![ We generally reserve bridging for individuals considered at
very high or high risk of thromboembolism .
recent stroke,
mechanical heart valve,
If they require interruption of warfarin.
The bridging agent is required.
therapeutic dose subcutaneous low molecular weight
[LMW] heparin
started three days before surgery.
A bridging agent may also be appropriate if there is a
prolonged period during which the patient cannot take
oral medications
Eg: Major maxillofacial and oral procedure.](https://image.slidesharecdn.com/managementofpatientsonlongtermanticoagulanttherapy-161113002858/75/Management-of-patients-on-long-term-anticoagulant-therapy-35-2048.jpg)
![ Bridging anticoagulation may be appropriate
in patients who will have a very high
thromboembolic risk with prolonged
interruption of their anticoagulant (generally
a vitamin K antagonist [VKA]).
Individual patient comorbidities that increase
bleeding risk may also need to be considered
because an increased postoperative bleeding
risk may be a reason to avoid bridging.](https://image.slidesharecdn.com/managementofpatientsonlongtermanticoagulanttherapy-161113002858/75/Management-of-patients-on-long-term-anticoagulant-therapy-38-2048.jpg)
![ Reversal of the patient's usual anticoagulant may
be required for more urgent or emergent surgery
or procedures, or to treat perioperative bleeding.
Agents with a potential prothrombotic effect (eg,
prothrombin complex concentrates
iplasma products
immediate reversal agents
should be reserved for the treatment of severe
bleeding (eg, intracranial hemorrhage, emergent
major surgery with elevated [PT/INR]).](https://image.slidesharecdn.com/managementofpatientsonlongtermanticoagulanttherapy-161113002858/75/Management-of-patients-on-long-term-anticoagulant-therapy-51-2048.jpg)
![ For semi-urgent reversal of warfarin is
required (eg, within one to two days),
warfarin should be withheld and vitamin K
should administered (eg, 2.5 to 5.0 mg of
oral or intravenous vitamin K)
If immediate reversal is required (eg, for
emergent surgery or active bleeding), this can
be achieved via the use of
prothrombin complex concentrates (PCCs)
plasma products Fresh Frozen Plasma [FFP]](https://image.slidesharecdn.com/managementofpatientsonlongtermanticoagulanttherapy-161113002858/75/Management-of-patients-on-long-term-anticoagulant-therapy-53-2048.jpg)
Uploaded byDiwakar vasudev
Management of patients on long term anticoagulant therapy.
This document discusses the management of anticoagulation in patients undergoing surgical procedures. It notes that anticoagulants prevent blood clotting but increase bleeding risks during surgery. Newer direct-acting anticoagulants like dabigatran, rivaroxaban, apixaban and edoxaban have shorter half-lives, making it easier to discontinue and resume them rapidly around procedures compared to warfarin. The risks of bleeding during surgery and thromboembolism without anticoagulation must be balanced on a case-by-case basis. Guidelines are provided for interrupting and resuming various anticoagulants based on procedure bleeding risk. Bridging with heparin may
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Similar to Management of patients on long term anticoagulant therapy.
Management of patients on long term anticoagulant therapy.
- 1.
- 2. Anticoagulants area class of drugs that work to prevent blood coagulation (clotting)
- 4. NEWER DIRECTACTING ANTICOAGULANT Dabigatran, rivaroxaban, apixaban, edoxaban
- 5. Management ofanticoagulation in patients undergoing surgical procedure is challenging. Interrupting of anticoagulation for a procedure transiently increases the risk of thromboembolism.
- 6. Surgery andinvasive procedures have associated bleeding risks that are increased by anticoagulants administered for thromboembolism prevention.
- 7. The patientsbleeds from the surgical procedure, their anticoagulant may need to be discontinued for a longer period of time , resulting in a longer period of increased thromboembolic risk.
- 8. A balancebetween reducing the risk of thromboembolism and preventing excessive bleeding must be reached for each patient.
- 9. It takesseveral days until the anticoagulant effect is reduced. And it is reestablished perioperatively the risk and benefits of bridging a shorter acting agent like heparin.
- 10. They haveshorter half lives. Direct thrombin inhibitor Dabigatran Factor Xa Inhibitor Rivaroxaban Apixaban Edoxaban They make easier discontinue and resume rapidly.
- 11. A higherthromboembolic risk increases the importance of minimizing the interval without anticoagulation. Patients with Atrial fibrillation Recent deep vein thrombosis Recent stroke Recent pulmonary embolism In this case surgery should be delayed untill the risk return to the baseline.
- 12. A higherbleeding risk confers a greater need for perioperative hemostasis. Bleeding risk is dominated by the type and urgency of surgery. Procedures with a low bleeding risk eg ; dental extractions, minor skin surgery often can be performed without interruption of anticoagulation.
- 13. The timingof anticoagulant interruption depends on the specific agent the patient is receiving Warfarin requires earlier discontinuation than the shorter acting direct oral anticoagulants.
- 14. For mostpatients, bridging anticoagulation is not used ( use of a short acting parenteral agent to reduce the interval without anticoagulation). It increases bleeding risk without reducing the rate of thromboembolism Patients on warfarin with especially high thromboembolic risk (eg : mechanical heart valve, recent stroke may be benefit from bridging with heparin.
- 15. Balance thromboembolicand bleeding risks must be made on case-by-case basis. No scoring system can substitute for clinical judgment in this decision making. In general, the anticoagulant must be discontinued if the surgical bleeding risk is high. Those at very high or high thromboembolic risk should limit the period without anticoagulation to the shortest possible interval. In individuals undergoing selected low bleeding risk surgery often can continue their anticoagulant.
- 16. PRACTICES TOREDUCE BLEEDING AND THROMBOEMBOLIC RISK SHOULD BE EMPLOYED REGARDLESS OF WHETHER THE PATIENT ANTICOAGULANT IS INTERRUPTED OR CONTINUED.
- 17. Agents thatinterfare with platelet function should be avoided for routine analgesia (eg: NSAIDS, asprin. Unless the benefit outweighs the increased risk of bleeding and routine perioperative use of asprin should be avoided due to increased risk of bleeding and lack of benefit.
- 18. In contrastif these agents are administered for separate indication eg : recent stroke, acute coronary syndrome , Implanted coronary stent, They should be continued For those not receiving an anticoagulant in the immediate postoperative period, thromboprophylaxis to reduce the risk of venous thromboembolism should be used when appropriate.
- 19. Individuals undergoingsurgery with a high risk of bleeding will require interruption of their usual anticoagulant perioperatively, putting them at higher risk of thromboembolic complications related to their underlying condition.
- 20. If thevery high risk of thromboembolism is transient eg: ischemic stroke with in the previous month attempts should be made to delay elective surgery, if possible, untill the thromboembolic risk has returned to baseline. Eg: Myocardial Infarction till 6 months have passed.
- 21. Delay electivesurgery in patients with atrial fibrillation who had inadequate anticoagulation in the preceding month. It has been observed that among patients with non vascular atrial fibrilation, over 85 percent of thrombi resolve after 4 weeks of warfarin therapy.
- 22. Individuals witha temporarily very high or high thromboembolitic risk in whom surgery cannot be delayed (eg: potentially curative cancer surgery) should limit the time interval of any without to anticoagulant minimize the risk of thromboembolism It involves stopping of the usual anticoagulant as close to the surgery as possible, restarting it as soon as possible, and using the bridging anticoagulant before and/or after surgery while usual anticoagulants is not therapeutic, especially for those on warfarin.
- 23. For individualswith a chronically elevated thromboembolic risk in whom surgery is performed often bridging anticoagulation should be used to minimize the period when anticoagulation is not being used. Individuals with moderate thromboembolic risk generally can interrupt their anticoaagulant for surgery without bridging. The bleeding risk from bridging may outweigh any potential benefit.
- 24. Dental proceduresare generally considered to confer a low risk of bleeding. Hence anticoagulation can be continued in most of the patients under these procedures. Anticoagulation therapy can be continued in patients who receiving warfarin with an INR in a therapeutic range.
- 25. In theARISTOTLE trial Patients receiving anticoagulation with warfarin vs apixaban for atrial fibrillation, perioperative bleeding rates were approx 1% in patients undergoing dental and other low bleeding risk procedure. Bleeding can be further reduce by the use of topical hemostatic agents eg: Tranexamic acid Aminocaproic acid mouthwash , used 3-4 times a day for one to two days. Multiple tooth extractions are expection , they are considered at high bleeding risk.
- 26. Cutaneous procedures Eg: skin biopsy Small Tumor excision These are also consider safe in the patients who are reciving anticoagulant. It comes under low risk category Local measure to controll bleeding further reduce the risk of bleeding
- 27. If thedecision has been made to interrupt the anticoagulant for surgery with a high or moderate risk , the agent should be stopped in sufficient time to allow anticoagulation to resolve. For some agents, laboratory testing is a reliable indicator that the anticoagulant effect has resolved after discontinuation (eg, warfarin); for others, well-validated and easily accessible testing is not always available.
- 28. Typical durationsof anticoagulant interruption are illustrated by the RE-LY trial, which randomized individuals with nonvalvular atrial fibrillation to warfarin or dabigatran for prevention of thromboembolism. In this trial, nearly half of patients treated with dabigatran had surgery within 48 hours of stopping the drug, whereas only approximately 1 in 10 patients treated with warfarin had surgery within 48 hours of drug discontinuation. The incidence of thromboembolism was low (<1 percent), and bleeding rates were similar for those receiving warfarin or either dabigatran dose.
- 29. Warfarin blocksa vitamin K-dependent step in clotting factor production; it impairs coagulation by preventing synthesis of factors II (prothrombin), VII, IX, and X. Resolution of warfarin effect is determined by measurement of the prothrombin time, which is standardized across institutions using an international normalized ratio (PT/INR).
- 30. discontinue warfarinfive days before elective surgery. when possible, check the PT/INR on the day before surgery. If the INR is >1.5, we administer low dose oral vitamin K (eg, 1 to 2 mg) to hasten normalization of the PT/INR and recheck the following day. We proceed with surgery when the INR is ≤1.4.
- 31. An INRin the normal range is especially important in patients undergoing surgery associated with a high bleeding risk (eg, intracranial, spinal, urologic) or if neuraxial anesthesia is to be used. This timing of warfarin discontinuation is based on the biological half-life of warfarin (36 to 42 hours)
- 32. the observedtime for the PT/INR to return to normal after stopping warfarin (eg, two to three days for the INR to fall to below 2.0; four to six days to normalize). Normalization of the INR may take longer in patients receiving higher-intensity anticoagulation (INR 2.5 to 3.5), and in elderly individuals.
- 33. Half-lives ofother vitamin K antagonists. 8 to 11 hours for acenocoumarol. 3-5 days for phenprocoumon. 3 days fluindione.
- 34. For amore rapid normalization of the INR, additional interventions may be needed to actively reverse the anticoagulant. it is estimated that if warfarin is withheld for five days before surgery. patients would have a subtherapeutic INR for approximately eight days Thus, for patients at very high or high thromboembolic risk, bridging may be appropriate.
- 35. We generallyreserve bridging for individuals considered at very high or high risk of thromboembolism . recent stroke, mechanical heart valve, If they require interruption of warfarin. The bridging agent is required. therapeutic dose subcutaneous low molecular weight [LMW] heparin started three days before surgery. A bridging agent may also be appropriate if there is a prolonged period during which the patient cannot take oral medications Eg: Major maxillofacial and oral procedure.
- 36. Resume warfarin12 to 24 hours after surgery, typically the evening of the day of surgery or the evening of the day after surgery. Condition there were no unexpected surgical issues that would increase bleeding risk and the patient is taking adequate oral fluids. same dose of drug can be used for patient which was receiving preoperatively. After warfarin is restarted in the perioperative setting, it takes 5 to 10 days to attain a full anticoagulant effect as measured by an INR above 2.0
- 37. Bridging anticoagulationinvolves the administration of a short-acting anticoagulant, typically a low molecular weight (LMW) heparin, during the interruption of a longer-acting agent, typically warfarin. There are no data on using the newer direct oral anticoagulants (eg, direct thrombin inhibitors, direct factor Xa inhibitors) as bridging agents. these agents lack a specific reversal strategy should bleeding occur.
- 38. Bridging anticoagulationmay be appropriate in patients who will have a very high thromboembolic risk with prolonged interruption of their anticoagulant (generally a vitamin K antagonist [VKA]). Individual patient comorbidities that increase bleeding risk may also need to be considered because an increased postoperative bleeding risk may be a reason to avoid bridging.
- 39. Bridging shouldbe used in individuals taking warfarin for following conditions. Embolic stroke or systemic embolic event within the previous three months Mechanical mitral valve Mechanical aortic valve and additional stroke risk factors Atrial fibrillation and very high risk of stroke Venous thromboembolism (VTE) within the previous three months (preoperative and postoperative bridging) Recent coronary stenting (eg, within the previous 12 weeks Previous thromboembolism during interruption of chronic anticoagulation
- 40. Two typesof heparin products are available: LMW heparins Unfractionated heparin Both have similar efficacy. LMW heparin for bridging anticoagulation in individuals with a very high risk of arterial thromboembolism and those with a moderate risk of thromboembolism.
- 41. For individualswith renal insufficiency and/or those requiring hemodialysis, intravenous or subcutaneous unfractionated heparin can be used more easily because dosing is unaffected by renal clearance
- 42. We donot use any of the newer direct oral anticoagulants. Dabigatran, rivaroxaban, apixaban, edoxaban for bridging, as there are no data on the safety or efficacy of these agents for perioperative bridging.
- 43. Heparins canbe dosed at prophylactic doses, therapeutic doses, or doses intermediate between the two. There are no clinical trial data or practice standards to guide dosing, clinical judgment is required to determine the appropriate dose for each patient
- 44. Therapeutic dosing– Therapeutic dosing (also called "full dose") Typical regimens include enoxaparin, 1 mg/kgsubcutaneously twice daily or dalteparin, 100 units /kg subcutaneously twice daily.
- 45. Intermediate dosing– Intermediate dose anticoagulation may be appropriate for individuals with atrial fibrillation or VTE within the preceding month when bridging is needed but concerns about bleeding are greater. Typical regimens include enoxaparin, 40 mg twice daily, or dalteparin, 5000 units subcutaneously twice daily
- 46. Prophylactic dosing:(also called "low dose") Typical prophylactic regimens include enoxaparin, 40 mg once daily, or dalteparin 5000 units subcutaneously once daily.
- 47. Preoperative timingof bridging Generally initiate heparin bridging three days before a planned procedure (ie, two days after stopping warfarin), when thePT/INR has started to drop below the therapeutic range. LMW heparin: discontinue LMW heparin 24 hours before the planned surgery or procedure. Ensures that no significant residual anticoagulant will be present at the time of surgery
- 48. Unfractionated heparin: For therapeutic dose unfractionated heparin, continue the intravenous infusion until four to five hours before the procedure t1/2- 45 min.
- 49. Postoperative timing ofbridging Postoperative resumption of unfractionated heparin and LMW heparin is similar. The resumption of bridging, especially when given as a therapeutic-dose regimen, should be delayed until there is adequate hemostasis. It should be based on clinical assessment.
- 50. FOR MAJORSURGICAL PROCEDURE For those undergoing major surgery or those with a high bleeding risk procedure, therapeutic- dose of unfractionated heparin or LMW heparin should be delayed for 48 to 72 hours after hemostasis has been secured FOR MINOR SURGICAL PROCEDURE For most minor procedures associated with a low bleeding risk in which bridging is used heparin can usually be resumed 24 hours after the procedure.
- 51. Reversal ofthe patient's usual anticoagulant may be required for more urgent or emergent surgery or procedures, or to treat perioperative bleeding. Agents with a potential prothrombotic effect (eg, prothrombin complex concentrates iplasma products immediate reversal agents should be reserved for the treatment of severe bleeding (eg, intracranial hemorrhage, emergent major surgery with elevated [PT/INR]).
- 52. WARFARIN Individualsrequire reversal of warfarin or other vitamin K antagonists, the appropriate reversal strategy is determined by the degree of anticoagulation (eg, PT/INR, clinical bleeding), urgency of the procedure, and degree of bleeding risk
- 53. For semi-urgentreversal of warfarin is required (eg, within one to two days), warfarin should be withheld and vitamin K should administered (eg, 2.5 to 5.0 mg of oral or intravenous vitamin K) If immediate reversal is required (eg, for emergent surgery or active bleeding), this can be achieved via the use of prothrombin complex concentrates (PCCs) plasma products Fresh Frozen Plasma [FFP]
- 54. Definition : HemophilaA is a deficency of factor 8. Hemophila B (christmas disease )is deficency of factor (9).
- 55. SEVERE: When plasmaactivity is less than 1I/U dl. MODERATE: If ranges between 2-5 I/U dl. MILD: If ranges between 6-40 IU/ dl (Normal range 50- 100IU/dl)
- 56. Involves the placementof the deficient clotting factors by intravenous infusion to either controll or prevent bleeding
- 57. Viral inactivationof plasma derived factors concentrate was introduced in the mid 80s and the use of recombinant ( non human derived ) factors concentrates started in the early 90s. These measures have reduced, if not removed , the risk of viral transmission with these product .
- 58. Class Subclass Drug AntiplateletAgents Asprin - ADP induced platelet activation inhibitor Clopidogrel Ticlopidine Platelet glycoprotein antagonist Abciximab Eptifibatide Tirofiban
- 59. Class Subclass Drug Antithrombinagent Unfractionated heparin - Direct Thrombin inhibitors Bivalirudin Hirudin Argatroban LMW Heparins (Xa inhibitor) Coumarin Enoxaparin Dalteparin Ardeparin Danaparoid Tinzaparin Warfarin
- 60. Class Subclass Drug FactorXa inhibitor Fondaparinux Thrombolytic agents Plasminogen actiavtors Sterptokinase Alteplase Reteplase Tenecteplase
- 61. Pregnant womenwith a prosthetic valve are at the highest risk for thromboembolic phenomenoa as also valve failure and so anticoagulation must be continue in these cases. LMW heparin is the treatment of choice as it does not cross the placenta.
- 62. In multipleextraction cases and complicated surgical procedure there is significant increase in the post operative INR. So monitoring of INR in the multiple extraction cases should be done.
- 63. Dabigatrin isa new direct thrombin inhibitor approved for prevention of the VTE after hip or Knee replacement and prevention of stroke or systemic embolism in atrial fibrilation . It used where other oral anticoagulants is inappropriate. Bleeding complications are as for LMWH and coagulation monitoring is usually not required. There is no definite evidence based guidelines for the dental management of patients receving this medication.
- 64. PROTHROBIN TIME THROMBOTEST INR NORMAL LEVEL< 1.3 >70% 1 THERAPUTIC RANGE 2-4.5 5-20% 2-5 LEVELS AT WHICH DENTOALVEOLAR SURGERY CAN BE CARRIED OUT <2.5 >15% <3.5 Uncomplicated forcep extraction of 1-3 teeth Normal PT- 12 seconds
- 65. Bleeding timeis a sensitive measure of platelet function. Usually there is a linear relationship between platelet count and bleeding time. Patients with bleeding time more than 10 minutes have increased risk of bleeding. Normal value : 2-5 minutes Dukes method.
- 66. It Determinesthe effectiveness of clotting pathway. Normal range : 8-15 min
- 67. Normal plateletcount is 1,50,000 to 4,50,000 per cumm of the blood. When count becomes 50,000 to1,00,000 per cumm, there is mild prolongation of bleeding time . Minor oral surgical procedure can be safely done, if platelet count is above 80,000 to 1,00,000 per cumm,
- 68. Prothrombin timescreens the extrinsic limb of coagulation pathway (Factors V, VII and X) and factors I, II and V of the common pathway. It is prolonged inpatients, who are on warfarin anticoagulant therapy vitamin K deficiency or deficiency of factor V, VII, X, prothrombin or fibrinogen Normal PT is usually 12-14 second.
- 69. Partial thromboplastintime screens the intrinsic limb of coagulation pathway and tests for the adequacy of factors VIII, IX, X, XI, XII of intrinsic system and factors I, II, V of the common pathway. It is prolonged in haemophiliacs. Normal PTT is less than 45 seconds.
- 70. The prothrombintime (PT) has been the conventional means used to monitor the degree of anticoagulation. WHO has recently recommended monitoring of these patients with international normalized ratio (INR), because PT has been shown to be imprecise and variable. There is little comparability of PT values taken in different laboratories. INR RECOMMENDED DVT, valvular heart disease , pulmonary embolism MI 2.0- 3.0. Artficial mechanical heart value 3.0-4.5
- 71. These differencesare primarily due to the thromboplastin used in performing the test as thromboplastin can be obtained from different sources and the type of instrumentation used in performing the test. In an effort to standardise the results of the PT, World Health Organization introduced the concept of INR.
- 72. These monitors makeit possible for patients to check their INRs at home, which is referred to as patient self-testing.
- 73. FOR CUTANEOUSSURGERY Excellent lighting and wound retraction to assist and isolate arteriole bleeding. Hemostat use for grasping blood vessel. Absorbable ligature for vessel. Electrocoagulation. Biploar forceps
- 74. A flap,which may mobilize large amounts of skin, is probably at greater risk for hematoma and wound necrosis. Pursestring closures may work well to minimize postoperative hemorrhage. A purse-string closure does not require undermining and serves to tamponade peripheral wound bleeding. The center of the wound remains open and acts as a drain.
- 75. Limit subcutaneous undermining. In severe cases, when patients have repeatedly soaked through the dressing can be primarily without any undermining, limiting potential bleeding foci. Close the wound meticulously with multiple layers of absorbable suture to minimize dead space.
- 76. Second intentionhealing is also a reasonable choice for wound management. In addition, one may apply Gelfoam® to the wound and secure a pressure dressing over the Gelfoam®. In severe cases, the surgeon can also run absorbable suture such as 5-0 Monocryl®, continuously around the wound edges.
- 77. Fenestrated fullthickness skin grafts with a tie-over bolster provide wound tamponade and a collagen substrate for hemostasis.
- 78. During woundrepair, consider using local anesthesia without a vasoconstrictor Vasoconstrictors provide helpful operative bleeding reduction, prolong anethesia duration and reduce total anethetic dose. However, reactive vasodilatation in the postoperative period may predispose to hematoma because potential bleeding points, such as arterial bleeding, are not recognized at surgery.
- 79. In caseswhere refractory bleeding may continue as a generalized slow oozing, often seen in underlying coagulopathies ,a Jackson-Pratt or Penrose drain can be placed into the wound prior to repair and withdraw the drain after 48 hours.
- 80. Prescribe analgesics. This not only keeps the postoperative period more restful but also reduces anxiety, pain and elevated blood pressure. High blood pressure increases intraoperative and postoperative bleeding.
- 81. Place thewound at rest. Have patient avoid stooping, bending or lifting anything heavier than a for 72 hours. Have them elevate the site and keep the area dry. Avoid any strenuous activity for 1 week. Emphasize that NSAIDs and aspirin are not to be taken for pain. Give written instructions.
- 84. Antiplatelet drugsare generally prescribed for the prevention of arterial and venous thrombosis in patients with ischemic heart disease, heart valve implants and stents, and in people at risk of suffering cerebrovascular events such as stroke Eg: ASPIRIN
- 85. Studies conductedin 1970s by Lemkin et al and Mc Gaul et al about postoperative bleeding after dental extraction due to aspirin. They have documented that there is increased postoperative bleeding after dental extraction and recommended to discontinue aspirin. For most surgical procedures it has been recommended that patient should stop taking aspirin before 7 – 10 days of the surgical procedure
- 86. Thomson etal in his study have found that there is a risk of bleeding after gingival surgery due to continuation of aspirin use and advised to stop aspirin before the procedure. Studies conducted in 1990s by Conti et al ,Speechley et al and Scher et al have recommended to discontinue aspirin for 7 - 10 days since the platelet survives upto 10days.
- 87. Studies by Scullyet al and Little et al in 2002 have advised to stop aspirin for 3 days until a time when the number of new platelets returned to a sufficient level before starting the dental procedures.
- 88. Madan etal and Valerin et al in their study have stated that there is increased risk of thrombotic outcomes with the discontinuation of low dose aspirin therapy. Article published in American Academy of Oral Medicine in 2006 there was no difference in bleeding outcomes between the two groups who received the treatment. 36 patients taking asprin therapy 325 mg 2 days before and after the treatment.
- 89. Studies relatedto general and cardiovascular surgery did not show any significance increase in bleeding Ardekian et al found that a daily dose of 100 mg of Aspirin did not increase the bleeding during tooth extraction. Sonksen et all showed that increase in bleeding time caused caused by daily aspirin dose of 300 mg did not increase the normal limits in patients. According to Crispian Scully et al for uncomplicated forceps extraction of 1 to 3 teeth there is no need to interfere the aspirin dose. In patients taking 100 mg of aspirin daily bleeding can be controlled by suturing and local hemostatic measures.
- 90. Its advisableand safe to continue low - dose aspirin therapy when routine dental extractions are performed unless certain circumstances exist . The current literature cautions dental practitioners not to discontinue aspirin therapy due to the risk of producing a thromboembolic event, increasing the morbidity and mortality risks for the patient.
- 91. Aspirin isused for secondary prevention of thromboembolism which can cause bleeding complications. However in stopping aspirin there is risk of cardio vascular issues which can cause high morbidity rate. So low dose Aspirin (75-300mg/day) monotherapy can be continued during tooth extraction.
- 92. Aspirin resistanceis defined as persistent platelet activation occurring in individuals who take a therapeutic dose of aspirin . The percentage of the population resistant to the cardio protective effects of aspirin has been reported to vary from 5% to 45% The mechanisms by which some patients are resistant to aspirin is unknown,
- 93. But mayinvolve polymorphisms in the COX-1 gene. These gene polymorphisms are carried by 12% of the population . Alternatively, enhanced platelet regeneration and an increased proportion of newly formed platelets expressing COX-2 in response to chronic aspirin administration could explain the development of resistance of platelets to inhibition by a low dose of aspirin. Aspirin resistance is partly reversible by increasing the dose of aspirin .
- 94. Scully andWolff recommend Performs all dental surgeries in the morning, in order to be able to resolve any bleeding complications in the course of the day. patient instructions • Apply pressure with a piece of gauze for 30-40 minutes • Avoid oral rinses during the first 24 hours • Follow a soft and cold diet during the first 24 hours • Avoid suctioning movements • Avoid touching the socket region with the tongue or manipulation of the operated zone
- 95. Hemostastic collagen:These products eg: colla plug, colla tape ,and helistant are soft pliable, non friable,coherent,sponge-like structures. They are fabricated from bovine collagen ( usually from deep flexor tendons) and all are nontoxic and non pyrogenic. The products are highly absorbent and able to hold many times their own weight of fluids. Their indications are for wound protection and for control of oozing or bleeding from oral wounds.
- 97. Monsel’s solutioncontains ferric subsulphate and it acts by precipitating proteins. It is quite effective in arresting thecapillary bleeding and post- extraction bleeding inmedullary bone. Tannic acid also helps in precipitating proteins and causes clot formation Patient can be asked to bite over a folded tea bag in case of post-extraction bleeding until he reaches clinic. Mann haemostatic is a mixture of tannic acid, alum and chlorobutamol. Silver nitrate and ferric chloride are other agents,which can be used.
- 98. It ismade from gelatin and is sponge like. Gelfoam has no intrinsic haemostatic action. Its main haemostatic activity is related to large surface area, which comes in contact with blood and further swells on absorbing blood. It exerts pressure along with acting as scaffold for fibrin network. It is absorbed by phagocytosis. Gelfoam should be moistened in saline or thrombin solution prior to application and all the air should be removed from interstices.
- 100. It isoxidized cellulose and on application releases cellulosic acid, which has marked affinity for haemoglobin, leading to formation of artificial clot. It should be applied dry, because acid formed during wetting process inactivates the thrombin or other haemostatic agent. Acid produced also inhibit epithelialization, therefore, it is not recommended for use over epithelial surfaces. It is removed by the process of phagocytosis.
- 101. Adrenaline appliedtopically induces vasoconstriction and thus helps in achieving haemostasis. Extensive application orundiluted preparation can cause systemic effects,therefore, one should be careful while using adrenaline. The drug is applied with the help of gauze pack in a concentration 1:1000 over oozing sites. It can also be injected along with local anaesthetic in concentration of 1:80,000 to 1:2,00,000. Hypertensive or previously existing cardiac patients should be avoided The vasoconstrictor effect is reversible and ones hould be careful to watch for recurrence of bleeding when its effect wears off.
- 102. Topical useof thrombin acts by converting fibrinogen into fibrin clot. It is very kind to tissues and quite effective. It is applied to the bleeding surface via a pack, gelatin sponge or surgicel .
- 103. Bone wax(Ethicon) it is a sterile mixture of beewax, paraffin, and isopropyl palmitate that is packaged in individual foil envelopes. It acts by mechanical occlusion of the bony canal. Large quantity of bone wax can lead to foreign body granuloma and infection. Therefore, it should be used judiciously..
- 104. Bone bleederpoints are commonly seen during the extraction of the mandibular third molar and if not adequately addressed during surgery can be a reason for postoperative bleeding. The wax is pliable enough to be placed within a vascular channel.
- 105. Fibrin glue:It fibrin glue is used as a local hemostatic measure , along with an oral antifibrinolytic agent, to achieve hemostatis and reduce the need for clotting factor replacement therapy. All Fibrin glue contains human or animals components .
- 106. It isa biological adhesive containing thrombin, fibrinogen, factor XIII and aprotinin. Thrombin converts fibrinogen to unstable fibrin clot, factor XIII stabilizes the clot and aprotinin prevents its degradation. During wound healing, fibroblasts move through the fibrin meshwork forming more permanent framework composed of collagen fibres.
- 107. If postextraction bleeding occurs : Contact hemophilla unit and consider using additional factor concentrate . Inspect the site of the bleed. If there is any evidence of tear in the gingiva or other obvious bleeding point this should be treated using local measure as described previously.
- 108. Instruct thepatient to sit up and bite on a damp gauze swab for at leat 10 min . Use 10% sol of tranexemic acid or EACA to dampen the swab or a mouth wash if the bleeding is difficult to stop. Monitor the patients blood pressure as it may increase due worry and pain.
- 109. Soft vacuumformed splints can be used to provide local protection following dental extraction or prolonged post extraction bleeding.
- 110. Manual reconstruction( Preoperatively) Take dental impression before extraction form the model in the lab Remove the tooth being extracted from the model . Construct a soft vacuum formed splint to cover the socket completely . Keep the splint in the place for at least 48 hr before checking the socket . If there is a sign of bleeding it should be replaced and checked every 24 hours.
- 111. REFERENCES : CANASPIRIN BE CONTINUED DURING DENTAL EXTRACTION DR. MADHULAXMI. M1 AND DR. P.U. ABDUL WAHAB Vol 6, Issue 1, 2014 Dental extraction in patients on warfarin treatment Dove press 19 agust 2014. Walid Ahmed Abdullah1,2Hesham Khalil1 Dental management of patient receiving anticoagulant therapy Ana Mingarro-de-León et al J Clin Exp Dent. 2014;6(2):e155-61. Perioperative management of patients receiving anticoagulants Gregory YH Lip, MD, FRCPE, FESC, FACC james D Douketis, MD, FRCPC, FACP, FCCP. Guidelines for dental treatment of patients with inherited bleeding disorder DENTAL PRACTICE / May june 2013 AUTHORS : Dr. Manoj goyal sir,et all Anticoagulants and dentistry DP march april 2012 Dr Manoj goyal sir et all Text book of oral medicine burkies
- 112.
- 116. References : Perioperative management of patients receiving anticoagulants Gregory YH Lip, MD, FRCPE, FESC, FACC james D Douketis, MD, FRCPC, FACP, FCCP Text book of oral medicine Burkets. Guidelines for dental treatment of patients with inherited bleeding disorder DENTAL PRACTICE / May june 2013 AUTHORS : Dr. Manoj goyal sir