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  • Writer's pictureLouie Romanos

Careful patient selection and screening is imperative for safely performing office-based anesthesia


Business owners understand that being successful means maximizing resources.  This means getting the most out of the space that you are leasing in terms of income.  Office-based anesthesia is a by-product of this idea and is feasible under the right circumstances.


Undeniably, in addition to the benefits associated with sedation dentistry, there are also side-effects.  These include: a difficult airway, anaphylaxis, respiratory depression, apnea, acute cardiovascular emergencies, aspiration and malignant hyperthermia (Saxen et al., 2019).  Being aware of these ill-effects and creating/using a tool that identifies potential barriers to providing office-based anesthesia is critical for ensuring patient safety.


Determining a patient’s appropriateness for office-based anesthesia must take into account a careful perioperative assessment involving: Medical History and Physical Examination.

What needs to be remembered is that the focus of any inquiry should entail uncovering potential respiratory and cardiac risk factors that would make performing the procedure in an office-based setting unsafe.  The biggest setback for performing office-based sedation is that healthcare professionals do not have emergency response teams on-site and therefore; will need to rely on their own skills and that of their team for managing patient cardio-respiratory emergencies.  

Individual and team training, in specialized courses such as Pediatric Life Saving (PALS), teaches the skills needed to manage an airway or support blood pressure until advanced emergency systems arrive (Cote and Wilson, 2019).


Goals of the preoperative evaluation:

  • Documentation of the condition that requires surgery

  • Assessment of the pt.’s overall health status

  • Uncovering any hidden conditions that could cause problems both during and after the surgery

  • perioperative risk determination (ASA class)

  • Optimization of the patient’s medical condition in order to reduce the patient’s anesthetic perioperative morbidity or mortality

  • Development of an appropriate perioperative care plan


Zambouri, 2017

Medical History and Physical Examination.


The patient’s medical history should be comprehensive with the objective being to uncover as much information as possible. Past and current medical conditions, surgical history, allergies, familial history and review of body systems are essential for identifying anesthesia suitability and ensuring patient safety (Zambouri, 2017).  The infant/pediatric patient requiring sedation dentistry will also benefit from a review of their birth history.  Gestational age, perinatal complications, and the presence of perinatal disease are important pieces of information for assessing surgical risk (Zambouri, 2017).


Physical examination determines the patient’s baseline health status and suitability for the procedure.  Vital signs and a detailed cardio-respiratory assessment could uncover potential contraindications for performing office-based sedation (Zambouri, 2017). Abnormalities such as the inability to see the uvula when directing the patient to open their mouth could be an indication of a difficult airway.  Although this isn’t an absolute deterrent for office-based sedation, it does suggest that the airway be investigated in more detail and that an emergency plan focusing on airway management be created.




ASA Grading system

​Is an important component of the preoperative screening process and is deduced from the patient history and physical examination.  The ASA grading system was initialy created to describe the physical status of a patient (Zambouri, 2017).  Despite its’ simplicity, the ASA Grading system classifications correlate well with a patient’s risk for anesthesia and surgery (Zambour, 2017).

  • It is recommended to restrict out-patient based anesthesia for ASA 1 and ASA 2 patients, without airway anomalies or craniofacial malformations that could pose airway risks, without risks for aspiration, that are not at the extremes for age and size, and who present with upper-respiratory tract symptoms such as secretions (Saxen et al., 2019).





Office-based sedation is an effective business practice as it maximizes the amount of revenue generated from a leased unit.  Patient scheduling is easier by eliminating the yellow-tape associated with coordinating OR time.  It benefits the patient by eliminating parking fees and OR booking costs.  Without question, discretion with respects to patient selection must be used before proceeding with sedation dentistry.  Dental offices practicing office-based sedation must adhere to policies mandating a preoperative history and physical assessment and documenting a preanesthetic evaluation (Saxen et al., 2019).  This will increase the likelihood that the right patients are being selected for office-based procedures and reduce the chances for sedation related morbidity and mortality.


References:

1. Cote, C.J., Wilson, S. (2019).  Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics, 143(6):e20191000

2. Saxen, M.A., Tom, J.W., Mason, K.P. (2019).  Advancing the Safe Delivery of Office-Based Anesthesia and Sedation. Anesthesiology Clinics, (37), 338-348. https://doi.org/10.1016/j.anclin.2019.01.003

3. Zambouri, A. (2017). Preoperative evaluation and preparation for anesthesia and surgery, 11(1), 13-21.



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