A member of DOCS Education writes:
I have an upcoming patient who is a 21-year-old male with Landau-Kleffner syndrome that is to be sedated for a two-surface filling. The patient was seen by another dentist four years ago, and at that time was given two .25 mg tabs of Triazolam prior to dental work. The patient has Autism-type movements and struggles to sit still, making monitoring difficult.
I would like to sedate with Triazolam, but worry about the monitoring. I was planning on one .25 mg of Triazolam prior to the appointment, followed by another .125 or .25 mg until the monitoring pulse oximeter can be used. The parents are questioning why I cannot simply administer the two pills and were still unsatisfied after my explanation.
The patient is currently taking 500 mg of Depakote® twice a day and 250 mg of Depakote® once a day. This level of medication was prescribed in 2012 following a seizure. The patient is also taking 1 mg of Rispredal® twice a day and 1.5 mg of Rispredal® three times a day. The patient is ASA 1 with no allergies or other medical problems and weighs 135 lbs.
I would like your advice on the proper medications and protocols to use with this case. Thank you.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
I will comment on the syndrome itself.
It is a rare neurological disorder where patients would begin to lose their speech function usually at or around ages 6-7. This is related to neurological developmental abnormalities that affect the speech centers (Broca's or Wernicke's). Seizures would originate from these areas as well. In a patient with Broca's aphasia, they understand but cannot use expressive speech. They are often frustrated because of this deficit. In patients with Wernicke's aphasia, they actually have trouble both understanding and formulating complex speech. At times, both areas can be involved.
Moreover, many patients with Landau-Kleffner syndrome can have autistic types of behavior with restlessness and repetitive action.
This patient clearly has, what seems like, all of the above.
With the history of seizure disorder, even though it is controlled, this patient is at least an ASA 2. I would like to know if he comprehends enough to cooperate. If not, he is an ASA 3.
Dr. Jerome Wellbrock, DOCS Education faculty, adds:
My first thoughts are that if you cannot place your monitoring equipment on this patient prior to sedating, then he is not an appropriate patient to sedate in your office. Second, if the parents are resistant to your sedation procedures you may anticipate that they do not understand what is involved on your end in both a time and a safety commitment for a safe sedation appointment. If you cannot do pre-sedation monitoring to establish a base-line then I would recommend separate anesthesia personnel being present for this appointment.
A different member of DOCS Education offers this advice:
In my opinion, various things point to treatment under general anesthesia in an outpatient surgery center. First is the patient's condition and potential for unpredictable behaviors. The other, and possibly more important aspect, is the parents. In an outpatient surgery center, the parents will be less likely to interfere with the procedure which, in this case, seems like it would be beneficial.
It’s always good to screen your patients AND the parents/spouse when possible.
