A member of DOCS Education writes:
My 60-year-old patient presents a number of complex medical issues, including the diagnosis of lupus and related progressive avascular necrosis. She has also had bilateral hip replacements. Additionally she is a heavy smoker.
Following represents a partial list of the woman’s current daily medications:
- Pilocarpine, 5 mg
- Simvastatin, 400 mg
- Citalopam, 20 mg
- Carisoprodol, one tab
- Lorazepam, 1 mg
- Oxycontin, 30 mg
- Zolpidem, 10 mg
The proposed treatment is the extraction of multiple teeth together with immediate denture delivery. The patient has maintained the listed prescription schedule for some time. If I undertake oral conscious sedation, which she has requested, I am considering the following: 0.25 mg triazolam two hours prior to the appointment; 0.25 triazolam crushed one hour before the appointment and 25 to 50 mg hydroxyzine one hour before treatment.
I expect this patient to be a hyporesponder. However, my primary concern is the possibility of hypotension and CNS depression. Am I on track?
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
The woman’s long history of lupus has produced many complications. They include:
Avascular necrosis is related to long-term steroid use, and also carries risk with respect to osteonecrosis. This is particularly true in the patient who also suffers from osteoporosis.
You are absolutely right—multiple narcotics together with baseline benzodiazepine complicate the sedation process.
An orthopedic surgeon should make the determination about whether or not to administer antibiotic prophylaxis on account of the prosthetic hip joints.
Her other medical issues are hyperlipidemia, depression, insomnia, chronic pain syndrome and probable Sjogren’s syndrome (pilocarpine). You should especially inquire about this as it significantly affects management of this patient.
Dr. Jerry Wellbrock, of the DOCS Education Faculty, adds:
You are correct that this patient will likely hyporespond and become difficult to sedate through oral means. I would do the prosthetics and refer her for the surgical phase of treatment. I’d also be concerned about the multiple extractions as they affect the avascular necrosis. Let an oral surgeon help on this one.
