A member of DOCS Education writes:
A 285 lb 52-year-old woman presented who has diabetes, high blood pressure, high cholesterol, arthritis and a back injury. She is a high-fear patient that we successfully sedated in 2008. The patient has an abscessed tooth that needs root canal treatment along with a crown. Her base line BP was 145/82; 81 pulse; 92% SA02. My office sent a fax to her primary physician, and he felt she should not have any complications diazepam and triazolam.
- Benazepril/hydrochlorothiazide, 10-12.5, once daily
- Calcium 1200 mg and Vitamin D 1200 mg one daily
- Diazepam 5 mg, 1 tablet every 4 hours as needed
- Docusate Sodium, three times daily
- Premarin® 0.625 mg tablet once daily
- Fentanyl 50 mcg/hr patch (patch to skin every 72 hours)
- Furosemide 40mg PO tablet once daily
- Hydromorphone 4mg up to 3 pills every 3 hours (up to 24 in 24 hours)
- Iron PO 160 mg once daily
- Metformin 1000 mg tablet once daily
- Methylcellulose 2 tablets twice daily
- Methylnaltrexone bromide 12 mg/0.06 ml
- Prilosec® 20 mg once every morning
- Miralax® twice daily
- Potassium chloride 2 tabs by mouth once daily
- Pravastatin 20 mg two tablets by mouth daily
Due to the long list of medication, I would like your input—especially since she is already taking Valium®.
Dr. Anthony Feck, Dean of DOCS Education Faculty, responds:
A challenging patient for oral conscious sedation to say the least.
You don't indicate how tall the patient is; therefore I don't know the patient's BMI. But for the sake of this discussion, I'll assume she is at least obese, and possibly morbidly obese.
You don't indicate the patient's HbA1c, so I don't know how well-controlled the patient's diabetes is. I won't assume anything regarding this—nor should you. Make sure that it is in the acceptable range (less than 9%, preferably less than 7%).
Other than the diabetes issue, the main concerns relative to sedating this patient are: obesity (airway), low baseline O2 saturation (airway, respiratory disease), and the patient's tolerance of CNS depressants.
The obesity places the patient's airway at risk and, absent any other unknown respiratory issues (including smoking related respiratory compromise, OSA or COPD), this patient likely has restrictive lung disease due to her obesity. This simply means that this patient cannot inspire deeply enough to create a higher level of oxygenation.
The three CNS depressants the patient is taking (one benzodiazepine and two opiates) make for tolerance to other CNS depressants, such as the ones you would attempt to sedate her with. This means the patient would hyporespond. The patient's obesity also adds to the likelihood of hyporesponse. The obesity also makes this patient more likely to stay sedated longer once she becomes sedated.
If you can get to the bottom of all of the medical issues raised above and you have advanced training to sedate ASA III patients (Sedation Solutions), then the best way to proceed is with the intent of sedating her to a lighter level. Use 100% supplemental oxygen throughout the appointment, following the diabetic modifications to DOCS Education sedation protocols, paying close attention to the patient's airway and leaving the patient on all her meds (including her diazepam that she would take the night before, but don't add any more).
Stay within the patient's TOP Dose, incrementally dosing to effect at appropriate intervals. I would let this patient know that she may need another sedation technique (IV) to accomplish the goal of comfortable sedation.
This is not a case for the inexperienced or minimally trained practitioner.
