preoperative assessment and medical managment in maxillofacial surgery.pptx

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1. JIMMA UNIVERSITY INSTITUTE OF HEALTH FACULTY OF HEALTH SCIENCES SCHOOL OF DENTISTRY 4/25/2024 1

2. MEDICAL MANAGEMENT AND PREOPERATIVE PATIENT ASSESSMENT BY- D R.GENENE GETACHEW(DENTAL INTERN) MODERATOR- DR. ALEMU(OMFSRII) @Jimma university, Ethiopia April 25,2024 4/25/2024 2

3. Seminar Outlines Introduction Components of preoperative patient assessment Cardiovascular assessment and disease Respiratory disease Renal disease Liver disease Blood disorders Endocrine disorders Pregnancy 4/25/2024 3

4. Introduction The preoperative assessment involves an overall analysis of the patient’s condition and preparation of the patient for the proposed procedure. The ultimate goal of the preoperative evaluation is: to identify medical concerns to plan the most effective perioperative treatment algorithm that minimizes patient morbidity. 4/25/2024 4

5. Components of preoperative assessment History physical examination Review of systems Laboratory tests Imaging consultations interventions 4/25/2024 5

6. History and Physical Examination A complete history and physical examination is the practitioner’s opportunity to identify abnormalities. history consists of: medical, surgical, and anesthetic history patient’s medications previous or current tobacco, alcohol, or illegal drug abuse with screening for pertinent 4/25/2024 6

7. Cont … Review of systems The medical review of systems is a sequential, comprehensive method of eliciting patient symptoms on an organ-by-organ basis. physical examination includes vital signs, examination of head and neck, airway, cardiac, pulmonary, and gastrointestinal, with expansion to other systems if relevant from history . Information gained from the history and physical should be used to generate a perioperative, surgical, and anesthetic plan for the patient. 4/25/2024 7

8. Laboratory investigations Complete blood count (CBC ) RBC: Females : 4.5 to 5.5 million cells per cu mm Males : 4.5 to 6.2 million cells per cu mm WBC: adults: 5000 to 10000 cells per cu mm 4/25/2024 8

9. Cont.. Differential of white blood cell count Neutrophils: 50 to 70 percent Lymphocytes: 25 to 40 percent Monocytes: 3 to 8 percent Eosinophils : 1 to 8 percent Basophils: 0 to 1 percent Platelet : 1,50000 to 400000 cells per cu mm 4/25/2024 9

10. Cont.. ESR Normal value: Females : 0 to 20 mm/hour Males : 0 to 10 mm/hour Coagulation tests Bleeding time: About 3 to 5 minutes Clotting time: About 4 to 10 minutes Prothrombin time: Usually 12 to 14 seconds. Partial thromboplastin time: Usually 25 to 45 seconds 4/25/2024 10

11. Biochemical analysis Renal Function Tests BUN : 10 to 20 mg/100 ml Serum creatinine : 0.7 to 1.4 mg/100 ml Serum Electrolytes Sodium : 135 to 145 mEq /L Potassium : 3.2 to 5.5 mEq /L Chloride : 95 to 105 mEq /L 4/25/2024 11

12. Liver Function Tests Alkaline phosphatase: 1.5 to 4.5 Bodansky Units Serum albumin : 3.5 to 5.0 gm /100 ml Serum bilirubin : Total bilirubin less than 0.8 mg/100 ml Direct bilirubin less than 0.5 mg/100 ml Indirect bilirubin less than 0.3 mg/100 ml 4/25/2024 12

13. Preoperative risk assessment Requires an understanding of the surgical stress and the patient’s medical condition. American Society of Anesthesiologists ( ASA) functional status 4/25/2024 13

14. Cont … 4/25/2024 14

15. Duke activity status index 4/25/2024 15

16. Cardiovascular Assessment and Disease Cardiovascular disease is a heterogeneous group of diseases that correlate with perioperative risk . (ACC/AHA) recommendation on evaluation of cardiac patients undergoing non-cardiac surgery . Major clinical predictors of risk includes acute coronary syndromes, decompensated congestive heart failure (CHF), significant arrhythmias, and severe valvular disease. Intermediate clinical predictors includes mild angina, prior ( MI), compensated CHF, and ( DM). Minor predictors includes advanced age, abnormal electrocardiogram (ECG ), low functional capacity, hx of CVA, and uncontrolled HTN. 4/25/2024 16

17. RCRI 4/25/2024 17

18. Coronary Artery Disease CAD  stable angina or acute coronary syndromes. Patients with acute coronary syndromes should not undergo non-cardiac surgery. Tests to consider include: Chest radiograph ECG Transthoracic Doppler echocardiography The initial treatment for suspected ACS or MI has traditionally been morphine, oxygen, nitrates, and aspirin (MONA). 4/25/2024 18

19. Cont.. The advent of anti-platelet drugs, fbrinolytics , and percutaneous coronary angioplasty (PCA) has reduced the mortality from MI to 3 %. beta blockers dual anti-platelet therapy (DAPT ) This typically involves the use of aspirin and a glycoprotein IIb / IIIa inhibitor. 4/25/2024 19

20. Congestive Heart Failure CHF is a result of inadequate cardiac output. Compensated CHF is considered an intermediate clinical predictor. decompensated CHF is considered a major clinical predictor and a contraindication to elective surgery. The diagnosis is best made with a transthoracic echocardiogram. PA and lateral chest radiography will often reveal cardiomegaly and may show pulmonary edema and plural effusions if decompensated. 4/25/2024 20

21. Cont … 4/25/2024 21

22. Cont … Treatment is primarily aimed at reducing afterload and increasing the cardiac contractility. Treatment may include: (ACEI; e.g., captopril, lisinopril , ramipril ) Diuretic (e.g., furosemide or hydrochlorothiazide) Beta blocker ( metoprolol or carvedilol ) Digoxin 4/25/2024 22

23. HYPERTENSION defined as a systolic blood pressure in excess of 140  mmHg or a diastolic blood pressure in excess of 90  mmHg measured on two separate occasions. Essential vs secondary HTN Most HTN is essential hypertension. Hypertensive urgency  Hypertensive emergency Elective surgery should be postponed for hypertensive urgency and emergency. 4/25/2024 23

24. Investigations Chest radiograph- posteroanterior view for detecting cardiac enlargement ECG Ophthalmic evaluation for papilledema and retinal hemorrhage Renal function tests (blood urea nitrogen, serum creatinine and serum electrolyte). 4/25/2024 24

25. Preoperative Medication and Management Recent guidelines from the Joint National Committee (JNC8) recommend initiating HTN treatment for: > 60  years when  SBP >150  mmHg or DBP >90   mmHg. < 60 years and those with chronic kidney disease or diabetes mellitus should begin when SBP >140 mmHg or DBP >90  mmHg . The morning dose of medication prior to surgery must be given with sips of water . Medications hydrochlorothiazide . metoprolol ACEI (captopril) Angiotensin- receptor blockers and calcium channel blockers 4/25/2024 25

26. RESPIRATORY DISEASES Complete history and physical examination to identify respiratory disease. The functional status of the patient. Smoking tobacco should always be considered in all patients because postoperative respiratory complications are more common in smokers. The risk declines by 50% after only 8  weeks of smoking cessation. results in elevated levels of carboxyhemoglobin . 4/25/2024 26

27. Cont … Pulmonary function testing (PFT) is the gold standard in evaluating pulmonary function . It measures lung volumes and lung dynamics The forced expiratory volume in 1 s (FEV1 ) and its relationship to the forced vital capacity (FVC) are particularly useful to quantitate disease severity and stratify patients. The net result of most respiratory diseases is hypoxemia. 4/25/2024 27

28. Cont … Treatment administration of oxygen to increase the fractional concentration of inspired oxygen (FiO2 ). Nasal cannula (1 L/min increases the FiO2 by 4% to a maximum of 40% at 6 L/min) Rebreathing facemask (increases the FiO2 to 60% at 10 L/min) Non-rebreathing facemask (increases the FiO2 to 90% at 10 L/min ) CPAP/ BiPAP (continuous positive airway pressure/ bilevel positive airway pressure) with positive pressure (increases the FiO2 to 80%) Intubate/tracheostomy (increases the FiO2 to 100%) 4/25/2024 28

29. AIRWAY A preoperative assessment of the airway is mandatory. Complications related to establishing an airway and maintaining ventilation continue to be a source of significant patient morbidity and mortality. Obese , pregnancy, Pierre Robin, oropharyngeal infections, tumors and temporomandibular joint ankylosis The difficulty of direct laryngoscopy and intubation correlates with advancing Mallampati class. 4/25/2024 29

30. 4/25/2024 30

31. ASTHMA is bronchial hyper-responsiveness and reversible bronchoconstriction due to smooth muscle contraction leading to reduced ventilation and hypoxemia. probably ASA class III patients history of asthma PFT that indicates a reduction in FEV1 , normal vital capacity, reduced FEV1 /FVC (proportional to severity), and an increase in FEV1 by 10% with bronchodilator treatment. A decline in the peak flow rate to less than 80% of baseline would suggest exacerbation, and elective surgery should be postponed until the patient can be stabilized and optimized. 4/25/2024 31

32. Management of asthma Short-acting beta agonist (SABA) such as albuterol Inhaled corticosteroids such as futicasone Anticholinergic medications such as ipratropium or tiotropium Long-acting beta agonists (LABAs) such as salmeterol or formoterol Leukotriene receptor antagonists such as montelukast and zafirlukast Cromolyn Theophylline 4/25/2024 32

33. CHRONIC OBSTRUCTIVE PULMONARY DISEASE Emphysema and chronic bronchitis. History, PFTs ,   ABGs- The chest x-ray reveals a loss of lung markings, hyper-inflation and a flattened diaphragm . Elective surgery in the face of a COPD exacerbation or a URI is contraindicated. Smoking cessation should occur longer than 8  weeks before the planned surgical procedure. 4/25/2024 33

34. PNEUMONIA Nosocomial pneumonia may occur in the postoperative period. ventilator associated pneumonia influenced by the use of perioperative antibiotics, the placement of nasogastric feeding tubes, and the propensity for aspiration . The net result is hypoxemia and sepsis.  chest x-ray or computed tomography (CT) scan The treatment of pneumonia includes the use of parenteral antibiotics. 4/25/2024 34

35. PULMONARY EMBOLUS More than 95% of PEs are from the deep veins of the legs. Most emboli are clinically silent owing to their small size. Prevention with sequential calf compressors, thromboembolic deterrent stockings, and perioperative UFH or LMWH is important. The treatment of PE may include an initial heparin bolus followed by a heparin drip and warfarin with a goal INR of 2.5–3. Massive PE leading to right ventricular strain may require chemical thrombolysis or surgical thrombectomy . 4/25/2024 35

36. RENAL DISEASE Renal disease and renal failure correlate directly with surgical morbidity and mortality. The normal glomerular fltration rate (GFR) is approximately 120 mL/min . azotemia and uremia. Renal disease also results in extrarenal disease including bone marrow suppression, thrombasthenia , pericardial effusion, and immunosuppression 4/25/2024 36

37. Cont … Basic assessment urine output, serum creatinine , serum electrolytes, bicarbonate, and hematocrit . Serum creatinine and urea provide indirect evidence of renal function . 4/25/2024 37

38. Perioperative management should focus on volume status because patients may become fluid overloaded quickly. The use of intravenous fluid replacement should be done conservatively and without the addition of potassium . Clinically significant anemia should be managed acutely with packed cells. erythropoietin subcutaneously or intravenously. Long-term iron supplementation is also appropriate. Dialysis 4/25/2024 38

39. LIVER DISEASE Screening for hepatic disease includes a review of risk factors for hepatic disease such as history of intravenous drug use, chronic alcohol intake, blood transfusions, and family history of jaundice or hepatic disease . Signs and symptoms concerning for hepatic disease include spider angiomas , telangiectasia, gynecomastia , ascites, pruritus, fatigue, and testicular atrophy in males . Patients with liver disease should be assessed for the presence of jaundice, coagulopathy, electrolyte disturbances, renal dysfunction, thrombocytopenia, ascites, and encephalopathy. 4/25/2024 39

40. Surgical risk can be estimated through the ChildTurcotte -Pugh classification or the Model for End Stage Liver Disease (MELD) score. 4/25/2024 40

41. ENDOCRINOLOGY Diabetes Mellitus DM is characterized by autoimmune destruction of the pancreatic islet cells or the development of insulin resistance . The American Association of Endocrinologists define diabetes at a fasting blood glucose (BG) >126 mg/ dL or HgA1c >5.7 %. Infections , illnesses, and surgical procedures can alter carbohydrate metabolism and present a risk for the diabetic patient. 4/25/2024 41

42. Cont … Signs and symptoms of DM polyphagia , polydipsia, polyuria, acanthosis nigricans , peripheral skin pigmentation/ulcers, peripheral neuropathy, decreased visual acuity, nonketotic hyperosmolar coma, diabetic ketoacidosis (DKA), altered mental status, and electrolyte abnormalities. 4/25/2024 42

43. D iagnosis of DM A random blood glucose above 200 mg/ dL is suggestive of DM.  A fasting blood glucose between 100 and 125 mg/ dL is considered to represent a prediabetic state . A fasting blood glucose above 126 mg/ dL is diagnostic of DM . oral glucose tolerance test ingestion of 75 mg of glucose after an 8-h fast. A post blood glucose is then measured at 2  h with a blood glucose level of 140–199  mg/ dL considered to represent impaired glucose tolerance and a blood glucose of greater than 200 mg/ dL diagnostic of DM. 4/25/2024 43

44. Cont … hemoglobin A1c (HbA1c). Help to estimate glucose control in the preoperative period measures the amount of glycosylated hemoglobin over the prior 3 months, which reflects the average glucose level over that time. It is an independent predictor of morbidity . HbA1c  ≥ 8% suggests poor preoperative glucose control and the patient will likely benefit from delaying elective surgical procedures until the HbA1c can be reduced. 4/25/2024 44

45. Cont … Preoperative management The general goal is to maintaining the blood glucose between 80 and 140 mg/ dL .  Adjustments to a patient’s insulin and/or oral hypoglycemic medications will need to be made and depend on the what type of insulin or oral hypoglycemic the patient is taking 4/25/2024 45

46. Surgery in diabetic patients not treated with insulin For all surgery : Hold any oral agents on the day of surgery. For “fair” metabolic control (FBG < 180 mg/ dL ), cover with regular or rapid-acting insulin such as lispro , aspart , glulisine as needed using the sliding scale. For “ poor” metabolic control (fasting blood glucose > 180 mg/ dL ), start continuous insulin infusion (CII ) 4/25/2024 46

47. Surgery in diabetic patients treated with insulin For minor surgery : Hold any oral agents (if treated with combination therapy) on the day of surgery. For “ fair” metabolic control, hold the short acting insulin and give half the dose of intermediate-acting insulin (neutral protamine Hagedorn [NPH]) the morning of surgery. While NPO, infuse 5% dextrose in normal saline (D5 NS) plus KCl (10–20 mEq /L) at 100 mL/hr. Patients treated with basal ( glargine ) insulin should receive their usual basal insulin dose. Similarly , patients treated with CII therapy (insulin pump) should receive their usual basal infusion rate. Restart preadmission insulin therapy once food intake is tolerated. For patients with “poor” metabolic control (fasting blood glucose > 180 mg/ dL ), start CII because the use of SSI is unlikely to obtain adequate blood glucose control . 4/25/2024 47

48. Cont … For major surgery: Hold any oral agents on the day of surgery. Start insulin infusion before surgery and continue during the perioperative period because the use of SSI is unlikely to obtain adequate blood glucose control. 4/25/2024 48

49. Thyroid Surgical patients may present with a history of hypothyroidism or hyperthyroidism. Hypothyroidism is typically characterized by the progressive destruction of thyroid tissue . It occurs in Hashimoto’s thyroiditis in which an autoimmune lymphocytic infltrate develops with antithyroid peroxidase antibodies. The diagnosis is usually established by observing a decreased free thyroxin (T4 ) and elevated thyroid-stimulating hormone (TSH) level. 4/25/2024 49

50. Cont … Hyperthyroidism is most often due to Graves’ disease, an autoimmune disease characterized by the presence of thyroid-stimulating antibodies. Treatment hypothyroidism levothyroxine . immediate intravenous levothyroxine and corticosteroids. Hyperthyroidism radioactive iodine or thyroidectomy beta blockers and either propylthiouracil (PTU) or methimazole 4/25/2024 50

51. HEMATOLOGY Initial hematologic assessment relies on the history and physical examination. laboratory tests Anemia is an absolute or relative reduction in the hemoglobin concentration or hematocrit. The history and physical exam may reveal symptoms such as malaise, dyspnea, palpitation, pallor, and cyanosis. The net result is hypoxemia due to a lack of oxygen-carrying capacity. Anemia may be due to a decrease in RBC production or an increase in RBC destruction. 4/25/2024 51

52. Cont … Microcytic anemia is defined by an MCV less than 80  fL and may be the result of iron deficiency , thalassemia, sideroblastic anemia, or sickle cell disease. Normocytic anemia is defined by an MCV of 80–100  fL and may be the result of renal failure, chronic disease, or aplastic anemia. Macrocytic anemia is defined by an MCV greater than 100  fL and is most often due to vitamin B12 or folic acid deficiency 4/25/2024 52

53. Cont … The general workup of the anemic patient CBC , peripheral smear MCV, and reticulocyte count Additional tests serum iron, ferritin, TIBC, vitamin B12, folate , Coombs’ test (direct and indirect), methylmalonic acid, homocysteine , and a bone marrow biopsy. Iron-deficiency anemia may be treated with iron supplements, whereas megaloblastic anemias should be treated with vitamin B12 or folate depending on the deficiency . Dietary change should also be instigated in all cases except pernicious anemia because a lack of intrinsic factor renders dietary vitamin B12 ineffective. 4/25/2024 53

54. Leukemia malignant diseases of lymphocytes or myeloid cells. The leukemias are classified according to cell type: acute lymphoblastic leukemia , acute myelogenous leukemia, chronic myelogenous leukemia, and chronic lymphocytic leukemia . The medical management of leukemia causes further immunocompromise , increasing patient morbidity. 4/25/2024 54

55. Thrombocytopenia is a quantitative platelet disorder, where there is increased platelet destruction, decreased platelet production, or abnormal distribution and/or increased sequestration. results in bleeding episodes that occur spontaneously or with minimal trauma when the platelet count falls below 50,000 cells/mm3. All patients with thrombocytopenia should be optimized before any surgical procedure. Patients with DIC should not be considered surgical candidates. This patient can be treated preoperatively with corticosteroids, immunoglobulin, or platelet transfusions. 4/25/2024 55

56. Cont … Platelet transfusion should be considered when platelet count is less than 50,000 / μL or higher if significant blood loss is expected. A single platelet concentrate usually yields an incremental rise in platelet levels of 10,000/ μL /m2. In general, a patient with a platelet count of 60,000 to 100,000/ μL or greater can tolerate most routine operations. 4/25/2024 56

57. Coagulation Disorders Hemophilia The most commonly inherited clotting factor defect is hemophilia A (factor VIII deficiency). Hemophilia B (factor IX deficiency ) Hemophilia A and B patients typically have an increased activated partial thromboplastin time ( aPTT ) and a normal PT. The severity of hemophilia A corresponds to the levels of factor VIII. Those with mild hemophilia A can at times be successfully treated with deamino -d-arginine vasopressin (DDAVP), which increases the level of circulating factor VIII. Those with more severe disease require supplementation with factor VIII . 4/25/2024 57

58. Cont … Von Willebrand Disease Von Willebrand factor is the carrier protein for factor VIII and, when activated, binds platelets to exposed collagen. The most common type and mildest form of von Willebrand disease, type 1, is a partial quantitative deficit of vWF . Preoperative management of von Willebrand includes DDAVP or vWF / factor VIII concentrate. 4/25/2024 58

59. Pregnancy Pregnancy results in many maternal physiologic changes. Anemia compression of the inferior vena cava , Being in supine position, reduces cardiac filling with a reduction in cardiac output and blood pressure. lateral decubitus position delayed gastric emptying and increased gastroesophageal refux disease. increased potential for aspiration. 4/25/2024 59

60. Cont … Preeclampsia is characterized by HTN, proteinuria, headache, and edema. The onset of tonic- clonic seizures heralds eclampsia . Any drug administered to the mother should be considered capable of crossing the placenta and entering the fetal circulation. 4/25/2024 60

61. References 4/25/2024 61

62. THANK YOU! 4/25/2024 62