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Special Patients > Chapter 3: Patients With Blood Disorder Alterations And Anticoagulation Treatment > Flashcards

Chapter 3: Patients With Blood Disorder Alterations And Anticoagulation Treatment Flashcards

1
Q

Hemostasis is?

A

The mechanism of defence of the organism to prevent or stop a haemorrhage, maintain the integrity of the vascular system, and restore circulation when interrupted.

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2
Q

4 stages of hemostasis?

A
  1. Vasoconstriction
  2. Platelet aggregation
  3. Activation of coagulation cascade
  4. Clot formation
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3
Q

Vasoconstriction is caused by?

A

Thromboxane A2 from activated platelets and injured epithelial cells. Vasoconstriction is brief.

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4
Q

Platelets adhere to the collagen fibers in the vessel wall by becoming adhesive and filamentous due to the stimulus of?

A

Von Willebrand Factor

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5
Q

For large wounds, which type of hemostasis is needed?

A

Secondary

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6
Q

For minor wounds, which type of hemostasis is needed?

A

Primary

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7
Q

3 pathways of the coagulation cascade?

A
  1. Intrinsic
  2. Extrinsic
  3. Common
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8
Q

Primary coagulation is?

A

Platelet formation

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9
Q

Secondary hemostasis is?

A

Coagulation cascade, fibrin mesh

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10
Q

The coagulation factors usually are? And how do they work?

A

Serine proteases (enzymes)

Coagulation factors circulate as inactive enzyme precursors, which, upon activation, take part in the series of reactions that make up the coagulation cascade

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11
Q

Factors in the intrinsic pathway:

A

12,11,9,8
Negatively charged molecules, HMWK, prekallikrein

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12
Q

Factors in the extrinsic pathway:

A

3,7
Thrombin burst, prothrombin, fibrinogen,

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13
Q

Factors in the common pathway:

A

10
Thrombin, fibrin, platelet plug.
After all: fibrinolysis

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14
Q

Blood vessel alterations: hereditary

A
  • rendu-osler diseases (telangiectasia: spontaneous bleeding)
  • ehlers-danlos syndrome
  • fabry disease
  • marfans syndrome
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15
Q

Blood vessel alterations: acquired

A
  • decreased collagen due to scurvy (vit c deficiency)
  • secondary to corticosteroids
  • vasculitis
  • purpura
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16
Q

Platelet alterations: thrombocytopenias can be due to?

A
  • Decreased production (anemia, leukemia, chemotherapy, radiotherapy, congenital).
  • Due to the increased peripheral destruction (idiopathic thrombocytopenic purpura, infection, hemorrhage).
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17
Q

In thrombocytopenia, the platelet count is?

A

Less than 100,000

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18
Q

If the platelet count is less than 50,000:

A

Variable risk

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19
Q

If platelet count is less than 20,000:

A

Transfusion appropriate

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20
Q

If platelet count is less than 10,000:

A

Spontaneous hemorrhage

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21
Q

Thrombocytopathies are:

A

Alteration of the function of platelets when the time of hemorrhage is prolonged and number of platelets is normal

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22
Q

Congenital Thrombocytopathies:

A

Bernard lousier syndrome

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23
Q

Acquired Thrombocytopathies:

A

Drugs, kidney failure, chronic liver disease

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24
Q

So with Thrombocytopathies: we can see

A

Gingival bleeding

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25
Q

Coagulopathies: hereditary and coagulopathies

A
  • Von Willebrand disease: factor 8
  • haemophilia A: factor 8
  • haemophilia B: factor 9
  • deficit of other factors (2, 5, 7)

Coagulopathies:
- vit k deficiency
- chronic liver diseases

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26
Q

Prolonged immediate bleeding —>

A

Primary hemostasis

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27
Q

Prolonged late bleeding—>

A

Secondary hemostasis

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28
Q

Number of platelets:
When is there a risk for hemorrhage?

A

150,000-450,000
Less than 50,000: risk for hemorrhages

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29
Q

Time of hemorrhage, superior normal limit

A

7 minutes

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30
Q

H2: 3 values:

A

thromboplastin, prothrombin, thrombin

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31
Q

TTP: meaning and value

A

Thromboplastin time
Coagulation inside the BV
25-35 seconds
Altered by heparin

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32
Q

TP: meaning and value

A

Prothrombin time
Coagulation outside the BV
10-15 seconds

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33
Q

TT: meaning and value

A

Fibrin capability to form a clot
9-13 seconds

34
Q

Normal INR for patients without anticoagulants:

A

0.9-1.1

35
Q

Normal INR for patients anticoagulated:

A

2-3

36
Q

Normal INR for patients anticoagulated with valvular prosthesis:

A

2.5-3.5

37
Q

Anticoagulant drugs: oral and subcutaneous

A

Oral: acenocoumarol (sintrom) , warfarin (aldocumar)
Subcutaneous injection: low molecular weight heparin (celaxane, fragmin)

38
Q

New anticoagulants are indicated for:

A
  • avoid strokes
  • 75-85 year olds
  • indicated for atrial fibrillation
39
Q

How many steps in the coagulation cascade do new anticoagulants affect?

A

1
Either factor 10a or thrombin

40
Q

Two types of new anticoagulants:

A
  1. Inhibitors of factor Xa: fondapanirux (arixtra), ribaroxaban (xarelto)
  2. Inhibitors of thrombin: argatroban (arganova, argatra, novastan), melagatran (exanta), dabigatran etaxilato (pradaxa)
41
Q

Advantages and disadvantages of new anticoagulants?

A

Advantages:
- don’t need to be replaced by heparin
- coagulation controls (INR) not necessary
- little pharmacological interactions
- the restrictions on diet not necessary

Disadvantages: no antidote

42
Q

When to stop and restart new anticoagulants?

A

2-3 days before, and day after then restart

43
Q

Old anticoagulants:

A

Vitamin k antagonsits, sintrom, warfarin. Vit k helps blood clot or coagulate properly

44
Q

Anti-platelet drugs:

A

Avoid platelet plug formation

Aspirin (adiro, tromalyt)
Clopidrogel (iscover, plavix)
Dipiridamol (persantin)
Ticlopidina (tiklid)
Trifusal (disgren)

Stop adiro 300 before big surgery

45
Q

When deciding on withdrawing treatment of anticoagulants or anti platelets before surgery?

A

Interconsult!!!!

46
Q

Bleeding control:

A
  • atraumatic extraction
  • anaesthesia with VC!!!!
  • pressure gauze for 20-30 mins
  • non-resorbable suture
47
Q

Hemostatic materials:

A
  • gelatin sponges
  • synthetic collagen
  • oxycellulose (surgicel)
  • thrombin (tissucol)
  • antifibrinolytic (tranexamic acid) amchafibrin))
48
Q

Safe prescription/medication: antibiotics?

A

Amoxicillin, amoxicillin-clavulanic acid, macrolides

49
Q

Safe prescription/medication: analgesics

A

Paracetamol

50
Q

Safe prescription/medication: NSAIDs

A

Diclofenac, ibuprofen

51
Q

Safe prescription/medication: benzos

A

Diazepam

52
Q

Treatment of thrombocytopenic purpura:

A
  • dental tx okay when stable
  • minimum number of platelets 50,000
53
Q

Treatment of hemophilia A, B, and Von Willebrand:

A

Administer deficit factor

Hemophilia A and VW: 8
Hemophilia B: 9

54
Q

No extractions if platelets under?

A

50,000!!!

55
Q

Anticoagulated patient:

A
  • never suppress medication
  • INR day of tx:
    *2.5: ok , hemostatic measures
    *>3: interconsult
    *>5: hospital check up
56
Q

Chronic liver disease:

A
  • Know the number of platelets.
  • Time of hemorrhage.
  • Time of prothrombin.
  • Lack of vitamin K.
  • Antibiotic therapy: bad absorption.
57
Q

Dialysis treatment:

A

Patients with heparin the days of dialysis.
Hemostatic measures.

58
Q

Anticoagulant protocols:

A
  • Avoid ambulatory treatment:
  • Important surgeries,
  • INR > 3 or not stable.
  • Cirrhosis.
  • Alcoholism.
  • Kidney insufficiency.
  • Hemostatic alterations.
  • Periodontal treatments:
  • Inter-consult with their main doctor to adjust INR to <2.
  • Tranexamic acid before and after treatment.
59
Q

Extractions in anticoagulated patients:

A
  • Don’t suppress anticoagulant treatment in INR 2-2.5.
  • Always INR before surgery.
  • Hemostatic measures.
  • Avoid NSAIDS. (NB: use paracetamol).
60
Q

If you do need to stop anticoagulation:

A

Change to heparin 2 days before surgery.
Use tranexamic acid for the patient.

61
Q

Acenocoumarol: suspension

A

2 days before

62
Q

Low weight molecular:

A

2 days before and 2 days after and day of

63
Q

Tranexamic acid:

A

Suspend day of extraction

64
Q

Medication to avoid:

A

• Metronidazole: longer effect of the S(-)-warfarin.
The most active part of the warfarin.
• Eritromicin: effects last longer and more effective.
• Piroxicam: potentiate the effects of the anticoagulants.

65
Q

Drugs that can potentiate anticoagulants:

A

• Penicillin: destroys bacterial flora and produces less vitamin K absorption. 20-40mg Vit K, 5 days before surgery.
• ASA: inhibits platelet aggregation and damages gastrointestinal mucosa.

66
Q

High risk potential to stomach hemorrhage drugs:

A
  • ASA
  • Piroxicam
  • Naproxen

Always with FOOD

67
Q

Prescription drugs (what we can prescribe):EXAM!!

A

• Paracetamol: 500mg every 4-6 hours. (NB: or 1g).
• Diclofenac: 50mg every 8 hours.
• Ibuprofen: 400mg every 6-8 hours. (NB: 600mg is also used in Spain).
• Amoxicillin: 500mg every 8 hours for 7 days.
• Diazepam: 2-10mg, 4 times per day.

68
Q

The antibiotic prophylaxis of a cardiac patient who takes antihypertensive, new anticoagulant, presents with a stomach ulcer and has a history of infecive endocardits will be?

A

a. Amoxicillin 2 gr intravenously 1 hour before treatment
b. Amoxicillin 750 mg orally 3-4 days before treatment
c. Amoxicillin 2 gr orally 1 hour before treatment
d. Clindamycin 600mg orally 1 hour before treatment e. Clindamycin 300 mg orally 3-4 days before treatment

C

69
Q

Regarding a patient taking drugs for hemostatic alteration, it is important to know

A

a. The new anticoagulants indirectly inhibit the synthesis of coagulation factors

b. The removal of the new anticoagulants before a surgical process will depend on the renal function of the patient

c. Currently it is advisable not to stop anticoagulation in most dental surgical procedures

d. Antiplatelets reversibly inhibit platelet aggregation

e.Oral anticoagulants decrease clotting time and prevent thrombus formation and the possibility of embolisms

?idk

70
Q

Which of the following mechanisms is not part of the physiology of hemostasis?

A

a. Hemolysis of erythrocytes
b.Fibrin thrombus formation
c. Platelet thrombus formation
d.Local vasoconstriction
e. Clot dissolution

A

71
Q

If a patient comes to the clinic to have an extraction and reports that he takes clopidrogel, how should we act?

A

A. Analytical request for the suspension of tto, INR of the day and if everything is correct we will do the extraction with hemostatic measures

B. We would change anti-platelet treatment for heparin two days before

C. Interconsultation to his doctor. If everything is correct, I would do the extraction and use local hemostatic measures

D. It is a new generation treatment so it would not be necessary to take any specific measure

E. I would suspend antiplatelet treatment

C

72
Q

Regarding haemostasis disorders, which of the following statements is false?

A

a. Telangiectasias on the tongue and lip are typical of Rendu-Osler’s disease

b. Hemophilia B is caused by a deficiency of factor IX

c. Platelet disease may be due to a quantitative or qualitative alteration of platelets

d. The prescription of antiplatelet or anticoagulant drugs does not usually have significant clinical repercussions.

e. In liver diseases there may be an alteration of coagulation

D

73
Q

If a patient comes to the consult and in its clinical history it says the patient suffer from haemophilia, i will consider:

A

A. Haemophilia is a disease in which a coagulation factor is missing and therefore the patient is more prone to hemorrhages due to deficiency of blood coagulation

B. The patient has a problem synthesising vit K by the intenstinal flora

C. The patient will be prone to hemorrhages due to a higher platelet aggregation problem

D. The patient has a renal alteration syndrome

E. The patient will be treated with plavix (clopidogrel) and there fore has no risk of hemorrhage

A

74
Q

Which of the following measures will i take regarding a patient with hemostatic problem?

A

A. For problems of secondary hemostasis, i will analyse the number of platelets to make sure its lower than 50,000 that way we can treat him safely

B. In anticoagulated patients, i can measure the thrombin time TP and if the INR value is between 1 and 2.5 i can perform the extraction

C. The new anticoagulants will always need the suspension of the medication and INR control

D. Before any type of dental treatment we must refer to the specialist to substitute the anticoagulant for heparin (Cleaxane)

E. It will not be necessary to interrupt the anticoagulant treatment as long as we take adequate local hemostatic measures, such as suturing with resorbable suture

E

75
Q

Regarding the following combinations of medications, which one will be the safest and of election in anticoagulated patients?

A

A. Piroxicam + metronidazole
B. Ibuprofen + erythromycin
C. Diclofenac + acetylsalicylic acid
D. Paracetamol + amoxicillin
E. Naproxen + amoxicillin

D

76
Q

Which of the following measures is INCORRECT when we want to perform an extraction of a 36 in a patient taking ADIRO?

A

A. We will prescribe acetylsalicylic acid as post extraction analgesic

B. We do not consult the INR

C. We irrigate the surgical area with tranexamic acid (amchafibrin)

D. Avoid hard and hot foods the days following the extraction

E. All the measures are correct

A

77
Q

Patient who goes to a consultation for an extraction of tooth 26 with vertical fracture, he takes sintrom, is hypertensive and suffered bacterial endocarditis years ago. point out the true answer

A

A. We would avoid anaesthesia with vasoconstrictor
B. The sintrom is a drug that lengthens the effect of coagulation
C. This patient may have an abnormal number of platelets
D. If this patient stops using sintrom, its effect may dure 4-5 days more
E. Sintrom is an anti aggregation drug, a vitamin K antagonist

B

78
Q

A heart patient with a valve prosthesis with an INR of 3.3 comes to the office to do and root scaling and root planing, our attitude will be?

A

A. Treat it, INR is within the values for a root scaling and doesn’t carry a high risk
B. DO not treat until your INR is below 1
C. Make a consultation to be administered low molecular weight heparin
D. None of the above
E. Do only one quadrant to decrease risk of bleeding

E

79
Q

19-year-old patient with no known systemic pathology who came to the emergency room presenting with bleeding after the extraction of tooth 28 that morning, our attitude Will be:

A

A. Check the extraction area
B. Perforrn tranexamic acid rinses
C. Perform local compression with gauze
D. In case of abundant and ? bleeding, perform
stitches
E. They are all correct

C

80
Q

To control inflammation and pain from a pericoronitis in a patient who takes sintrom and is hypertensive controlled, we will prescribe?

A

A. Amoxicillin 750mg every 8 hours, nolotil and paracetamol 1gr every 8 hours

B. Azithromycin 500mg every 8 hours, ibuprofen 600mg and paracetamol 1g intercalated every 6 hours

C. Azithromycin 500mg every 8hours, ibuprofen 600mg and paracetamol 1g every 6 hours

D. Augmentine 875mg every 8 hours, diclofenac 50mg and nolotil intercalated every 6 hours

E. Augmentine 875mg every 8 hours, nolotil and paracetamol 1g intercalated every 8 hours

D

81
Q

If I have to perform an extraction of a 48 included. Which of the following patients would you treat without fear of bleeding?

A

a. Patient with a 10 second increase in prothrombin
b. Patient with INR of 3.8
c. Patient with 25,000 platelets
d. Haemophiliacs with 20% factor VIII
e. I would safely undergo dental surgical treatment for none of these patietns, and would undergo

A, inc of 10 seconds is fine

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