Sedation of Patient Taking Tramadol

A DOCS Education Gold Member writes:
We plan to treat a 73 year old female patient. Patient takes Tramadol 50 mg bid and that received a D when checking through Lexicomp. We have prescribed Tramadol after sedation for pain relief. Patient takes this medication for chronic back pain and is reluctant to stop meds for any length of time. What is your recommendation for Tramadol before sedation? Our typical sedation regiment would be as follows: Diazapam 5 mg the night before. Triazalam 0.125 1 hour prior to appt, with patient bringing 0.125 with her to appt. Hydroxyzine 25 to bring to appt. Thank you!

A DOCS Education member responds:
If everything checks fine health wise, I would not give the diazepam the night before unless this patient has taken benzodiazepines in combination with tramadol in the past without incident. The risk here is that tramadol can be a respiratory depressant and in combination with benzodiazepines they can potentiate one another, then again if this patient has been taking tramadol for months or years , then she more than likely has become desensitized/adapted to the tramadol. if you do not have an answer for that question then I would not give her any benzodiazepines to take at home, furthermore if you want to sedate this patient I would suggest a combination of nitrous oxide inhalation and midazolam.

At her age I would consider half doses to begin with any way. I suggest midazolam because if you end up with an over-sedated patient then you can reverse with flumazil and end the sedation.

Dr. PJ Goyal, DOCS Education faculty member, responds:

Please advise as to patients BMI? I do not think there is too much of concern keeping the patient on the Tramadol. Her level of oxygen will need to be monitored consistently, to prevent any type of apnea. I would dose low because of age. Avoiding the diazepam night before would be a good idea. I would avoid using Midazolam, that is not part of our DOCS protocol.

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