A DOCS Education member asks: I have a 24-year-old moderately anxious female patient who came to me requesting sedation for extraction of wisdom teeth. She reports that it takes 1 ½ hours to have freezing take, and it still doesn't take well. She has sarcoidosis, which she reports is in remission, but takes prednisone when it flares up. Her last respiratory exam was six months ago and was normal. She was diagnosed with Graves' disease at age 14. She was treated with iodine therapy and currently takes levothyroxine 2 mg. In addition, she takes naproxen prn, and Depo-Provera®. She has seasonal allergies and smokes 5 cigarettes a day.
Weight: 235 lbs
BP: 140/90
PO2: 99
Pulse: 90
I don't believe that there are any contraindications with the meds. I am only concerned with the respiratory factor of the sarcoidosis. I am thinking diazepam the night before with a hydroxyzine and triazolam combination. Are there any thoughts, suggestions or warnings?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
As you say, drug interactions are not a problem. sarcoidosis is an immune disorder with multiple clinical manifestations that include two systems of utmost concern to the sedation process - the lungs and the liver. If you haven't already done so, obtain a medical consult regarding the control of her condition and any medical compromises she presents with. If all of this checks out, then your suggested sedation protocol is appropriate.
Dr. Leslie Fang, DOCS Education Faculty responds:
There is no concern about the Graves' disease since she appears to have burnt out her Graves' and is now hypothyroid on Levoxyl® replacement.
Sarcoidosis can cause systemic manifestations:
- Lymphadenopathy
- Skin involvement
Pulmonary involvement:
- Hilar adenopathy
- Granulomatous hepatitis
- Granulomatous interstitial nephritis
- Neurosarcoidosis
As it is listed, her sarcoidosis appears to be of low virulence. Of all of the issues listed, you should inquire if there is pulmonary interstitial Disease, which can cause trouble. You would get a good clue from the resting SaO2 and from the medical consultation.
I suspect that there is little cause for concern for this sedation.
This blog post should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece.
