Preoperative Health Status

Preoperative Health Status 

BOX 1-20
Management of Patient with Adrenal Suppression.Who Requires Major Oral Surgery*

If patient is currently on corticosteroids:
1. Use anxiety reduction protocol.
2. Monitor pulse and blood pressure before, during,
and after surgery.
3. Instruct patient to double usual daily dose on the day
before, day of, and day after surgery. .
4.0n second postsurgical day, advise the patient to
return to a usual steroid dose. . •
If the patient is not currently on steroids, but has
received at least 20 mg of hydrocortisone (cortisol or
equivalent) for more than 2 weeks within past year:
1. Use anxiety reduction protocol.
2. Monitor pulse and blood pressure before, during,
and after surgery .
‘3. Instruct the patient to take 60 mg of hydrocortisone
(or equivalent) the day before and the morning of
surgery (or the dentist should administer 60 mg of
hydrocortisone or equivalent intramuscularly or intravenously
before complex surgery). ‘
4. On the first 2 postsurgical days, the dose’ should be
dropped to 40 mg a’nd.dropped to 20 mg for 3 days
‘thereafter. The clinician can cease administration of
supplemental steroids 6 days after -surgery.

-If a major surgical procedure ~ planned, the clinician should strongly consider hospitalizing the patient. The clinician should consult the patient’s physician if any questions arise concerning the need for or the dose of supplemental corticosteroids.

Thyrotoxic patients are usually treated with agents that block thyroid hormone synthesis and release, with a thyroidectomy, or both, However, patients left untreated or incompletely treated can develop a thyrotoxic crisis, caused by the sudden release of large quantities of preformed thyroid hormones. Early symptoms of a thyrotoxic
crisis include restlessness, nausea” and abdominal cramps. Later symptoms are a high fever, diaphoresis, tachycardia, and, eventually,cardiac decompensation, ‘The patient becomes stuporous and hypotensive, with
death resulting if no intervention occurs.

The dentist may be able to diagnose previously  recognized hyperthyroidism by taking a complete medical history and performing a careful examination of the patient, including thyroid inspection and palpation, If severe hyperthyroidism is suspected from the history and inspection, the gland should not be palpated because that manipulation alone can trigger a crisis. Patients suspected of being hyperthyroid should be referred for medical evaluation before oral  surgery.

Patients with treated thyroid disease can safely undergo ambulatory oral surgery. However, if a patient is found to, have an oral infection, the primary care physician should be notified, particularly if the patient shows signs of hyperthyroidism. Atropine and excessive amounts of eplnephrlne-contatning solutions should be avoided if a patient is thought to have incompletely treated hyperthyroidism (Box 1-21).

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