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.

In the present case, a traumatic and lengthy extraction procedure was expected as the tooth was firm and grossly destructed. A minimally traumatic forcep extraction was performed. The management of trauma by the human body and post-operative recovery depends not only on the infectious condition, but also the condition of the body - general health, fitness, immunity levels, age, gender, underlying medical conditions and psychological states. Poor body conditions increases the chances of complications - post-operatively and even intra-operatively. In the case report, the patient was heavily medically compromised. She was on multiple medications such as chymoral forte, thyroxine 25, dexamethasone eye drop, proton pump inhibitors and other gynaecological drugs owing to her medical history. Oral painkillers were not effective for her dental pain and IV painkillers had to be prescribed. Additionally, the patient was severely anemic and hypotensive. Hence, poor recovery and complications were expected in this case. Although not commonly used in dentistry, medical fields readily supplement traumatic medical procedures or surgeries with IV fluids. IV fluids are not used in all patients, its use depends on the intensity of the procedure and the medical state of the body. IV fluids are used to treat dehydration, replenish fluids lost due to illness or injury and provide essential nutrients to body. The most popular IV fluid, Ringers Lactate (RL or Hartman's solution), is a sterile solution composed of water, sodium chloride (salt), sodium lactate, potassium chloride and calcium chloride. It is often used in place of saline solution (water and 0.9 % sodium chloride) because it is less likely to cause fluid to build up in body. RL is used to :

• Treat dehydration.
• Restore body fluids after significant blood loss or severe burn.
• Aid in transport of IV medications in vein.
• Keep an IV catheter open.

The rationale of using IV RL in the above case report was to avoid dizziness & syncope during extraction. RL is given intravenously to treat low blood volume or low blood pressure. It is used during and after surgery. RL solutions of high potassium levels are useful to maintain serum potassium and glucose levels at more normal levels. RL is ideal for people with sepsis or respiratory acidosis . RL is contraindicated in:

• People suffering from congestive heart failure.
• Chronic kidney disease.
• Cirrhosis and other liver diseases.
• Hypoalbuminemia.

A detailed medical history of the patient was elicited during consultation, and the patient was not suffering from any of these conditions, including diabetes. The patient was additionally prescribed a DNS 5% IV mixed with Multivitamin (MVI) once after 24 hours of extraction. DNS infusion is a combination medicine used as a short term fluid replacement after trauma. DNS is a combination of two medicines, dextrose & sodium chloride. They work by restoring blood plasma lost due to bleeding. DNS is used:

• After blood and fluid loss.
• For Dehydration.
• In Carbohydrate depletion.

DNS is contraindicated in diabetics. Multivitamin Injection (MVI): MVI mixed with DNS helps in boosting energy levels & improve metabolism. It is used to treat vitamin deficiency and is essential for healthy skin, bones, cells, and healthy immune system. The rationale of using IV DNS in combination with MVI was to prevent 'weakness' post extraction. It was not advised on the same day of extraction so as to prevent too much of IV fluid in the body. Currently, there are no clear guidelines for fluid administration in dental or oral and maxillofacial surgery. As such, there is not much literature available on which fluid to use when in day to day dental procedures but safe fluids such as RL and DNS helps patients who are hypotensive and have nutritional deficiencies.

Limitations

• To administer IV Fluids, clinicians should have thorough knowledge of pharmacokinetics and pharmacodynamics of various drugs, so that there are no adverse reactions and the patient is not harmed in any way.
• Clinicians should have an in-depth knowledge of medicines they are prescribing
• Prior to using any IV fluid, clinician should have sufficient knowledge of contraindications and dosages of all IV fluids, as too much of IV fluid in body may cause hypervolemia.
• Clinicians must mandatorily take a detailed, time-consuming medical history of the patient in such cases at consultation itself so that such treatments can be planned
• Clinicians must be skilled enough to insert the IV cannula and have the necessary armamentarium for the sme.
• Informed consent is a necessity in such cases.
• Sufficient clinical trials are needed to substantiate the safe use of IV fluids during dental extraction procedures.

Polypharmacy requires medication reconciliation and medical-risk assessment within a complete dental extraction plan.

This IV-fluid extraction case is not a general protocol; treatment decisions require individual medical-risk assessment for dental procedures and appropriate clinical capability.