A DOCS Education Member asks:

I have a 71-year-old Type 1 diabetic patient on whom I have previously used triazolam, but the patient's medications have changed. Our office is doing a single crown procedure lasting approximately one and one-half hours. The patient is on:

  • Lantus® 100 units at night
  • Carvedilol 25 mg
  • Ranexa® 500 mg
  • Metformin 1000 mg daily
  • Effexor XR® 25 mg daily
  • Metoprolol 25 mg
  • Lisinopril 30 mg daily
  • Atorvastatin 20 mg
  • Hydrocodone/acetaminophen 3.5 mg daily

I got some "D" interactions with Septocaine® 4 percent with EPI 1/100,000 and for Xylocaine® 2 percent with Epi 1/100,000. The patient was on the carvedilol, Effexor XR® and metoprolol the last time we did sedation. My question is: In interaction analysis it gives these categories as "D", but the alert summary of those drugs listed above says no information available to require special precautions. These two results seem to contradict one another. I have been using DOCS Education protocols for 12 years and feel comfortable with monitoring and probably using only one carpule of anesthetic.

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

Medication interactions would not be my biggest concern. I would pay close attention to the current medical status of this patient and the level of control in conditions for which he is taking these medications. What is his current diabetic status/Ha1c? He is taking the Lantus® and metformin for diabetes? I would also look at the patient's vital signs: BP, heart rate, pulse ox readings. Carvedilol, metoprolol, lisinopril, elevated BP, arrhythmia? Does the patient suffer from angina? These are all questions you must ask and have a firm understanding of. You have a 71-year-old who is most likely an ASA III or even an ASA IV with significant medical conditions that require multiple medications to control and we don't have information on that level. My recommendation would be a physician consult on both his physical condition and ability to be safely sedated in your office. If you do decide to sedate in your office, then I would skip the diazepam the night before and consider a single dose of zaleplon or triazolam. Limit your local anesthetic to no more than two cartridges with a vasoconstrictor. Know your patient. Dose low and go slow while closely monitoring.

A DOCS Education Gold Member adds their experience:

I have to chime in and reinforce Dr. Wellbrock's assessment. At the risk of overstepping, here are my thoughts: My son has Type 1 diabetes. It is not the same as the more common Type 2. Please understand this patient's real medical risk if he is indeed Type 1. His medications indicate he could be Type 2 (no short acting insulin listed) with significant cardiovascular disease. His risk is compounded by the likely microvascular damage done in a patient who has had this disease for what sounds like decades. It is very important this patient's full medical condition be understood before proceeding.

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.

issue_no
1
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.
DOCS Membership

Upcoming Events
Streaming
May 17- 18, 2024
Atlanta, GA skyline
GA
August 23- 24, 2024
Streaming
October 04- 05, 2024

More Articles