Managing patients at risk of bleeding

Risk assessment:

What histories are important?

who is responsible for undertaking these?

• Medical and drug history will identify patients at risk and help you plan measures to reduce chances of a problem arising

• Modifying planned tx or referral to hospital may be appropriate because of general health or for some dental procedures

• History to be taken by the dental practitioner

What scoring system can be used to help with risk stratification?

ASA classification

What is the ASA classification?

Try to understand a bit more about their condition, e.g is it well-controlled?, under consultant care?

Name specific haematological disorders associated with increased risk of post-op haemorrhage? (5)

• Leukaemia

• Lymphoma

• Bleeding disorders (Haemophilia A/B, VWD)

• Anticoagulant therapy

• Antiplatelet therapy

Leukaemia:

What are problems associated with leukaemia (acute and chronic) (9)

• Oral infections, immunocompromising, anaemia, gingival swelling, ulceration, bleeding

• May have hep B or C, HIV or be receiving Corticosteroid tx

Leukaemia:

Management of leukaemia (4)

• Elective dental tx should be postponed until remission period

• Infections treated aggressively with AB and AF (they are IM)

• NSAIDs - can cause gastrointestinal bleeding

• LA blocks should be avoided

Lymphoma:

How does it present?

Problems associated with lymphoma?

What are 2 complications following mediastinal irradiation?

Management similar to what?

• Enlarged cervical lymph nodes

• Oral infections, immunocompromised, bleeding, anaemia (similar to those with leukaemia)

• Cardiac issues and impaired respiratory function

• Similar as for leukaemia

Bleeding disorders:

haemostasis consists of 3 main things?

• Vessel constriction, platelet plug formation and coagulation cascade

• Defects of any component will be of significance in dentistry

Bleeding disorders:

What should you do with patients with bleeding disorders before attempting tx ideally in what setting?

Who could become involved with tx planning?

What should be avoided in terms of LA

• Patients should be investigated and managed in the hospital setting even for tx under LA

• Haematologist

• Blocks should be avoided

Thrombocytopenia:

Patients with platelet count below what require a platelet transfusion?

• 50 × 10^9/L

What can be done with regards to specific coaguation defects?

• Coagulation factor replacement is required

Emergency management of a bleeding patient may involve giving the patient what? (2)

• Giving fresh frozen plasma and vitamin K

Anticoagulation therapy:

Anticoagulants may be used in the treatment of what? (4)

• Preventing venous thrombosis and embolism in rheumatic heart disease and atrial fibrillation

• Atrial fibrillation and valve heart disease

• Tx and prophylaxis of deep vein thrombosis and pulmonary embolism

• Stroke prophylaxis

• Mechanical heart valves

What does warfarin inhibit?

• Inhibits vitamin K dependent synthesis of clotting factors

• Factors: 7,9,10,prothrombin 2

• This affects the formation of fibrin clot

Anticoagulation therapy:

How long does it take for warfarin to get to peak anticoagulant effect?

warfarin’s anticoagulation effect can be measured using what ? (2)

What is the usual INR for patients taking anticoagulants compared to that of normal?

• 36 hours or longer

• Prothrombin time (PT) and activated partial thromboplastin time (APTT)

• 2-4 in anticoagulated pt, INR of 1 is normal

Pts within normal range, do they require any changes to their warfarin dose?

When should the INR measurement be carried out?

• May not require any change to their warfarin dose for minor surgery but should be warned that there is an increased risk of bleeding after surgery

• Local measures for haemostasis are likely to be adequate

• within 24 hours preferably on the day of surgery

What happens if a patient bleeds (on warfarin)?

• transferred to hospital for haematological management - administration of vitamin K by slow IV injection or fresh frozen plasma

What type of injections and LA techniques should be avoided in all patients with a haemostatic disorder or on anticoagulants and alt (2) techniques?

• Intramuscular injections

• ID nerve block - infiltration or intraligamentary injections techniques used instead

What medications can interact with Warfarin?

• Metronidazole, erythromycin, amoxycillin

• Aspirin, NSAIDs

• (azole antifungals - from prev lectures)

NOACs

name some, and what do they inhibit?

• Rivaroxaban, apixaban, edoxaban, - Factor 10a

• dabigatran - thrombin (factor 2a) INHIBITOR

What can be used for guidance with regards to the NOACs?

• SDCEP

Brief advice for NOACs?

• Low risk of bleeding procedure - treat without interrupting their anticoagulant medications

• High risk of bleeding procedure - advise to miss (DA)/delay(R) their morning dose on the day of their treatment

What should the patient be informed of if they are taking NOACs before dental treatment as part of the consent process?

Appointments ideally at what times?

How is bleeding managed?

• Risks and benefits

• Morning and early in the week

• Oxidised cellulose, sutures, gauze pressure packs

More recommendations for practice?

What do do with multiple extractions?

Certain drugs to avoid concomitant use of?

What if the patient is on a limited course of therapy or at the start of therapy (where initial doses may be higher)?

• Staged

• NSAIDs

• Delay invasive dental procedures

Severe post op bleeding is managed how?

• Application of mechanical pressure

• Haemostatic measures

• Maintenance of intravascular volume with fluid replacement

Antiplatelet therapy

Name some antiplatelet medications? (3)

Which will have more prolonged bleeding, is it a problem?

multiple extractions?

• Aspirin, clopidogrel, dipyridamole,

• Aspirin and dipyridamole - in minor surgery this may not be clinically significant

• Staged - maximum of 3 per visit

Antiplatelet therapy:

Management?

In significant surgery what might be done?

What combination of antiplatelets should be referred to a specialist?

• Haemostatic dressing placed in socket and sutured using resorbable material

• Managed in hospital, antiplatelet therapy may be stopped before surgery

• Aspirin + Clopidogrel

Hepatic disease:

Clotting dysfunction:

What should be arranged and confirmed before tx/surgery?

Why should these patients be managed in hospital?

• Diagnosis and severity by arranging for coagulation screen

• Patients may need vitamin or fresh frozen plasma to correct coagulation

Hepatic disease:

alcohol

What alcohol intake would warrant further investigations and what investigation would that be?

• High number of units of alcohol

• Liver function test

Hepatic disease:

Drugs

Name some drugs to be cautious of?

Any drug prescribing should include what?

• Paracetamol, NSAIDs and sedatives

• Reference to a drug formulary

• Difficult to predict the impairment of a drug metabolism even when using liver function tests

Hepatic disease

can cause problems with production of what factors?

• Fibrinogen (later converted to fibrin) and clotting factors 2,5,7,8,9,10,11,12,13

• drug metabolism

What other hepatic disease can be an issue in terms of cross-infection?

Hepatitis

What is tranexamic acid?

• Antifibrinolytic drug

What 2 procedures are high risk?

• extractions and surgical extractions

Reduction of risk for extractions? (3)

• Reduce number of extractions for high risk patients (staged)

• Not Friday afternoon

• Telephone at 24 hours

Surgical removal of teeth?

What vessel may be sacrificed if doing a flap on the palate?

Manage?

• Incisive foramen vessels

• Pressure with oxidized cellulose mesh

• Bone wax - must be removed as not resorbable

Surgical removal of teeth, what artery is at risk?

management?

• palatal artery

• pressure with oxidized cellulose mesh

• suture with vicryl

Management of haemorrhage:

Post dental extraction

Bleeding usually stops x minutes after extraction

why might it prolong?

• 10 minutes

• Mucosal tear or from the bone of the socket

Reactive haemorrhage:

What is it, how common is it?

• After effects of the LA with adrenalin vasoconstriction has worn off

• several hours after

• not very common

Secondary haemorrhage:

caused by what? how common is it?

• caused be secondary infection of clot

• several days later

• rare

Post dental extraction haemorrhage: what advise might you give patients?

How to measure blood lost if bleeding occured?

• measure what is left

• pulse rate and volume and arterial blood pressure

• (loss of blood increases HR and decreases blood pressure due to reduction in blood volume)

How to take BP?

Boundaries for bradycardia and tachycardia?

Blood loss can cause what condition?

• hypovolemic shock

Severity of the shock will depend on what?

• Severity of the haemorrhage and length of time

What is shock and symptoms/signs? (5)

• Inadequate tissue perfusion to meet tissue demands

• hypotension, decreased urine, increased HR, restlessness, cyanosis of extremities

Mild vs moderate and severe shock?

Management of shock?

If pt comes to primary care with bleeding what should you do? 3 things to prepare

do what before to inform management?

(vomit of they swallowed blood as it can irritate the stomach)

• Good light and suction

• Appropriate clothing

• Identify source of haemorrhage: socket, gingival margin, mucosal tear

Management if bleeding is from socket? (2 main)

Management if it is from gingival margin or mucosal tear?

• Suturing

Summary