Special Care - Liver and Renal Flashcards
What reasons are there for inability to achieve haemostasis?
Inherited bleeding disorders - haemophilia and VW disease
medication
- anticoagulants: warfarin, heparins
- antiplatelets: aspirin, clopidogrel
- side effects of some chemotherapy as it suppresses bone marrow
- anti seizures: phenytoin
Haematological diseases: leukaemia and myeloma
infections - HIV or HEP C
liver disease - ALD, Cirrhosis, cancer
How do we manage inability to achieve haemostasis after an extraction?
Apply pressure to the socket with a damp gauze +/- LA soaked gauze for 20 mins
pack the socket with a haemostat agent - gelatine sponges
suture the site
transexamic mouthwash if available
if the bleeding doesn’t stop contact a local OMFS or oral surgery department or A&E
What should platelet levels be for extractions etc in primary care setting?
50-100 x 10(to the power of) 9/L = health
anything less than 50x 10(to the power of) 9/L = don’t touch in primary care
What are symptoms of end stage liver disease?
Jaundice clubbing palmar erythema ascites oesophageal varicies increased bleeding encephalopathy
What are the causes of liver disease?
Infection:
Hepatitis A, B, C and D
Non-infectious: ALD Non-ALD malignancy haemochromatosis drug induced
What are the stages of liver disease?
Hepatitis - inflammation
Cirrhosis - irreversible necrosis
failure of normal function
What is the UKELD score?
The United Kingdom model for end stage liver disease
a system which predicts a persons prognosis in chronic liver disease
guide to determining the need for transplant
What UKELD score indicated the need for a transplant?
49
= > 9% risk of mortality within the year
What tests are required for a patient with liver disease (end stage) before treatment? (3)
liaise with herpetology unit;
FBC
Coagulation screen - APTT, PT
INR
If a patient has a safe platelet count but has other defects in their haemostat mechanisms can they be treated in primary care?
no
An individual with severe liver disease has reduced metabolism, what are the implications for this in terms of LA? (2)
Preferred use of articaine as only 5-10% of this drug is metabolised in the liver
(all of lignocaine is metabolised in the liver)
also preferred use of infiltrations to prevent the formation of a haematoma
What medications should u be cautious with in a patient with liver disease? (3)
- AVOID NSAIDS - can increase bleeding risks
- Paracetamol - hepatotoxic but less risky than NSAIDS
- Antibiotics:
Altered (smaller) dose
Can use amoxicillin
Can use metronidazole but alter the dose
Avoid erythromycin - antibiotic
What considerations are required when treating a patient with severe liver disease?
Where should they be treated?
Do they require agents that will allow haemostasis?