med complex management Flashcards
precautions to take in patients with uncontrolled hypertension
avoid cox 2
avoid nsaids
avoid azoles with statins
avoid macrolides with ccb
caution vasoconstrictor eg avoid adrenaline containing retraction cord, topical vasoconstrictor for hemostasis
avoid intraligamentary, intraosseous, iv injection
aspirating syringe
what medication should i not give a patient who has recently undergone CABG
cox 2 inhibitors
nsaids
macrolides
azoles
how long to defer treatment by after cabg or ptca
3-6 months
defer by 1 year for elective surgical procedure
min 6 weeks for bare metal stent
6 months for drug eluting stent
how long to defer treatment by after AMI
3 months for routine treatment
6 months for invasive treatment, GA
precautions to take for a patient post ceid insertion
avoid diathermy electrocautery mri due to electromagnetic interference
defer by one month post insertion, ensure functional capacity is adequate
no antibiotic prophylaxis is required
avoid bupivacaine
caution vasoconstrictors
Patient is on clopidogrel for hypertension management. Needs to do extraction. What pre op planning needs to be done
Do not stop anti platelets
max dosage of adrenaline for patient with uncontrolled hypertension
0.04mg
why do we avoid azoles and macrolides in patients with htn
macrolides inhibit cytochrome, causing accumulation of statins and ccbs
azoles can increase the risk of statin associated myopathy
what is an acute hypertensive crisis
sudden severe increase in bp to ≥180/120mmHg
what should you check for if you suspect acute hypertensive crisis
dyspnea – pulmonary edema
chest discomfort – MI, aortic dissection
neurological deficit – stroke
nausea and vomiting – increased intracranial pressure
can you treat a patient with chest pains
Unstable angina eg occurs at rest, unresponsive to GTN – do not do elective dental treatment
stable angina eg only on exertion, relieved with rest and medication – treat with precautions such as stress reducing protocol, caution vasoconstrictor, avoid NSAIDs and COx2 inhibitors, GTN on standby
how long to defer treatment by afeer MI
if patient is deemed low risk, non invasive treatments can be deferred by 60 days
otherwise, non invasive treatment should be deferred by 3 months
invasive, surgical procedures should be deferred by 6 months
what medication is a patient on 3 months after PTCA? and what is my management?
dual anti platelets (high risk of stent thrombosis within first year of placement)
do not stop anti platelets, current recommendation is to not modify, though some may continue with aspirin and stop other anti platelet
avoid elective care for 6 months to 1 year. consult cardio for invasive procedure
> 3 exo, do over multiple visits
patient on dual anti platelet therapy will need to undergo major dental surgery. what to do?
stop p2y12 inhibitor 5-7 days prior to surgery, continue with aspirin unless bleeding risks prohibitive
restart 3 days after surgery
can i do routine dental treatment for a patient with an arrythmia?
yes (with stress reducing protocols, pain control, monitor pulse rate and pressure)
however, in some situations, treatment should be deferred
- symptomatic
- pre existing cardiac disease
- high grade av block
- ventricular arrhythmia
- supraventricular arrhythmia with uncontrolled ventricular rate
why do i need bleeding precautions in a patient with cardiac arrhythmia?
may be on warfarin or dabigatran or rivaroxaban due to increased risk of stroke
what medication to avoid in patients with cardiac arrhythmias
macrolides
azoles
bupivacaine
what does chads2 score mean
measures the thromboembolic risk in a patient with non valvular atrial fibrillation
congestive heart failure
hypertension
age>75
diabetes
stroke/tia
can i treat a patient with congestive heart failure?
nyha 1 and 2 can be treated. nyha 3 and 4 (marked limitation or unable to carry out physical activity) should not receive elective treatment
simplify treatment
bleeding precautions
minimise vasoconstrictors
avoid erythromycin, tetracycline if on digoxin
avoid nsaids, cox 2 inhibitors, corticosteroids (fluid retention)
consider terminating procedure if patient starts getting breathless
avoid supine position
signs of poor compensation for congestive heart failure
paroxysmal nocturnal dyspnea
orthopnea
dypsnea on exertion at level of activity that is usually well tolerated
peripheral edema
fluctuating body weight
when do symptoms of infective endocarditis develop
2 weeks after procedure
signs of infective endocarditis
fever in the presence of risk factors
- previous ie
- recent dental or surgical procedure
- congenital heart defect
- immunosuppression
- injection drug use
heart murmur
persistent bacteremia
immunological and emboli phenomenon
oral petechiae
conditions requiring antibiotic prophylaxis for prevention of infective endocarditis
previous ie
unrepaired congenital cyanotic heart defect
congenital heart defect repaired with prosthetic patch or device with residual defect, or within 6 months of procedure
prosthetic heart valve
prosthetic material for heart valve repair
cardiac transplant with with valve regurgitation due to abnormal structure of valve
how is antibiotic prophylaxis given
amox 2g 1h before procedure
if allergic to amox, cephalexin 2g or azithromycin 500mg or doxycycline 100mg
what guidelines should be followed if multiple rounds of ab prophy needed
1 month before 2nd dose of same antibiotic
10-14 days interval for alternating antibiotic regime
precautions that should be taken for a patient with asthma
should use regular asthma medication several days before and after dental treatment
consider prophylactic puff before procedure
bring inhaler to appointment
avoid nsaids, cox2 inhibitors, aspirin, macrolides and ciprofloxacin wtih theophylline, avoid narcotic analgesics with benzodiazepine
avoid ga
treatment best done in the late morning or early afternoon
short appointments with frequent rests
consider terminating treatment if becomes dyspneic
how to assess whether patient’s asthma is suitably controlled to tolerate dental treatment
≥80% peak expiratory flow rate
when can a pregnant person get dental treatment
best to do treatment in 2nd trimester or early 3rd
elective dental treatment should be avoided in the first trimester
what medication to avoid in pregnant women
aspirin, nsaids (ductus arteriosus closure, adverse events associated at third trimester)
tetracycline
drug administration should generally be avoided in pregnancy, especially in the first trimester
what analgesic can i prescribe a pregnant woman
acetaminophen/paracetamol
what antibiotics can i give a pregnant woman
amoxicillin, cephalexin, clindamycin , erythromycin, penicillin
what is well controlled diabetse
hba1c < 7%
routine dental treatment and minor oral surgery procedure can be carried out in well controlled diabetics
when do i need to prescribe supplemental steroids prior to procedure, and how is it administered
stressful procedure eg extensive procedure, oral surgery
patient is currently on systemic steroid
on systemic steroids ≥7.5mg in the past 2 weeks to one month
on systemic steroids for more than one month in the past year
administration:
within 2 hours before LAOP, take double regular dose of oral steroids, or 25-50mg IV hydrocortisone hemisuccinate for minor surgery
in a patient with untreated hypothyroidism, avoid use of
cns depressants eg narcotic analgesics, barbiturates
management of hemophiliac patient
consult hematologist and determine severity of disease, level of factor correction if required
patient may require pre op transfusion of 50-100iu/dl factor 8 or 9
local hemostatic measures eg antifibrinolytic agents such as tranexamic acid, surgicel
prolonged observation
avoid nsaids, aspirin. use acetaminophen +/- codeine for analgesia
management for patient on single anti platelet therapy prior to minor oral surgical procedure
modification not required
if major bleeding is anticipated, drug holiday is needed.
7 days preop and 3 days post op; aspirin only 3-5 days pre op required
following acute venous thrombosis episode, how long should dental treatment be deferred for
patient should have received 3 months of anticoagulation (min 1 month)
guidelines for how to proceed with patient on warfarin
check inr
<2.5 safe to proceed with routine dental treatment such as simple extractions, with the use of local hemostatic measures
2.5-3.0 refer to OMS
> 3.0 refer for reversal, defer until INR controlled. consult medical physician.
options for warfarin reversal
decrease in dosage
bridging IV heparin therapy
bridging LMW subc heparin
stop for 3 days prior to procedure, take inr on the day of procedure. stop heparin 6-18 hours prior to procedure. restart warfarin 12-24 hours after surgery. heparin min 4 days as warfarin takes 96 hours to reach peak effect
in case of emergency, fresh frozen plasma, vitamin k, prothrombin complex concentrate
drug interactions with warfarin
nsaids, aspirin, tramadol, metronidazole, erythromycin, doxycycline, corticosteroids potentiate bleeding
barbiturates and carbamazepine inhibit warfarin, putting patient at risk of clotting
pre operative local hemostatic measures
vasoconstrictors
intra op local hemostatic measures
thorough curettage to remove granulation tissue
atraumatic procedure
post op local hemostatic measures
pressure
suturing
TXA (antifibrinolytic agent)
local hemostats eg gelatin sponge, oxidised cellulose
poig
how to discontinue heparin bridging after procedure
continue heparin for minimum of 4 days as peak antithrombotic effect of warfarin is delayed 96 hours, until INR reaches desired range
what patients are at high risk for bleeding
known bleeding disorders eg clotting factor defects
abnormal blood parameters despite no known bleeding disorders
** anti coag and anti platekets are moderate risk
dental surgery can be performed how many hours after heparin dose
Ufh: 6-8h
LMWH: 18-24h
management of patients on noacs eg dabigatran, rivaroxaban
no reversal agent
for minor surgical procedures, do not alter. but avoid performing surgery at peak activity (2-3h after dose)
for major surgical procedures, consider cessation for 24h
avoid medications that can affect anticoagulation effect.
erythromycin, nsaids, clopidogrel can increase anticoagulation in dabigatran
nsaids can increase anti coagulation in rivaroxaban
what are the various laboratory tests available to test hematologic parameters
FBC - platelet, rbc, wbc
PT - extrinsic pathway, warfarin
ApTT - intrinsic pathway, heparin, hemophilia
INR - standardised PT time, measure extrinsic pathway
Bleeding time - time from onset to first arrest of bleeding
what are the considerations in treating a patient with hepatic disease?
bleeding tendency (production of coagulation factors), need local hemostatic and possibly systemic hemostatic measures
impaired drug metabolism – nsaids, paracetamol, lidocaine, mepivacaine
hepatotoxic drugs eg clarithromycin
defer elective treatment in patients with decompensated liver disease eg present with jaundice
considerations for patient with renal disease
avoid nephrotoxic drugs
impaired metabolism eg amoxicillin
on anti thrombotic medication during hemodialysis (LMWH, defer procedure 12h after last dose)
platelet destruction during hemodialysis
schedule appt outside of dialysis days
oral manifestation of hiv/aids
linear gingival erythema
kaposi sarcoma
oral hairy leukoplakia
oral candidiasis
nug
management of patient undergoing active chemotherapy
patient is very immunosuppressed
emergency dental treatment only, consider need for ab prophy
do nothing + prescribe antibiotics
oral manifestations
timing of dental management for epileptic patients
anti convulsants 2-3h prior to procedure
avoid elective dental procedures in patients with poorly controlled seizures (>1 per month), hospital based if necessary
avoid if lethargic, behavioural changes
intraoperative precautions for epileptic patients
strong suction
avoid multiple cotton rolls
avoid precipitators
mouth prop
medications to avoid in patients with epilepsy
increased bleeding risk due to action of valproic acid on platelets, avoid nsaids and aspirin
avoid tramadol as can precipitate seizures
avoid macrolides in patients taking anti convulsants
long term aed use can cause osteoporosis, caution oms
caution paracetamol – hepatotoxicity as side effect of AED
