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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 3  |  Page : 163-169

Knowledge and awareness about preanesthetic evaluation for performing procedures under general anesthesia among dental students - A cross-sectional study


1 Department of Paediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Public Health Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Submission10-May-2022
Date of Acceptance18-Jul-2022
Date of Web Publication18-Sep-2022

Correspondence Address:
Dr. Kanamarlapudi Venkata Saikiran
Department of Paediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpdtsm.jpdtsm_41_22

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  Abstract 


BACKGROUND: Lack of knowledge on preanesthetic evaluation before any general anesthesia (GA) procedures will lead to uncertainty in the outcome of the surgery. Hence, the present study aimed to evaluate the knowledge and awareness about preanesthetic evaluation for performing procedures under GA among dental graduates.
METHODS: A 13-item questionnaire was prepared from the standardized method using focus group discussion. The questionnaires were sent to 1020 students (508 house surgeons, 512 postgraduates) through the registered E-mail address and WhatsApp as a Google form link. We received 246 responses at the end of 2 weeks, and finally, 509 responses were received at the end of 4 weeks. The data from the responses were collected, and descriptive analysis was done using a Microsoft Excel sheet (Version 2016). A Chi-square test was performed to compare the responses from house surgeons and postgraduates.
RESULTS: A total of 523 responses out of 1020 were received within a period of 4 weeks. From this, 14 responses were excluded from the final analysis due to repeated responses and the final analysis was done using 509 responses (270 postgraduates [53%] and 239 house surgeons [47%]). More than half of the participants had insufficient knowledge regarding preanesthetic evaluation.
CONCLUSION: The knowledge and awareness were good among the dental postgraduate students compared to house surgeons but implementing that in practice was relatively negligible. Therefore, understanding the importance of preanesthetic evaluation can help the students to reduce potential risk and improves the quality of life among the patients.

Keywords: Dental students, general anesthesia, preanesthetic evaluation


How to cite this article:
Kavitha P, Saikiran KV, Elicherla SR, Anchala K, Prasanth PS, Nuvvula S. Knowledge and awareness about preanesthetic evaluation for performing procedures under general anesthesia among dental students - A cross-sectional study. J Prev Diagn Treat Strategies Med 2022;1:163-9

How to cite this URL:
Kavitha P, Saikiran KV, Elicherla SR, Anchala K, Prasanth PS, Nuvvula S. Knowledge and awareness about preanesthetic evaluation for performing procedures under general anesthesia among dental students - A cross-sectional study. J Prev Diagn Treat Strategies Med [serial online] 2022 [cited 2022 Oct 1];1:163-9. Available from: http://www.jpdtsm.com/text.asp?2022/1/3/163/356289




  Introduction Top


Preanesthetic evaluation is defined as the process of clinical assessment that precedes the delivery of anesthesia care for surgery and nonsurgical procedures.[1] Performing elective procedures under general anesthesia (GA) is considered an essential aspect of patient care. This preanesthetic procedure involves taking a medical history and performing a thorough physical examination and laboratory tests.[2] A preanesthetic evaluation aims to identify clinical factors that may complicate a patient's intraoperative clinical course and optimize the individual before surgery to reduce the potential risk and improve treatment outcomes and quality.[3]

Children and adults have different preoperative anesthesia approaches. Children's anesthetic management differs from that of adults. These variations include using cognitive and age-appropriate language and determining a child's developmental stage.[4]

In dentistry, GA is indicated for significant surgical procedures, where local anesthesia is ineffective due to acute infection, anatomic variation or allergy, or for patients needing immediate comprehensive care.[5] Furthermore, the decision should be made based on the patients' age, level of cooperation, and dental and medical histories.[6],[7] Whereas GA should only be considered in children after other behavioral interventions have been attempted and found unsatisfactory or unsuccessful, alternative treatment modalities are not always specified.[8],[9],[10]

However, many practitioners are unaware of the importance of preanesthetic evaluation, which may result in poor patient optimization before surgery. Lack of knowledge and perception regarding preanaesthetic evaluation before any elective surgical procedures will lead to compromised patient care, uncertainty in the outcome of the surgery, and increased preoperative rates of morbidity and mortality.[11] Therefore, the present study is intended to assess the knowledge and awareness about preanesthetic evaluation for performing procedures under GA among dental graduates.


  Methods Top


This online cross-sectional study was conducted using Google forms, based on Strengthening the Reports of Observational studies in Epidemiology guidelines between November 2021 and January 2022. A detailed patient information sheet about the nature and purpose of the study were also attached to the questionnaire. A pilot study was conducted among 30 students to estimate the sample size. Based on the prevalence of knowledge obtained, the estimated sample size was 468 with an alpha error of 5% and a power set at 90%. The results from the pilot study were not included in the final analysis.

The questionnaire used in the study was developed by a standardized method under the following phases: (a) formation of a conceptual framework, (b) systematic development of questions, c) refinement of the questions by focus group discussion, (d) pretesting, and (e) validity.

A conceptual framework includes the key components that describe and define preanesthetic evaluation. After that, an initial pool of questions was generated for each component by multiple strategies. Questions were written as whole sentences, avoiding double negatives, two-edged questions, slang and abbreviations. Later, questions in all the components were subjected to a thorough refinement process using focus group discussion between the researcher and participant. The researcher evaluated the questions regarding any confusion, deception or unfamiliarity with the terms. The responses from the participants were analyzed, and necessary changes were made to the wordings and terminology. The questionnaire was tested among 30 participants (15 house surgeons and 15 postgraduates) to identify any difficulties in understanding the questionnaire and increasing data accuracy. Data were collected from the participants through a face-to-face interview. The suggestions and opinions of the participants in terms of understanding the wordings and adequacy of questions were noted. After that, subject experts, including pediatric dentists, anesthesiologists, oral and maxilla facial surgeons, and paediatricians independently reviewed the questionnaire. The team verified whether the question reflected what they intended to ask and evaluated the response options and their feasibility. Each expert rated each question as appropriate, inappropriate or needs modification. Any remarks or recommendations for each item were also recorded. Finally, the questionnaire consisting of 13 questions was created by considering all the relevant changes the subject experts and the participants provided (Annexure).

The prepared questionnaire was designed in Google forms, and a link was created. This link was sent through E-mail, WhatsApp, and all accessible WhatsApp groups to all the house surgeons and postgraduate students. The questionnaire was sent to 1020 students (508 house surgeons, 512 postgraduates), and a reminder was sent every week. We received 246 responses at the end of 2 weeks, and finally, 509 responses were received at the end of 4 weeks. Care was taken to avoid the repetition of responses from all the participants. If more than one response was received from the same E-mail address, the first response from the E-mail address was included, and the second response was excluded from the analysis. The collected responses from all the participants were entered in the Microsoft Excel spreadsheet 2016. The statistical analysis was performed using the SPSS 17.0 software version for windows (Chicago, IL, USA). A Chi-square test was performed to compare the responses from house surgeons and postgraduates. The level of significance was set as 0.05.


  Results Top


A total of 523 responses out of 1020 were received within a period of 4 weeks. From this, 14 responses were excluded from the final analysis due to repeated responses and the final analysis was done using 509 responses (270 postgraduates [53%] and 239 house surgeons [47%]). The distribution of the study participants is represented in [Table 1]. Thirteen questions were asked to assess participants' knowledge regarding preanesthetic evaluation in dentistry [Table 2]. The majority (238, 88.1%) of them postgraduates and house surgeons (190, 79.5%) were aware of preanesthetic evaluation for performing dental procedures under GA. However, the results were statistically significant, with a P = 0.02. On being asked what they had thought the reason behind doing preanesthetic evaluation; 87% of postgraduates and 78.7% of house surgeons answered for anticipation of possible complications perioperative, whereas 7.4% of postgraduates and 5% of house surgeons answered the reason could be to comply with surgeons instructions. An almost equal percentage of professionals, 2.5%, stated that preanesthetic evaluation should be done to get surgery. Only 3% of postgraduates and 13.8% of house surgeons did not know why the preanesthetic evaluation results were statistically significant, with a P < 0.001.
Table 1: Distribution of study population based on their education

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Table 2: Comparison of knowledge and awareness regarding preanaesthetic procedures among the study population based on their education

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In reply to, what will be done during the preanesthesia check-up, 56.7% of postgraduates and 8.4% of house surgeons answered it as assessment and optimization of potential risks before surgery. In comparison, 22.6% of postgraduates and 4.2% of house surgeons answered it as a general patient assessment before anesthesia. Whereas 13.7% of postgraduates and 1.7% of house surgeons answered preanesthesia checkups as some kind of test to be performed to assess anesthesia fitness, the results were statistically significant with a P < 0.001.

Similarly, a statistically significant difference was seen for the question of who will perform the preanesthetic evaluation. 70.7% of postgraduates and 64.4% of house surgeons knew that only anesthesiologists could perform preanesthesia check-ups. In comparison, 19.6% of postgraduates and 10% of house surgeons stated that general physicians could perform anaesthetic evaluation, whereas 9.3% of postgraduates and 15.1% of house surgeons reported that dentists could perform the preanesthetic evaluation.

For the question, if they are aware of co-morbid conditions that have to be evaluated before inducing GA, most of them (84.8% of postgraduates and 77.8% of house surgeons) have stated yes, with no significant difference among them.

In reply, if they are aware of developmental milestones to be considered during preanesthetic evaluation, 71.9% of postgraduates and 64% of house surgeons have answered yes, with no significant difference among them.

Similarly, 80% of postgraduates and 69.5% of house surgeons knew the airway assessment to be considered before the administration of GA, and the results were significant, with a P = 0.008.

For the question, if they are aware of hematological assessment to be evaluated in preanesthetic check-ups, more than half of the study participants in both the groups (80.4% of postgraduates and 76.6% of house surgeons) reported answer as yes, with no significant difference among them. More than half of dental professionals, i.e., (53.1% of house surgeons), did not know mento hyoid distance and mouth opening that has to be evaluated during preanesthetic evaluation.

When participants were asked about the importance of the American Society of Anesthesiologists (ASA) physical status classification system, 59.6% of postgraduates and 54.4% of house surgeons knew the ASA system, with no significant difference among the study groups. Most of the participants (56.9%) had adequate knowledge of Nil per oral/Nothing by mouth and the importance of caste during preanesthetic evaluation (55.6%). For the type of intubation for performing dental procedures, most participants reported that both nasal and oral could be performed (46.3% of postgraduates and 38.5% of house surgeons) with a significant difference of P = 0.002.


  Discussion Top


The use of GA in oral care procedures can be indicated both in healthy patients and special care patients. Under GA, comprehensive dental treatment can be carried out in a single session and require minimal cooperation from the patient, thereby improving the quality of treatment.[12],[13],[14] However, GA has associated risks, and serious complications have been documented to occur in 0.7/1000 cases where GA are administered to young children for various surgeries. With a minor to moderate complication rate of 22.4 per cent, Boynes et al. reported an even higher complication rate in dental-related GA.[15] To minimize the risk of procedures and anesthesia, all patients undergoing sedation or GA must have a preanesthetic evaluation that includes focused history and physical examination before the procedure. Although preoperative assessment is a well-structured and studied area in medicine, the literature reveals relatively little knowledge among dental graduates about the same. Hence, the present study was intended to assess the knowledge and awareness regarding preanesthetic evaluation for performing dental procedures under GA.

In the present study, there is a significant difference between house surgeons and postgraduates regarding knowledge and perception of preanesthetic evaluation, which signifies the level of education. The findings obtained from the present study were consistent with the previous studies done by Baaj et al., Singla, and Mangla.[11],[16] The preanesthetic evaluation is to assess, diagnose, and anticipate possible complications and unknown co-morbidities that directly or indirectly affect the perioperative management of patients.[17] Interestingly, in the present study, a significant difference among the house surgeons and postgraduates has opted for other responses, indicating adequate knowledge among them. Similarly, the individuals qualified to administer anesthesia can perform the preanesthetic evaluation and cannot be delegated to others.[18]

Nevertheless, in the present study, most postgraduates and house surgeons have opted for options other than anesthesiologists to perform the preanesthetic check-up, and the results were statistically significant. These findings suggest a need to increase awareness regarding the role of anaesthesiologists, as dentists and general physicians are not reliable and certified to carry out the preanesthetic evaluation. In general, assessing co-morbid conditions is necessary between the operating surgeons and the anaesthesiologist to develop optimal care. These conditions include a thorough assessment of cardiovascular condition, functional capacity, hematological assessment, and the surgery specific risk.[19] The majority of the participants (more than 75%) in the present study were aware of comorbid and hematological conditions to be evaluated for carrying out dental procedures under GA, which implies no significant difference among the study populations.

Similarly, the patient's airway and mouth opening assessment should be carried out as a routine preoperative workup to predict potential problems and avoid an unanticipated difficult airway.[20],[21] This is essential for children, as any recent or preoperative acute airway infections will be a frequent challenge for anesthesiologists. After all, these infections are responsible for a significant increase in intraoperative and postoperative respiratory hypoxia and related complications.[22] A significant difference was noticed among the study population regarding the awareness of airway assessment before GA. This established the lack of practical knowledge among these students. Among the various clinical predictors, the modified Mallampati classification was the most sensitive (sensitivity of 66.7%), and the mentohyoid distance was the most specific (specificity of 97.5%) in predicting difficult laryngoscopy.[23] A likely indication of difficult intubation is present if the inter-incisor or hyoid-mental distance is less than three fingers or the hyoid-thyroid cartilage distance is less than two fingers. Most of the present study had insufficient knowledge of mentohyoid distance, with no significant difference among the study participants.

The ASA grading system was introduced initially as a simple description of a patient's physical state. Similarly, for any surgical procedures under GA, a minimum fasting duration for oral intake of solids or liquids is necessary to minimize the risk of regurgitation and pulmonary aspiration.[24] In the present study, most participants had insufficient knowledge of Nil Per Os with a significant difference of P = 0.041. This indicates the importance of Nil Per Os to be evaluated before the induction of GA for performing dental procedures to decrease the chances of aspiration.

Assessment of caste also plays an essential role before performing any procedures under GA. In communities, such as the Vaishya community, due to a lack of pseudocholinesterase, the effect of the anesthetic drug does not wean off eventually.[25] In turn, the patient will not breathe on their own and continue to be in that coma-like state. More than half of the participants in both the study groups had insufficient knowledge and awareness about the importance of caste in the current study but without any significant difference. Finally, most study participants have opted for both oral and nasal for the type of intubation preferred, with a significant difference. However, most pediatric dentists prefer nasotracheal intubation because it does not interfere with treatment and decreases the likelihood of tube displacement from head movement during procedures and evaluation of the dental occlusion can efficiently be completed.[26] This should be emphasized clearly in study regulations to provide sufficient knowledge on the choice of intubation for carrying out dental procedures under GA.


  Conclusion Top


Based on the results from this study, the knowledge and awareness regarding preanesthetic evaluation were good among postgraduates compared to house surgeons but implementing it in practice is limited. Hence, efforts should be made to educate the undergraduate in the teaching curriculum to emphasize preanesthetic evaluation's importance in decreasing preoperative morbidity and mortality as well as improving patient quality of life.

Limitations

This research was performed as an online questionnaire, it is likely that the individual received the correct answers from web searches and from acquaintances, which might be a study constraint. This has influenced the amount of appropriate responses and the survey findings.

Ethical issue

Ethical clearance for the study was obtained from the institutional review board (Ref. No: IEC/NDCH/2021/OCT-NOV/P-21).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexure: Questionnaire Top


1. Are you aware of pre anesthetic evaluation that is necessary to be performed under general Anesthesia before carrying out dental procedures?

Yes/No

2. What do you think the reason behind doing the pre-anaesthetic evaluation?

  1. To comply with surgeon's instructions
  2. To get data for surgery
  3. Anticipation of possible complications perioperatively
  4. I do not know


3. What will be done in the pre-anaesthesia check-up?

  1. General assessment of patient done before anaesthesia
  2. Some test is to be performed to assess anaesthesia fitness
  3. Assessment and optimization of potential risks before surgery
  4. All of the above


4. Who will perform the pre-anaesthesia check-up?

  1. Dentist
  2. General physician
  3. Anesthesiologist
  4. I do not know


5. Are you aware of co-morbid conditions such as (heart disease, breathing difficulties, renal problems) that have to be evaluated before inducing general anesthesia?

  1. Yes
  2. No
  3. Not, if well controlled
  4. I do not know


6. Are you aware of developmental milestones to be considered during pre-anaesthetic evaluation?

Yes/No

7. Are you aware of thorough and focused airway assessment prior to the general anaesthesia in pre anaesthetic evaluation?

Yes/No

8. Are you aware of hematological assessment in pre anaesthetic evaluation?

Yes/No

9. Are you aware of mento hyoid distance and mouth opening to be evaluated during pre-anaesthetic evaluation?

Yes/No

10. Are you aware of American Society of Anaesthesiologists (ASA) physical status classification system?

Yes/No

11. Are you aware of NBM (Nil per oral/Nothing by mouth) to be considered during pre-anaesthetic evaluation?

Yes/No

12. Are you aware of importance of caste (vyshyas/Non vyshyas) during pre-anaesthetic evaluation?

Yes/no

13. Are you aware of type of intubation for performing dental procedures under general anaesthesia?

  1. Nasal
  2. Oral
  3. Both A & B
  4. Don't know




 
  References Top

1.
Committee on Standards and Practice Parameters; Apfelbaum JL, Connis RT, Nickinovich DG; American Society of Anesthesiologists Task Force on Preanesthesia Evaluation; Pasternak LR, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012;116:522-38.  Back to cited text no. 1
    
2.
Zambouri A. Preoperative evaluation and preparation for anesthesia and surgery. Hippokratia 2007;11:13-21.  Back to cited text no. 2
    
3.
Gupta A, Gupta N. Setting up and functioning of a preanaesthetic clinic. Indian J Anaesth 2010;54:504-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Ahmed Z, Rufo PA. Pediatric preoperative management. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 4
    
5.
American Academy of Pediatric Dentistry; American Academy of Pediatric Dentistry Committee on Sedation and Anesthesia. Guideline on the elective use of minimal, moderate, and deep sedation and general anesthesia for pediatric dental patients. Pediatr Dent 2005;27:110-8.  Back to cited text no. 5
    
6.
Mallineni SK, Yiu CK. A retrospective review of outcomes of dental treatment performed for special needs patients under general anaesthesia: 2-year follow-up. ScientificWorldJournal 2014;2014:748353.  Back to cited text no. 6
    
7.
American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline on management of dental patients with special health care needs. Pediatr Dent 2012;34:160-5.  Back to cited text no. 7
    
8.
Chaudhary K, Bagharwal P, Wadhawan S. Anesthesia for intellectually disabled. J Anaesthesiol Clin Pharmacol 2017;33:432-40.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Jockusch J, Sobotta BA, Nitschke I. Outpatient dental care for people with disabilities under general anaesthesia in Switzerland. BMC Oral Health 2020;20:225.  Back to cited text no. 9
    
10.
Rosenberg M; American Dental Association. New guidelines for the use and teaching of general anesthesia and sedation by dentists. J Mass Dent Soc 2010;58:22-7.  Back to cited text no. 10
    
11.
Singla D, Mangla M. Patient's knowledge and perception of preanesthesia check-up in rural India. Anesth Essays Res 2015;9:331-6.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
López-Velasco A, Puche-Torres M, Carrera-Hueso FJ, Silvestre FJ. General anesthesia for oral and dental care in paediatric patients with special needs: A systematic review. J Clin Exp Dent 2021;13:e303-12.  Back to cited text no. 12
    
13.
Rajavaara P, Rankinen S, Laitala ML, Vähänikkilä H, Yli-Urpo H, Koskinen S, et al. The influence of general health on the need for dental general anaesthesia in children. Eur Arch Paediatr Dent 2017;18:179-85.  Back to cited text no. 13
    
14.
Kvist T, Zedrén-Sunemo J, Graca E, Dahllöf G. Is treatment under general anaesthesia associated with dental neglect and dental disability among caries active preschool children? Eur Arch Paediatr Dent 2014;15:327-32.  Back to cited text no. 14
    
15.
Boynes SG, Moore PA, Lewis CL, Zovko J, Close JM. Complications associated with anesthesia administration for dental treatment in a special needs clinic. Spec Care Dentist 2010;30:3-7.  Back to cited text no. 15
    
16.
Baaj J, Takrouri MS, Hussein BM, Al Ayyaf H. Saudi patients' knowledge and attitude toward anesthesia and anesthesiologists – A prospective cross-sectional interview questionnaire. Middle East J Anaesthesiol 2006;18:679-91.  Back to cited text no. 16
    
17.
Dhaka VW, Nanavati AJ, Shakil M, Nagral SS. Pre-anaesthetic check-up In India: A review. Surg Pract Sci 2020;1:100005.  Back to cited text no. 17
    
18.
Shaikh SI, Hegade G. Role of anesthesiologist in the management of a child with cerebral palsy. Anesth Essays Res 2017;11:544-9.  Back to cited text no. 18
[PUBMED]  [Full text]  
19.
Basel A, Bajic D. Preoperative evaluation of the pediatric patient. Anesthesiol Clin 2018;36:689-700.  Back to cited text no. 19
    
20.
Rosenberg MB, Phero JC. Airway assessment for office sedation/anesthesia. Anesth Prog 2015;62:74-80.  Back to cited text no. 20
    
21.
Strauss RA, Noordhoek R. Management of the difficult airway. Atlas Oral Maxillofac Surg Clin North Am 2010;18:11-28.  Back to cited text no. 21
    
22.
Karcz M, Papadakos PJ. Respiratory complications in the postanesthesia care unit: A review of pathophysiological mechanisms. Can J Respir Ther 2013;49:21-9.  Back to cited text no. 22
    
23.
Parameswari A, Govind M, Vakamudi M. Correlation between preoperative ultrasonographic airway assessment and laryngoscopic view in adult patients: A prospective study. J Anaesthesiol Clin Pharmacol 2017;33:353-8.  Back to cited text no. 23
[PUBMED]  [Full text]  
24.
Toms AS, Rai E. Operative fasting guidelines and postoperative feeding in paediatric anaesthesia-current concepts. Indian J Anaesth 2019;63:707-12.  Back to cited text no. 24
[PUBMED]  [Full text]  
25.
Ramaiah M, Ramakrishna P. Pseudocholinesterase deficiency in an Indian community. J Pharm Pract Community Med 2017;3:27-30.  Back to cited text no. 25
    
26.
Bowman JP, Nedley MP, Jenkins KA, Fahncke CR. Pilot study comparing nasal vs. oral intubation for dental surgery by physicians, nurse anesthetists, and trainees. Anesth Prog 2018;65:89-93.  Back to cited text no. 26
    



 
 
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