Special Care - Liver and Renal

Question 1

What reasons are there for inability to achieve haemostasis?

Answer 1

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

Question 2

How do we manage inability to achieve haemostasis after an extraction?

Answer 2

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

Question 3

What should platelet levels be for extractions etc in primary care setting?

Answer 3

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

Question 4

What are symptoms of end stage liver disease?

Answer 4

Jaundice 
clubbing 
palmar erythema 
ascites 
oesophageal varicies 
increased bleeding 
encephalopathy

Question 5

What are the causes of liver disease?

Answer 5

Infection:
Hepatitis A, B, C and D

Non-infectious:
ALD
Non-ALD 
malignancy 
haemochromatosis 
drug induced

Question 6

What are the stages of liver disease?

Answer 6

Hepatitis - inflammation

Cirrhosis - irreversible necrosis

failure of normal function

Question 7

What is the UKELD score?

Answer 7

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

Question 8

What UKELD score indicated the need for a transplant?

Answer 8

49

= > 9% risk of mortality within the year

Question 9

What tests are required for a patient with liver disease (end stage) before treatment? (3)

Answer 9

liaise with herpetology unit;

FBC

Coagulation screen - APTT, PT

INR

Question 10

If a patient has a safe platelet count but has other defects in their haemostat mechanisms can they be treated in primary care?

Answer 10

no

Question 11

An individual with severe liver disease has reduced metabolism, what are the implications for this in terms of LA? (2)

Answer 11

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

Question 12

What medications should u be cautious with in a patient with liver disease? (3)

Answer 12

1. AVOID NSAIDS - can increase bleeding risks
2. Paracetamol - hepatotoxic but less risky than NSAIDS
3. Antibiotics:
   Altered (smaller) dose
   Can use amoxicillin
   Can use metronidazole but alter the dose

Avoid erythromycin - antibiotic

Question 13

What considerations are required when treating a patient with severe liver disease?

Answer 13

Where should they be treated?

Do they require agents that will allow haemostasis?