OMS rotation pearls Flashcards
normal hb1ac
below 4 is good
5-6 pre diabetic
over that is diabetes
maximum dose of epi per visit in adult with HTN
0.04 mg
if pt has hx of HTN what must be done before and after procedure?
take BP and pulse before AND after
document it prior to procedure and prior to discharge
Following any oral surgery procedure in a patient with cardiac or HTN history or an abnormal pre-operative value, a BP and Pulse check must be documented after completion of procedure, prior to discharge
how to manage patient with stage 2 HTN?
what is the BP in these patients?
systolic is over 140
diastolic is 90+
- Retake and confirm blood pressure and consider other risks factors for the high BP.
- Monitor blood pressure during the appointment.
- Proceed with the elective dental treatment, avoid pain and intravascular epinephrine
- Systolic =180, diastolic >90 ≤99 with a true dental emergency, may be OK to
proceed with caution
definition of severe HTN and how to manage?
systolic 180+ and diastolic 120+
- Retake and confirm blood pressure with an alternate device, such as a mercury manometer–type sphygmomanometer.
- If the blood pressure is unchanged, consider referring the patient to his/her
physician or emergency room for evaluation if any symptoms of Hypertensive Emergency. - Typically, no treatment of any type should be undertaken.
**MEDICAL CONSULT VS EMERGENT/ URGENT REFERRAL
** HTN patient rules in the U M OMS clinic
for urgent / emergent tx?
for elective tx?
for urgent / emergent tx
- BP must be below 199/114 to be preformed in UMSOD clinic and only in select circumstances
for elective treatment
- BP systolic must be below 160 and diastolic below 100 and ASYMPTOMATIC (not light headed/dizzy/ lethargic)
patient presents with hx if MI.
What questions will you ask?
when would you defer txx?
defer tx if MI occurred within the last 2-3 months
more than 3 but less than 6 - typically defer elective tc
over 6 months - typically OK for elective tx BUT must have had a follow up with cardiologist prior
ASA if MI less than 3 months? more than 3 months?
more than 3 = ASA III
less than 3 motnhs automatic ASA IV
patient presents with agina
what to ask?
how to manage?
when to defer?
When does s/he feel the chest pain
At rest ?
On exertion?
How often does s/he feel the chest pain
How does the chest pain resolve?
-Spontaneously or with medications (nitroglycerin, aspirin, etc)
Does the patient have the medication for the chest pain relieve? Is it present? Has it expired?
When was the last episode?
if episode is in last week or occurs often then needs a med consult if not under active care from cardiologist or unstable
patient presents with CHF
questions to ask and
how to manage?
what do you have to request in a med consult?
Ask patient how active he/she is.
Flights of stairs without shortness of breaths? Exercise tolerance? Sleeps flat or upright?
- usually will require a med consult to request the following
1. is it systolic or diastolic failure - note the EJECTION FRACTION in systolic failure will be decreased
determine the drugs being used and the dosages
requests recommendations from cardiologist for procedures and plan to avoid epinephrine
no more than 0.04 mg
ejection fraction in terms of systolic vs diastolic heart failure
formula for EF and SV?
EF = stroke volume / EDV (end diastolic volume)
this determines how efficient the ventricle is at emptying itself or % of EDV that is moved out of ventricle
SV = EDV - ESV (ESV is approximately 50 mL and EDV is approximately 120mL, giving a difference of 70 mL for the stroke volume.)
in systolic heart failure — the ejection fraction
Heart failure with reduced ejection fraction (HFrEF), also called systolic failure: The left ventricle loses its ability to contract normally. The heart can’t pump with enough force to push enough blood into circulation.
Heart failure with preserved ejection fraction (HFpEF), also called diastolic failure (or diastolic dysfunction): The left ventricle loses its ability to relax normally (because the muscle has become stiff). The heart can’t properly fill with blood during the resting period between each beat.
patient presents with aFib?
questions and management
continue or discontinue drug?
include PT/ INR levels
ask if pt is taking a blood thinner
- if not ask why that is at it is likely a problem
DO NOT DISCONTINUE IF the blood thinner if it is not patients physician recommendation
warfarin need to request 24-48 hours ma prior to the surgery
get PT/ INR
PT/INR below 3.5 = can usually proceed with extraction of up to 3 teeth
normal PT, PTT and INR values
PT= 10-12 seconds PTT = 20-45 seconds
PT/ INR for warfarin patients is usually 2-3
general management tips for active cardiovascular patients
- use anxiety reducing protocol
- consider nitrous oxide
- consider no epi use or the smallest amount of epi needed for profound anesthesia (max 0.04 mg/ epi/adult/ day)
- aspirate before injecting
- ensure profound anesthesia
no extraction if active cardio disease if?
- MI less than 2 months
- decompensated CHF
- acute coronary syndromes
- systolic over 180 and diastolic over 110
- severe valvular disease
- severe arrythmia
- INr over 3.5
major basic difference between 1:50,000 epi and 1:200,000 epi?
1: 50,000 epi has MORE concentration of epi in 1.7 mL of lidocaine
1: 200,000 epi has LESS concentration of epi
amount of epi in?
1 carpules of 1:50
1:100
1:200?
1: 50
0. 034 mg epi
1: 100
0. 017 mg
1: 200
0. 0085 mg
amount of epi in?
2 carpules of 1:50
1:100
1:200?
1:50
.068
1: 100
0. 034
1: 200
0. 017
amount of epi in?
4 carpules of 1:50
1:100
1:200?
1:50
.136 epi
1:100
.068 mg epi
1: 200
0. 034
when does patient have to use antibiotic prophylaxis
- artificial / prosthetic heart valve
- hx of infective endocarditis
- crdio valvulopathy with regurg
- patient have serious heart condition present from birth (congenital) including
- unrepaired or incompletely repaired
cyanotic congenital heart disease, including those with palliative shunts and
conduits
a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months
after the procedure
any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
antibiotic prohy with mitral valve prolapse?
if invasive and confirmed murmer = yes
if presence not determined but need for procedure is urgent = yes
(lack of significant mitral regurgitation makes prophylaxis unnecessary )
when to take the antiobotic prophylaxis?
30-60 minutes before procedure
antibiotic if able to take oral med?
dose in adult?
child?
amoxicillin
adult 2g
so 250-500 mg qid
child 50 mg/ kg
patient cant take oral meds? rx for prophy?
ampicillin
2g IM / IV
child = 50mg/kg IM IV
OR
cefazolin/ ceftrixone
1g IM/IV
child = 50 mg IM/ IV
medication and dose if patient allergic to penicillin?
dose for prophylaxis adult and child
clindamycin
600 mg
child
20 mg/kg
OR azithromycin or clarithromycin 500 mg
child = 15 mg/kg
questions to ask patient with pulmonary diseases?
Frequency & severity When was last attack? When was the last hospitalization? Current Medications Ask for response to pain medications
asthma LA contraindicated? nitrous?
No, nitrous not contraindicated for mild and moderate asthma
COPD LA contraindicated? nitrous?
LA no contraindication
nitrous – No for unknown status or severe COPD due to risk of pneumothorax
Use semi-supine position or upright position
always take initial Sp)@ as a reference of severity of COPD
caution with oxygen administration and keep SpO2 between 88-92% and use only if necessary
pulmonary emphysema
considerations
Oxygen dependent – use wall-oxygen during the procedure
Upright or semi-supine position
SpO2 levels
above 95% considered normal
suspect kidney disease if?
med consult for?
if patient has long term uncontrolled hypertension and diabetes
med consult for creatine clearance and medication dose adjustment
avoid what drugs in renal insufficiency
avoidance of drugs that depend on renal metabolism or excretion
avoid the use of nephrotoxic drugs sucj as NSAIDs
- like aspirin
- ibuprofin (advil, motrin)
- naproxen (aleve)
major concerns in liver disease
- bleeding
2. post-op pain managment
liver is involved in?
- synthesis of coagulation factors
2. drug metabolism
severe liver damage usually from what 3 top things?
- infectious disease (HepB/C)
- alcohol abuse – cirrhosis
- vascualr / biliary congestion
management of patient with hepatic insufficiency
in patients with severe disease screen for?
attempt to learn the cause
- if it is hep B - then take the necessary precautions
avoid drugs that require hepatic metabolism
screen for bleeding disorders by using tests for determining platelet count, prothrombin time, partial thromboplastin time, and bleeding time
NSAID list
max dose?
indications?
not recommended in?
- ibuprofen
max dose = 3200 mg day
(OTC 1200 mg/day due to fillers in them) - naproxen
1250 mg/day - Diclofenac
150 mg/day - ketorolac tromethamine *RX only
40 mg/day
*use with caution - only short term with cardiovasucalr and kidney disease - doses subjected to renal dysfunction severity
ibuprofen RX?
over the counter?
OTC 200 mg 1-2 tab q4-6 hr
rx
600 mg q4-6 hr
800 mg TID
Ibuprofen 600mg
Disp: 28 tabs
Sig: 1 tab PO q6h, PRN pain with food.
(Available also as 800mg q8h prn pain with food)
nproxen dose
250-500 mg BID
1250 mg/day
diclofenac rx
rx only
35 mg TID
diclo potass
50 mg BID or TID
diclo sodium
50 mg BID or TID
150mg/day
ketolorac tromethamine indication
dosing?
ONLY after IV or IM dosing
10 mg/ TID or QID
40mg/day
potent analgesic for post extraction pain.
no more than 5 days
selective NSAID and dosing?
Celecoxib
rx only
200 mg BID
400 mg /day
NOT recommended in cardiac disease patients
acetaminophen OTC dosing and max
dose adjustment in?
500 mg / QID
1000 mg/tab BID
4000 mg/day
doses adjustment in liver disease patients is subjected to hepatic dysfunction status
opiod analgesic prescribing more than 3 days requires?
review of opiod history of the patient by using MAPS
Acetaminophen with codeine access? dose? max dose? indication?
considerations in liver or kidney disease?
schedule III - RX only
acetaminophen / codeine:
300mg/15mg (tylenol #2)
300mg/30mg (#3)
300mg/60mg (#4)
15-60 mg codeine dose q4-6 hour
max acetaminophen dose is 4000mg / day
max codeine dose is 360mg/day
for moderate to severe pain
liver = not recommended in severe disease states
as it is not converted to morphine - leading to poor analgesia
(as it is metaboized by the liver)
kidney = not recommended due to acccumulation
(as it is excreted by the kidneys)
acetaminophen with hydrocone is? access? dose? max dose? indication?
considerations in liver or kidney disease?
Norco (like vicodin)
5/325 (hydrocodone 5mg/acetaminophen 325mg
Disp: 12 (twelve) tabs
Sig: 1 tab PO q4-6h, PRN pain.Do not take with ETOH
indicated for severe pain and is a schedule II drug
acetaminophen with oxycodone is?
Rx?
percocet
Percocet (oxycodone 5mg/ acetaminophen 325mg)
Disp: 12 (twelve) tabs
Sig: 1 tab PO q4-6h, PRN pain. Do not exceed 8 tabs within 24hrs. Do not take with ETOH
schedulel II - rx only
indicated for severe pain
liver disease - dose adjustment is 1/2 to 1/3 orginal
morphine not recommended in?
kidney disease patients due to metabolites
as clearance is decreased in liver failure - so there is an accumulation of metabolites
morphine dose and max
indication?
class?
caution in?
schedule II - rx only
15-30 mg q4-6 hrs
1600mg/day
for severe or chronic pain
dose adjustments in liver
not recommended in kidney
tramadol rx?
class?
indication?
caution in?
Tramadol 50mg
Disp: 12 (twelve) tabs
Sig: 1 tab PO q4-6hrs, PRN pain
schedule IV drug - rx only
max =400 mg/day
for moderatley severe pain
not recommended in liver disease tht is moderate to severe
dose adjustments needed in kidney disease
P.O means?
oral route of administration
subcutaneous abbrev? intramuscular? Intravenous? Intraperitoneal? Intrathecal?
SC/SQ IM IV IP IT (intrathecal - around the spinal cord)
normal blood glucose levels
A blood sugar level less than 140 mg/dL (7.8 mmol/L) is normal. A reading of more than 200 mg/dL (11.1 mmol/L) after two hours indicates diabetes. A reading between 140 and 199 mg/dL (7.8 mmol/L and 11.0 mmol/L) indicates prediabetes
BG levels less than 70 mg/dL?
provide oral glucose prior to procedure
emergency / LOC give IM glucagon
fasting or post prandial BG levels to consider delaying elective tx?
BG levels above 180 or 230 post prandial (meal)
BG levels 200+ to 400 consider
consider slide scale patient adminstered dose of own insulin if indicated under supervision of faculty
BG levels above 400 consider
no elective tx
emergent tx for infection in the hospital
avoid prescribing what basic drug with patients that have bleeding disorders?
avoid prescribing nonsteroidal antiinflammatory drugs
antifibrinolytics
Antifibrinolytics are medicines that promote blood clotting by preventing or slowing down a process called fibrinolysis, which is the break down of blood clots. Antifibrinolytics are used as a treatment for hemophilia, in surgical procedures to prevent excessive blood loss, and for heavy menstrual bleeding
blood tests in hemophelia
normal PT (as the extrinsic pathway is not affected) normal bleeding time and platalet because platalets not affected in this disease
*prolonged PTT because extrinsic factors are affected
hemophelia A = factor VIII
hemophelia B= IX factor deficiency
main uses for anticoagulants
DVT, PE, aFib, stroke, etc
vitamin K antagonists
name?
lab test?
surgery?
warfarin (coumadin)
PT/INR within 24 hours to surgery
if PT/ INR is below 3.5 may proceed
low molecular weight heparins
name?
lab test?
surgery?
dalteparin (Fragmin)
Enoxaparin (Lovenox)
lab tests not needed and may proceed with surgery
direct thrombin inhibitors
name?
lab test?
surgery?
dabigatran (pradaxa)
lab tests not needed and can proceed with surgery
thrombin is an enzyme in blood plasma which causes the clotting of blood by converting fibrinogen to fibrin
factor Xa inhibitors
what is factor Xa?
activates prothrombin to thrombin
thrombin converts fibrinogen to fibrin to cause a clot
so can use this agent to inhibit the clotting
apixaban (eliquis)
rivaroxaban (Xarelto)
antiplatalet or platalet aggregation inhibitor use?
names?
lab test?
surgery?
used for CAD, heart attack, stroke, DVT
aspirin 81 mg
Clopidogrel (plavix)
ticagrelor (brilinta)
lab tests not needed and may proceed with surgery
drugs not to be used on pregnant patients?
LA?
no nitrous (N2O) no NSAIDs
limit epi or no epi and follow the OBGYN clearance / info
consider prilocaine - plain if available - category B but also short duration and risk of methemoglobinemia)
If a patient mentions in the list of current medication the following 2 meds, ALWAYS ask what is the reason he/she is taking it.
suboxone (buprenorphine)
methadone
suboxone use
buprenorphine for opiod addiction
methadone use
heroin and opiod addiction
What to do prior to the procedure in patient who is on suboxone or methadon?
cocaine?
Discuss with the patient the pain management
If the patient reports not be able to handle post- op pain with NSAIDS
Medical consultation to inform physician about the surgical procedure and the possible post-op pain level
- do not use epinephrine if a patient has consumed cocaine in the last 24 hours
postpone the procedure
advise patient to bite down for how long after extraction?
for at least 30 minutes
Oral antral communication protocol if less than 2mm?
no surgical tx
blood clot and sinus precautions +/- medications
Oral antral communication sinus precaution medications antibiotic? pain? decongestant? spray?
antibiotic: augmentin 850/125 BID x10 days
decongestant
1. oxymethazoline (aphrine nasal spray) 2 sprays in each nostril BID
do not exceed 2 doses in 24-hour period. use for 3 days
2. pseudoephedrine 240 mg/day for 10 days
saline nasal spray -two puffs in each nostril 6 times per day
Oral antral communication protocol if 3-6mm?
clot-promoting substances (Gelfoam)
figure of eight suture
medications
sinus precautions
Oral antral communication protocol if over 7mm?
surgical flap repair
sinus precautions
medications
Afrin/ Oxymetazoline Hydrochloride % and use with the rx
Afrin/ Oxymetazoline Hydrochloride 0.05%
Disp: 15mL bottle
Sig: Spray into both nares twice a day for 3 days.
used in OAC protocol
use in OAC’s that are above 3
cimetidine?
implication?
cimetidine is a histamine H2 receptor blocker
- decreasing acid made in the stomach
- has been shown to significantly reduce the metabolic clearance of amide local anesthetics through the liver
- interaction could occur with LA leading to toxic doses
- however at therapeutic levels of LA this interaction is unlikely but noteable
