Anesthesia for Special Needs Patients
Anesthesiology is not only about selection of anesthetic drugs, but also involves patient care. Anesthesiology practitioners must consider a patient’s health conditions, anxiety level, environment and other factors when selecting the best anesthesia method for a procedure. A key example of the importance of quality patient care in anesthesiology is caring for patients with special needs. Given the anxiety and challenging behavior that a dental procedure can provoke, patients with special needs may require general anesthesia for a successful surgery.1 Additionally, techniques such as psychological intervention, physical support or protective stabilization may be indicated.2 In cases with special needs patients, the anesthesiology practitioner is responsible for performing a preoperative assessment, ensuring that the patient is aware of potential risks and obtaining informed consent for sedation.1 The anesthesia provider must also monitor patients closely to avoid complications in a procedure that might not usually necessitate general anesthesia.1
The first step of providing general anesthesia for a patient with special needs is defining the patient’s condition and performing a preoperative assessment. Dental patients with special needs include those with intellectual disability, dementia, physical limitations, movement disorders, behavioral or psychological disorders and chronic medical conditions.3 Though many of these patients can be treated with minimal accommodations that are within the scope of dentistry, some patients require care that is beyond routine, such as desensitization, anti-anxiety medications, therapeutic immobilization, sedation and general anesthesia.3 The complexity of these techniques may even indicate performance of the procedure in a hospital, rather than in a private setting.4 Also, for several of these processes, an anesthesia professional must be present, and a preoperative risk assessment is key. Given the absence of standardized preoperative assessment for patients with special needs, Prabhu et al. developed a tool to evaluate the suitability of general anesthesia for these patients.5 The tool included the American Society of Anesthesiologist’s (ASA) Physical Status Classification System and the Prognosis and Assessment of Risk Scale (PARS) to screen the patient’s health history.5 It also assessed the level of patient cooperation, type of procedure, type of anesthesia (route and locality) and best setting for the procedure.5 Despite some assessment difficulties that may arise due to lack of patient compliance, Prabhu et al.’s screening tool serves as a step towards appropriate preoperative evaluation of patients with special needs. In addition to using this tool, anesthesia providers may also need to do extensive research before a procedure and use a combination of treatments based on the patient’s needs and health conditions.2
If general anesthesia is deemed appropriate for the patient’s procedure, the anesthesiology practitioner must account for potential intra- and postoperative complications.1 After all, using general anesthesia means that patients are unconscious during treatment, and their protective reflexes and vital signs are depressed.3 According to a study of 202 patients with special needs by Boynes et al., there was a complication rate of 23.8 percent for all forms of sedation and anesthesia.6 Patients with cerebral palsy experienced the highest percentage of complications (44.4 percent), mostly associated with airway problems. Also, 30.4 percent of patients experiencing a complication had autism, 29.2 percent had Down syndrome, 25 percent had Alzheimer’s disease, 17.1 percent had other forms of intellectual disability and 14.3 percent had a behavioral disorder.6 According to a study by Caputo, 79 percent of patients with special needs had postoperative issues, such as vomiting, nausea, elevated temperature and decreased appetite.7 Overall, complication rates vary in patients with special needs depending on their conditions, and it remains unclear if patients with special needs are more affected by complications than patients without special needs.1
Preoperative assessment and prevention of complications are important roles of the anesthesia provider during a procedure for a patient with special needs. However, the data on general anesthesia in patients with special needs are limited.3 Future research should investigate if it is appropriate and safe for general anesthesia to become part of routine dental care for a patient with special needs.1 Additionally, reimbursement systems should aim to support all appropriate treatment options—including psychological support and behavioral therapies—to allow practitioners more flexibility in their recommendations of anesthetic techniques.2
1. Lim MAWT, Borromeo GL. The use of general anesthesia to facilitate dental treatment in adult patients with special needs. Journal of Dental Anesthesia and Pain Medicine. 2017;17(2):91–103.
2. Glassman P. A review of guidelines for sedation, anesthesia, and alternative interventions for people with special needs. Special Care in Dentistry. 2009;29(1):9–16.
3. Dougherty N. The dental patient with special needs: A review of indications for treatment under general anesthesia. Special Care in Dentistry. 2009;29(1):17–20.
4. Hulland S, Sigal MJ. Hospital-based dental care for persons with disabilities: A study of patient selection criteria. Special Care in Dentistry. 2000;20(4):131–138.
5. Prabhu NT, Nunn JH, Evans DJ, Girdler NM. Development of a screening tool to assess the suitability of people with a disability for oral care under sedation or general anesthesia. Special Care in Dentistry. 2008;28(4):145–158.
6. Boynes SG, Moore PA, Lewis CL, Zovko J, Close JM. Complications associated with anesthesia administration for dental treatment in a special needs clinic. Special Care in Dentistry. 2010;30(1):3–7.
7. Caputo AC. Providing deep sedation and general anesthesia for patients with special needs in the dental office-based setting. Special Care in Dentistry. 2009;29(1):26–30.