Sedation For Medically-Compromised

Patients

Is ASA Grading Out-dated?

Dr Yusof (Joe) Omar MBBCh, DA, MRCA, PDD (Pain & Sedation)

Sedationist Senior Teaching Fellow, Eastman CPD, UCL

2016

ASA I A normal healthy patient

ASA II A patient with mild systemic disease

ASA III A patient with severe systemic disease

ASA IV A patient with severe systemic disease

that is a constant threat to life

Mrs X

66years old, retired, smoker, Alcohol 8-10u/w

Lung disease, emhysema, usual Sats 87-89%

Depression, under psychiatrist’s care.

Steroids in the past

Excessive thirst, pt thinks she may have Diabetes.

Drugs: Inhalers only

ASA I A normal healthy patient Healthy non-smoking, no or minimal alcohol use ASA II A patient with mild systemic disease Mild diseases only without substantive functional

limitations. Examples include (but not limited to): current smoker, social alcohol drinker, (<14 u/w )

pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease

ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.

ASA IV A patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): Recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction,

severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled

dialysis

Mrs X

66years old, retired, smoker, Alcohol 8-10u/w

Lung disease, emhysema, usual Sats 87-89%

Depression, under psychiatrist’s care.

Steroids in the past

Excessive thirst, pt thinks she may have Diabetes.

Drugs: Inhalers only

Minor Surg Procedure. At Induction P 64/min BP 140/70 O2Sats 87% Midazolam 0.5 mg Total time 45min Total Midaz 1.5mg Total Propofol 20mg Uneventful Sedation

Mrs X

Escort took Mrs X back to Devon by car, no problems reported.

How many of you would be happy with that?

Mrs X was found dead the next morning.

Did the Sedation contribute towards her Demise

Post Mortem: No cause of death found.

RETIRE NOW

It is a severity-of-disease classification system (Knaus et al., 1985)

APACHE II Acute Physiology and Chronic Health Evaluation II

Is there an Alternative to ASA

A conceptual model for outcome after surgery.

Gary Minto, and Bruce Biccard Contin Educ Anaesth Crit

Care Pain 2013;bjaceaccp.mkt020

© The Author [2013]. Published by Oxford University Press on behalf of the British Journal of

Anaesthesia. All rights reserved. For Permissions, please email:

journals.permissions@oup.com

Surgery Specific Estimates Of Risk (Cardiac Risk)

High risk (cardiac risk >5%) Eg Open aortic

Intermediate risk (1–5%) Eg Elective abdominal

Low risk (cardiac risk <1%)

Eg Dental

(adapted from The Royal College of Surgeons of England/Department of Health3). © The Royal College of Surgeons of England. Taken from The Higher Risk Surgical Patient, 2011.3 Reproduced with permission.

Risk Factors in Dental Sedation

• Age

• Fitness

• Fear and anxiety of Pt

• Nature of procedure

• Duration of procedure

• Training of sedationist

• Experience of sedationist

• Gut Feeling

The age & fitness of the Pt

The fear & anxiety

level

Nature & duration of the treatment

Experience of the

sedationist

Risk/ Safety

Risk / Safety Assessment

Safe

Unsafe Phobic

Normal

Grey-Area

Easy Ext

Zygomatic Implants

Beginner

>10y Exp

The age & Fitness of the Pt

The fear &

Anxiety Level

Nature & Duration

of the Treatment

Experience of the

Sedationist

0 1 2 3 4

5

0 1 2 3 4

5 Extremes

of Age

Safe

Unsafe Phobic

Normal

Age:

• -Within the experience & comfort

zone of the sedationist

• 16-59y treat as adults

• 12-15 years:

• 5-12 years: Individual assessment

• 2-4 years: Is conscious sedation

really possible in a frightened child? Grey-Area

The age & fitness of the Pt

0 1 2 3 4

5

ASA2

ASA3

ASA4

ASA1

5

3-5

3

0

Safe

Unsafe ASA 4

Fitness: RISK ASSESSMENT ASA 1= ASA 4 = L=Look externally (facial trauma, large incisors, beard

or moustache, and large tongue)

E=Evaluate the 3-3-2 rule (incisor distance <3

fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths)

M=Mallampati (Mallampati score ≥3 )

O=Obstruction (presence of any condition that

could cause an obstructed airway)

N=Neck mobility (limited neck mobility).

Grey-Area

0 1 2 3 4

5

The age & fitness of the Pt

ASA 1

5

0 1 2 4

1-5

0

Safe

Unsafe

0 1 2 3 4

5

The fear &

anxiety level

Normal

Phobic

Phobics Difficult venipuncture They expect Oblivion Increased movements Increased Tremor Increased likelihood of vagal

effects Undiagnosed problems Neglected OH Loose Teeth

4

5

1

Safe

Unsafe

0 1 2 3 4

5

Grey-Area

Nature & duration

of the treatment

Easy Ext

Zygomatic Implants

Lowest Risk: Short, dry, procedure Anterior extractions Endo with Rubber dam

Moderate Risk Duration of 2 hours or more Two-Quad Restoration Scaling Sensitive Teeth without LA

High risk Four Quad Surgery Complex Surgery Social reasons Public Transport Living alone

1

2

3

4

Safe

Unsafe

0 1 2 3 4

5

Grey-Area

Experience of the

Sedationist

Training Formal Training PGCert or Grand-Father

Skill in Venipuncture Communication skills In simple CBT

Experience Suggestions <20 cases/year = score 5 20-50 cases/y – score 4 50-100 cases/year = score 3

Up-to-Date: minimum ADA or SAAD annually

Training No Training Anaesth Training Skill Venipuncture Communication skills In simple CBT

Experience Suggestions <20 cases/year = score 5 20-50 cases/y – score 4 50-100 cases/year = score 3

Up-to-Date: minimum ADA or SAAD

Safe

Unsafe

0 1 2 3 4

5

Grey-Area

Experience of the

sedationist

4

0

Score

Low Score and Safety

High Score and High Risk

6

0

A 4y old fallen off his Scooter, broken 2 teeth, and cut lip. Distraught mother, frightened child. Child wheezing but mum says it’s because he’s crying. Young dentist Sedates once /month Learnt to do it at Dental school and as SHO No PGC in Sedation

0 1 2 3 4 5

Age x

Fitness x

Fear Level x

Nature of procedure

x

Duration of procedure

x

Training of sedationist

x

Experience of sedationist

x

Total Score = 30 4y old Asthma Crying ? Difficult ? Week-end Course Low Gut Feeling: Under Pressure

Mr MS aged 64y, BMI 33.5

•PMH

Anaemia of unknown origin

Asthma

Knee probs

Benign tumors of chest

Diabetes

Carpel tunnel release

Heavy snorer

MEDICATIONS : 1. Pravastatin 2. Dosulepin 3. Bumetanide 4. Meformin 5. Irbesartan 6. Tamsulosin 7. Novomix 8. Cocodomol 9. Amitriptyline 10. Ventolin 11. Omeprazol

Mrs PP 95y old, mobile, lives independently

PMH Angina, uses GTN very occasionally Pacemaker 2005 and 2014 Tripple CABG 2004 Hypertension L knee replacement 2010 Surgery to lower back 2014 Small cell Ca lunging remission Untreated Aortic Aneurism Cataracts Bunions Appendectomy

MEDICATIONS :

Aspirin

Bendroflumethiazide 2.5mg

Ramipril 1,25mg

Isosorbide 10mg

Bisoprolol 2.5 mg

Lansoprazole

Ferrous Sulphate

Quinine

Co-codomol

Poswillo Report

1993-1995 no deaths

1996-1999 eight deaths

Of which five were children.

Critical of the standard of care provided in:

• Pre-operative assessment

• Monitoring

• Start of resuscitation

• and transfer to specialist

critical care.

General Anaesthesia, Sedation and Resuscitation in Dentistry, Report of an expert working party prepared for the Standing Dental Advisory Committee March 1990 (AKA The Poswillo Report).

Thank you

THE ULTIMATE IGNORANCE IS THE

REJECTION OF SOMETHING YOU KNOW NOTHING

ABOUT

YET, REFUSE TO INVESTIGATE

Dr Wayne Dyer