Sedation of Two Complex Pediatric Patients

A DOCS Education member writes:
I am a GP in Albany, NY and one of the very few providers who treat adolescents on State Funded Managed Care, in need of extensive restorative treatment: endodontics, crowns, etc. There are very few options for these patients, and as a result, I am starting to see referrals with some more difficult management situations, even from pediatric offices. Here are two cases I could use some advice with:

Case number one is a 12-year-old boy with weight 240lbs, Mallampati 1/Brodsky 1. His medical issues include schizophrenia, bipolar disorder, and obesity. He is taking lithium, Zyprexa, lamotrigine, and Trilafon, and estimate he would require four sedation appointments for root canals, fillings and crowns.

Assuming I can only use lorazepam/hydroxyzine the day of the appointment, and diazepam night before, how do we manage his other medications? I'm concerned about efficacy of the drugs due to his obesity, and managing him if he is taken off his medications. Can he be observed safely at home after the visit?

Case number two concerns a 17-year-old boy weighing 147lbs, Mallampati 2/Bodsky 2. His medical issues are primarily ADHD, with a history of seizures that have been successfully controlled with Keppra. He has not had a seizure for 7 years since being prescribed Keppra, the current dosage being 100mg in the morning and 150mg in the evening. He is also taking Stratera, 50mg in the morning.

Baseline vitals: BP 120/75 Pulse 79 SpO2 90% (Low?) He will need 4 visits to include root canals, crowns and fillings. I am assuming the proper protocol would be diazepam night before, and lorazepam/hydroxyzine the day of the appointment. I don't expect there to be an issue taking him off Stratera for a short time, but is the Keppra likely to be an issue? Should I be concerned about seizures in any event?

Thanks for your input!

DOCS Education faculty member, Dr. Jerome Wellbrock, offers his advice:

With patient one, I would be very concerned about airway and psychotic behavior from the schizophrenia. I would not do oral sedation with a schizophrenic patient! He should be treated by a dedicated anesthesiologist, while you do the dentistry in one or two appointments.

For number two, I don't see a particular problem here – just dose low and go slow!

DOCS Education faculty member, Dr. Kenji Saisho, adds:

I agree with Dr. Wellbrock - patient one should not be treated under oral conscious sedation due to his medical conditions, though I want to point out that his weight should not be an issue with efficacy of the medication unless he has built up a tolerance to benzodiazepines.