A patient requests treatment under sedation, and discloses she has had two back surgeries with morphine as the principal painkiller. Can she safely be sedated per DOCS protocols?
A DOCS Education Member writes:
I have a 45 year old female presenting for treatment with severe anxiety. She is taking the following medications:
- Morphine ER 15mg every 12 hours
- Tramadol 50mg 3 times a day
- Lisinopril 40mg 1x nightly
- Metoprolol 100mg 1x nightly
- Amlodipine 5mg 1x nightly
- Gabapentin 600mg 2 pills 3 times a day
- Robaxin 750mg 3x day
- Vitamin D once a week 50,000 units
- Vitamin B12 injected 1x week
The patient has had two back surgeries in the last two years and is obese. She had a physical completed a few weeks ago (but without any blood work) in preparation to undergo a two hour sedated MRI procedure next week. Her brother is a dentist in another state, and she states that in order to have a filling completed with him, she took 2mg of Xanax and "fell asleep". She said the only thing she did not do was take the morphine before she saw him in the morning.
I am not sure how to proceed with this patient. She is a nurse, so she thinks she needs Ativan which is an option under the DOCS protocols. Could you please give guidance on this case? I want to do a test appointment with only nitrous oxide to see how she reacts, but I want to be able to give her another sedation option as well. Thanks!
Dr. Jerome Wellbrock, DOCS Education faculty member, responds:
This is a very difficult and challenging patient to sedate in your office. She most likely would be a hypo-responder with her history of morphine and Tramadol use, and she is obese making both airway a concern. She is likely to need a large amount of medication to sedate her. I recommend a detailed history, pre-sedation evaluation and physician consult before you commit to sedating this patient. This may be a patient better referred to a facility equipped to handle any emergency event with dedicated anesthesia providers.
If you only use nitrous oxide/oxygen, I would consider giving that a trial and explain to her your concerns over her health and current medications.
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.
