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Checklist for geriatric dental anaesthesia

Anaesthesia for the geriatric dental patient - summary

This article summarises and combines "What should we consider when anaesthetising the geriatric patient" by Carl Brabrook and "What should we consider when anaesthetising patients, including geriatrics, for dental procedures?" into a single checklist on anaesthesia for the geriatric dental patient. 

A downloadable checklist for "Anaesthesia for the geriatric dental patient" may be found here

PHYSIOLOGICAL AND ANATOMICAL CONSIDERATIONS

Reduced muscle mass

• Reduced IM  injection sites & reduced maximum drug volumes/site
• Reduced protection for bony prominences
• Disrupted thermoregulation

Reduced body fat

• Increased risk of hypothermia (reduced insulation)
• Reduced protection for bony prominences

Reduced respiratory function

• Reduced lung elasticity, thoracic compliance & functional residual capacity

Reduced cardiac reserve

• Reduced cardiac output & vascular tone - reduced autoregulation and increased potential for hypotension

Altered hepatic & renal function

• Hypoproteinaemia and reduced drug binding
• Reduced metabolism & excretion of drugs – prolonged drug effects
• Reduced compensation for dehydration and haemorrhage.

Reduced CNS function

• Increased depressant effects of drugs, reduced MAC – potential for excessive anaesthetic depth & prolonged recoveries
• Depressed thermoregulation

Osteoarthritis

• Potential problematic IV access & endotracheal intubation (TMJ OA)
• Exacerbation of joint pain from inappropriate positioning

Increased stress and anxiety

Other co-morbidities

PRE-ANAESTHETIC ASSESSMENT

• Full history, signalment and clinical examination (including extent of dental disease & TMJ range of motion if possible)
• Blood analysis if dogs >7-8yo & cats >10yo
• If ASA III-V aim to stabilise prior to elective anaesthesia

SAFETY CHECKLISTS

• Focused approach based on the individual patient
• Reduce anaesthetic & procedure risk

PREMEDICATION

Drug selection

• Based on health of the individual
• Reduced doses?

Acepromazine

• Long duration may be further prolonged due to reduced hepatic metabolism
• Not antagonisable or analgesic
• Mild anti-emetic effect

Alpha-2 agonists

• Analgesia and sedation
• Suitable if no contraindications
• Reduce dose
• Antagonisable (also antagonises analgesia)

Opioids

• Full mu opioids preferable (can be “topped up”)

Benzodiazepines

• Not recommended for healthy patients (disinhibition)
• Respiratory depression reported with diazepam

Route

• IV preferable (reliable, maximal effect)
• IM may be painful (reduced muscle mass, comparatively large volumes, accidental periosteal trauma)

Considerations

• Allow time to achieve peak effect (including IV)
• Monitor temperature following premedication & minimise heat loss

PRE-OXYGENATION

• 3-5 minutes via tight fitting facemask increases desaturation time

INDUCTION

• Intravenously, slowly and to effect
• Avoid inhalation induction
• Alfaxalone has minimal cardiovascular and respiratory effects & is suitable for all ASA categories 

INTUBATION

• Mandatory for dental procedures
• SGADs not likely to create an adequate pharyngeal seal
• Pack pharynx & replace if saturated
• Careful patient repositioning to minimise pharyngeal/tracheal trauma

MAINTENANCE

• Volatile maintenance is superior to TIVA
• Monitor carefully and adjust vaporiser based on observation
• Multimodal anaesthesia to minimise vaporiser settings & reduce incidence of hypotension & respiratory depression

ANALGESIA

• Locoregional (dental) nerve blocks
• Opioids
• Low dose ketamine
• Lidocaine infusions (dogs only)

MONITORING

• Continuous
• Dedicated, suitably trained personnel
• Electronic monitoring to allow early detection of abnormalities
• Regular temperature monitoring - increased risk of hypothermia (open mouth, irrigation fluids, evaporation etc)

FLUID THERAPY

  • Balanced electrolytes e.g. Hartmanns unless otherwise indicated
  • Begin at approximately 3ml/kg/hour for healthy cats
  • Begin at approximately 4-5ml/kg/hour for healthy dogs
  • Careful monitoring especially for lung/heart disease patients

RECOVERY

• Remove all pharyngeal packing
• Check (& empty) bladder prior to recovery
• Continuous monitoring until extubated and can maintain sternal recumbency then:
• Regular until temperature >37oC and fully recovered
• Regular pain assessment and provision of analgesia
• Continue fluid therapy until fully recovered, eating and drinking
• Quiet environment
• Minimal stimulation
• Soft, comfortable bedding
• Considerate nursing (turning, urination, defaecation, human contact etc)

Article by
Dr. Karen Heskin
BVSc CertSAO MRCVS

Veterinary Technical Manager, Jurox UK

Originally published: Thursday, 15th August 2019

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