Should I Take on this Case or Punt to OR?

Get by with a little help from your friends at EliteDOCS. A DOCS Education Fellow consults with the DOCS Education faculty about whether he should use oral conscious sedation, IV sedation or refer a case to a hospital. Dr. Wellbrock advises.

A DOCS Education Fellow and Live Patient Instructor inquires:

Patient: 36-year-old female. January 2014 auto accident resulting in traumatic brain injury. Anxiety/depression. Severe dental anxiety. Needs one extraction and 10 restorations.

Current medications:

  • Fentanyl patch
  • Morphine
  • Gabapentin
  • Paxil®
  • Xanax®
  • Lamictal®

I checked Lexicomp: No real issues if doing IV sedation, except nalbuphine would be an issue. No real problems with oral conscious sedation (OCS) medication interactions beyond standard "C" interactions with CNS depressants.

My concern is about adequate pain management and length of case.

One option is to have "Dr. B" do the case in an operating room (OR) where pain management and length of case are not issues. Of course, she's swamped with cases and doesn't typically treat adults, but I do not have OR credentials.

Which direction would you advise?

Attention DOCS Education Members: Even DOCS Education Fellows and instructors sometimes have questions—don't be afraid to ask yours.

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

I would expect this patient to most likely be a hypo-responder and difficult with OCS. I think IV is the way to go, and I would probably use Versed® and avoid additional narcotics, if possible. If you have any concerns then off to the OR is best for you and your patient.

Thanks for posting. It is great to know that all of us—no matter what our training or experience—come across these difficult patients. We are not always the right person to be doing both the dentistry and sedation. We always have to put the patient's best care and safety first even if that means referral.

The DOCS Education Member responds:

Dr. B and I discussed it and feel that, with the patient's traumatic brain injury and current meds, OR and intubation is best for her. The time it takes to do the case is not relevant since we'll be at the hospital, as opposed to an ambulatory surgery center. Also, pain management will be the anesthesiologist's worry, not ours. We'll focus on taking care of the patient.

Sometimes, dropping back ten and punting is best for the patient and doc.

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.