Seeking advice on first oral sedation dentistry appointment

A DOCS Education member seeks assistance on his first oral sedation dentistry procedure: I have my first sedation case on Wednesday, and I would like to double check my medical work up and protocol to confirm this is an acceptable case. I am anticipating a 4.5 hour sedation for extractions, bridge prep and restorations. Here is the information I have on the patient: ASA 1 Allergies: Pollen Weight: 245 lb Heigh:t 5' 7" No alcohol, uses marijuana for recreation Baselines: pulse 96, Sa O2 96% BP: 125/81 Mallampati: Class III Medications: Gabapentin, lamotrigine, bupropion, sertraline and zolpidem. I ran the meds in Lexicomp® and most are C interactions besides zolpidem (Ambien®) which is D. I figured the diazepam the night before would replace the zolpidem. Medical History: Psychiatric therapy (counseling), ostomy (has a pouch for excretions), slight asthma (uses an inhaler once a day). Patient admits that, due to his weight, he feels as though he often needs more than the recommended dosages to feel the effects of sedative medications. I was thinking of protocol 2 because of the asthma: 10 mg of diazepam at bedtime, 0.25 mg of triazolam one hour before appointment. Hydroxyzine at initial assessment. What are your thoughts on the dosage because he is hyporeactive to medications? Do you have any concerns that I should be aware of? Any advice would be helpful. Thank you for your time and attention on this matter.

DOCS Education faculty member, Dr. Jerome Wellbrock, responds:

This is NOT an ASA I patient and I would advise not sedating a patient like this until you have a great deal of experience. Even with many sedation cases under your belt, you could still choose not to have this patient sedated in your office. The greatest risk here is going to be airway maintenance and the increased risk of rapid de-saturation from increased sedation. At 5'7" and 245 lb he has a BMI far greater than 30, making him obese. His SaO2 of 96 percent before sedation is already lower than desired. A heart rate of 96 should be investigated. A medical history of psychiatric therapy and counseling is not a medical diagnosis. Is this patient bipolar, depressed or something else? Is the patient taking multiple medications for either seizure disorder or depression? Slight asthma to me is "patient carries an inhaler that they rarely if ever use," not utilizing this medication at least once a day. I am also hesitant to assume what the "ostomy" is or why it was preformed. This patient is an ASA II at the least, but more likely an ASA III. If I were to consider sedating this patient in my office, a physician consult is absolutely necessary for a complete and current medical diagnosis of all conditions being treated. My advice is to not sedate this patient in your office. The DOCS Education member follows up: Thanks for the bringing these issues to my attention. I am in contact with patient's psychiatric and counseling clinic and will complete a better work up. I can tell you that the patient does not have a history of seizures, and based on my conversations with the patient, he appears to be stable. I'm in the process of getting his psychiatric diagnosis. The patient had his colon removed in 1998 and then an ileostomy in 2011 due to familial adenomatous polyposis. I understand why you are advising not to sedate this patient in my office. Would you clarify if doing a single dose protocol and keeping the dose low would be safer or even an option? Dr. Wellbrock clarifies: My advice remains unchanged: do not sedate this patient regardless of the returned psychiatric diagnosis. Airway Maintenance is still going to be your greatest concern. This patient would most likely have some airway compromise just from placing him in a reclining position in the dental chair. In regards to your question about single-dose protocol: It would be more difficult to use a single dose with this patient than an incremental dose, especially since you consider him to be a potential hypo-responder. I would not want to give him a CNS depressant at bedtime due to his airway risk. I also do not find it advisable to be using hydroxyzine in an asthmatic patient. You need to look for a true ASA I patient for your first several sedation cases and then you'll get off to a great start. A case such as this one has too many variables for you to consider. Start simple and consider taking on a case like this after you have been practicing sedation for a while.