A DOCS Education member asks:

I have a patient that I plan on doing a RCT under sedation. Health history is normal. Allergic to morphine and NSAID. Meds taking: estrogen, metroprolol tartrate. BP: 146/74, Pulse: 66, SPO2: 99. She said Valium® didn't do much for her before, and one dentist had tried to do IV sedation on her and she was awake the whole time and "felt everything he did". My initial plan is do single Dose Protocol #3 with diazepam 5 mg night before, triazolam 0.25 mg and hydroxyzine 25 mg one hour before procedure.
Is it worth the try or would another protocol be better served for this patient?

Dr. Jerome Wellbrock, Live Patient Experience Director at DOCS Education, responds:

Diazepam by itself will not do much for most patients. To properly assess, we will need some more information: How old is this patient, BMI or height and weight? How long ago was the IV Sedation attempt? What sedation medications were used and in what dosages? When was her last physical exam? Why is she taking estrogen and metoprolol? Airway classification? Sleep disorders or habits? Can you be more specific about her medication allergies? She may be a candidate for oral sedation but I’d hesitate to make a call on just the information provided.

The member provides the requested information:

Patient is a 48 year-old, 5’6 150 lbs female. She is taking metoprolol for hypertension, and the estrogen as a hormone replacement. Patient states that she is going through menopause. As of her physical two months ago, everything appears to be normal. She has insomnia for which she has taken Ambien®, though the patient claims that it had no effect. Her last dental appointment was 12-15 years ago, last failed IV sedation was 15 years ago, she does not know what kind of IV medication was used. Airway classification is CL II and III. Patient is a smoker.

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

If you're considering a single dose protocol, then it is likely because you are limited to administering a single dose, along with dosage limitations. This is not a good patient for a single dose protocol, and likely not a good candidate for any form of oral sedation. If a previous IV sedation appointment was unsuccessful, then this patient most probably will need a deeper form of sedation not possible with oral medication. If you don't provide IV sedation services, I recommend referral to someone who does, or having such an individual sedate the patient for you. That IV protocol would be without any opioids due to the patient's potential allergy to morphine.

Keep in mind that an extreme hyporesponder like this may have developed a tolerance to CNS depressants as a result of a prior history with medications.

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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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