18 Surgery for the compromised patient
This chapter offers guidance and general principles for dealing with patients who are suffering from a disorder that might affect their treatment. It is not possible to deal with every situation or disease state. Drug interactions and adverse effects are not described in detail.
Patients presenting for treatment may be compromised in a variety of ways—financially, socially, psychologically or medically. An ability to identify patients who are disadvantaged is an important clinical skill. Observation of the patient when they are first seen, and an ability to ask appropriate questions during the interview, will provide most of the information required.
Important factors include the patient’s general appearance and demeanour, and whether they are accompanied when they attend the surgery. These factors become increasingly important when the patient is elderly.
During the history-taking procedure, in addition to the standard medical enquiries (see Ch. 2) it is important to explore the patient’s attitude to previous treatment, and their probable responses to planned treatment. It is also advisable to assess whether the patient is unusually anxious or shows evidence of any other departures from normal behaviour. Discussions regarding the patient’s social background should identify, particularly for older patients, whether they live alone or have family support.
When surgery is contemplated, it is in response to a patient’s clinical complaint. However, it is important to ensure that the problem is given appropriate priority within the patient’s general, social and health care, so that the treatment recommended is relevant and is seen by the patient to be acceptable and desirable.
For the compromised patient the likely outcome must be considered against the risks and consequences of the surgery’a treatment plan which may be routine and sensible for a healthy patient may need to be modified considerably when dealing with an elderly or sick patient.
Patients who are psychologically vulnerable and who may become confused when treatment is described to them should be encouraged to discuss the proposals with a family member or friend whilst in the surgery. It is often beneficial to arrange a second appointment specifically for this purpose. It is also important not to increase anxiety by emphasizing unlikely risks, particularly if the treatment proposed is essential. If the surgery is part of a longer-term treatment plan, then the patient’s ability to complete the whole course (physically and financially) must be confirmed.
A patient’s aftercare must also be taken into account. The recovery period will require an adjustment for the patient in terms of daily activities and diet, and support at home (from partner, relatives or friends) is an important factor. For patients who are unwell, the effects of their illness, including their medications, on wound healing and the prescription of drugs required to aid recovery are additional important factors to take into account.
When the history is documented, a detailed medical enquiry (often obtained initially from a questionnaire completed by the patient) will have identified whether the patient has had, or is suffering from, any significant disease. It is important to remember that even if the patient has been seen at the practice for many years, the history must be checked before arranging any surgery.
Patients may be suffering from diseases of which they are unaware and the surgeon must take into account the patient’s social status when interpreting the medical history; for example, an overweight, middle-aged man who consumes alcohol should be considered a possible risk for a degree of liver dysfunction. Also, with increasing age, patients may suffer from undiagnosed cardiovascular (cardiores-piratory) disorders such as hypertension and ischaemic heart disease.
As well as identifying the disease some attempt should be made to assess its severity. For example, the length of time the patient has suffered from the problem and the effect it has on their life and mobility are helpful measures. Direct enquiries about whether the patient has been hospitalized (and when and how often) and how the patient is managed (whether by their practitioner or with regular outpatient visits to a hospital specialist unit) will also assist.
The assessment scale first introduced by the American Society of Anesthesiologists (see Ch. 3) has provided a basis for similar classifications, such as scales for the severity of congestive heart failure or for severity of cardiopulmonary disease. This type of grading may be helpful in the assessment of a patient’s general medical status. A suggested system is given below.
In general terms, most dentoalveolar surgery could be provided in the practice environment, under local anaesthesia, using premedication or sedation when beneficial. It would be wise to be extremely cautious with some patients in this group if general anaesthesia is contemplated, e.g. elderly people or patients with suspected risk factors.
Most of these patients could be managed in the practice environment, given sensible responses to the medical history and medications required (e.g. antibiotic cover for valvular disease). In some patients (e.g. epileptic patients) the positive prescription of sedation would assist in management.
Simple surgical procedures could be undertaken in general practice for selected patients, but it would be wise for most patients to be managed in a hospital environment—even if the surgery is to be provided under local anaesthesia.