Use of IV Ringers Lactate During Extractions in Patients with Polypharmacy: A Case Report

Abstract

A female patient reported to the clinic for extraction of her grossly carious but firm maxillary central incisor. The patient was severely anemic, hypotensive and taking multiple medications. To prevent dizziness or syncope during extraction, IV Ringers Lactate was administered during extraction. 24 hours post extraction, IV DNS 5% with Multivitamin Injection (MVI) was administered to prevent weakness. The article describes a novel approach to the age-old problem of dental extractions in heavily medically compromised patients and provides rationale for the same.

Introduction

According to Geoffray L Howey , the ideal tooth extraction is defined as - ‘The painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no post-operative prosthetic problem is created.' Saving teeth is topmost priority for all dentists. But teeth have to be extracted due to:

• Traumatic avulsion or intrusion due to fracture of alveolar bone
• Grossly carious tooth
• Teeth involved in fracture line of jaws
• Periodontal diseases
• Caries tooth in which root canal treatment cannot be done
• In cancer patients, before radiation therapy
• In cases where tooth extraction is the only option available to reduce the suffering of the patient.

Various mechanical principles are applied during tooth extraction such as:

• Expansion of the bony socket
• Use of fulcrum and lever
• Wedge insertion
• Wheel and axel

Traumatic surgical procedures in the medical field have traditionally been supplemented by use of intravenous fluids or IV Fluids. These fluids are medicinal liquids, administered directly into the veins through an intravenous tube. There are several types of IV Fluids each with its own composition and purpose, such as:

• Crystalloids: These fluids contain small molecules that can pass through cell membranes easily. They are classified as isotonic, hypotonic or hypertonic, depending on their solute concentration relative to cells. Common types of crystalloid solutions include:

1. Normal Saline.
2. Half Normal Saline.
3. Lactated Ringers.
4. Dextrose.

• Colloids: Colloidal solutions contain larger molecules that remain in the blood stream and are used as plasmic expenders for severe hypovolemic shock.

Normal saline is the most common crystalloid used in dentistry, although not through the IV route of administration. Polypharmacy is an umbrella term to describe simultaneous use of multiple medicines by a patient for their diseases or conditions. Such patients are usually heavily medically compromised and susceptible to complications. Any traumatic procedure to be attempted in such patients must be done with utmost care, using as many preventive protocols as possible.

Case Report

A 48 year old female patient, reported to the clinic with a chief complaint of severe pain in anterior region of jaw since many days. Intra oral examination revealed a severely carious maxillary central incisor. Her medical history revealed that she was taking several medications owing to her orthopaedic, gynecological, ophthalmic and gynaecological problems. Patient was not diabetic but was severely hypotensive. Her usual blood pressure reading was 95/68 mmHg. She was also taking chiropractic treatment. Patient was prescribed injection diclofenac sodium intra muscularly once a day SOS for two days as oral medications like Chymoral Forte were not reducing her dental pain. She was also prescribed a Complete Blood Count (CBC) blood test investigation. The patient reported after two days with the investigation reports, which revealed severely reduced haemoglobin. Since patient was anemic and medically compromised, she was referred to a physician for his consent. The patient reported again after a week without the physician’s consent and insisted on extraction as the dental pain was becoming unbearable day by day. The patient was informed about all possible complications and the entire surgical procedure was explained. An informed consent was taken after designing a treatment plan using as many preventive protocols as possible. The tooth to be extracted was a firm but severely carious tooth. A traumatic and lengthy extraction procedure was expected. It was decided that the patient should be given Intra Venous Ringers Lactate during the procedure itself so that she doesn't go into syncope or feel dizziness as she was hypotensive with reduced haemoglobin. The patient consent was taken for the same. After giving the anterior superior alveolar nerve block using lignocaine to anesthesize the offending tooth, IV Ringers Lactate was administered simultaneously. A less traumatic forcep extraction was performed following strict sterilisation protocols. Continuous sutures were placed. Non-absorbable sutures were used. She was asked to asked to follow the standard post extraction guidelines. Soft and cold diet for next 24 hours was advised and she was strictly instructed not to spit blood or saliva for next 24 hours. Post extraction, she was prescribed a tablet of tranexamic acid 'Stat' and two antibiotics (Amoxicillin 500 & Metrogyll 400 for twice daily after food for 7 days). She was additionally prescribed a DNS 5 percent IV mixed with Multivitamin(MVI) once after 24 hours of extraction. The patient re-visited after 7 days for suture removal and reported no post operative complications.

Discussion

Even a simple tooth extraction is a minor surgical procedure and causes trauma. The amount of trauma caused depends primarily on the type of extraction. Extractions may be:

• Intra-alveolar extraction or conventional extraction or forcep extraction.
• Transalveolar extraction or surgical extraction.