med complex management Flashcards

1
Q

precautions to take in patients with uncontrolled hypertension

A

avoid cox 2
avoid nsaids
avoid azoles with statins
avoid macrolides with ccb
caution vasoconstrictor eg avoid adrenaline containing retraction cord, topical vasoconstrictor for hemostasis
avoid intraligamentary, intraosseous, iv injection
aspirating syringe

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2
Q

what medication should i not give a patient who has recently undergone CABG

A

cox 2 inhibitors
nsaids
macrolides
azoles

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3
Q

how long to defer treatment by after cabg or ptca

A

3-6 months
defer by 1 year for elective surgical procedure

min 6 weeks for bare metal stent
6 months for drug eluting stent

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4
Q

how long to defer treatment by after AMI

A

3 months for routine treatment
6 months for invasive treatment, GA

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5
Q

precautions to take for a patient post ceid insertion

A

avoid diathermy electrocautery mri due to electromagnetic interference

defer by one month post insertion, ensure functional capacity is adequate

no antibiotic prophylaxis is required

avoid bupivacaine

caution vasoconstrictors

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6
Q

Patient is on clopidogrel for hypertension management. Needs to do extraction. What pre op planning needs to be done

A

Do not stop anti platelets

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7
Q

max dosage of adrenaline for patient with uncontrolled hypertension

A

0.04mg

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8
Q

why do we avoid azoles and macrolides in patients with htn

A

macrolides inhibit cytochrome, causing accumulation of statins and ccbs

azoles can increase the risk of statin associated myopathy

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9
Q

what is an acute hypertensive crisis

A

sudden severe increase in bp to ≥180/120mmHg

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10
Q

what should you check for if you suspect acute hypertensive crisis

A

dyspnea – pulmonary edema
chest discomfort – MI, aortic dissection
neurological deficit – stroke
nausea and vomiting – increased intracranial pressure

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11
Q

can you treat a patient with chest pains

A

Unstable angina eg occurs at rest, unresponsive to GTN – do not do elective dental treatment

stable angina eg only on exertion, relieved with rest and medication – treat with precautions such as stress reducing protocol, caution vasoconstrictor, avoid NSAIDs and COx2 inhibitors, GTN on standby

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12
Q

how long to defer treatment by afeer MI

A

if patient is deemed low risk, non invasive treatments can be deferred by 60 days

otherwise, non invasive treatment should be deferred by 3 months

invasive, surgical procedures should be deferred by 6 months

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13
Q

what medication is a patient on 3 months after PTCA? and what is my management?

A

dual anti platelets (high risk of stent thrombosis within first year of placement)

do not stop anti platelets, current recommendation is to not modify, though some may continue with aspirin and stop other anti platelet

avoid elective care for 6 months to 1 year. consult cardio for invasive procedure

> 3 exo, do over multiple visits

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14
Q

patient on dual anti platelet therapy will need to undergo major dental surgery. what to do?

A

stop p2y12 inhibitor 5-7 days prior to surgery, continue with aspirin unless bleeding risks prohibitive

restart 3 days after surgery

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15
Q

can i do routine dental treatment for a patient with an arrythmia?

A

yes (with stress reducing protocols, pain control, monitor pulse rate and pressure)

however, in some situations, treatment should be deferred
- symptomatic
- pre existing cardiac disease
- high grade av block
- ventricular arrhythmia
- supraventricular arrhythmia with uncontrolled ventricular rate

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16
Q

why do i need bleeding precautions in a patient with cardiac arrhythmia?

A

may be on warfarin or dabigatran or rivaroxaban due to increased risk of stroke

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17
Q

what medication to avoid in patients with cardiac arrhythmias

A

macrolides
azoles
bupivacaine

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18
Q

what does chads2 score mean

A

measures the thromboembolic risk in a patient with non valvular atrial fibrillation

congestive heart failure
hypertension
age>75
diabetes
stroke/tia

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19
Q

can i treat a patient with congestive heart failure?

A

nyha 1 and 2 can be treated. nyha 3 and 4 (marked limitation or unable to carry out physical activity) should not receive elective treatment

simplify treatment

bleeding precautions

minimise vasoconstrictors

avoid erythromycin, tetracycline if on digoxin

avoid nsaids, cox 2 inhibitors, corticosteroids (fluid retention)

consider terminating procedure if patient starts getting breathless

avoid supine position

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20
Q

signs of poor compensation for congestive heart failure

A

paroxysmal nocturnal dyspnea
orthopnea
dypsnea on exertion at level of activity that is usually well tolerated
peripheral edema
fluctuating body weight

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21
Q

when do symptoms of infective endocarditis develop

A

2 weeks after procedure

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22
Q

signs of infective endocarditis

A

fever in the presence of risk factors
- previous ie
- recent dental or surgical procedure
- congenital heart defect
- immunosuppression
- injection drug use

heart murmur

persistent bacteremia

immunological and emboli phenomenon

oral petechiae

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23
Q

conditions requiring antibiotic prophylaxis for prevention of infective endocarditis

A

previous ie
unrepaired congenital cyanotic heart defect
congenital heart defect repaired with prosthetic patch or device with residual defect, or within 6 months of procedure
prosthetic heart valve
prosthetic material for heart valve repair
cardiac transplant with with valve regurgitation due to abnormal structure of valve

24
Q

how is antibiotic prophylaxis given

A

amox 2g 1h before procedure
if allergic to amox, cephalexin 2g or azithromycin 500mg or doxycycline 100mg

25
what guidelines should be followed if multiple rounds of ab prophy needed
1 month before 2nd dose of same antibiotic 10-14 days interval for alternating antibiotic regime
26
precautions that should be taken for a patient with asthma
should use regular asthma medication several days before and after dental treatment consider prophylactic puff before procedure bring inhaler to appointment avoid nsaids, cox2 inhibitors, aspirin, macrolides and ciprofloxacin wtih theophylline, avoid narcotic analgesics with benzodiazepine avoid ga treatment best done in the late morning or early afternoon short appointments with frequent rests consider terminating treatment if becomes dyspneic
27
how to assess whether patient's asthma is suitably controlled to tolerate dental treatment
≥80% peak expiratory flow rate
28
when can a pregnant person get dental treatment
best to do treatment in 2nd trimester or early 3rd elective dental treatment should be avoided in the first trimester
29
what medication to avoid in pregnant women
aspirin, nsaids (ductus arteriosus closure, adverse events associated at third trimester) tetracycline drug administration should generally be avoided in pregnancy, especially in the first trimester
30
what analgesic can i prescribe a pregnant woman
acetaminophen/paracetamol
31
what antibiotics can i give a pregnant woman
amoxicillin, cephalexin, clindamycin , erythromycin, penicillin
32
what is well controlled diabetse
hba1c < 7% routine dental treatment and minor oral surgery procedure can be carried out in well controlled diabetics
33
when do i need to prescribe supplemental steroids prior to procedure, and how is it administered
stressful procedure eg extensive procedure, oral surgery patient is currently on systemic steroid on systemic steroids ≥7.5mg in the past 2 weeks to one month on systemic steroids for more than one month in the past year administration: within 2 hours before LAOP, take double regular dose of oral steroids, or 25-50mg IV hydrocortisone hemisuccinate for minor surgery
34
in a patient with untreated hypothyroidism, avoid use of
cns depressants eg narcotic analgesics, barbiturates
35
management of hemophiliac patient
consult hematologist and determine severity of disease, level of factor correction if required patient may require pre op transfusion of 50-100iu/dl factor 8 or 9 local hemostatic measures eg antifibrinolytic agents such as tranexamic acid, surgicel prolonged observation avoid nsaids, aspirin. use acetaminophen +/- codeine for analgesia
36
management for patient on single anti platelet therapy prior to minor oral surgical procedure
modification not required if major bleeding is anticipated, drug holiday is needed. 7 days preop and 3 days post op; aspirin only 3-5 days pre op required
37
following acute venous thrombosis episode, how long should dental treatment be deferred for
patient should have received 3 months of anticoagulation (min 1 month)
38
guidelines for how to proceed with patient on warfarin
check inr <2.5 safe to proceed with routine dental treatment such as simple extractions, with the use of local hemostatic measures 2.5-3.0 refer to OMS >3.0 refer for reversal, defer until INR controlled. consult medical physician.
39
options for warfarin reversal
decrease in dosage bridging IV heparin therapy bridging LMW subc heparin stop for 3 days prior to procedure, take inr on the day of procedure. stop heparin 6-18 hours prior to procedure. restart warfarin 12-24 hours after surgery. heparin min 4 days as warfarin takes 96 hours to reach peak effect in case of emergency, fresh frozen plasma, vitamin k, prothrombin complex concentrate
40
drug interactions with warfarin
nsaids, aspirin, tramadol, metronidazole, erythromycin, doxycycline, corticosteroids potentiate bleeding barbiturates and carbamazepine inhibit warfarin, putting patient at risk of clotting
41
pre operative local hemostatic measures
vasoconstrictors
42
intra op local hemostatic measures
thorough curettage to remove granulation tissue atraumatic procedure
43
post op local hemostatic measures
pressure suturing TXA (antifibrinolytic agent) local hemostats eg gelatin sponge, oxidised cellulose poig
44
how to discontinue heparin bridging after procedure
continue heparin for minimum of 4 days as peak antithrombotic effect of warfarin is delayed 96 hours, until INR reaches desired range
45
what patients are at high risk for bleeding
known bleeding disorders eg clotting factor defects abnormal blood parameters despite no known bleeding disorders ** anti coag and anti platekets are moderate risk
46
dental surgery can be performed how many hours after heparin dose
Ufh: 6-8h LMWH: 18-24h
47
management of patients on noacs eg dabigatran, rivaroxaban
no reversal agent for minor surgical procedures, do not alter. but avoid performing surgery at peak activity (2-3h after dose) for major surgical procedures, consider cessation for 24h avoid medications that can affect anticoagulation effect. erythromycin, nsaids, clopidogrel can increase anticoagulation in dabigatran nsaids can increase anti coagulation in rivaroxaban
48
what are the various laboratory tests available to test hematologic parameters
FBC - platelet, rbc, wbc PT - extrinsic pathway, warfarin ApTT - intrinsic pathway, heparin, hemophilia INR - standardised PT time, measure extrinsic pathway Bleeding time - time from onset to first arrest of bleeding
49
what are the considerations in treating a patient with hepatic disease?
bleeding tendency (production of coagulation factors), need local hemostatic and possibly systemic hemostatic measures impaired drug metabolism -- nsaids, paracetamol, lidocaine, mepivacaine hepatotoxic drugs eg clarithromycin defer elective treatment in patients with decompensated liver disease eg present with jaundice
50
considerations for patient with renal disease
avoid nephrotoxic drugs impaired metabolism eg amoxicillin on anti thrombotic medication during hemodialysis (LMWH, defer procedure 12h after last dose) platelet destruction during hemodialysis schedule appt outside of dialysis days
51
oral manifestation of hiv/aids
linear gingival erythema kaposi sarcoma oral hairy leukoplakia oral candidiasis nug
52
management of patient undergoing active chemotherapy
patient is very immunosuppressed emergency dental treatment only, consider need for ab prophy do nothing + prescribe antibiotics oral manifestations
53
timing of dental management for epileptic patients
anti convulsants 2-3h prior to procedure avoid elective dental procedures in patients with poorly controlled seizures (>1 per month), hospital based if necessary avoid if lethargic, behavioural changes
54
intraoperative precautions for epileptic patients
strong suction avoid multiple cotton rolls avoid precipitators mouth prop
55
medications to avoid in patients with epilepsy
increased bleeding risk due to action of valproic acid on platelets, avoid nsaids and aspirin avoid tramadol as can precipitate seizures avoid macrolides in patients taking anti convulsants long term aed use can cause osteoporosis, caution oms caution paracetamol -- hepatotoxicity as side effect of AED