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Medically compromised 2
 

Medically compromised 2

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    Medically compromised 2 Medically compromised 2 Presentation Transcript

    • Medically compromised Patient Islam Kassem ikassem@dr.com
    • 1- Cardiovascular problems2-Pulmonary problems3-Renal problems4-Hepatic disorders5-Endocrine disorders6-Hematologic problems7-neurologic disorders8-Manaement of pregnant & postpartum patients ikassem@dr.com
    • 1st lecture1- Cardiovascular problems2-Pulmonary problems3-Renal problems4-Hepatic disorders ikassem@dr.com
    • 2nd Lecture5-Endocrine disorders.6-Hematologic problems.7-neurologic disorders.8-Manaement of pregnant & postpartum patients. ikassem@dr.com
    • Endocrine Disorders Diabetes Mellitus Adrenal Suppression Hyperthyroidism
    • Endocrine Disorders Diabetes Mellitus
    • Endocrine DisordersDiabetes MellitusInsulin dependentnon-insulin-dependent
    • Endocrine DisordersDiabetes MellitusINSULIN-DEPENDENT DIABETES1. Defer surgery until diabetes is well controlled; consult physician.2. Schedule an early morning appointment; avoid lengthy appointments.3. Use an anxiety-reduction protocol, but avoid deep sedation techniques in out patients.4. Monitor pulse, respiration, and blood pressure before, during, and after surgery.
    • Endocrine DisordersDiabetes MellitusINSULIN-DEPENDENT DIABETES5. Maintain verbal contact with patient during surgery.6. If patient must not eat or drink before oral surgery and will have difficulty eating after surgery, instruct patient not to take the usual dose of regular or NPH insulin; start an IV with a 5% dextrose in water drip at 150 mL/h.7. If allowed, have the patient eat a normal breakfast before surgery and take the usual dose of regular insulin, but only half the dose of NPH insulin.
    • Endocrine DisordersDiabetes MellitusINSULIN-DEPENDENT DIABETES8. Advise patients not to resume normal insulin doses until they are able to return to usual level of caloric intake and activity level.9. Consult physician if any questions concerning modification of the insulin regimen arise.10. Watch for signs of hypoglycemia.11. Treat infections aggressively.
    • Endocrine DisordersDiabetes MellitusNON-INSULIN-DEPENDENT DIABETES1. Defer surgery until diabetes is well controlled.2. Schedule an early morning appointment; avoid lengthy appointments.3 Use an anxiety-reduction protocol.4. Monitor pulse, respiration, and blood pressure before, during, and after surgery.
    • Endocrine DisordersDiabetes MellitusNON-INSULIN-DEPENDENT DIABETES5. Maintain verbal contact with the patient during surgery.6. If patient must not eat or drink before oral surgery and will have difficulty eating after surgery, instruct patient to skip any oral hypoglycemic medications that day.7. If patient can eat before and after surgery, instruct patient to eat a normal breakfast and to take the usual dose of hypoglycemic agent.8. Watch for signs of hypoglycemia.9. Treat infections aggressively.
    • Endocrine DisordersAdrenal Suppression
    • Endocrine DisordersManagement of Patient with Adrenal SuppressionIf patient is currently taking corticosteroids:1. Use an anxiety-reduction protocol.2. Monitor pulse and blood pressure before, during, and after surgery.3. Instruct patient to double usual daily dose on the day before, day of, and day after surgery.4. On second postsurgical day, advise the patient to return to a usual steroid dose.
    • Endocrine DisordersManagement of Patient with Adrenal SuppressionIf the patient is not currently taking steroids but has received at least 20 mg of hydrocortisone (Cortisol or equivalent) for more than 2 weeks within past year1. Use an anxiety-reduction protocol.2. Monitor pulse and blood pressure before, during, and after surgery.
    • Endocrine DisordersManagement of Patient with Adrenal SuppressionIf the patient is not currently taking steroids but has received at least 20 mg of hydrocortisone (Cortisol or equivalent) for more than 2 weeks within past year3. Instruct the patient to take 60 mg of hydrocortisone (orequivalent) the day before and the morning of surgery (orthe dentist should administer 60 mg of hydrocortisone orequivalent intramuscularly or intravenously before complexsurgery).
    • Endocrine DisordersManagement of Patient with Adrenal SuppressionIf the patient is not currently taking steroids but has received at least 20 mg of hydrocortisone (Cortisol or equivalent) for more than 2 weeks within past year4. On the first 2 postsurgical days, the dose should bedropped to 40 mg and dropped to 20 mg for 3 days thereafter.The clinician can cease administration of supplementalsteroids 6 days after surgery.
    • Endocrine Disorders Hyperthyroidism
    • Endocrine DisordersHyperthyroidismManagement of Patient with Hyperthyroidism1. Defer surgery until thyroid gland dysfunction is well controlled.2. Monitor pulse and blood pressure before, during, and after surgery.3. Limit amount of epinephrine used.
    • Neurologic Disorders Seizure Disorders
    • Neurologic DisordersSeizure DisordersManagement of Patient with a Seizure Disorder1. Defer surgery until the seizures are well controlled.2. Consider having serum levels of antiseizure medicationsmeasured if patient compliance is questionable.3. Use an anxiety-reduction protocol.4. Avoid hypoglycemia and fatigue.
    • Hematologic Problems Patient with a Coagulopathy Anticoagulated Drugs
    • Hematologic ProblemsPatient with a Coagulopathy
    • Hematologic ProblemsManagement of Patient with a Coagulopathy1. Defer surgery until a hematologist is consulted about the patients management.2. Obtain baseline coagulation tests as indicated (prothrombin time, partial thromboplastin time, Ivys bleeding time, platelet count) and a hepatitis screen.3. Schedule the patient in a manner that allows surgery soon after any coagulation-correcting measures have been taken (after platelet transfusion, factor replacement, or aminocaproic acid administration).
    • Hematologic ProblemsManagement of Patient with a Coagulopathy4. Augment clotting during surgery with the use of topical coagulation - promoting substances, sutures, and wellplaced pressure packs.5. Monitor the wound for 2 hours to ensure that a good initial clot forms.6. Instruct the patient in ways to prevent dislodgment of the clot and in what to do should bleeding restart.7. Avoid prescribing nonsteriodal anti-inflammatory drugs.8. Take hepatitis precautions during surgery.
    • Hematologic Problems Anticoagulant Drugs
    • Hematologic ProblemsManagement of Patient Whose Blood Is Therapeutically Ant coagulatedPatients Receiving Aspirin Or Other Platelet-inhibiting Drugs1. Consult physician to determine the safety of stopping theanticoagulant drug for several days.2. Defer surgery until the platelet-inhibiting drugs have beenstopped for 5 days.3. Take extra measures during and after surgery to helppromote clot formation and retention.4. Restart drug therapy on the day after surgery if no bleeding is present.
    • Hematologic ProblemsManagement of Patient Whose Blood Is Therapeutically AnticoagulatedPatients Receiving Warfarin (Coumadin)1. Consult the patients physician to determine the safety ofallowing the prothrombin time (PT) to fall to 2.0 to 3.0 INR(international normalized ratio) for a few days."2. Obtain the baseline PT.3. (a) If the PT is less than 3.1 INR, proceed with surgery and skip to step 6. (b) If the PT is more than 3.0 INR, go to step 4.
    • Hematologic ProblemsManagement of Patient Whose Blood Is Therapeutically AnticoagulatedPatients Receiving Warfarin (Coumadin)4. Stop warfarin approximately 2 days before surgery.5. Check the PT daily, and proceed with surgery on the daywhen the PT falls to 3.0 INR.6. Take extra measures during and after surgery to helppromote clot formation and retention.7. Restart warfarin on the day of surgery.
    • Hematologic ProblemsManagement of Patient Whose Blood Is Therapeutically AnticoagulatedPatients Receiving Heparin1. Consult the patients physician to determine the safety of stopping heparin for the perioperative period.2. Defer surgery until at least 6 hours after the heparin is stopped or reverse heparin with protamine.3. Restart heparin once a good clot has formed.
    • Management of pregnant & lactating females ikassem@dr.com
    • ikassem@dr.com
    • ikassem@dr.com
    • ikassem@dr.com
    • Study source? ikassem@dr.com
    • Contemporary Oral & maxillofacial surgeryPage 10-20 ikassem@dr.com