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med complex management Flashcards

1
Q

precautions to take in patients with uncontrolled hypertension

A

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

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2
Q

what medication should i not give a patient who has recently undergone CABG

A

cox 2 inhibitors
nsaids
macrolides
azoles

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3
Q

how long to defer treatment by after cabg or ptca

A

3-6 months
defer by 1 year for elective surgical procedure

min 6 weeks for bare metal stent
6 months for drug eluting stent

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4
Q

how long to defer treatment by after AMI

A

3 months for routine treatment
6 months for invasive treatment, GA

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5
Q

precautions to take for a patient post ceid insertion

A

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

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6
Q

Patient is on clopidogrel for hypertension management. Needs to do extraction. What pre op planning needs to be done

A

Do not stop anti platelets

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7
Q

max dosage of adrenaline for patient with uncontrolled hypertension

A

0.04mg

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8
Q

why do we avoid azoles and macrolides in patients with htn

A

macrolides inhibit cytochrome, causing accumulation of statins and ccbs

azoles can increase the risk of statin associated myopathy

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9
Q

what is an acute hypertensive crisis

A

sudden severe increase in bp to ≥180/120mmHg

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10
Q

what should you check for if you suspect acute hypertensive crisis

A

dyspnea – pulmonary edema
chest discomfort – MI, aortic dissection
neurological deficit – stroke
nausea and vomiting – increased intracranial pressure

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11
Q

can you treat a patient with chest pains

A

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

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12
Q

how long to defer treatment by afeer MI

A

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

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13
Q

what medication is a patient on 3 months after PTCA? and what is my management?

A

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

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14
Q

patient on dual anti platelet therapy will need to undergo major dental surgery. what to do?

A

stop p2y12 inhibitor 5-7 days prior to surgery, continue with aspirin unless bleeding risks prohibitive

restart 3 days after surgery

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15
Q

can i do routine dental treatment for a patient with an arrythmia?

A

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

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16
Q

why do i need bleeding precautions in a patient with cardiac arrhythmia?

A

may be on warfarin or dabigatran or rivaroxaban due to increased risk of stroke

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17
Q

what medication to avoid in patients with cardiac arrhythmias

A

macrolides
azoles
bupivacaine

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18
Q

what does chads2 score mean

A

measures the thromboembolic risk in a patient with non valvular atrial fibrillation

congestive heart failure
hypertension
age>75
diabetes
stroke/tia

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19
Q

can i treat a patient with congestive heart failure?

A

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

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20
Q

signs of poor compensation for congestive heart failure

A

paroxysmal nocturnal dyspnea
orthopnea
dypsnea on exertion at level of activity that is usually well tolerated
peripheral edema
fluctuating body weight

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21
Q

when do symptoms of infective endocarditis develop

A

2 weeks after procedure

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22
Q

signs of infective endocarditis

A

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

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23
Q

conditions requiring antibiotic prophylaxis for prevention of infective endocarditis

A

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

24
Q

how is antibiotic prophylaxis given

A

amox 2g 1h before procedure
if allergic to amox, cephalexin 2g or azithromycin 500mg or doxycycline 100mg

25
Q

what guidelines should be followed if multiple rounds of ab prophy needed

A

1 month before 2nd dose of same antibiotic
10-14 days interval for alternating antibiotic regime

26
Q

precautions that should be taken for a patient with asthma

A

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

27
Q

how to assess whether patient’s asthma is suitably controlled to tolerate dental treatment

A

≥80% peak expiratory flow rate

28
Q

when can a pregnant person get dental treatment

A

best to do treatment in 2nd trimester or early 3rd
elective dental treatment should be avoided in the first trimester

29
Q

what medication to avoid in pregnant women

A

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

30
Q

what analgesic can i prescribe a pregnant woman

A

acetaminophen/paracetamol

31
Q

what antibiotics can i give a pregnant woman

A

amoxicillin, cephalexin, clindamycin , erythromycin, penicillin

32
Q

what is well controlled diabetse

A

hba1c < 7%

routine dental treatment and minor oral surgery procedure can be carried out in well controlled diabetics

33
Q

when do i need to prescribe supplemental steroids prior to procedure, and how is it administered

A

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

34
Q

in a patient with untreated hypothyroidism, avoid use of

A

cns depressants eg narcotic analgesics, barbiturates

35
Q

management of hemophiliac patient

A

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

36
Q

management for patient on single anti platelet therapy prior to minor oral surgical procedure

A

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

37
Q

following acute venous thrombosis episode, how long should dental treatment be deferred for

A

patient should have received 3 months of anticoagulation (min 1 month)

38
Q

guidelines for how to proceed with patient on warfarin

A

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.

39
Q

options for warfarin reversal

A

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

40
Q

drug interactions with warfarin

A

nsaids, aspirin, tramadol, metronidazole, erythromycin, doxycycline, corticosteroids potentiate bleeding

barbiturates and carbamazepine inhibit warfarin, putting patient at risk of clotting

41
Q

pre operative local hemostatic measures

A

vasoconstrictors

42
Q

intra op local hemostatic measures

A

thorough curettage to remove granulation tissue
atraumatic procedure

43
Q

post op local hemostatic measures

A

pressure
suturing
TXA (antifibrinolytic agent)
local hemostats eg gelatin sponge, oxidised cellulose
poig

44
Q

how to discontinue heparin bridging after procedure

A

continue heparin for minimum of 4 days as peak antithrombotic effect of warfarin is delayed 96 hours, until INR reaches desired range

45
Q

what patients are at high risk for bleeding

A

known bleeding disorders eg clotting factor defects
abnormal blood parameters despite no known bleeding disorders

** anti coag and anti platekets are moderate risk

46
Q

dental surgery can be performed how many hours after heparin dose

A

Ufh: 6-8h
LMWH: 18-24h

47
Q

management of patients on noacs eg dabigatran, rivaroxaban

A

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

48
Q

what are the various laboratory tests available to test hematologic parameters

A

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

49
Q

what are the considerations in treating a patient with hepatic disease?

A

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

50
Q

considerations for patient with renal disease

A

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

51
Q

oral manifestation of hiv/aids

A

linear gingival erythema
kaposi sarcoma
oral hairy leukoplakia
oral candidiasis
nug

52
Q

management of patient undergoing active chemotherapy

A

patient is very immunosuppressed
emergency dental treatment only, consider need for ab prophy
do nothing + prescribe antibiotics
oral manifestations

53
Q

timing of dental management for epileptic patients

A

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

54
Q

intraoperative precautions for epileptic patients

A

strong suction
avoid multiple cotton rolls
avoid precipitators
mouth prop

55
Q

medications to avoid in patients with epilepsy

A

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

Oms (24 decks)

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