medically complex Flashcards
what post op drugs to avoid in HTN patients
NSAIDs as prolonged use decreases the efficacy of antihypertensives and increases risk for MI/ stroke
whats the difference between STEMI and NSTEMI
STEMI is ST segment elevation MI that is caused by complete blockage of coronary blood flow and more profound ischemia
NSTEMI is MI without ST segment and is caused by a partial blockage of coronary flow
drugs contraindicated in patients who recently undergone CABG surgery or patients with recent MI
all NSAIDs contraindicated
what is normal INR, INR for mechanical heart valves and INR that we can do exo
normal INR is 1, above 1 means clotting time is prolonged
INR maintained at 2.5-3.5 for mechanical heart valves bc they are thrombogenic
only do exo when INR is <3 for NUH guidelines
what painkiller portentiates warfarin
paracetamol!!!! if you take 2g a day for more than several days its unsafe bc it potentiates the anticoag response
NSAID is also a potentiator, we will still advise patient to take paracet for pain relief rather than NSAIDs but just beware not to take a higher dose of paracet
what is the INR required to hit after LMWH BRIDGING
<1.5
what are local measures to prevent excessive bleeding
- remove granulation tissue as granulation tissue tends to bleed more
- wound compression with pressure gaze
- local hemostatic agents - surgicel or gelfoam
- suture
- 5% tranexamic acid m/w 4x a daily for 2 days (Carter, Gross et al 2003)
- if necessary can consider electrocautery and bone wax
what platelet count is normal, and what count is necessary for the following
- major os procedure
- minor os procedure
- routine dental procedure
- defer all elective dental tx
normal is 150k to 400k per microliter or 150-400 x 10^9/L
> 80k major oral surgery can
> 50k minor oral surgery can
30-50k routine dental procedure
<30k defer all elective dental tx
how to test for if the patient is stroking out in chair, and what are the other possibilities?
FAST guideline
- face drooping
- arm weakness (raise both arms, see wheother one side drops)
- speech difficulty
- Time to call emergency services
other possibility might be that the LA injected into facial nerve
when is the safest to treat preggers
if really need to treat, treat in second trimester because first trimester is when all the embrylogical components are forming
and third trimester very hard for them to lie flat
what are the drugs to avoid after they give birth, when breastfeeding?
avoid:
codeine & tramadol bc ultra metabolism can cause infact death
use with caution:
- nsaids (avoid aspirin in particular due to reyes risk)
- antipsychotics
- antiepileptics
- metronidazole (controversial, some say pump & dump for 12-24 hours)
cat B drugs?
common causes of bleeding
coagulation disorders
1) long term use of anticoags or antiplatelets
- watch out for patients with CVD
2) HEMATOLOGIC disease
- hemophilia (lack of coag factor)
- leukemia
- thrombocytopenia
3) end stage liver disease
- lack of coagulation factors
what drugs to be cautious of for patients with asthma
- aspirin, NSAIDS (can cause bronchospasm)
- penicillin (adv reactions like hives, swelling, difficulty breathing, anaphylaxis)
- if patient is taking theophylline, avoid macrolides (erythromycin) because macrolides decrease clearance of theophylline and vice versa
- cant use cipro either as it reduces the clearance of theophylline
will cause respiratory depression:
- narcotic analgesics
- benzodiazepine
- sulfite preservatives in LA (eg sodium/ potassium metabisulfite) can cause adverse effects in some asthma patients, especially those with sulfite sensitivity and exposure can trigger bronchospasm, wheezing or even anaphylaxis
who are some patients at major risk of perioperative cardiovascular event
- unstable AP
- AP after MI
- MI <60 days to 6 months
- decompensated heart failure
- significant arrhythmias
are cardiac patients on anticoagulants or antiplatelets
usually anti platelets unless AF then its anti coagulant
for cardio, thrombus is usually protected by platelets so use anti platelet but for AF and DVT, clot is more of fibrin so we use anti coagulants
mx of dental patients who experience AP
if it is unstable, dont treat
if it is stable
- need to have precautions
- stress reducing protocol, short appts w rest
- monitor bp, pulse
- minimise vasoconstrictor
- bleeding precautions
- GTN (spray)
- standby o2
why cant nsaids be used for patients with cvd
because:
- nsaids can increase risk of heart attack, stroke, heart failure
- nsaids impair kidney function, lead to fluid retention, increased blood pressure, worsens heart failure and increase CVS risk
difference between mechanical Heart valves and bioprosthetic heart valves
mechanical heart valves
- more durable, usually used for younger patients
- but chronic anticoagulation with warfarin is required
- more thrombotic than bioprosthetic heart valves
bioprosthetic heart valves
- no long term anticoagulation needed (usually 3-6 months only)
- durability < mechanical HV (about 10-20 years)
What is CHF
An advanced stage of impaired heart function with oedema and congestion of pulmonary and systemic venous circulationImpaired
ability of ventricles to fill with or eject blood
Characterised by
- fluidoverload
- inadequate tissue perfusion
- dyspnoea and fatigue
What painkillers to avoid in CHF
All NSAIDs, because can induce fluid retention
What is the time period to defer provision of dental treatment for AMI
- highest risk < 30 days
- defer 3 months
- invasive dental procedures defer 6 months
- GA procedures defer 6 months
What time period to defer for PTCA/ DES
Percuteneous trasluminal coronary angioplasty / drug eluding stent
Routine dental work 3-6 months defer
Elective surgical dentistry defer 1 year
Time period to defer dental treatment for post CEID insertion and what to avoid
Defer 1 month
Avoid diarthemy, electrocautery sets and MRI (but now pacemakers are quite compatible with MRI)
what bacteria involved in causing IE
- Staphylococci
- strep and enterococci
do we think that dental procedures are the main cause of IE?
NO
new guideline is that we dont really prophy excpet for thos groups with risk of getting th worst adverse effects
- no consistent association between dental procedure and the development of IE
- regular toothbrushing almost presents a greater risk of IE than a single dental procdure bc of repetitive exposure to bacteremia with oral flora
- then they say ab prophy against IE for dental procedures may actually lead to a greatr number of deaths through fatal anaphylaxis than a strategy of no AB prophy, not cost effective
- poor OH and dental infections can produce bactermia in the ABSENCE of dental procedures so patients maintaining best possible oral health to reduce incidence of bacteremia from daily activities may be more important than prophylactic AB for reducing risk of IE
what AB to use for IE prophy
1) amox 2g oral
but if unable to take oral meds
- 2g ampicillin IM or IV
- 1g cefazolin/ ceftriaxone IM or IV
if allergic to penicillin
- 500mg azi or clari
- 100mg doxy
allergic to penicillin and unabel to take oral meds
- cefazolin/ ceftriaxone 1g IM or iv
what systemic disorder associated with increased seizures
Sturge weber
- port wine birthmark on face
- potential neuro complications like seizures
- oral vascular malformations
what do we need to note for epilepsy drugs
can have side effects
- dissiziness
- ataxia (cannot control muscle movements)
- hepatotoxicity
** drugs like sodium valproate can cause increased risk of bleeding and hence we should avoid aspirin and nsaids bc nsaids increase risk of bleeding
what dental stuff might precipitate seizures
- stress!
- hunger (make sure patient has had meals)
- infection
- lidocaine* (in large doses, because it has a concentration dependnet effect on seizures)
dental considerations for epilepsy patients in terms of drugs they are taking
- long term anti epileptic drugs can cause osteoporosis so we must be careful and check if the patient is on bisphos
- be aware that anti epileptic drugs can cause bone marrow suppression, decreased platelets (valproate)
- avoid NSAIDs post op if bleeding is a concern, prescribe panadol but not too much to avoid hepatotoxicity
- avoid tramadol as it can ppt seizures
oral manifestations of stroke ** (AR say he might as for finals)
- slurred speech
- flaccid, weak tongue
- dysphagia (difficulty swallowing)
- unilateral paralysis of orofacial musculature
- open jaw posture
- poor control of oral secretions, drooling
- end up developing cavities because they have food in their mouth and forget (food hoarding)
- risk of aspiration
- halitosis, infection
- denture issues
- decreased lip force so decreased masticatory efficiency
- loss/impaired protective reflexes so end up having decreased swallowing/ gag reflexes
- impaired oral sensitivity
- bleeding problems (because patients usually on anti thrombotic meds)
how long to defer treatment for stroke
defer elective dental procedures until 6-9 months post stroke
if it is a TIA, >3 months
what is sjogrens and how is it linked to RA
is the autoimmune destruction of exocrine glands (salivary & lacrimal)
- immune system attacks moisture producing glands and causes progressive inflammation & fibrosis
- T cells, B cells, plasma cells infiltrate the glands and leads to apoptosis of glandular epithelial cells thus reduce tear and saliva production
primary sjogrens will occur alone, without another autoimmune condition whereas secondary sjogrens will occur alongside another autoimmune disease, most commonly RA
why they are linked is because they have common autoantibodies
- rheumatoid factor found in both SS and RA
- Anti Ro and Anti La more specific to SS but sometimes seen in RA
what is an oral side effect that ppl with severe gastric issues might have
candidiasis due to long term omeprazole
omeprazole is PPI and it reduces stomach acid production, creating low acid environment that allows candida fungi to thrive and colonize stomach & esophagus
what considerations for renal patient during dental visit
- main cause of ESRD is diabetes, so px might be diabetic, need to ask bc affects wound healing, meds
- if its hemodialysis then patients are heparinized
- patients might have renal osteodystrophy because kidneys play a crucial role in maintaining mineral balance and hence bones might be more brittle in these folks
- likely have HTN because damaged kidneys cant regulate blood pressure effectively, leading to fluid buildup and hormonal imbalances that further increase blood pressure
- might have AV shunt in arm, when checking bp, dont cuff that arm
- have to avoid NSAIDs as it is excreted by kidney
- reduce dose of penicillin (normally is amox 500mg tds, but reduce to 250mg OD) bc most penicillins are excreted by kidneys and we dont want the drug to accumulate
- alternatively can give clindamycin (300mg qds or 400mg tds) as it is cleared by liver
what oral presentation sometimes if we drink too much alcohol or tea
alcohol and tea affects vit b12 absorption and when we are vit b12 deficient, get recurrent ulcers
what to give for hypoglycemia cases
1mg glucagon IM with glucose drink
or
IV 50% dextrose 50ml
oral manifestations of kidney disease patients
- more prone to infections/ candidasis because of grossly weakened immune system (can be because of immunosuppressants by renal transplants also)
- anemic tissues
- xerostomia
- halitosis (ammonia breath due to build up of urea products)
- renal osteodystrophy (bone resorption occurs at a higher rate, may have perio problems or may need to adjust dentures frequently)
what are some possible drugs taken by transplant patients and their oral side effects
1) cyclosporin (immunosuppressive to prevent rejection) -> gingival hyperplasia
2) mTOR inhibitors like tacrolimus, sirolimus -> oral ulcers
3) corticosteroids can give candidiasis
4) antihypertensives can cause xerostomia
what antibiotic to avoid in patients with liver disease
amox clauv aka augmentin because it is a common cause of drug induced liver injury
what drugs to avoid for renal disease patients
- Aminoglycosides (are neprhotoxic)
- NSAIDs
- antihypertensives
what are the drugs that might cause lichenid lesions that we have to look out for in HTN patient
- diuretic
- ACEI
- B blocker
drug considerations for hypertensive patients
1) potential oral side effects from anti hypertensive drug therapy
- Ca2+ channel blocker - DIGO
- diuretics, ACEI, B blcokers - lichenoid lesion
- hyposalivation
2) avoid prolonged use of NSAIDs
- NSAIDs inhibit COX, which will result in imbalance of TXA2 which is a potent vasoconstrictor
- NSAID also promote Na and water retention in kidneys, decreasing efficacy of anti HTN drugs, increase risk for MI and stroke
3) avoid macrolides in patients taking Ca channel blockers
- bc macrolides can exacerbate hypotensive effect, resulting in AKI
what drug to avoid in patients taking statins or ca2+ channel blockers and why
avoid macrolides because it will increase plasma level of statin, increasing risk of rhabdomylosis (myalgia and muscle weakness)
and also increase plasma level of ca channel blocker, result in severe hypotension and acute kidney injury
what antifungal therapy to give for candidiasis
local (nystatin, clotrimazole)
or
systemic (fluconazole)
what is the MOA of warfarin, DOA and reversal agents
it is a vit k antagonist which inhibits biosynthesis of vit k dependent coagulation factors
without vit k, coagulation factors cannot bind to ca+, preventing formation of membrane bound complexes
DOA 2-5 days
reversal agent is Vit K and Prothrombin complex concentrates
moa of heparin, DOA and reversal agent
- it is not an anticoagulant by itself but a catalyst for the formation of plasma antithrombin III which inhibits factor IIa, Xa equally
- requires monitoring with aPTT
- DOA 4-6 hours (half life 1-2 hours)
- reversal agent is proamine sulfate
how to do LMWH bridging
- stop warfarin 5-6 days before surgery
- start LMWH 3 days before with last dose 24h before surgery (DOA of LMWH is 12hours)
- after surgery, resume LMWH 24h after for 4-6 days + start warfarin
what is the differenece between dabigatran VS apixaban/ rivaroxaban
all are DOACs but inhibit different factors
Dabigatran inhibits factor IIa (thrombin)
Apixaban, RIvaroxaban inhibits factor Xa
drugs to avoid in patients on warfarin
potentiation of effect
- analgesics: aspirin, NSAIDs, paracteramol (unsafe is >2g a day for several days), tramadol
- azole antifungals
- prolonged broad spectrum AB - augmentin, amox, ampicillin, tetracyclin, cephalosporin (penicillin V & clindamycin are safe, use those)
- clarithromycin, erythromycin, metro, sulphonamides
- corticosteroids
inhibition of effects
- barbiturates
- carbamazepine
- cyclosporine
dabigatran can be discontinued how long before and after surgical procedures?
- 24-48 hours before
- 24 hours after
it has a rapid onset of 2 hours, DOA 22h
short half life 11h
what drugs to avoid if patient is taking DOAC
- aspirin
- nsaids
- Azole (increase anticoagulant effect)
- macrolide antibiotics
- carbamazepine
what to give when there are signs of hypoglycemia
- 1mg glucagon (IM) if the patient is unconscious, followed by a glucose drink
- if there is IV line, give 50ml of 50% dextrose
which groups of patients need supplemental steroids before stressful clinical procedures
those on long term corticosteroid therapy or have primary adrenal insufficiency
because primary concern is adrenocortical crisis if patient is subjected to trauma or stress
patients who need supplemental steroids
- those currently on systemic corticosteroids
- those on systemic corticosteroids in the past 2 weeks - 1 month
- patients who were on it for > 1 month in the past year where the amount of corticosteroids taken was more than equivalent of 7.5mg prednisolone daily
for those who require corticosteroid cover, what is the cover regime for
1) routine non surgical dental tx under LA
2) minor oral surgical procedure under LA
3) tx under GA
1) routine non surgical dental tx under LA
- no supplementation required
2) minor oral surgical procedure under LA
- double oral steroid dose within 2 hours of surgery
- 25-50mg hydrocortisone hemisuccinate (IV)
3) tx under GA
- 50-100mg hydrocortisone hemisuccinate within 1 hour of surgery
- post op is 50mg hydrocortisone IV 8 hourly
what meds to avoid in hypothyroid
avoid routine prescribing of CNS depressants in severe untreated hypothyroidism
- benzodiazepines
- narcotic analgesics
as these can result in CNS, CVS and respiratory depression
dental considerations for parkinsons patients
- schedule morning appts after taking anti parkinsonism meds
- allow for rests during procedures, terminate if patient becomes fatigued
- put patient in semi supine or upright position with adequate suction as they have dysphagia
- observe patient for tremors or involuntary facial and body movements before treatment, use mouth props, rubber dam
- anti parkinsonism drugs can cause postural hypotension so dont make sudden changes to position of dental chair
- anticholinergic anti parkinsonism drugs can cause hyposalivation so might need to give salivary substitutes and oral lubricants
what drugs to avoid in patients with liver disease
- paracetamol (limit to <2g a day for adults)
- aspirin, nsaids: can aggravate bleeding tendencies and fluid retention
- narcotic analgesics
- benzodiazepines
- azole antifungals
- clindamycin: provokes acute hepatic toxicity
drugs that require dose reduction - those that are metabolised by liver
- metronidazole
- macrolides
- tetracyclines
- carbamazepine
- amide LA *
what are the safest analgesics, antibiotics, LA for pregnancy?
analgesic - paracetamol
antibiotics:
- penicilliins
- erythromycin
- clindamycin
LA = lidocaine
