A female patient, who has sleep apnea which requires the use of a CPAP, is taking what a DOCS Education member describes as an "interesting mix" of medications with a "D" interaction. DOCS Education faculty members Drs. Feck and Fang weigh in with advice on getting a medical consult and being careful of CO2 retention when modulating with CO2 and oxygen.
A DOCS Education Member asks:
I sedate incrementally in Connecticut.
I have a female patient in need of oral conscious sedation who is taking the following medications:
- Bupropion HCl XL150 mg 3x day
- Lexapro® 10 mg 1x day
- Spironolactone 25 mg 1x day
- Pantoprazole sodium 40 mg 1x day
- Montelukast sodium 1x day
- Metoprolol succinate 50 mg 1x day
- Tretinoin cream 1x day
Additionally, she has sleep apnea and uses a CPAP.
I used Lexicomp® Online and got one "D" interaction with the use of hydroxyzine and Lexapro®. I would not use hydroxyzine.
I would probably use 5 mg diazepam the night before; 0.25 mg triazolam one hour before; and assess at the appointment.
DOCS Education faculty member, Dr. Anthony S. Feck, responds:
Given this patient's list of medications and associated medical conditions, it is important that she has had a medical evaluation within the past year. Her medical conditions need to be under control.
If that all checks out, she needs to bring an inhaler to the appointment, and not take any diazepam the night before (due to her sleep apnea and the number of CNS depressants she is currently taking). I would use 100 percent supplemental oxygen throughout the entire appointment. And, as you already know, do not use hydroxyzine.
Member follows up with another question:
Is there a hard contraindication to modulating the sedation with nitrous oxide/oxygen?
DOCS Education faculty member, Dr. Leslie Fang, responds:
Just want to make sure that you do follow up on the medical consult on this case.
Patients with sleep apnea have varying degrees of hypopnea and apnea. Many would have significant apnea and de-saturate significantly to 70-80 percent. During these periods, they would have significant CO2 retention. I would want to know about the degree of apnea prior to using 100 percent oxygen. If you use supplemental oxygen in a CO2 retainer, you can develop progressive CO2 retention without the possibility of kicking in the hypoxic drive, which is what eventually makes the patient take in a breath. Progressive CO2 narcosis will result in respiratory arrest.
Please check with a physician specifically with respect to the risk of CO2 retention for any patient with sleep apnea.
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