A member of DOCS Education writes:
I have been sedating patients for over ten years but I wanted your help. I have an 85 year old insulin-dependent diabetic patient that has requested sedation. Her BP reads 146/74, pulse 69. She takes 20 units of Lantus® insulin at 100 unit/ML once a day and 15 units of Humalog® insulin at 100 unit/Ml once a day. If I were to sedate her, should she eat a small dinner, her normal small breakfast and not take any insulin on the day of sedation? Other medications the patient is taking are: amlodipine 5mg, lovastatin 40 mg, quinapril GCL 10 mg, HCTZ 12.5 mg, aspirin 325 mg, 2 x 220 mg Aleve®, CalCarb 600/D 600-400 MG-unit. The patient does not have asthma or any breathing issues but I don't feel comfortable with sedation.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
You are right in feeling uncomfortable, but that doesn't mean that sedation isn't possible with the proper precautions. As the patient is an insulin-dependent diabetic, you must know her most recent HgA1c for assessment of adequacy control. As for her breakfast, a normal meal size is fine. Keep it to non-fatty foods. The patient should continue her normal insulin regiment, and whatever work you plan on doing should be as short a procedure as possible.
Her hypertension is less of a concern as she is on a three-drug regimen designed to control it. Also be weary, as she is on a calcium supplement, osteoporosis and an increased risk of osteonecrosis in the jaw is also a concern. To round out my recommendation fully, please find out more information about her cardiac history and the main purpose of the Aleve® dosage, though I assume that is for her arthritis.
Her advanced age actually bothers me more than any of the other issues. She will be exceptionally sensitive to sedation, so much so that you will need to reduce her dosage by one half, if not more.
Bottom line is that she is ASA 3/4. You are right in feeling uncomfortable.
Dr. Anthony Feck, Dean of DOCS Education Faculty, adds:
I agree with Dr. Fang's recommendation for a light breakfast, normal medication regimen and an early morning appointment no longer than three hours. This is standard for a diabetic patient under good control.
However, We do need more information per Dr. Fang's recommendations. She is indeed a high-risk patient due to her medical conditions, but moreover due to her advanced age. If you have done all your homework, the interactions check-out, you have advanced training and lots of experience with sedation, then you can proceed with extreme caution. If you don't, again I agree with my colleague that you are correct in feeling uncomfortable, and should seek an alternate method of treatment.
The DOCS Education member responds:
Her age and diabetes were my biggest concerns as well. After carefully reviewing both of your responses I called the patient on the phone and she agreed to N2O instead of oral sedation. I am sticking with my gut feeling and with your advice feel far more confidant in managing her appointment now. Thank you for your help.
