A DOCS Education Member asks:
We have a fearful 50 year-old female who is requesting sedation in our office. She claims a history of chest pains, shortness of breath and ulcers. Additionally she has had gallbladder and ovarian cyst surgery and a past skin disease, she has been diagnosed bipolar, has a thyroid condition and COPD per her pulmonologist. The patient also smokes, snores, has frequent headaches, chronic dry mouth and exhibits psychogenic polydipsia.
- The patient takes a number of medications, many of which don't play well together:
- Levothyroxine 50mg---- Thyroid hormone
- Pantoprazole 40mg----- GI disorders
- Progesterone 200mg--- post menopausal Treatment
- Carbamazepine 600mg---- TMD
- Seroquel® 400mg-----Antipsychotic
- Lexapro® ----- Antidepressant
- Lisinopril---- ACE inhibitor for BP
- Lithium----- Antimanic agent for bipolar disorders
She is, in my estimation, an ASA III, Mallampati 3 or 4. This patient needs multiple endodontic treatments, as well as several crowns and other restorative work. I believe she would stand a chance in tolerating the treatments with sedation. She has requested that the dentistry be performed here, in my practice, but I would like your opinion on whether or not she would be best treated in a hospital environment with IV sedation. Is there any chance that OCS would work, and what would you suggest for a protocol.
Thanks in advance for your help.
Dr. Jerome Wellbrock, DOCS Education faculty, responds:
I know anesthesiologists who don’t want to sedate this patient. I would say absolutely do not perform sedation on this patient in your office. She should have her dentistry done in a hospital or outpatient facility where the anesthesia can be done by dedicated anesthesia personal. I think she is more of an ASA IV than an ASA III, and OCS is not for ASA IVs.
Let's look at the red flags: Obesity, Chest Pains, Shortness of Breath, COPD, Smoker, uncontrolled Bipolar (4 meds for Bipolar Disorder, some heavy hitters), Mallampati 3/4, snoring (likely Obstructive Sleep Apnea), and "Psychogenic Polydipsia".
I would not be surprised if she is diabetic with the excessive thirst when you look at everything else that is going on with her health.
Breathing and maintaining her airway are your greatest concerns. Establishing an airway in an emergency would be very challenging.
Again, I have to stress: do not sedate this patient in your office. Get her dentistry done in a facility where she has dedicated anesthesia care and you or someone else can do the dental treatment.
