Transcript care of the medically compromised patient

CARE OF THE MEDICALLY COMPROMISED PATIENT
Saleh Albazie
CAGS OMFS, DSc OMFS, Dipl ABOMS.
Oral and Maxillofacial Surgeon.
CARE OF THE MEDICALLY COMPROMISED PATIENT
Patient is a 63 year old male who presents to your clinic for full mouth
extractions and alveloplasty prior to planned placement of immediate
dentures. Past medical history is negative except that the patient used to
take a "pressure medicine" which he did not refill 2 months ago.
Pre-operative blood pressure readings were 215/110. A second reading was
208/103
CARE OF THE MEDICALLY COMPROMISED PATIENT
Classification of Hypertension in Adults
Diastolic
< 85 mm Hg
85 - 89
90 - 104
105 - 114
>115
Normal BP
High normal BP
Mild hypertension
Moderate hypertension
Severe hypertension
Systolic
< 140 mm Hg
140 - 164
> 165
Normal BP
Borderline hypertension
Isolated systolic hypertension
CARE OF THE MEDICALLY COMPROMISED PATIENT
Essential hypertension
Secondary hypertension
Malignant hypertension
Treatment and the Importance of Diastolic pressures
Most diagnostic and treatment decisions are based on diastolic pressures for
two reasons Diastolic HTN = enhanced peripheral vascular resistance, and
Systolic HTN = increased cardiac output and/ or large vessel stiffness
Treatment of diastolic HTN results in clinical benefit, treatment of systolic
HTN is not clearly associated with reduction of cardiovascular
complications
CARE OF THE MEDICALLY COMPROMISED PATIENT
Medical Treatment of Hypertension
Detection
Nonpharmacologic
- weight loss
- restriction of dietary sodium
- moderation of alcohol intake
- reduction of dietary fats, cholesterol
- smoking cessation
- regular aerobic exercise
- stress reduction, relaxation therapy
- increased dietary calcium intake
CARE OF THE MEDICALLY COMPROMISED PATIENT
Medical Treatment of Hypertension
Pharmacologic (for DBP > 95 mm Hg)
- Step 1 = diuretic, beta blocker, ACE inhibitor, or calcium channel
blocker
- Step 2 = (1 to 3 mos.) increase the dose, add a different class of
drug, or substitute another drug
- Step 3 = add a third drug, discontinue the second drug and
substitute another
- Step 4 = add a third or fourth drug
Lack of compliance is the single greatest problem, therefore MONITOR
PERIODICALLY
CARE OF THE MEDICALLY COMPROMISED PATIENT
DENTAL MANAGEMENT
Identify patient
- Take relaxed BP (two if necessary)
- Medical and medication history
Stress and anxiety reduction
- doctor patient relationship
- pharmacologic (Valium, Nitrous oxide)
- short, morning appointments
Avoid sudden changes in chair position, sit patient up slowly at the end of
the procedure (orthostatic hypotension)
CARE OF THE MEDICALLY COMPROMISED PATIENT
DENTAL MANAGEMENT
Decrease exposure to epinephrine
- Exogenous (limit to 0.04 mg = 2 carpules 1:100,000)
- Endogenous
POTENTIALLY A MUCH BIGGER PROBLEM
if individual is stressed, adrenal medulla can produce 0.28 mg of
epinephrine/minute
Avoid topical vasoconstrictors
Adverse drug reactions
-epinephrine and beta blockers, peripheral adrenergic agonsists
(Reserpine), MAO inhibitors
-rarely a problem if small doses of epinephrine used
CARE OF THE MEDICALLY COMPROMISED PATIENT
DENTAL MANAGEMENT
Avoid excessive stimulation of the gag reflex
Surgical hemostasis, observe for post-op bleeding
Antihypertensives - dry mouth
NO ELECTIVE DENTAL PROCEDURES SHOULD BE PERFORMED
ON A PATIENT WITH SEVERE UNCONTROLLED
HYPERTENSION!!
CARE OF THE MEDICALLY COMPROMISED PATIENT
Cardiovascular problems
Coronary artery disease/ Ischemic heart disease ( Angina, MI, CHF)
Dysrhythmias and conduction disturbances ( SVT, VT,VF …..)
Valvular heart disease (Rheumatic heart disease, Infective endocarditis,
Mitral/aortic stenosis or regurgitation and prosthetic valve)
Congenital heart disease( Teratolgy of fallot)
CARE OF THE MEDICALLY COMPROMISED PATIENT
Patient is a 59 year old male with a history of angina who was cleared for
surgery by anesthesia. In the recovery room s/p iliac crest graft to the
mandible the patient complains of chest pain, dyspnea, nausea and is
diaphoretic with palpitations.
CARE OF THE MEDICALLY COMPROMISED PATIENT
What clinical examination would you do?
Look at neck veins - elevated jugular venous pulse
VS = BP =105/75, P=105, R = 26, Pulse Ox = 95
Auscultate chest - coarse rales and wheezes = pulmonary edema, No
Auscultate heart - S3, or S4, or arrhythmia, No
CARE OF THE MEDICALLY COMPROMISED PATIENT
Terminate therapy and position patient
upright 45 deg. Trendellenburg if SBP < 100 mm Hg)
Calm patient
Sublingual Nitroglycerin 0.4 mg
should relieve pain in 3-5 mins
can repeat twice at 5 min. intervals
failure to relieve pain- suspect MI
100% O2
Assess vital signs every 3-5 mins
Transport to hospital prn
CPR prn
CARE OF THE MEDICALLY COMPROMISED PATIENT
Lets say its not angina. What is a differential diagnosis?
MI
CHF
PE
Pneumothorax
Cholecystitis
Pancreatitis
Pericarditis
Perforated peptic ulcer
Ruptured esophagus
Aortic dissection
CARE OF THE MEDICALLY COMPROMISED PATIENT
How do you rule out MI?
1. Clinical history and examination
2. Serial Enzymes
ONSET
PEAK
CPK/MB q 8h (3 Iso.)
4-6h
12-20h
MM- Muscle
MB - Myocardium
BB - Brain
Best enzymatic test, >3-5% CK/MB evidence of a MI
Low CK will not run MB
LDH Isoenzymes q 12h (5 Iso.) 12h
24-48h
LDH 1/LDH 2>1 MI
Good for patients presenting > 24h after symptoms
AST q12h
3. Serial ECG's
4. CXR
5. ECHO cardiogram,
6. Thailium scan
7. Tech-99- scan
BASELINE
36-48h
10-14 days
CARE OF THE MEDICALLY COMPROMISED PATIENT
How would you treat this patient?
Treatment of MI
1. Oxygen (ABG's).
2. Nitroglycerin, Morphine,
3. ECG (12 Lead)
4. CXR
5. Beta-blocker - be careful
6. Sedation
7. Lidocaine, Procainamide
8. CCU with invasive monitoring (enzymes)
CARE OF THE MEDICALLY COMPROMISED PATIENT
Patient is a 72 year old female on Digitalis and Lasix referred to you for
bone grafting to the anterior maxilla.
Digitalis
Used to treat CHF, A-flutter, A-fib, and other SVT's
+ Ionotrope (increases force of contraction)
- Chronotrope (slows heart)
Narrow therapeutic range
*Hypokalemia and hypoxia and renal insufficiency can exacerbate toxicity
*DO NOT cardiovert someone with Digitalis Toxicity (can precipitate a
fatal arrhythmia)
CARE OF THE MEDICALLY COMPROMISED PATIENT
What are the signs and symptoms of Digitalis Toxicity?
Dysrhythmias (all types)
GI (Anorexia, nausea, vomiting, diarrhea)
Mental status changes (agitation, lethargy, visual disturbances)
How do you treat someone with Digitalis Toxicity?
Treatment of Digitalis toxicity
1. Stop Digitalis administration
2. Monitor (type of dysrhythmia)
3. Correct precipitating factors (i.e. serum potassium to > 3.5)
4. Atropine for bradycardia (avoid catechols)
5. Lidocaine for dysrhythmias
6. Digitalis specific antibodies = Digibind (life threatening)
CARE OF THE MEDICALLY COMPROMISED PATIENT
A 19 year old black female third molar patient presents to your office three
weeks following surgery. She was feeling well until seven days ago. Since
then she has a history of anorexia, malaise, myalgia, weight loss and low
grade fever.
Physical exam:
Pale
Lungs clear
Abdomen soft, bowel sounds decreased
Heart: NSR with grade II/VI late systolic murmur at left sternal border
Labs:
CXR normal
U/A 1.018, 3+ protein, 4+ RBC's, Glucose = 0, WBC's = 0, Casts = 0
H/H = 10.2/31, MCV= 85 (84-96), MCHC= 30 (30-35)
WBC = 11,000, P 65, L 20, M10, B3, E2
Sed. rate = 85
Chem. = WNL except BUN = 24
CARE OF THE MEDICALLY COMPROMISED PATIENT
Why is the sed. rate elevated?
Chronic inflammation
Rheumatoid diseases
What are you going to do?
Physical Exam
Blood culture ECHO
(look for vegetation, document murmur)
Blood culture = Alpha hemolytic Streptococcus (what if this was Staph.
Aureus) IF CANDIDATE PUTS PATIENT ON ANTIBIOTICS
BEFORE BLOOD CULTURE THEN CULTURES NEGATIVE
ECHO = Mitral vegetation
CARE OF THE MEDICALLY COMPROMISED PATIENT
What is your diagnosis?
SBE
What are causes of SBE?
Causes of SBE
Any flow disturbance
Rheumatic heart disease
Congenital heart disease
Mitral valve prolapse
Degenerative heart disease
IVDA