Management Of Medically Compromised Patient Flashcards
How to identify someone who’s medically compromised
ASA classification
Which patients can be seen in practice
Systems review
Cardiovascular -> ANGINA
2 key factors affecting dental treatment
At risk of angina attack, MI
Ensure glyceryl trinitrate (GTN) spray & oxygen available
(Avoid NSAIDS)
Cardiovascular - Recent myocardial infarction
When do you not do an extraction on a heart attack pt?
When do you not use GA?
Other relevant factors to dentistry?
What do you avoid?
3 /12 post - consider deferring elective treatment
Up to 6/12 post- no GA as 50% increase risk of repeat MI
Treatment in late morning/ early afternoon to prevent cardio-vascular event
Good anaesthesia, analgesia & anxiety management (consider IVS if no CIs)
Avoid high dose NSAIDs (associated with a small increased risk of thrombotic events - eg myocardial infarction and stroke)
Paracetamol can be prescribed +/- short term low dose ibuprofen if needed (200-400mg TDS).
Cardiac arrythmias, Cardiovascular disease/ failure
• Consider medication that patients are on esp anticoagulants
• Consider risk of long-term medication e.g. NSAIDs
• Consider important of oral hygiene
Cardiac defects/valve replacements/ previous IE
• No antibiotic cover needed (NICE guidelines)
• Maintain good oral hygiene
• Warn re. IE possibility & awareness of symptoms
(Extra from denmark hill - we are only country who does no antibiotic cover so Liaise with pt cardiologist)
Extirpate UL5 only and dress as likely to turn into a surgical procedure
Hypertension patients
1- what is normal BP?
2- when do you avoid extraction - what BP reading?
They are at increased risk of?
2 key things to note
What do you need to check before extractions?
1- NORMAL BP = 120/80mmHg
2- 160 and above
Check BP before extraction
Ask pt to come early in morning
Respiratory - Asthma
1 - Risk assessment / Qs to ask pt
2- what do we avoid in asthmatics?
1-
•Hospital admissions- when, how long for, management
•Type & frequency of inhaler use
•Use of nebuliser?
•Oxygen saturation on air
•SOB at rest/ on exercise?
•Supplemental oxygen – at rest/ on exercise
2- AVOID NSAIDS + Aspirin
COPD
1- Avoid?
2- how do you treat these patients?
• COPD patients is contraindication for IV sedation & GA is also best avoided
• COPD patients treat upright
Referral
• Poorly controlled respiratory disease patients (e.g. severe asthma, COPD)
• Patients with co-morbidities (e.g. cardiac failure, recent MI)
Diabetes
1- 3 relevant factors / risks
2- what questions do we want to know?
3- when do we give glucose drink?
4- what can happen during dental infection? When is it unsafe to treat?
1-
• Hypoglycaemic emergency -> want to make sure pt eaten before they come and if haven’t then glucose drink
• Delayed healing
• Increased risk of infection (immunocompromised)
2-
Time last eaten, taken insulin/ oral hypoglycaemics?
Patient normally well controlled?
Medications?
3-
Consider glucose drink if level 4mmol/l or less –check BM first
Signs of hypoglycaemia
ALWAYS check BM prior to IV sedation as signs of hypoglycaemia less detectable
Hb1Ac levels
4-
Hyperglycaemic individuals
• BM raised in dental infection
• Suggests treatment unsafe if BM> 15mmol/l
• Extraction of tooth and contact GP/ referral to diabetic team/ send to A&E
Bleeding disorders
1 - List 3 bleeding disorders that CANNOT be treated in practice + where are they treated instead?
2- list bleeding disorders that CAN be treated in practice
1-
1. Haemophilia (A and B) & Von Willebrand’s disease
2. Platelet disorders (e.g. thrombocytopenia)
3. Multiple/dual anti-coagulant therapy
Treatment in hospital setting only with joint preparation/management with haematology
2- Single anticoagulant therapy and no co-morbidities
Bleeding disorder Cont
Anticoagulant therapy
1- what needs to be done prior to procedure?
2- warfarin patients what does INR have to be for treatment ?
3- What is AVOIDED in WARFARIN patients?
4- give 2 examples of DOAC
5- Do DOACs need monitoring? What is avoided?
1-
Check coagulation screen prior to procedure
Ask demonstrator to check blood results on EPR/ check INR chair-side
2- For warfarinised patients INR<4 treatment can go ahead for simple XTN of ≤ 3 teeth or single surgical XTN
If INR>4 refer back to haematology clinic for medication adjustment for therapeutic range INR <4
3 - AVOID NSAIDs & antibiotics (including amoxicillin, erythromycin & metronidazole) as anticoagulant effect of warfarin can be potentiated
4- apixaban & rivaroxaban
5 - Direct oral anticoagulants (DOAC) apixaban & rivaroxaban do not require routine monitoring – avoid NSAIDs and use local haemostatic measures
Liver disease
1- Give examples of liver disease
2- 5 RISKS of liver disease - related to oral surgery
1-
• Liver cirrhosis/failure/ Hep A, B, C, D, autoimmune liver disease
• Alcoholism/ binge drinking, jaundice
2-
• Prolonged bleeding –(see S.Woolcombe lecture on liver disease & bleeding)
• Cross infection risk Hep B,C,D,E
• May be immunocompromised
• Impaired drug metabolism
• Caution with drug administration (including LA, sedation, analgesia, Abs)
Need blood tests - LFT, coagulation and FBC / work up before extractions
Refer to secondary care if patient has liver disease
Kidney disease
1- Give examples of kidney disease
2- 3 RISKS with kidney disease
3- What do you have to do before treatment?
4- WHEN should dialysis patients be treated?
5- when do you consider steroid cover
1-
• Chronic kidney disease/ renal dialysis/ renal transplant
2-
• Bleeding tendency (reduced platelets)
• Drug prescription with caution (NSAIDs contraindicated)
• May be immunocompromised - may require AB cover •
3-
Liaise with renal team •
Check blood screen (may already be available on EPR)
-Renal profile (urea, creatinine & eGFR (estimated Glomerular Filtration Rate) assess kidney function)
-FBC (WBC, platelet levels)
-Ensure blood results are printed, checked & filed.
4- Dialysis patients to be treated the DAY AFTER dialysis (best blood picture& heparin metabolised)
5- Steroid cover if on long term, high dose corticosteroids
Epilepsy
1- seizures may be caused by 2 things in dentistry?
2- if poorly controlled epileptic where might you consider treatment
3- If a patient with uncontrolled epilepsy needs treatment under LA but cannot bring an escort
4- if patient has a seizure, how do you manage this?
1-
1. stress of surgery/ pain
2. (also careful overhead light)
2-
• IV sedation in hospital with midazolam -> anticonvulsant effect
3- Elective cannulation with venflon
4-
Ensure good airway control
Adminster buccal/ intranasal midazolam (10mg) (in LA only patients)
If longer than 5 mins - call 999 - from CHATGPT
TB
1- When do you avoid treatment in a TB patient?
2- What do you avoid for TB pts?
1- Avoid dental treatment in patient with pulmonary TB until on TB treatment for at least 2 weeks
Other types of TB are non-infectious
2- Avoid GA because anaesthetic equipment can become infected
Patients with cervical gland TB may present to dentist
HIV
1- What do you need to ask the patient?
2- when do you consider AB pre and post op
3- RISK of?
HIV Infects CD4 lymphocytes- immunodeficiency
1- Ask patient what CD4 count & viral count- consider bloods if CD4 low
2- CD4 <200 x 10^6/l increased risk of infection consider AB pre & post-op
3- • Bleeding tendency due to risk of thrombocytopenia
• PEP (postexposure prophylaxis) may be required up to 4 weeks if exposure occurs
Cancer
Cancer can lead to 3 main things - what are their effects
- Thrombocytopenia (decreased platelets) –> increased bleeding risk
– <50 x 109/l may need platelet transfusion
– local haemostatic measure needed - Neutropenia (decreased neutrophils) –> Risk of infection
– <1.0 x 109/l may need antibiotic prophylaxis (pre& post op) d/w oncologist - Anaemia
Request recent blood investigations from GP/physician
Chemotherapy –
– Steroid cover (25 mg IV hydrocortisone) may be needed for patients on high dose steroids
– IV bisphosphonates for patients with bone metastases, multiple myeloma – risk of MRONJ
Radiotherapy
1) What can radiotherapy of head and neck lead to
2) What information is needed from a patient who has had radiotherapy?
3) What is radiation induced fibrosis?
1) Risk of osteonecrosis of jaw
2) Area of radiotherapy, dose & duration
3) Radiation-induced fibrosis- bone cell damage through acute inflammation, free radicals & chronic activation of fibroblasts by a series of growth factors
Radiotherapy
What are the key post-operative management strategies for patients with a history of head and neck radiotherapy after extractions?
