A member of DOCS Education writes:
My patient reports significant dental anxiety. She’s 40 years old. At her last visit she posted a blood pressure of 120/70, with an irregular pulse beat of 72 to 96. When I conferred with the woman’s cardiologist he responded with this:
Arrhythmias appear well-controlled. The current prescription regimen consists of warfarin, Tiazac™ and Ventolin™. The diagnosis of this patient is stable congenital-valvular heart disease. Repair of anomalous pulmonary venous drainage to the left and two mitral valves took place in the 1990s. She has residual aortic stenosis-insufficiency and well-controlled supraventricular arrhythmias (New York Classification I-B).
With this information in hand, would you classify the patient as ASA II or III? Her cardiologist considers oral conscious sedation safe for this woman and does not believe any special precautions are necessary. Do you agree? Also, would nitrous be preferable to OCS in this case? Finally, is antibiotic prophylaxis warranted?
Dr. Jerome Wellbrock, DOCS Education faculty, responds:
OCS can be safe for this patient. However, you need more information before sedating her.
Let’s discuss warfarin first. I assume she is taking this for atrial fibrillation? If so, you can still sedate her, but I would definitely have an EKG monitor on this patient along with your other monitoring. If you need post-op pain medication consider Celebrex™ so as not to promote interaction with the warfarin.
Ventolin™ is albuterol, of course. Yet you don’t mention asthma or other respiratory problems. Make sure she is under good control and know the frequency of any attacks requiring albuterol. If you treat her make sure she brings her medication, but have yours as a backup.
Tiazac™ is diltiazem. That’s a calcium channel blocker. It is also a “D” interaction with diazepam, triazolam and midazolam. You can use lorazepam.
Alternatively you might discuss with her physician the possibility of switching her Tiazac™ with Norvasc™ (amlodipine). This has no interactions with diazepam, triazolam or midazolam. Also she may experience more gingival hyperplasia with diltiazem and a lower incidence of hyperplasia with Norvasc™.
The need for antibiotic prophylaxis depends upon the type of her repairs and the degree of their success. If she has a mechanical valve—or repaired valves with residual defects—yes. If she has completely repaired valves or bovine/porcine valves, no.
Remember, if she stays on Tiazac™ it is OK to use lorazepam and hydroxyzine and nitrous oxide.
If she switches to Norvasc™ you can use any of the oral sedation or IV medications recommended in DOCS Education courses.
If you do choose to sedate this patient I would closely monitor her, and dose low and slow.
Dr. Leslie Fang, Medical Director of DOCS Education faculty, adds:
This is an ASA III patient.
I agree with Jerry’s analysis. Here are some additional thoughts:
- The diltiazem is most likely there for rate control and can’t be changed. That indicates the lorazepam protocol.
- Presence of warfarin most probably linked to AF. However, you still need to know the INR (International Normalized Ratio). This should be in the low-2 range.
- Discuss with the cardiologist the need for antibiotic prophylaxis to determine the nature of the valve repair. I would guess there will be no need for prophylaxis.
