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BDS2 BAMS > Thrombophilia and Acquired Anticoagulation > Flashcards

Thrombophilia and Acquired Anticoagulation Flashcards

1
Q

thrombophillia

A

Increased risk of clots developing
- Clot excessively

When clots break off, embolise in blood stream, block of chambers in heart and vessels in lungs

Often an acquired condition superimposed on a genetic condition

Can be inherited or acquired

Usually possible to find a cause for the clot

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2
Q

4 inherited syndromes of thrombophillia

A
  • Protein C deficiency
  • Protein S deficiency
  • Factor V Leiden
  • Antithrombin III deficiency

May have abnormalities of these
- Maybe all slightly altered
Different reasons why might have but not necessarily fit into one

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3
Q

7 examples of acquired syndromes of thrombophillia

A

Antiphospholipid syndrome
- Lupus anticoagulants

Oral contraceptives

Surgery
- Bed bound makes surgery more likely to form clots

Trauma
- Exaggerated repair mode

Cancer

Pregnancy

Immobilisation
- Higher risk of blood clots, DVT, pulmonary embolism

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4
Q

3 types of platelet abnormalities

A

Thrombocytopenia

Qualitative disorders

Thrombocythemia

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5
Q

thrombocytopenia

A

Reduced platelet numbers

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6
Q

qualitative disorders

A

Normal platelet number but abnormal function

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7
Q

Thrombocythemia

A

increased number of platelets

uncommon

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8
Q

causes of thrombocytopenia

A

Idiopathic

Drug related Alcohol

  • Penicillins
  • Heparin

Secondary to lymphoproliferative disorder

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9
Q

issues of thrombocytopenia

A

too little - not OK not making enough

Dental treatment can proceed safely providing the platelet count > 50*10^9

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10
Q

3 rare causes of qualitative platelet disorder

A

Bernard Soulier Syndrome

Hermansky Pudlak

Glanzmann’s thrombasthenia

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11
Q

4 acquired causes of qualitative platelet disorder

A

Cirrhosis

Drugs

Alcohol

Cardiopulmonary bypass

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12
Q

what are thrombocythemia pt usually on

A

aspirin to prevent clot formation

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13
Q

3 common causes of liver disease

A

alcohol

hepatitis

drug induced

(sources of acquired bleeding)

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14
Q

haematological change in haemoglobin in liver disease

A

little change

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15
Q

haematological change in platelets in liver disease

A

decrease

stops blood initially before clot formed

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16
Q

haematological change in prothrombin time in liver disease

A

increase

fewer CF made

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17
Q

haematological change in APTT in liver disease

A

increase

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18
Q

haematological change in TT in liver disease

A

increase

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19
Q

increase in INR indicates

A

coagulopathy pt

- serious coagulation issue

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20
Q

effect on dental surgery of mild stage liver disease

A

blood results often normal so normal precautions apply

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21
Q

effect on dental surgery of moderate stage liver disease

A

often only one parameter abnormal and platelet count >100

no problem with tx

local measure following extraction

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22
Q

effect on dental surgery of severe stage liver disease

A

all blood results abnormal (platelets and INR)

problems with haemostasis

extraction must be carries out in conjunction with haematologist

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23
Q

3 anti-thrombotic medications

A

oral anticoagulation

heparins

anti-platelet medications

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24
Q

what do anti-thrombotic medications induce

A

drug induced coagulopathy

common cause of bleeding issue is medical Tx bot issue itself

25
Q

advantage of oral anticoagulation and anti-platelet medication

A

swallow (not injection)

26
Q

advantage and disadvantage of heparins

A

disadvantage: injection
advantage: very responsive

low molecular weight and normal types

27
Q

5 indications for anticoagulation medications

A

Atrial fibrillation

Deep venous thrombosis

Heart valve disease

Mechanical heart valves

Thrombophilia

28
Q

what is the deciding factor on anti-thrombotic medication choice

A

Onset and duration of Tx is deciding factor on method

Whilst stay in hospital post operation
- heparin for short term as not in community care so pills less efficient

Pills at home

  • less likely to clot in atria
  • less likely stroke in brain
  • managed in community
29
Q

3 types of oral anticoagulatns

A

coumarins (warfarin)

direct factor Xa inhibitors

  • rivaroxaban
  • apixaban (common in Ggow)

direct thrombin inhibitors

30
Q

warfarin

A

Most used drug in the world for anticoagulation (coumarin)

Cheap

Process to put on and Monitoring is complicated

31
Q

new oral anticoagulants NOAC

A

Rivaroxaban
Apixaban
Dabigatran

Increasing use as ‘safer’ and ‘cheaper’ alternative

No routine monitoring

  • Always 50% bioavailability
  • Easy to work out dose
  • Constant
  • – Warfarin bioavailability is unpredictable

not in hospital on heparin first – physicians, nurse
- Used in short term treatment
time established would need to stop if used warfarin

32
Q

bioavailability

A

amount of drug doing work

33
Q

advantages of NOAC

A

Increasing use as ‘safer’ and ‘cheaper’ alternative

No routine monitoring

  • Always 50% bioavailability
  • Easy to work out dose
  • Constant
  • – Warfarin bioavailability is unpredictable

not in hospital on heparin first – physicians, nurse
- Used in short term treatment
time established would need to stop if used warfarin

34
Q

how is response measured for warfarin

A

INR

  • checked every 4-8 weeks
  • all pt should carry an anticoagulant booklet

daily dose between 1 and 15mg varies

35
Q

what is the safe precaution to take with warfarin

A

Safest all drugs would interfere with warfarin

Test warfarin the day after starting new medication (24-48hrs)

  • Less effect - increase dose
  • More effect - lower dose

Always seek advice from GP if you are prescribing
- They need to do testing – rare to do at home

Antibiotic - get GP involved as need treatment next today

36
Q

particular medications to use with caution in combination with warfarin

A

Aspirin (as an analgesic)

Most antibiotics
- Amoxycillin least likely to cause problems

Azole antifungal drugs

  • Fluconazole
  • Itraconazole
37
Q

INR

A

internationalised normalised ratio

Prothrombin time ratio corrected for the warfarin sensitivity of the thromboplastin reagent
- Ratio between pt and control pt
If normal pt – should be 1
Bigger ratio – PT time of pt will increase??

INR = Patient PT/ Mean Normal PT (international sensitivity index)

38
Q

INR =

A

Patient PT/ Mean Normal PT (international sensitivity index)

should be 1

39
Q

target INR for mechanical heart valves

A

3.0-4.0

vary from person to person – depending on what you need to do

40
Q

target INR recurrent VTE while adequately anti-coagulated

A

3.0-4.0

vary from person to person – depending on what you need to do

41
Q

atrial fibrillation/other causes target INR

A

2.0-3.0

vary from person to person – depending on what you need to do

42
Q

key warfarin risk

A

Haemorrhage (higher risk than if not on, greater trauma risk)

1% per annum risk of serious bleed (needing hospitalisation/transfusion)
- 25% of these are fatal

Issue in elderly – need to have operation, stroke

43
Q

3 risks of adjusting INR

A

Fatal thromboembolic events

Non-fatal thromboembolic events

Rebound hypercoagulable state
- Restarting warfarin makes coagulation more likely

44
Q

what does warfarin stop production of and needs replaced medically for correct coagulation

A

Use warfarin stop function of vitamin K

  • Restore Clotting Factors to normal
  • —-give pt vit K to overcome fact warfarin stop making vit K

Reverse effect of warfarin quickly
- No excess bleeding with trauma

45
Q

4 treatments when INR must be checked

A

Extractions

Minor oral surgery

Periodontal surgery

biopsies

46
Q

4 treatments where INR is not needed to be checked

A

Prosthodontics

Conservation

Endodontics

Hygiene phase therapy

(less risk of blood)

47
Q

general recommendation regrading anaesthetics and warfarin

A

use LA containing a vasoconstrictor
- reduce blood flow to tissue, decrease bleeding issue

Where possible use an infiltration, intrafilamentary or mental nerve injection
If there is no alternative an inferior alveolar nerve block is used the injection should be administered slowing using an aspirating technique
- Very dangerous for haemophilia if give ID nerve block – don’t give

48
Q

when should thrombophillia/coagulopathy pt be seen

A

in morning and early in the week

- still available in surgery in coming days if an issue

49
Q

timing of INR check for treatment

A

INR must be checked in the 48 hours prior to treatment but should be as near as possible to time of treatment

50
Q

INR value for treatment to proceed

A

<4.0

51
Q

what is the maximum extraction for pt with thrombophillia/coagulopathy

A 
3 teeth (roots)
i.e. 3 incisors or 1 lower 6
52
Q

4 local measures that can aid haemostasis

A

LA infiltration

oxidised cellulose

sutures

pressure

good post operative instructions (must inc emergency contact details)

53
Q

2 types of heparins

A

unfractionated

low molecular weight

(less common that oral anticoagulants)

54
Q

unfractionated heparins

A

Given by IV infusion in hospital – check APPT
- Drip stand with pump on it in hospital, not out in community

Very short half-life so very controllable

55
Q

low molecular weight heparins

A

Given by subcutaneous injection by the pt at home

Once daily injection

Doesn’t bleed excessively – no issues

Dose weight related – no monitoring

56
Q

3 drugs available for anti-platelet medications

A

Low dose aspirin (95mg daily)

Clopidogrel

Dipyridamole

57
Q

guideline for single agent anti-platelet use

A

Delayed haemostasis but adequate haemostasis

58
Q

guideline for dual agent anti-platelet use

A

usually aspirin and clopidogrel

If stent pt, discuss with cardiologist

Otherwise – stop one of the drugs 7 days prior to surgery (discuss with doctor)

Do not stop unless discuss with doctor first

59
Q

what is the half life of platelts

A

7 days

takes 7 days for anti-platelet medication to leave system

BDS2 BAMS (54 decks)

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