Anti-Coaugulant + Anti-PLT Guidelines

Question 1

How does bleeding get controlled?

Answer 1

Primary Haemostasis

this is where there is vasoconstriction for acute management of bleed and PLT activation and formation of PLT plug

Then SECONDARY HAEMOSTASIS:

This is where body wants to form stable clot so coagulation pathways and fibrin clot formed

Question 2

What can affect bleeding?

Answer 2

Liver disease - alcohol, hepatitis, liver conditions

Chronic renal failure

Haematological malignancy

Chemotherapy

Advanced HF

Bleeding disorders

Question 3

Why does liver disease affect bleeding?

Answer 3

This is because liver responsible for production of coagulation factors so any damage to liver reduces production and results in inc bleeding risk

Question 4

Why does chemo cause bleeding risk?

Answer 4

Chemo causes pantocytopenia which is where reduction in all types of blood cells and inc bleeding risk

Question 5

What is an anti-plt drug?

Answer 5

Affects primary haemostasis and reduces PLT activation and aggregation and inhibits thrombus formation

Question 6

What does aspirin do?

Answer 6

Inhibits COX-1 which prevents formation of Thromboxane A2 which prevents PLT activation - irreversible - life span 7-10 days

Question 7

What does clopidogrel do?

Answer 7

Blocks activation of PLTS

Question 8

If pt is on aspirin or clopidogrel what do we do?

Answer 8

TX as normal but be aware of increased bleeding, stage and plan tx `

Question 9

What are some dental procedures unlikely to cause bleeding?

Answer 9

BPE
LA infiltration, block
Supragingival PMPR
Direct/indirect with supra gingival margins
Endo
impressions

Question 10

What are some procedures with low risk of bleeding?

Answer 10

SIMPLE EXTRACTIONS 1-3 TEETH, RESTRICTED WOUND SIZE

INCISE AND DRAIN SWELLINGS

6PPC

RSD AND SUBGIGVAL SCALING

DIRECT INDRECT WITH SUB GINGIVAL

Question 11

What are some procedures likely to cause bleeding and have high risk of post op bleeding complications?

Answer 11

Complex extractions, >3 teeth, multi rooted, surgical procedures

flap raising procedures

crown lengthening

implant
surgical xla

Question 12

How do we manage pts at high risk of bleeding?

Answer 12

Early in week appts
Early in day appts
check recent bloods
consider limiting area or staging extractions
surgical
tranexamic acid wash - however we can prescribe so need to lease with GP
POI
NO NSAIDs or aspirin

Question 13

How do we manage post op bleeding?

Answer 13

Suture and pack
Surgical
Re check MH
Pressure and gauze
LA adrenaline
diathermy

Question 14

What is tranexamic acid?

Answer 14

Drugs that binds to plasminogen and prevents fibrin clot being broken down

Question 15

What is VWD?

Answer 15

This is a clotting disease where pt produced less or no VWF which is responsible for binding to factor 8 And prevents breakdown of this factor and also has role in PLT plug formation

Question 16

What is warfarin?

Answer 16

Vitamin K antagonist, 27910 (prevents formation of these clotting factors)

Question 17

What is haemophilia A and B?

Answer 17

Sex linked bleeding conditions
Factor 8 = a
Factor 9 = B

Question 18

Why is pt given warfarin?

Answer 18

Given warfarin if had stroke, TIA,to prevent stroke, to prevent DVT or PE, CHD, prosthetic heart valves

Question 19

Warfarin management?

Answer 19

INR 24-48 hours

INR<4 for tx

if >4 GP or refer if emergency tx

Question 20

Warfarin interactions?

Answer 20

Refer to BNF as warfarin has many interactions as metabolised by cytokine p450 which interacts with many meds that can increase/reduce effect of warfarin

Question 21

What is guidance on NOACS?

Answer 21

New drugs, more stable half life, more predictable, shorter half life

Taken for stroke prophylaxis, AF, prevent DVT, PE

Apixiban - taken 2x day (if low risk take as normal, if high risk miss morning dose)

Dabigitran - taken 2x day, if low risk as normal, if high risk missing morning dose

Rivaroxaban - taken 1x day, delay 4 hours post bleeding

Edoxaban - taken 1x day, delay 4 hours

Question 22

How do NOACS work?

Answer 22

Apixiban - inhibits factor 10a

Riviroxaban - inhibits factor 10a

Ebdoxaban - inhibits 10 a

10A CONVERTS PROTHROMBIN TO THROMBIN AND WILL THEREFORE PREVENT THE FORMATION OF SOLUBLE FIBRIN SO PREVENTS CLOTTING

DABIGITRAN = DIRECTLY BIND TO THROMBIN

Question 23

If pt has had HA or stroke in last 6 months?

Answer 23

SDCEP guidance delay all non emergency tx for 6 months

however new emerging evidence that we can have 4-6 week period of caution, emergency tx in secondary care and routine after 6 weeks