A first sedation case presents with the tricky subject of vaping and its effects when compared to cigarettes. The doctor puts his questions and concerns to the DOCS Education faculty for appropriate direction.
A DOCS Education Member enquires:
This is my first sedation case. The office has all the necessary equipment and has been doing OCS for 10 years as the retiring dentist offered this service. I have done work on sedated patients but this is my first case entirely in control. I was hoping for a single tooth—short and simple. Instead I have a longer case with 16 fillings, one molar endo and a crown prep. I am not concerned about the work itself, rather I'm interested in tips/hints for efficiency and a few other general questions. Here is the background for the patient:
25-year-old-female with moderate anxiety. She has been sedated once before.
Pulse: 106
BP: 142/79
SpO2: 98%
BMI: 28.9 (weighs 190 lb)
Allergies: Latex
Medications: None
Medical Hx: Insignificant
No caffeine or sugar intake issues
Nicotine-Vapor Pen 3-4 times per day
ASA: Class II (because of BP and vaping)
Questions:
1) I will be doing incremental dosing which is quite straightforward and was planning on adding hydroxyzine (protocol #2). Would this be appropriate in this scenario? Also, how do I determine if I should give 50 or 100 mg?
2) Vapor Pens: Do they differ in guidelines from traditional cigarettes? In this specific case I tried to talk the patient into not using starting the night before based on her usage and the guidelines, but she said she would not do that. Are there any problems with this other than liver enzyme function and decreased efficacy of benzos? With sedation in general, is it better to have no smoking/vaping but potential irritability or a small amount of smoking/vaping beforehand?
3) Any tips or recommendations for lengthy sedation appointments? i.e. How often to give bathroom breaks? Do you recommend an order of treatment? For example, do the RCT and crown first or last?
I appreciate your time.
Dr. Jerome Wellbrock, DOCS Education faculty member, responds:
There's nothing like jumping right in—good for you and your patient. I think you should be fine with your proposed protocol. I will make a recommendation, but based on her previous sedation experience you may want to adjust dosages. The night before I'd suggest either 5 or 10 mg of diazepam and triazolam 0.25 mg one hour before beginning of appointment. Re-evaluate patient's level of sedation and decide on the amount of triazolam and hydroxyzine to give. Most likely I would use 50 mg of hydroxyzine and your determined amount of triazolam. Your TOP DOSE of triazolam will be 1.75 mg based on her weight of 190 lb. Remember, TOP DOSE is not a goal, and is an absolute maximum amount that can be given.
As far as vaping goes, it will depend on the amount of nicotine the patient is getting to compare it to regular cigarettes. I am probably a little more relaxed about smoking since so many of my patients do, and I usually plan on them smoking before the appointment rather than dealing with an anxious patient who is wound up from not smoking.
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.
