A DOCS Education member seeks the faculty’s assistance:

I would like to get all suggestions for sedating a 79-year-old female with a pacemaker and a history of heart problems. The patient is on clonazepam, 81 mg aspirin, verapamil, digoxin, hydroxychlorine, levothyroxine, meloxicam, metropolol, saccurate(?), Nitrostat® and potassium. Her MD has instructed us not to use any epinephrine. The patient is allergic to penicillin and MD suggested clindamycin, which is what I will prescribe.

I would appreciate any insight into this case.

I also wanted to let you know that I just attended three day course in San Francisco. It really was a great and informative course.

Thank you.

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

I am not sure this is a patient that I would want to sedate in my office, especially if I was newer to sedation. Even without more information on your patient I would have to classify her as an ASA III or even closer to an ASA IV depending on the stability of her angina. This patient has some serious cardiac issues and should probably be sedated in a hospital setting. There are "D" interactions with the verapamil and all of our benzodiazepines including triazolam, lorazepam, and midazolam. There are also "D" interactions with metoprolol and any of the local anesthetics with a vasoconstrictor. Her meloxicam and ASA is a "D" interaction as is her verapamil and Klonopin®. I could not find anything on the "saccurate" or the "hydroxychlorine." I am not sure why you want to give her clindamycin. What is your reasoning for sedation and what is the proposed dental treatment and estimated time of appointment?

The DOCS Education Member responds:

Thank you very much for your feedback. I will be performing two extractions and placing four mini-implants without creating a flap in anterior mandible.

The two medications you mentioned are hydroxychloroquine Sulfate (Plaquenil®) 200mg and metoprolol succinate.

I plan to use Carbocaine® or Citanest® without any epinephrine for the bilateral mandibular blocks.

She takes one to two clonazepam 1 mg tabs at bedtime. Her husband said she is sedated in the morning.

Estimated time for surgery is about one hour. Following this surgery, I retrofit FLD to minis chair side (non-surgical) for about one hour.

I did NOT give her any medications to take one hour before our appointment.

My question to you is: how about doing the procedure with just local anesthetic without epi (blocks can get good anesthesia)? My concern is patient's anxiety and stress level.

I appreciate your timely comment as I will be seeing this patient for the procedure soon.

Thank you again.

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

Physicians will almost always say "no epinephrine." I would consider the use of two cartridges of local with a vasoconstrictor and plain local for any additional anesthesia. Your patient will most likely still have some sedative effect from the clonazepam and I would closely monitor her and proceed slowly. If your extractions are on the same side, you may get by with one cartridge of local with a vasoconstrictor. If the extractions are on opposite side of the arch you may consider blocking one side first, finish the procedures on that side then block and proceed on the opposite side. I hope you get this post in time for your morning appointment and let us know how it goes.

One more note: clindamycin is often associated with C-dif which could be especially devastating in a 79-year-old. Consider another antibiotic if you feel it is necessary.

The DOCS Education member responds:

Thank you again for your timely response.

I successfully finished the case without any medication. I used nitrous oxide mainly with lots of oxygen.

I used bilateral mand block with Citanest® plain and she was profoundly numb for extractions and mini-implants.

She was very calm throughout the treatment.

Thank you very much for your insight and feedback. I really appreciate it.

Dr. Jerome Wellbrock responds:

I want to sincerely thank you for posting about this interesting patient. Every case posted is an opportunity for all of us on the forums to learn from each other. Sounds like you had a very successful case.

Disclaimer

The information contained in this, or any case study post in Incisor 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. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.

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The information contained in this, or any case study post in Incisor, 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. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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