Help Sedating a Patient Who Requires Higher Airway Attention

A DOCS Education member asks:
I am looking for advice on how next to adjust sedation meds for this patient. Her next visit will be for scaling and root planning and will require anesthesia which is a big fear for her.

She is a 40 year old patient that has been away from dental care for many years due to fear. She has only returned when problems have arisen. Recently she became determined to get in good dental health. She has had a limited but successful sedation treatment in 2011.

Her current weight is 200 lbs. She is approx. 5'6" . Her first sedation visit with me was today. My case notes:

Pt took Diazepam 10 mg HS at bedtime and Triazolam 0.5 mg 1 1/2 hours before appointment . Vitals were WNL. Pt was evaluated and determined that additional Triazolam 0.25 SL 15 mins after arriving. Hydroxyzine 100mg slurry was given 40 mins after arrival.. Pt was comfortable enough to started with CRS.

Vitals were stable through restorative and perio charting. Occasionally, O2 levels dropped below 90 but instructed pt. to breathe, which immediately restored normal levels. When gross debridement was started around the 50 min. mark, it became more difficult for her to be at the 90 O2 mark.

Pt has a Mallampati Class III tongue. One hour after arrival it became necessary to have pt. sit up to maintain O2 levels at 90 and above. As gross debridement processed it became increasingly difficult to instruct pt. to breath with oral instructions. When O2 level dropped to below 90 at the 90 min. mark of appointment. the procedure was stopped and pt. given sugar packet and then pudding.

Pt 's O2 levels responded quickly . Pt was oriented x3 . Reviewed and obtained signed home care instructions with care taker and patient. Escorted pt to car and pt. left at 11 am (120 min. mark). Her ride called 30 mins. later and confirmed they had arrived safely at pt.'s home.

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

What meds are the patient taking? What are her medical conditions? When was the patient's last medical evaluation?

Patients who have a BMI of 30 or greater and/or have a CL III Mallampati should be sedated lighter, 100% supplemental oxygen should be administered throughout, and special attention paid to the airway.

The loading dose for OCS should not exceed 0.25mg of triazolam.

The DOCS Education member elaborates:
The patient has been seen regularly by her physician. A current signed medical clearance was received from her physician per DOCS protocol.

She is 200 lbs. and would be considered obese for her height ( 5' 5'').
She has Cyclic Vomiting Syndrome as well as lactose intolerance.
She is only on Mirena. She supplements with Glucosamine and Cranberry Extract.

In my follow-up call with the patient the next day revealed that the patient felt it as a "10" visit on the success scale. She did recall the discomfort during the perio exam. She had been away from the dentist for 6 years and had heavy bleeding and calculus everywhere . She also was aware of my initial tarter removal and my instructions of needing to breath. If we have given her anesthesia the discomfort may have been addressed but she sounds like she remembered a lot of the visit.

Additional questions:

Would you suggest that the overall dose of the hydroxyzine be lowered to 0.5 mg?

Reducing the loading dose to Traizolam 0.25mg makes sense. How would to proceed from there given that the patient remembered a lot of her visit? What would you see as the upper limit for her?

Should I discuss the patient losing weight prior to any additional dental treatment?

Dr. Feck responds:
The dose of any sedation medication, including hydroxyzine given inside the office depends on the patient assessment scale. It should not be determined beforehand. You will find that patient assessment scale in the incremental protocol section of your DOCS workbook.

More important than how much the patient remembered, and I wouldn't consider it a lot based on what you write, and the patient's description of the visit being a "10", is safety. This patient has a compromised airway and desaturated very low during her prior sedation visit. While the patient's TOP Dose is an equation you can easily calculate, you should always use the least amount of medication necessary to successfully and safely sedate the patient. Patients with a compromised airway should be sedated lighter than average, close attention paid to the patient's airway, and 100% supplemental oxygen used throughout the entire appointment.

You can certainly have a conversation with the patient about how excess weight affects the sedation process.

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.