Download Sedation For Medically

Sedation For
Medically-Compromised
Patients
Is ASA Grading Out-dated?
2016
Dr Yusof (Joe) Omar
MBBCh, DA, MRCA, PDD (Pain & Sedation)
Sedationist
Senior Teaching Fellow, Eastman CPD, UCL
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
Is there an Alternative to ASA
APACHE II
Acute Physiology and Chronic Health Evaluation II
It is a severity-of-disease classification
system (Knaus et al., 1985)
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:
[email protected]
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
Experience
of the
sedationist
Risk/
Safety
Nature &
duration
of the
treatment
Risk / Safety
Assessment
The fear
& anxiety
level
The age
& Fitness
of the Pt
The fear
&
Anxiety
Level
Nature &
Duration
of the
Treatment
Normal
Easy
Ext
0
Experience
of the
Sedationist
>10y
Exp
0
1
1
2
2
Grey-Area 3
3
4
4
5
Extremes
of Age
5
Safe
Unsafe
Phobic
Zygomatic
Implants
Beginner
The age
& fitness
of the Pt
Age:
• -Within the experience & comfort
zone of the sedationist
Normal
0
ASA1
1
Safe
2
ASA2
Grey-Area
ASA3
3
ASA4 4
Unsafe
5
Phobic
•
16-59y treat as adults
•
12-15 years:
•
5-12 years: Individual assessment
•
2-4 years: Is conscious sedation
0
3
35
really possible in a frightened child? 5
The age
& fitness
of the Pt
ASA 1
0
1
Safe
2
Grey-Area
3
Fitness: RISK ASSESSMENT
ASA 1= 0 ASA 4 =
5
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
1-5
fingerbreadths)
M=Mallampati (Mallampati score ≥3 )
O=Obstruction (presence of any condition that
could cause an obstructed airway)
N=Neck mobility (limited neck mobility).
4
Unsafe
5
ASA 4
0
1
2
4
The fear
&
anxiety
level
1
Phobics





Difficult venipuncture
They expect Oblivion
Increased movements
Increased Tremor
Increased likelihood of vagal
effects
 Undiagnosed problems
 Neglected OH
 Loose Teeth
Normal
0
1
Safe
2
3
4
Unsafe
5
Phobic
4
5
Nature &
duration
of the
treatment
0
Easy
Ext
1
Safe
2
Grey-Area 3
4
Unsafe
5
Zygomatic
Implants
Lowest Risk:
1
Short, dry, procedure
Anterior extractions
Endo with Rubber dam
Moderate Risk
Duration of 2 hours or more 2
Two-Quad Restoration
Scaling Sensitive Teeth without LA
High risk
Four Quad Surgery
Complex Surgery
Social reasons
Public Transport
Living alone
3
4
Experience
of the
Sedationist
Training
Formal Training PGCert or Grand-Father
Skill in
0
Venipuncture
Communication skills
In simple CBT
1
Safe
2
Grey-Area 3
Experience
Suggestions
<20 cases/year = score 5
20-50 cases/y – score 4
50-100 cases/year = score 3
4
Unsafe
5
Up-to-Date: minimum ADA or SAAD
annually
Experience
of the
sedationist
0
1
Safe
2
Grey-Area 3
4
Unsafe
5
Training
No Training
Anaesth Training
Skill
4
0
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
Score
High Score and High Risk
6
0
Low Score and Safety
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
5
Total Score = 30
Age
x
4y old
Fitness
x
Asthma
Fear Level
x
Crying
0
Nature of
procedure
Duration of
procedure
Training of
sedationist
Experience
of
sedationist
1
2
3
4
x
? Difficult
x
?
x
Week-end
Course
x
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
Critical of the standard of
care provided in:
1996-1999 eight deaths
Of which five were
children.
•
•
•
•
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