Healthy male patient agitated during sedation appointment

A sedated patient moves around a lot in the chair during eight difficult extractions. The clinician is able to finish the treatment, and the patient reports no memory of the appointment nor pain. The end result is good, but what could have caused the agitation?

A DOCS Education Member asks:

Last week I had a healthy 34-year-old, height 6'2", weight 180 lb, ASA Class I male patient. He states he does not take any medications. He came in for a sedation review the day prior to his appointment and BP was 122/76, HR 72 and pulse ox was 99. We reviewed sedation protocols.

When the patient arrived he said he was wide awake. Vitals were all WNL—about the same as the day before during review. I dispensed 0.25 mg triazolam sublingually and anesthetic was given. After approximately 45 minutes the patient stated that he was still very wide awake but relaxed. When the procedure began his vitals were all WNL but he seemed very agitated in the chair, moving around trying to talk. I dispensed another 0.25 mg triazolam and waited.

The patient was sleeping until the procedure began again. However, the same thing happened: he would not sit still; his legs kept moving which made it difficult to work, but we were able to finish the appointment.

When I contacted the patient at the end of the day he said he did not remember anything about the appointment and had no pain at all. I was happy about the end result, but what could have caused his agitation?

DOCS Education faculty member, Dr. Jerome Wellbrock, responds with several questions:

Did you give this patient diazepam the night before?

Did the patient take a dose of triazolam at home before coming into the office?

You mentioned that the patient stated he was "wide awake" when he came to the office. Awake is a good thing, but was he sedated at all at this point in time?

After administering the 0.25 of triazolam in the office did you administer the local anesthetic immediately or did you wait until you reached the desired level of minimal or moderate sedation?

After you administered the second dose of 0.25 triazolam you mention the patient was sleeping until the procedure began. A sleeping patient is either very tired or over-sedated.

You also mentioned the patient seemed agitated and moved around during the dental procedure, but you do not state what dental procedures were being done. There are several things that could be arousing a patient from what appears to be an appropriate level of sedation: extreme dental anxiety that reacts more to noise and touch; the need to urinate can be a powerful agitator (no one can sit very still then); lack of adequate local anesthetic and a response to painful stimuli; etc.

Did you use nitrous oxide/oxygen during the appointment?

It seems from the patient's experience that you had a successful appointment. One of the great things about the benzodiazepines, especially triazolam, is the amnesic effect.

If you are going to sedate this patient again, I would do an in-depth review of everything from your pre-op instructions to at-home compliance with any medications and NPO to what could be done different in-office. You may hit upon something and have that aha moment.

Thanks for posting as it makes all of us look at these cases as if they are our own patients and makes us all think!

Member clarifies:

The patient did receive 5 mg diazepam the night prior to appointment and 0.25 mg triazolam one hour prior to treatment.

The patient was given anesthetic approximately 30 minutes after additional medications were given, and was in a minimal state of sedation.

The procedure was eight difficult extractions due to the level of decay present.

He used the bathroom approximately an hour after he arrived at the office. He stated that he was tired as he has three small children at home.

If this patient is to be sedated again we will take additional time to stress the importance of following our guidelines.

I appreciate your response and it really does make us think harder about every sedation we do. Thanks!