The 28-year-old patient uses neither drugs nor alcohol and her medical history is unremarkable. However she does take medication for migraine headaches. After three successive administrations of .25 mg triazolam the woman was still anxious about dental treatment. What went wrong, if anything? A DOCS Education member writes:
Please advise about a female migraine patient. She currently takes Topamax™ and Sumavel™ for her headaches. The woman is 28 and possesses high fear regarding dental care. She was given .25 mg triazolam one hour before her appointment, but arrived with no apparent effect from this medication.
We administered another .25 mg triazolam and waited for thirty minutes. She still appeared very alert. She indicated she did not feel nearly relaxed enough to begin local anesthesia or for that matter any treatment. Finally a third dose of .25 triazolam was administered. Another 25 minutes passed and while she was relaxed, the woman still reported feeling somewhat tense and apprehensive.
However, the woman did consent to let periodontal scaling begin. She later indicated she did not experience discomfort, but she did express disappointment at the minimal effects of the triazolam. How can I alter her protocol?
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
I need a little more information. First, how much does your patient weight? How tall is she? Was any diazepam taken the night before? Does your patient smoke? Does she use either recreational drugs or alcohol, and if so, how frequently? Was the woman NPO for six hours before the appointment?
DOCS Education member replies:
My patient weighs 215 pounds and stands 5 feet 10 inches tall. She doesn’t smoke, drink or use recreational drugs. She confessed to eating one-half a banana prior to the appointment. Because of the fact she takes 300 mg Topanax™ every night I didn’t prescribe diazepam. I feared synergistic effects.
Dr. Anthony Feck, Dean of DOCS Education faculty continues:
First of all, you could have administered 5 mg of diazepam the night before. When a patient is taking only one CNS depressant, it does not affect the night-before dose.
Next, your patient's BMI is 30, placing her in the "obese" category. This means the woman is very likely to require more total medication in order to sedate her due to the high percentage of body fat. In addition, your patient's TOP Dose for triazolam is 2 mg. Given her response to the 0.75 mg, you were too conservative in your dosing to sedate this patient--who is prone to hyporesponding.
Next time, use incremental protocol number 2, and dose to effect with appropriately sized incremental doses of triazolam at appropriate intervals until your patient is comfortable, staying within the patient's TOP Dose.
Hope this helps.
