Management of the medically compromised patient.pptx

Improving knowledge in oral and maxillofacial surgery

1. Management of the medically compromised patient PRESENTER :DR. SIAD ASRAR MIAKHIL INSTRUCTER TEACHER :TRAINER DR.ABDUL KAREEM SHARIF

2. Out lines introduction Cardiovascular disease Respiratory system Renal disease Endocrine system Neurological disorder Hematopoietic system Infectious disease Pregnancy and lactation

3. Introduction Patients with medical compromised condition suffer from certain systemic condition which puts him/her at risk from undergoing regular treatment. Importance: Majority of patients need oral and health care. How can we know? History taking and clinical examination

4. ASA Classification of physical status ASA 1: without systemic diseases ASA 2:Mild to moderate systemic disease ASA 3: Sever systemic disease that limit activity . ASA 4:Sever systemic diseases threatening life . ASA 5:morbid patient.

5. Stress reduction protocol based on ASA physical status For normal healthy and anxious patient(ASA 1) For Patient with medical risk Recognized the level of anxiety by proper communication. Evening before dental appointment (diazepam) Trizolam Sedation or GA for long procedure Schedule the appointment late in the morning Minimize waiting time Use a adequate pain control with local anesthetic Follow up with post operative pain /anxiety control, Recognized the patient degree of medical risk and receive complete medical consultation . Appointment late morning Control vital sign Used anxiolytic Use pain control Decrease the length of appointment Follow up with post operative pain /anxiety control,

6. Cardiovascular diseases not absolute contraindication for oral and maxillofacial surgery

7. Preoperative investigation Posterior anterior chest r adiograph Echo cardiograph ECG Stress test Lipid profile BT/CT/PT-INR

8. Cardiovascular diseases Antibiotic prophylaxis for cardiac disease Intraoperative consideration Monitoring ECG, pulse ox meter and arterial line Continuous the ongoing cardiac drugs Fluid volume should be monitored throw CVP

9. Long term anticoagulant drug used DVT,PE,RHT,AF,PVR,CAD,MI,UA and strokes

10. Protocol for patients on long terms anticoagulant drug used Drug history Antibiotic cover Obtain PT-INR Consult physician regarding dose modification A traumatic surgical technique and control post operative bleeding with local measure

11. PT INR range for reference PT 1.5-2 and INR 2-3 don't stop or alter the drug dosage PT 2-2,5and INR 2,5-3,5 dosage me be altered PT >2,5 and INR >3,5 delay invasive procedure ,until dosage is decrease

12. PATIENTS ON ANTIPLATELETS DRUGS Mechanism of action Inhibit cyclooxygenase enzyme and prevent thromboxane a2 and inhibiting platelet aggregation Aspirin 75-150mg Clopiedogril 75mg ticlopidine 250mg

13. Protocol for patient on antiplatelet drugs History and physician consultation Obtain platelet function analyzer Normal 60-120 sec Bleeding time

14. Congenital Heart Diseases invasive procedure for patient CHD can cause Infective endocarditis Post operative bleeding (right to left shunt ) Congestive heart failure

15. Rheumatic heart disease Infected endocarditis can be prevented with antibiotic prophylaxis using amoxicillin 2gr 1hour before the procedure .

16. Cardiac condition where antibiotic indicated or not indicated are presented Prophylaxis indicated Not indicated Prosthetic cardiac valve Previous endocarditis Unrepaired cyanotic congenital heart disease Cardiac transplant Rheumatic heart disease ASD VSD mitral valve prolapse Hypertrophy cardio apathy CABG Bicuspid aortic valve Coarctation of aorta Calcified aortic stenosis Pulmonary stenosis

17. Prophylaxis recommended or not recommended for dental procedure Recommended Not recommended extraction Periodontal procedure Scaling and root planning Probing Restorative dentistry Local anesthesia Intra canal endodontic or restorative treatment Placement of rubberdum Post operative suture removal Oral impression Fluoride treatment Oral radiograph Orthodontic appliance adjustment

18. Ischemic heart disease Angina pectoris Patient with angina pectoris present with series of risk during procedure Stress and anxiety can lead to an angina attack during procedure MI Cardiac arrest-death

19. Dental considerations Stress reduction protocol Premedication for reducing anxiety (diazepam 5-10 mg) Prophylactic nitroglycerine should be given preoperatively Limit administration of epinephrine(0,04mg)r If angina pectoris occurs stop the treatment ,administer oxygen, minimize stress and wait till pain resolve and follow the emergency protocol

20. Emergency protocol

21. Acute myocardial infarction(MI) Patient with 6 months of an MI (recent MI) have greater risk of further MI Chest pain ,dysrhythmias and other complication as ASA class 4 Recent MI patient have 50% of reinfection during major surgery therefore in recent MI High risk procedure(elective surgery) should be deferred elective dental care should be deferred Simple emergency dental treatment under local anesthesia my be given but opinion of physician should be sought first

22. Myocardial infarction asymptomatic Older MI (more than 6 but below 12 months ) can normally elective dental care under stress reduction protocol but higher risk procedure should be deferred Dental consideration Stress reduction protocol Monitor vital sign All emergency drug should be available Pre medicate with diazepam 5-10mg Anticoagulant dosage should be adjusted based on PT-INR Short appointment

23. Hypertension Refer a blood pressure that is consistently above 140/90 for than 6 month Complication of elevated blood pressure May cause MI or CVA Intra operative and post operative bleeding And target organ damage

24. Hypertension Dental aspect and treatment modification Preoperative investigation Chest x-ray to view cardiac enlargement , ECG,USG of the kidneys , ophthalmic evaluation –papilledema and retinal hemorrhage, RFT-BUN ,serum creatinine serum electrolyte Complete medical and drug history is recorded BP should be controlled before procedure and opinion of physician should be sought first

25. Hypertension Preoperative consideration Follow stress reduction protocol Patients are best treated in the late morning Regular antihypertensive drudges should be used before procedure

26. Hypertension Intra operative and postoperative consideration Continuous BP ,ECG ,and pulse ox meter monitoring Regular antihypertensive drug should be continued Change in position suddenly from supine can cause postural hypotension Avoid adrenalin In local anesthetics Post operative supplement of potassium for patient on diuretics

27. Hypertension ASA grading and dental management Systolic mmHG Diastolic mmHG ASA grading Hypertension stage Dental management <120 <80 1 normal Routine dental care 120-139 80-89 1 Prehypertension Routine dental care Lifestyle modification 140-159 90-99 2 Stage 1HTN Physician consult Dental care with stress reduction protocol >160 >100 3 Stage 2HTN Recheck BP after 5 min physician consult before dental care , epinephrine ,noninvasive >220 >120 4 Stage 3HTN RBP 5mini,avoid extraction until BP is control

28. Respiratory system Brachial asthma a chronic condition that effects the airways in the lungs Cause by immunological ,chemical ,and infections It is treated immediately with corticosteroid inhaler ,and B adrenergic stimulators

29. Dental consideration and management Preoperative consideration Asthmatic patient should be asked to bring their usual medication Use stress reduction protocol Check for any wheezing at time of surgery A bronchodilator inhaler should be easily available Avoid NSIAD Ask patient to continue the medication

30. Drug aspect during asthma Interaction of theophylline with epinephrine ,erythromycin ,clarithromycin , or ciprofloxacin may result in high level of theophylline Patient on leukotriene –modifying drug may have prolonged INR and bleeding tendency because of impaired liver metabolism Patient on systemic corticosteroid treatment provide prophylaxis for adrenal insufficiency patient with asthma may react to sulphites in vasoconstrictor containing local anesthetics their for it should be avoided

31. Renal disease medical history and consultation with the nephrologist Investigation :renal function profile –BUN ,serum creatinine , serum electrolytes, serum Ca ,serum phosphorus Proper hemostatic measure and blood replacement is done by washed pack RBC If the patient is on heparin , perform the dental procedure on day that not receiving dialysis Bone marrow susceptible to fracture Care dental extraction technique to avoid fracture

32. Endocrine system Diabetes mellitus Two types Type 1 diabetes (insulin dependent diabetes mellitus ) an autoimmune disease Loss of pancreatic insulin producing B cell type 2 diabetes (insulin non dependent diabetes mellitus ) Beta cell continue to produce insulin Resistance against insulin

33. Dental consideration ASA physical status and treatment consideration ASA 2 : eat normal breakfast and take usual insulin dose in the morning , avoid missing meals before and after surgery 2. ASA 3 :monitor blood glucose more frequently for several days following surgery 3. ASA 4: consult physician before surgery

34. Hematopoietic system Hemophilia X-linked dominant trait Is defective factor 8 Factor 8 have three component 8 C :procoagulant that participates in the clotting cascade 8 R ,WF :von willebrand factor which play roll in platelet aggregation and platelet adhesion 8 R Ag: which support platelet aggregation In hemophilia A only factor 8 C is reduced

35. Diagnosis and management o hemophilia Findings Prolonged activated partial thromboplastin time (APTT) Normal prothrombin time Evaluation of clotting factors and time :low factor 8C but normal 8WF and 8R Ag

36. Hemophilia Management of hemophiliac requiring oral surgery Sever case (human freeze dried factor 8 ) Milder case factor 8 (5-25%)desmopressin and tanexamic acid, avoid prescription of NSAID which can prolonged bleeding Injection

37. Hemophilia Minor surgery Endotracheal intubation for general anesthesia may bleeding from nasal trauma Factor 8 dose schedule Operation Factor 8 level require Preoperatively given Postoperative schedule Dental extraction Dentoaleveolar surgery Or periodontal surgery Minimum of 50% at operation Factor 8a iv , tanexamic acid 1 gr iv Soft diet for 10 days , given tanexamic acid .if bleeding occur after surgery repeat factor 8 Maxillofacial surgery 100% at operation 50% for 7 days post operative Factor 8b iv Soft diet , factor 8b iv twice daily for 7 days

38. Hemophilia Antihaemophilic factor Tanexamic acid used 1. 1 gr orally 4 times daily 24 hr. preoperatively also used topically reduce bleeding ten milliliter of a 5% solution as mouth rinse for 2 mini 4 times daily for 7 days Desmopressin Impacted lower third removal Local hemostasis Antibiotic Postoperatively

39. Pregnancy and lactation First trimester: no dental treatment except in emergency Second trimester :this is appropriate time for all dental procedure Third trimester :no dental treatment except in emergencies