Case Week 5 (w/c 31/10/11)
This week we return to the elective theatres. This is the kind of case that gets listed in most hospitals. However, don’t be surprised where the discussions will lead us.
The Community Dental Service have listed a 36 year old female for dental treatment, conservation and one extraction.
What are the indications for general anaesthesia?
No single tweet should cover this answer. I would really be interested to see whether any GPs and GDPs have an answer as they will often be asked the question long before the patient gets as far as the hospital to see an anaesthetist…….
You meet the dentist who has brought the medical notes for you to review. The 38 year old female has Down’s Syndrome. She has been reviewed in the dental surgery. The proposed surgery is the best plan possible although further treatment may be necessary once they have had a chance to carry out a more complete examination.
What will your proposed anaesthetic plan be? At this stage it is not necessary to consider cardiovascular complications of Down’s Syndrome.
50% of patients with Down’s Syndrome have congenital cardiac disease. The dentist has recorded a peripheral oxygen saturation of 78. The note from the General Medical Practitioner says that she had an uncorrected Ventricular Septal Defect but only takes 75mg Aspirin per day. She is not under Cardiology review.
What anaesthetic goals do you aspire to? What is the evidence?
Following discussion with the parents by anaesthetist and dentist as well as discussion within the team it is agreed that this a quality if life issue. She hasn’t been eating due to toothache.
A more detailed history shows that up to two months ago she was getting out of the house with her mother. Two courses of antibiotics have had temporary improvement in toothache but the tooth needs to come out. She attends a daycare centre where she has a little job in the shop.
The Dentist is fairly convinced the 6 will come out easily. The filling request can be considered as icing on the cake.
How will you proceed?
The initial Twitter feed discussed that the indications for General Anaesthesia GA for Dentistry relate to small children, learning disability and extreme dental phobia. Adults requiring GA for dentistry are relatively unusual and the majority of these patients have some form of learning disability and as such may also have some comorbidities which make anaesthesia more complicated.
In this case Downs Syndrome with Eisenmengers Syndrome as a result of reversed Right to Left Shunt provided an interesting discussion. Anaesthesia in these circumstance presents very high risk due to worsening shunt and hypoxia exacerbated by all of the normal effects of anaesthesia. High risk means there must be a significant benefit to proceeding. This is one of the actual indications that crops up most frequently.
Although case series and actual evidence are less than comprehensive there is general agreement that there is no such thing as a minor anaesthetic and invasive monitoring and a comprehensive anaesthetic plan is required. However, a lot depends on the possibility of minimising the surgical procedure and how easy it will be to achieve this monitoring. If the monitoring is more complex than the surgery some may find that it might be pragmatic to proceed with a minimalist approach. This is not a decision for the junior anaesthetist!
The full transcript will follow.
Thank you for taking part in Week 5 of #gasclass
Next week Case 6 (w/c 7/11/11)