The 44-year-old patient was ASA I and possessed a relatively uncomplicated health profile. However, near the conclusion of a dental appointment that included sedation she was not only quite alert but acutely uncomfortable due to muscle spasms. Nor did the unusual effects dissipate in the hours following her return home. According to the woman’s husband, “she just wasn’t herself.” What, if anything, went wrong?
A member of DOCS Education writes:
My patient is a 44-year-old nonsmoker, ASA I. She’s 5’4” and weighs 125 pounds. The woman declined preoperative diazepam on account of work demands (her appointment was scheduled for 12:30 p.m.). I had anticipated a fairly straightforward session, but this didn’t prove to be the case. I’m writing to learn your thoughts about why this was so.
First, I was surprised by how alert my patient was upon arrival. She said she might get sleepy in the chair, but this didn’t happen, so I administered 0.5 mg triazolam. Within 20 minutes the woman was snoring, and I couldn’t rouse her. While I considered reversal after another 15 minutes her vitals were WNL. Now I was able to get her attention through verbal cues. Treatment progressed smoothly until we were within 45 minutes of completion. After 3 hours of sedation she grew increasingly alert.
I elected to add only 0.25 mg triazolam to resume sedation; this dose had no effect at all. Still choosing to follow a conservative path, I did not add another 0.25 mg triazolam dose, because the patient’s responses continued to be unpredictable. The woman required more anesthetic at this point. This, too, seemed to have very little impact upon her discomfort. After further questioning, it became apparent that woman was suffering more from TMJ spasms than tooth pain. This became her focal point, and our appointment was quickly completed.
Between hours 2 and 5 the patient’s HR hovered around 107-110. She had normal vitals otherwise and was still responsive. She was dismissed having shown alert X 3; she left the office in the company of her husband. We provided Flexeril™ 10 mg TID for TMJ issues along with cold packs.
When I checked on the patient the following day, she said her comfort level was much improved. She hadn’t needed any more Flexeril™. When I subsequently recently saw her post-op the dental issues were okay except for minor occlusal adjustment. However, her husband insisted I review the woman’s ongoing disorientation. He described her eyes as appearing droopy and tired and said the woman’s demeanor demonstrated heavy fatigue. In sum, the spouse believed the patient “just wasn’t herself.”
The patient shared this view. Her job as a Crisis Center counselor requires 24-hour call shifts. While she explained she did have some Sunday and Monday late calls, in normal circumstances these would have presented no problem. This time, however, she found herself struggling to concentrate. Her memory was poor and she couldn’t complete a sentence. She wears a fleece jacket everywhere and in addition to night sweats experiences hot flashes several times a day—a highly unusual event. While I suspected she wouldn’t experience amnesia due to alertness, she did in fact forget everything between the first onset of pain and her awakening the next morning.
Why is my patient failing to fully rebound from the sedative effects of just one drug?
Dr. Anthony Feck, Dean of DOCS Education faculty, responds:
Several possibilities occur to me as explanations for such uncommon phenomena. When a patient acts unusually late in an appointment, it is often related to hypoglycemia. The low blood sugar can cause physiologic symptoms only effectively addressed with sugar. If the patient did not respond to the low blood sugar well, the hypoglycemic symptoms can linger for an extended time.
Another reason the patient may have emerged abruptly from her sedation at the appointment’s end is pain from the muscle spasm. Pain is challenging to overcome with oral CNS depressants that have little or no analgesic activity.
The woman’s odd behavior post-op can be attributed to lingering sedation as a result of not hydrating properly after the appointment (especially with the combination of a muscle relaxant and the oral sedation meds), an idiosyncratic reaction to the sedation meds, or a neurological phenomenon that may or may not be related to the sedation appointment. If the patient's symptoms linger for another day despite good hydration and nourishment, then I would refer the patient to a neurologist for an evaluation.
Dr. Jerome Wellbrock of DOCS Education's faculty, responds:
I have a couple of thoughts. You dosed the patient to 1.0 mg triazolam. Her top dose would be 1.25 mg triazolam based upon a weight of 125 pounds. Your decision not to offer additional triazolam was sound. That’s because at 3 hours into the appointment the triazolam was wearing off, as was the local anesthetic.
Once your patient grew uncomfortable she became alert. Even with the addition of local anesthetic she felt pain. Remember pain is subjective. Now, you were behind the eight ball. It’s also possible the woman was experiencing bladder discomfort—that’s a sure trigger to alertness and discomfort. Add the muscle spasms and you faced a very difficult task
While your patient was dismissed alert X 3, it’s normal to expect amnesic effects to last most of the day. The majority of my patients remember neither leaving the office nor the ride home. As for the prolonged effects after sedation, the woman may have been physically exhausted from her work schedule, possibly dehydrated after being npo, or maybe just evidencing an individual idiosyncratic reaction. .
