A DOCS Education member seeks the faculty’s assistance:

I have a patient who is ASA III, Mallampati 2, base line BP 135/86 Spo2 98%. The patient has depression, stable angina, high blood pressure, hyperlipidemia and arthritis. Last exam was 3 weeks ago.

He needs a short procedure that should take approximately 1.5-2 hours to complete. The patient is difficult to numb and has mild anxiety. He is on multiple drugs which have class D interactions with each other.

How should I proceed?

Here is the list of medications:

  • Aspirin 81 mg daily
  • B complex vitamins
  • Bulk chemicals base a polygycol powder
  • Calcium carbonate
  • Clopidogrel 75 mg 1 Tab daily
  • Cyanocobalamin
  • Docusate Sodium 100 mg cap
  • Fluoxetine 40 mg cap, 2 caps every morning
  • Hydrocodone/acetaminophen 10 mg/325 mg
  • Isosorbide mononitrate 24hr-cr 30 mg tablets SR 24 hr take 2 tabs twice daily
  • Lamotrigine 100 mg
  • Losartan 50 mg tab
  • Metoprolol tartrate 25 mg tab 1 tab twice daily
  • Morphine 12hr-cr (ms contin) 60 mg tab 1 tab every 8 hrs
  • Nitroglycerine sl 0.4 mg SL Tab
  • Pantoprazole 40 mg tab EC
  • Simvastatin 40 mg tab

My current plan is 2.5 mg of diazepam the night before and 0.125 mg of triazolam 1 hr before.

Or should I refer him out instead?

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

This is not a patient that I would want to sedate in my office. I would refer to an outpatient center where he can have dentistry done with a dedicated anesthesia provider and the capability of advanced emergency care in the event of an unwanted outcome. I would be cautious with this patient in your office even without sedation meds on board.

Dr. Anthony Feck, Dean of Faculty at DOCS Education, responds:

I classify this patient as ASA IV.

I agree with Jerry's appraisal. In my opinion, this patient is ASA IV, whose definition is severe medical condition that is a constant threat to life. While this patient may live a long life, they don't handle stress as well as most. Given that they are anxious, hard to numb, and have built up tolerance to CNS depressants, they are likely to be highly anxious before they get comfortably sedated which could take longer than usual, and likely to need more anesthetic with vasoconstrictor.

In my opinion, walk away from this one.

The DOCS Education Member gives thanks:

Thanks. Referred patient out for IV sedation in hospital setting.

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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