Invasive Management for Patients with Hepatitis PDF

Dr.Aseel M. AbdulMajeed Specialist dentist Patients in the acute stage of viral hepatitis not treated for anything other than urgent care. All patients with a history of hepatitis managed...

Dr.Aseel M. AbdulMajeed Specialist dentist Patients in the acute stage of viral hepatitis not treated for anything other than urgent care. All patients with a history of hepatitis managed as potentially infectious.  Before any invasive procedure is performed  The patient’s physician in such patients, should be consulted to coagulation and discuss which drugs are hemostasis tests should used, and their possible be conducted. interactions. o Complete blood exam o International normalized ratio (INR) o Coagulation tests (Prothrombin time, Activated partial thromboplastin time) o Liver function tests (Aspartate aminotransferase (AST) and Alanine aminotransferase (ALT) If test results are significantly abnormal then any dental treatment must be provided only after consultation with the relevant medical specialist.  Caution should be used in prescribing medications metabolized in the liver, such as acetaminophen and non-steroidal anti-inflammatory agents.  Local anesthetics should be administered cautiously to patients with hepatic impairment. Articaine (plasma) and prilocaine (partly in lungs), however, have other sites of metabolism.  Insome cases, lower drug dosages are required (ampicillin), while some drugs (erythromycin, metronidazole, tetracycline's) should be avoided completely.  Local hemostatic measures may be necessary, including: compression, sutures, dressings such as oxidized cellulose, and antifibrinolytic agents such as tranexamic acid.  Pre-operative optimization with vitamin K therapy or transfusions may be necessary.  Where immune impairment is present, antibiotic prophylaxis may be necessary.  Attention should be paid to minimization of surgical trauma.  Based upon history, examination, and laboratory profile, the relative risk of Hepatitis infectivity can be assessed:  A/ patient at low risk  B/ patient at high risk:  C/ persons at substantial risk HBV or HCV  Little or no risk of  Patients with histories transmission of HAV, HEV. compatible with  patients with histories Hepatitis B who have compatible with Hepatitis normal liver tests and A &E infection who have negative antigen and normal liver tests and positive antibody tests negative antigen are at are not infectious. low risk.  It connotes recovery and immunity to HBV. They can be managed utilizing normal protocols with the single addition of masks and gloves for the dentists and assistants.  Patients with positive HBsAg.  Patient with abnormal liver function tests.  Patient with jaundice and symptoms of viral Hepatitis No elective dental treatment but Refer to physician, for medical diagnosis and treatment.  An isolated operatory and with adherence to strict standard precautions  Minimal aerosol production.  Drugs metabolized in liver should be avoided as much as possible.  If surgery is necessary, preoperative prothrombin time and bleeding time should be obtained and abnormal results discussed with the physician.  Screening for HBsAg and anti-HCV is recommended for individuals who fit into one or more of these categories unless they are already known to be seropositive.  Even if the patient is found to be a carrier, no modification in treatment approach would be necessary.  If the patient is found to be a carrier, the information could be of extreme importance for lifestyle modification.  In addition, the patient might have undetected chronic active H, which may lead to bleeding complications or drug metabolism problems. Component Recommendations After touching blood, body fluids, secretions, excretions, Hand contaminated items; immediately after removing gloves; between hygiene patient contacts Personal protective equipment (PPE) For touching blood, body fluids, secretions, excretions, Gloves contaminated items; for touching mucous membranes and non intact skin Mask, eye During procedures and patient-care activities likely to generate protection, splashes or sprays of blood, body fluids, secretions face shield During procedures and patient-care activities when contact of Gown clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated  Handle in a manner that prevents transfer of microorganisms to others and to the environment; Soiled patient-care wear gloves if visibly contaminated; perform hand equipment hygiene Environmental Develop procedures for routine care, cleaning, and infection disinfection of environmental surfaces, especially control frequently touched surfaces in patient-care areas Handle in a manner that prevents transfer of Textiles (linen and microorganisms to others and to the environment laundry) Do not recap, bend, break, or hand-manipulate used Needles and other sharps needles; use safety features when available; place used sharps in puncture-resistant container  Never administer medications from the same syringe to more than one patient; do not enter a medication vial with a used needle or Injection safety syringe; never use single-dose vials for more than one patient; follow proper infection control practices during administration of injected medications Respiratory hygiene/cough Instruct symptomatic persons to cover etiquette(source containment mouth/nose when sneezing/coughing; use of infectious respiratory tissues and dispose in no-touch receptacle; secretions in symptomatic observe hand hygiene after soiling of hands patients, beginning at initial with respiratory secretions; wear surgical mask point of encounter) if tolerated or maintain spatial separation, > 3 feet if possible  Use as many disposable covers as possible, covering light handles, drawer handles, and bracket trays. Headrest covers should also be used  All disposable items (e.g., gauze, floss, saliva ejectors, masks, gowns, gloves) should be placed in a lined wastebasket.  After treatment, these items and all disposable covers should be bagged, labeled, and disposed of, following proper guidelines for bio-hazardous waste.  Remember that saliva contains a distillate of the virus. Pre-rinsing with chlorhexidine gluconate for 30 s is highly recommended  When the procedure is complete, all equipments should be scrubbed and sterilized. If an item cannot be sterilized or disposed of, it should not be used  All working surfaces and environmental surfaces should be wiped with 2% activated glutaraldehyde (Cidex). J Clin Exp Dent. 2011: Dental considerations in patients with liver disease.  ASHM 2012: Dental and Orofacial Health and Hepatitis C.