NEWGIZA UNIVERS ITY The decision to give or withhold Voluntary consent must be made by the person Voluntary & not influenced by pressure from others including healthcare staff. Informed To make that decision, the person must be given accurate information about the Informed intervention’s risks, benefits, alternatives, & Capacity consequences of inaction. Most importantly, consent must be recognised as a process that evolves Ongoing along with the situation & person. ItConsent can be withdrawn at any time.  NEWGIZA UNIVERS ITY Valid consent is an essential preliminary to sedation. Information should be provided at an appropriate time (not at the last moment) when there is a chance to have a discussion and for the patient to be able to ask questions, understand the choices and risks before making a decision to sedate. Risks and benefits must be clearly explained. Alternatives to sedation (typically general anesthesia or local anesthesia with behavioral techniques) should be clearly explained. Psychological preparation of patients, especially children and their carers is an important part of preparation for sedation. Certain patient groups will require additional bespoke information for example children, pregnant and lactating women. Fasting NEWGIZA UNIVERS ITY Recommendation s Click icon to add picture Minimum Fasting Period Ingested Material 2h Clear liquids These 4h Breast milk recommendations apply to healthy 6h Infant formula patients who are undergoing elective 6h Nonhuman milk procedures. ASA guidelines, 2017 6h Light meal Additional fasting time Fried foods, fatty foods, or (e.g., meat 8 or more hours) may be Needed  An example of good practice NEWGIZA UNIVERS ITY  Streamlining Pre-assessment NEWGIZA UNIVERS ITY Pre-assessment is one of the most impactful interventions for reducing intra-operative morbidity/mortality & improving efficiency on the day of surgery. Completed by a trained member of the clinical team. Patient self-assessment is not enough. This misses the entire point of the process. Ultimate responsibility is on the person who administers sedation regardless of who assessed the patient. That person should therefore confirm the pre-assessment information on the day of procedure.  NEWGIZA UNIVERS Reading Material ITY Girdler, N. M., Hill, C. M., Wilson, K. E. (2017) Conscious for Dentistry, 2nd ed. Hoboken: Wiley-Blackwell. Chapter 3: Patient Assessment. Intercollegiate Advisory Committee for Sedation in Dentistry (2020) Standards for Conscious Sedation in the Provision of Dental Care. London: IACSD. Sedation Page 10: Options for Care. Aims NEWGIZA UNIVERS ITY The aim of this lecture is to introduce pre-assessment as an integral part of safe sedation practice and highlight the role it plays in reducing complications and ensuring safety through appropriate patient selection. The aim is also to explore the impact of common medical co-morbidities on the delivery of safe conscious sedation. Objectives On completion of this lecture, the student should be able to: Define pre-assessment and describe its different components. Explain the role of pre-assessment in the context of the patient journey through an episode of sedation. Summarise the possible outcomes following pre-assessment including the features that would identify a patient as 'safe’ for dental chair sedation. Identify clinical features that impact sedation for common conditions: chronic obstructive pulmonary disease (COPD), coronary artery syndrome (CAS), atrial fibrillation (AF) and Type 1 & 2 Diabetes Mellitus.  NEWGIZA UNIVERS ITY o u y n k h a T