MED 2 HEMAT ASA Flashcards
Anemias, Stress Management
1
Q
Mild Nuetropenia vs MOD?
A
Mild = pre-med with major tx
MOD- pre-med with all
Seve = no tx
2
Q
23 yo Male, college athlete. Got it with a hockey puck. Trauma sustained only to #9. Drinks on occasion. No family hx of illness. What is his ASA status?
A
ASA 1
3
Q
The ANC count helps assess _______?
A
the gravity of the leucopenia
4
Q
Healthy patient with NO organic, physiologic, or psychiatric disturbance and with good exercise tolerance, non-smoking, no or minimal alcohol use
Patients are able to walk up one flight of stairs or two level city blocks without distress.
Patient has little or no anxiety
A
ASA 1
5
Q
ANC Calculation Formula:
A
ANC = Total WBC count x (% Neutrophils + % Bands*)
Example: WBC 2000 x (45 Neutrophils + 5 Bands ) ÷ 100 = 1000 Neutrophils
6
Q
T/F. Ok to use local anesthetics containing EPI in ASA 2 pts
A
True
Stress management for ASA 1/2 pt: O2 + N2O ; Benzos
EPI ok
7
Q
Only use which local anesthetic _____________ (if not hypoxic) in the ASA IV patients
A
Carbocaine (3% mepiv) or Citanest plain (4% Prilocane)
8
Q
MCP with MOD perio needs gum flap surgery. Labs show ANC of 700. Can you treat this patient now or wait for better health status. Does he needs any medication pre/post- tx?
A
MOD NEUTROPENIA: 500-1000
OK to treat
Gum flap sx = major dent tx –> needs pre-med
Give antibiotics for 3-5 days after major dentistry
9
Q
Stress management for ASA 1/2 pt:
A
O2 + N2O
Benzos [Versad; Triazolam; Diazepam (Valium); Ativan (Benadryl)]
LA with Epinephrine or epinephrine cords can be used
10
Q
47 YO M. DM2. Homeless. Right foot ulcer. Chronic bronchitis. ETOH dependence.
A
ASA 3
11
Q
79 yo granny in SNF d/t TIA last month with wiht defecits to Right side.
A
ASA 4
12
Q
T/F.
ASA 3/4 patients may be treated for 3 hours in a horizontal or semi-sitting position
A
F.
These patients should not be in the chair for more than 1 ½-2 hours
13
Q
66 yo fm. Former athlete now gym teacher. Lives alone. No family/spouse.Drinks glass of wine with dinner. HTN for the past 10 years. Takes SSRIs for bouts of depression. ASA status.
A
ASA 2
14
Q
T/F. Ok to give ativan or NO2 to mod anx ASA 2 pt
A
T
Stress management for ASA 1/2 pt: O2 + N2O ; Benzos
EPI ok
15
Q
Calc ANC:
WBC: 2000
% Neutrophils: 45
% bands: 5
A
[ 2000 * (45+5) ] / 100 = 1000
16
Q
Male pt with ANC of 1000-1,500 Neutrophils/mm3
A
MILD NEUTROPENIA:
17
Q
SEVERE NEUTROPENIA:
A
0-500 Neutrophils/mm3
Severe life threatening infection risk
18
Q
- Male personal trainer. MOD anx to dentist. NOo illness or dz. ASA status
A
ASA 2
19
Q
Female pt with Hgb 12-16. Anemia status?
A
None. 12- 16 is normal in Females
Male normal is 13.5 - 17.5 g/dL
20
Q
Examples include (but not limited to): Recent ( < 3 months): MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia, unstable angina or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing dialysis; symptomatic COPD, symptomatic CHF, hepatorenal failure
Patients are unable to walk up one flight of stairs or walk two level city blocks. Distress is also present at rest.
A
ASA 4
21
Q
MODERATE NEUTROPENIA = ANC value of?
A
500-1,000 Neutrophils/mm3
Moderate risk of infection
22
Q
Hgb lvls for :
MILD (M/F)
MOD (M/F)
SEV (M/F)
A
- MILD: 10-13(m) ; 9-12 (F)
- MOD: 7-9 (m) ; 6- 8 (f)
- SEV: <7 (m) ; <6 (f)
23
Q
47 YO M. DM2. Homeless. Right foot ulcer. Chronic bronchitis. ETOH dependence. ESRD scheduled for dialysis MWF but goes when he feels like, sometimes not at all.
A
ASA 4
24
Q
T/F. Ok to use Epi cord in ASA 3/4 pts
A
NO F.
Avoid LA with 1:100,000 EPI in ASA3/4
LAs with 1:200k epi may be used in the ASA III patient
Use Alum cords instead of epinephrine cords
Alum is a good substitute as a hemostatic agent
Alum is safer and has fewer systemic effects
25
AIDS pt comes into the office with pain in RUQ. Labs show ANC of 420. What is his immune status? Can you treat him?
SEVERE NEUTROPENIA: 0-500 Neutrophils/mm3
Severe life threatening infection risk
NO TX
26
56 yo dad retired veteran. Hx of agina/MI 6mo ago. No surgical intervention needed.
ASA 3
27
The Normal ANC Count:
1,500-7,200 cells/mm3
28
28 yo female. Walks 5miles a day. 26 wks gestation. No hx of illness/dz.
ASA 2
29
Males pt wiht Hgb <7
SEV Anemia
30
Pink puffer/Blue bloater
ASA 4 - COPD with symptoms
31
No functional limitations; has well-controlled mild disease of ONE body system. & without substantive functional limitations
Examples include (but not limited to):
Well controlled DM/HTN without systemic effects; current cigarette smoking/social drinking,
mild lung disease but without COPD;
pregnancy, obesity (30 < BMI < 40),
healthy ASA I patients who show a more extreme anxiety and fear toward dentistry
Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop after reaching the top
ASA 2
32
28 yo teacher. Frightened, worried or teary eyed when hears high-speed hand drill
ASA 3
33
Stress management for ASA 3/4 :
O2 + N2O ( is a must)
Stress management can also be preemptive using NTG/Isordil/inhaler spray
DO NOT use Benzodiazepines
34
70 yo male with mild lung disease but without COPD. ASA status?
ASA 2
35
Substantive functional limitations; One or more moderate to severe diseases involving more than one system or one major system. No immediate danger of death.
Examples include (but not limited to):
Poorly controlled DM/HTN,
COPD with INTERMITTENT symptoms, morbid obesity (BMI ≥40),
active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction,
ESRD undergoing dialysis, controlled congestive heart failure (CHF), stable angina, old history of (>3 months): MI, CVA, TIA, or CAD/stents.
Frightened, worried or teary eyed patient
Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop frequently because of distress.
Thus have substantive functional limitations.
ASA 3
36
Can you give ASA3/4 Benzos? Lidocane?
NO!!
NO!! ( lido/Xylocaine = 1:50k or 1:100k)
Avoid LA with 1:100,000 EPI in ASA3/4
LAs with 1:200k epi may be used in the ASA III patient
Only use Carbocaine or Citanest plain (if not hypoxic) in the ASA IV patients
37
T/F. YOu can give COPD pt NO2 but not benzos
F.
All types of stress management is contraindicated especially with MO-SEV-very severe COPD: Use preemptive inhalers instead
Use low dose Ativan or Valium cautiously in the MILD COPD patient after
confirming with MD: Preemptive inhalers instead can also be used
38
T/F. Low does Ativan is ok in MOD-SEV COPD pts
F.
low dose Ativan or Valium ok when used cautiously in the MILD COPD patient after confirming with MD
39
T/F. Avoid LA with 1:100,000 EPI in ASA3/4
T/F. LAs with 1:200k epi may be used in the ASA III patient
T
T
Use Alum cords instead of epinephrine cords
Alum is a good substitute as a hemostatic agent
Alum is safer and has fewer systemic effects
40
86 yo f. Third degree heart block. Implanted pacer to LUChest. On Digoxin, metoprolol, asprin 81mg.
ASA 3
41
LAs ok to give with each degree of anemia (mild, mod, sev)
MILD: xylocaine (epi) , max 2 carpules
MOD: Marcaine 1:200k for major procedures; Carbocanie for routine
SEV: NO/Defer Tx
42
Stress Management drugs (3):
Benzos, Barbituates, Narcotics
43
MAx dose Valium?
Max. dose 10 mg PO
44
AVOID CITANEST or ARTICAINE in
| 4 pt groups
>Patients with moderate to severe anemia
>Patients with severe COPD
>Patients with cyanotic congenital cardiac defects
>Patients with neuro-muscular dysfunction such as:
- MD, MG, MS, ALS, Neuropathies of various kinds
45
Can you tx pt with stress management drugs if they walked to the office/was dropped off?
NO.
Use Benzodiazepines only if the patient can be ESCORTED to the office
46
Common causes for Macrocytic cells are:
Pernicious anemia/B12 /Folic acid deficiency
HIV/AIDS medications
Some Cytotoxic drugs
47
Draw out Anemia Patterns chart:
Micro,Hypo Marco,Normo Normo,normo
hgb dec dec dec
hct dec dec dec
MCV dec INC NORM
MCHC dec NORM NORM
Dx: Hgb Synth: DNA synth: Dec RBC:
Fe Def Pernic Anem SLE
Thalassemia B12 and Folate RA
Cytotox rx CRF
HIV/AIDS
Dilantin
48
Oxygen + IV methylene blue 1% solution (10 mg/ml) 1-2 mg/kg slowly over 5 minutes( Repeat the dose in 1h if needed) is the treatment for?
Methemoglobinemia crisis
[Methglob lvls inc by sulfonamides (abx), LA (citanest/articaine/benzocaine) ]
49
Safe abx for anemias?
- Penicillins
- Macrolides (NOT with iron pills for Fe def anemia)
- Clindamycin
- Cephalosporins
50
Polycythemia Vera should be considered when:
Hematocrit is _____ in women and ____ in men
Hemoglobin is _____ in women ____in men
Hct: > 48% FM and > 52% M
Hgb: > 16.5 FM and > 18.5
51
Polycythemia is a condition associated with an _____ number of circulating RBCs
increased
Neoplastic bone marrow disorder characterized by ↑ production of hematopoietic cells
It mainly causes an increased Red Cell mass; MCV, MCH may be normal or decreased
52
Polycythemia Vera Treatment (PAAS)
PAAS
- Phlebotomy: 1/k keep hct < 45% in men < 42% in women
- Aspirin: 81 mg daily
- Antineoplastic therapy: ↑ risk for thrombosis (Hydroxyurea)
- Splenectomy: if splenomegaly or repeat splenic infarction
53
In the presence of significant thrombocytopenia assess CBC with platelets. The lab test must be_________
less than 7 days old
54
Out-patient OMFS/Periodontal surgery: Platelet count must be_______.
Major dental procedures done in OR: Platelet count must be _________.
> 75,000/mm3
> 100,000/mm3
55
LA to avoid with anemias
AVOID CITANEST & ARTICAINE with all anemias ESPECIALLY if the anemia is moderate-severe
56
LA to use in pt with G6PD anemia
Use Carbocaine ONLY with G6PD anemia
57
Anelgesics to avoid wiht anemic pts
AVOID Aspirin & NSAIDs
58
___________ is a form of hemoglobin that contains iron in the oxidized or ferric state which does not bind oxygen
Methemoglobin
Methemoglobin >30% of total hemoglobin causes hypoxia & cyanosis
59
Iron Deficiency Anemia & Thalassemia: Comparison
Iron Deficiency Anemia RDW: INCREASED
Thalassemia: RDW: NORMAL
All else equal (RBC, Hgb,Hcty, MCV, MCHC all dec/microcytic/hypochromic)
60
Congenital / Hemolytic Anemias? (4)
- Sickle cell
- Thalassemia major / minor
- Hereditary Spherocytosis
- G6PD Deficiency Anemia
61
When abundant immature cells enter the circulation, CBC can show:
Shift to the Left” or Myeloid Reaction:
assoc w/ an influx of immature bands in the bld--> response to acute bacterial infection, like Pneumonia
Shift to the Right” or Lymphoid Reaction:
Assoc w/ an influx of immature lymphocytes in bld
--> response to viral infections
62
AVOID using Benzodiazepines in:
- MG
- Pregnant or Lactating
- Obese
- Frail elderly
- severe respiratory insufficiency or sleep apnea
- severe hepatic insufficiency
- CNS drugs or H2 blockers
BENZOs ( Versed, Valium, Ativan)
Antidote= Romazicon
63
INC WBC Count + DEC Neutrophils + INC Lymphocyte Pattern
viral infections
64
Can LAs like articaine or cinest be give to anemic pt?
No.
NO sve anemia
NO COPD
NO Congentical heart defects
NO MS, MD, MG, ALS
65
T/F. All epinephrine containing LAs contain metabisulfite
T
66
Initial Narcan dose?
0.4 mg to 2 mg is given IV increments of 0.1-0.2 mg q2-3 minutes intervals
UNDILUTED IV Narcan for Acute Respiratory Distress (ARD) needing full Reversal:
Administer 0.4 mg UNDILUTED (entire 1 mL vial) IV, push over 15 seconds
May repeat q2-3 minutes as needed till patient opens his/her eyes & talks in 1-2 minutes
67
Analgesics for G6PD:
- OxyContin without Tylenol
- Codeine Phosphate
- Tramadol
68
Safe anagelsics for anemics
SAFE Analgesics: Regular strength/RS Tylenol
| Oxycodone/Codeine/Hydrocodone with Tylenol
69
The normal Hematocrit:
37%-47%
70
_____is the leading cause for MICROCYTIC cells followed by Thalassemia
Iron deficiency
71
Polycythemia Vera (PV) Oral Features
| NVIP
```
Pale mucosa
Reactive keratosis
Different forms of candidiasis
Mucosal ulcers
Gingival bleeding and various degrees of gingival enlargement
```
72
INC WBC Count + INC Neutrophil Count Pattern
bacterial infection
73
Abx to avoid in G6PD pt?
Avoid sulpha drugs (eg Bactrim) - to prevent hemolysis
Bactrim (Trimethoprim & Sulphamethoxazole) is not effective for oral infections - treats RI/UTIs
74
The normal RBC Count:
Male patients: 4.5-5.9 million/microL
| Female patients it is 4-5.2 million/microL
75
Bleeding disorders associated with oral manifestations & complications are (5):
- Iron deficiency anemia
- Hemolytic anemia
- Vitamin B12 & Folate deficiency anemia
- Aplastic anemia
- Polycythemia
76
The Reticulocyte count (not part of CBC) also evaluates the status of:
Anemia
Polycythemia
Hemochromatosis
77
Drugs affecting Platelet Function
- Aspirin
- NSAIDS**
- ADP inhibitors
- Clopidogrel (Plavix)
- Ticlopidine (Ticlid)
*The Platelet COUNT is not affected by any one of these drugs
**All except NSAIDS, irreversibly & permanently affect entire life-span of platelets
NSAIDS affect is temporary lasts till drug clears system (24 hours )
78
Should I stop the thrmobosis regime (asa + plavix) for my dental pt? Minor tx? Major tx?
NO. Minor tx ( amalgams/Composites, Cleanings, Deep scaling) No need to stop any one of these drugs
MAJOR:
Consult with the patient’s MD before you plan to stop any of these drugs.
If approved,all stopped 7 days prior to surgery. Then restarted 1-2 days post op.
Stop NSAIDS 24 h prior to surgery; restart evening of/next day once bleeding stops
79
Thrombocytopenia Causes:
Drugs ( IV Heparin, Chemo, etoh)
Cancer ( Leukemia, Lymphoma or BM tumors)
Infections (HIV, Mumps, Rubella or Parvovirus)
Spleen (Sequestration of PLTs by enlarged Spleen)
ITP (Autoimmune destruction of PTLS by IgG)
80
ITP occurs from antibody destruction of the___
platelets
81
Always consult with MD prior to dentistry if platelet count is______
< 50,000/mm3
82
Thrombocytopenia Treatment (except ITP):
Platelet Rich Plasma (PRP)
Platelet Rich Concentrate (PRC) transfusion
Desmopressin/Stimate/DDAVP
83
______ Occurs more commonly in men and post menopausal women and is the most common genetic disease in Caucasians
Hemochromatosis
Excess iron is stored in the tissues of major organs, esp liver and this --> toxic to the body --> organ failure
84
T/F:
1. All Type 3 are not able to transport Factor VIIIc
2. All Type 2 patients are not able to transport Factor VIIIc
1. True.
2. False
All Type 3 & some Type 2 patients are not able to transport Factor VIIIc
85
Local Hemostats
- Microfibrillar Collagen (Avitene or Helistat)
- Gel foam
- Thrombostat
- Fibrin Glues
- Surgicel
- Amicar or Cyklokapron Mouthwashes
- Calcium Sulfate
- Moist tea bag ( tannic acid)
86
VWD Dental Guidelines
Surgery can begin immediately after Factor transfusion
Cryoprecipitate contains 10 times the amount of Factor VIII compared to
FFP & the highest concentration of VWF
The use of Cryoprecipitate is strongly discouraged by National
Hemophilia Foundation, (except in life-threatening situations) when no
VWF concentrate is available
This is because Cryoprecipitate is NOT virally inactivated
87
ORAL ANTI-FIBRINOLYTIC DRUGS:
Tranexamic acid (Cyklokapron)
Epsilon Aminocaproic acid (Amicar)
Before you prescribe anti-fibrinolytic drugs PO, always confirm patient has no prior hx of:
Mod-sev HA, acute vision problems, TIAs, CVAs, blood clots or H/O thrombosis
Confirm that the liver and kidney are optimally functioning
88
t/f. Chronic small bowel disease affects Vitamin K absorption
t
89
ITP is treated with
| ?
Corticosteroids, immune-globulins or splenectomy
- Initial(1mg/kg/day Prednisone, P.O for 2-6 weeks)
- Subsequent (Prednisone dose is individualized, usually tapered to < 10mg per day x 3 months and then withdrawn)
- Splenectomy is done if discontinuation of Prednisone causes a relapse
90
In patients who have mild to moderate VWD what can be given for hemostasis?
Tranexamic acid is given topically as "swish & spit" every 6 hours
Applied pressure
Other Topical agents
Suturing of surgical sites
91
Platelet transfusion when needed is given______prior to planned procedure
20 minutes
1 platelet concentrate transfusion increases the platelet count by 10,000
92
With chronic steroid use, check for ___?
- oral candidiasis,
- increased susceptibility to infections
- osteoporosis
93
VWD Dental Guidelines
Consult with the patient’s MD for the Type & severity of the condition
Relay to the MD the type of procedures planned, both major and minor dentistry
Confirm if DDAVP/Factor/Platelet transfusion/Topical rinses is/are needed
With IV DDAVP the surgery can begin in 30-60 minutes
With oral/PO or intranasal DDAVP, the surgery can begin 60-90 minutes later
With Platelet transfusion the surgery can begin in 20 minutes
94
Avoid_______ with Coumadin, IV Heparin, LMWH & all NOACs
ASPIRIN or NSAIDs
95
______ can occur without interruption of anticoagulation with NOACs
Extractions
Novel Oral Anticoagulants (NOACs)
