1. Factor replacement 2. Consultation with a Hematologist
3. Measures to control bleeding & promote clot formation.
First Question: Is the surgery essential ? Are there any alternatives that can be planned without needing transfusion because:
1. Every transfusion is a potential risk (in spite of transfusion science growing to such safety and complexity!)
2. Every transfusion increases the risk of the patient becoming 'resistant' to the factor thereby making it useless. (antibody formation)
3. Every transfusion is costly including the product and administration costs with monitoring.
4. If care is not taken, one may end up 'wasting' the transfusion. The effect of the factor lasts about 8 - 12 hours (for factor VIII) after which it needs to be repeated if further activity is required. So co-ordination of care is required for making sure the primary procedure is completed and clot stabilised within that period before it's effect wears off.
So apart from textbook discussions about 'transfusion / replacement of factor', 'hematologist consultation' and 'measures to control bleeding/clot formation', above issues are pertinent. But before even that, the levels of factor needs to be assessed as replacement will be based on the current level of factors and the surgical insult with bleeding risk that may occur. Also use of anti-fibrinolytic agents like Tranexamic acid are routinely advocated preferably started prior to procedure and continued post procedure for 3-4 days in a suitable dose according to weight either as IV or oral. Local application of Tranexamic acid is also an "off-lable" use where powdered tranexamic acid is placed along with a guaze piece on the bleeding site intraorally. Desmopressin has a role in Factor VIII deficient bleeding disorders.
As an additional note:
While surgical procedures require hospitalisation and monitoring, many non surgical alternatives can be done without the need for transfusion or risk of bleeding routinely in a dental chair. So a preventive plan that involves the patient-family for avoiding invasive dental procedures / surgeries may be the best route to take. This is best both in terms of clinical time. monetary benefits and safety for the hemophiliac patient as well as for the clinician.
Regards,
Akilesh. R
India
Dear Alok,
Our approach is as follows :
It is important to assess the severity of hemophilia and current clotting factor levels in patient. In case of single tooth extraction hemostyptics are often sufficient if plasma levels of factor VIII or IX are above recommended levels. Otherwise consider use Tranexamic acid or fibrin glue.
Sincerely
Peter
Dear Alok,
Our approach is as follows :
It is important to assess the severity of hemophilia and current clotting factor levels in patient. In case of single tooth extraction hemostyptics are often sufficient if plasma levels of factor VIII or IX are above recommended levels. Otherwise consider use Tranexamic acid or fibrin glue.
Sincerely
Peter
Dear Dr Alok Dubey,
I recommend you this article.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4304051/
Sincerely
Jose
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