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Important reminders regarding anesthesia and elderly patients.
When giving injections to our patients there are several things we need to consider. Health history status, vital signs, patient’s anatomy, along with anesthetic selection and dosage to name a few. These factors are especially true when we work with pediatric and geriatric patients.
Lets look at a few of these key factors and how they relate to our geriatric population.
HEALTH HISTORY and VITALS:
Having thorough health history allows us to understand our patient’s capacity for receiving the anesthetic drugs we are about to administer. Remember, as we age our internal organs have reduced function. Plus, I believe it is safe to say, we've all had patients come into our office with a novella of medications. I am so thankful for the ability to search drug interactions online instead of the old fashioned 5 inch think reference book. Don't forget, many drugs impact the bodies ability to effectively metabolize anesthetic drugs. Some even have adverse side effects when combined with anesthetics. Plus we can't forget that if our patients are on blood thinners they are more likely to develop a hematoma after the injection. By the way, make sure to have a conversation with your patient regarding their INR levels and the possible complication of a hematoma.
We even need to look at the over the counter (OTC) medications too. For example, Tagamet (OTC medication for GI issues) and lidocaine don’t play nice with each other. If a patient takes this medication it can severely impact the bodies ability to process lidocaine, increasing the risk for a toxic reaction.
Articaine is one anesthetic we should highly consider for our elderly patients. It is metabolized in the blood stream by plasma cholinesterase. This means the liver and kidney are barely impacted by this drug. Plus, the amount of time for it to clear the body is the fastest of all the injectable anesthetics we use in dentistry (half-life 45 min).
Prilocaine is another option to consider. This anesthetic is more liver friendly, but it can put a strain on the kidneys since there is some drug breakdown happening there as well.
We also need to consider the patients cardiac condition. The health history discussion along with taking the vitals (especially BP, pulse, and respiration) we gain an understanding of how much vasoconstrictor our patients can tolerate.
According to the American Society of Anesthesiologists, patients with significant cardiovascular disease which classifies them as an ASA status of III or higher, must receive a lower dose of vasoconstrictor. If you need an anesthetic with a vasoconstrictor, some common choices are 4% Articaine with 1:200,000 epinephrine, 4% prilocaine with 1:200,000 epinephrine, and 2% mepivacaine with 1:20,000 levonordefrin.
PATIENT ANATOMY and SIZE:
When I think of our elderly patients and size considerations, I picture my great-grandmother. She was maybe five feet tall and 100 pounds. All I remember is I was about 11 years old when I was the same size as her. Or this one patient I used to care for. When I first began as his hygienist, he was 65 years old and very strong. He could build a fence faster than anyone I knew and did it all by hand. Fast forward 8 years and the inevitable happened. Time and disease caught up with him. He was now struggling with cardiovascular disease and looking at joint replacement.
As we age, not only does our physical stature begin to diminish but the function of our internal organs does as well. We need to consider this for our doses. There are some clinicians who tend to reduce the maximum dose for our medically compromised patients. Thinking , we should consider adopting the maximum recommended dose guidelines set for pediatric patients. This dramatically lowers the amounts recommended by the FDA and manufacture packaging. This may not be a bad idea, however there is minimal research to support it. Not only should we have a high understanding of our patient’s health status but their weight as well. No matter we should consider weighing your elderly patients prior to care. This assures we have the correct dosage requirements to meet their needs.
And finally….
How many times have you looked inside your patients mouth and the once beautifully plump and defined anatomy is now a thing of the past? Or due to trauma and disease the typical landmarks we use for guidance are now gone? This is when a review of the head and neck anatomical features is highly recommended. Taking a moment to refresh your memory of the neural and vascular pathways can help you visualize where the needle must travel.
Palpate the tissue of the area to be anesthetized. This will help you identify your needle pathway.
Also, due to general bone resorption anesthetic may penetrate the bone easier. This means infiltration techniques on the mandible my be more effective.
Some final thoughts to consider is to understand your patients mental capacity. If your patient suffers from cognitive and memory issues, such as Alzheimer's or Dementia, be sure to have a conversation with their caregiver. Patients with these diseases can easily have self-traumatic injuries post injections.
Of course, there are several other factors to evaluate and always exceptions to the rules. Use your best clinical judgement. If your patient has health issues you are unsure about the best advice is to connect with their primary care provider. This way both parties can be working towards the best interest of the patient.
CHEERS!
Tina
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