A DOCS Education member writes:
I am preparing to treat a 23-year-old female with cystic fibrosis, arthritis and panic attacks and need some recommendations. Currently I do not have her specific medications or health history. The patient will be traveling quite a distance to see me. Is this an IV sedation case or would it be more suitable for a surgery center similar to COPD patients?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Cystic fibrosis patients have substantial respiratory problems and should be treated as an ASA IV patient when considering oral conscious sedation (like a COPD patient). These patients should be sedated with IV access in a facility where competent advanced emergency care is readily available. A separate individual dedicated to the patient's anesthesia monitoring and administration should be present.
Member response:
I examined this patient yesterday. She was very anxious because her previous dentist completed treatment without anesthesia. BP was normal, O2 95-96, but upon reclining dropped to 91. I believe that this patient's anxiety can be managed without IV sedation. Her primary concern is that she is anesthetized.
Do you think continuous O2 will help prevent her O2 levels from dropping? Or are these drops related to mucous buildup blocking O2 transport over a wider surface area when she is reclined?
The patient is taking Cayston® 75 mg bid, 28 days on 28 days off, and albuterol times daily. FVC is 3.34 (88%). FEV is 2.62 (86%). Her primary care physician recommends Levaquin 750 mg as a pre-med. The patient's last lab values were taken April 21, 2011.
If this patient is categorized as ASA IV for sedation, is she ASA III for local anesthetic, and would you recommend more recent testing? Her physician indicates that in-office sedation is safe.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
A baseline O2 saturation of 91% unsedated in a patient with significant compromise to their respiratory system means a patient who will be well below the 90% threshold while sedated. There are multiple systemic ramifications to patients with chronically low oxygen saturation, often due to excessive mucous production that obstructs airways. Due to the desensitization of the hypercarbic drive mechanism in the brainstem, the patient becomes dependent on the hypoxic drive and retains carbon dioxide.
Even though you can elevate the patient's oxygenation with 100% supplemental O2 (which will make you think that everything is fine), you can thwart the patient's ventilatory drive with higher concentrations of O2. As you can see, this gets somewhat convoluted and while you're concentrating on the patient's dentistry, negative things can be happening in the patient's cardiovascular and respiratory compartments.
Although you may be able to manage the patient while they are in your office, when they leave your office still sedated (because you're using oral sedatives), the patient is at increased jeopardy to be at very low oxygenation while at home unattended and unmonitored. Shorter-acting IV sedation; dedicated personnel responsible solely for the patient's sedation and monitoring; as well as competent personnel who could intervene medically in an emergency situation is in the patient's best interest. That is what our primary concern should be.
The physician's opinion that in-office sedation will be safe is not important to me. I want medical information related to the control of the patient's condition from the physician; he or she is not well acquainted and inexperienced with oral sedation used in dentistry. If something goes wrong the physician is not liable—you are.
Member Response:
And what about treating without IV or oral conscious sedation?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
As long as you can manage the patient, then treatment without the use of sedatives is appropriate.
