CARE OF THE MEDICALLY COMPROMISED PATIENT

1. CARE OF THE MEDICALLY COMPROMISED PATIENT SalehAlbazie CAGS OMFS, DSc OMFS, Dipl ABOMS. Oral and Maxillofacial Surgeon.

2. 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

3. CARE OF THE MEDICALLY COMPROMISED PATIENT Classification of Hypertension in Adults Diastolic < 85 mm Hg Normal BP 85 ‑ 89 High normal BP 90 ‑ 104 Mild hypertension 105 ‑ 114 Moderate hypertension >115 Severe hypertension Systolic < 140 mm Hg Normal BP 140 ‑ 164 Borderline hypertension > 165 Isolated systolic hypertension

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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!!

10. 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)

11. 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.

12. 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

13. 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

14. 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

15. CARE OF THE MEDICALLY COMPROMISED PATIENT How do you rule out MI? 1. Clinical history and examination 2. Serial Enzymes ONSET PEAK BASELINE CPK/MB q 8h (3 Iso.) 4‑6h 12‑20h 36‑48h 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 10‑14 days LDH 1/LDH 2>1 MI Good for patients presenting > 24h after symptoms AST q12h 3. Serial ECG's 4. CXR 5. ECHOcardiogram, 6. Thailium scan 7. Tech‑99‑ scan

16. 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)

17. 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)

18. 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)

19. 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

20. 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

21. 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