A DOCS Education Member writes:
My patient is a 68-year-old white male who was in the Pentagon during the 9/11 attack. He has since been diagnosed with RADS (Reactive Airways Dysfunction Syndrome) and also has open-angle glaucoma. He had mitral valve repair in 1977, but reports no other medical issues. His meds include pravastatin, metoprolol, aspirin, Advair®, albuterol, brimonidine and Travatan®.
This patient desires implant placement with oral conscious sedation. Suggestions for management would be appreciated. I have been sedating patients for several years using DOCS Education protocols, but this one caused me to hesitate and seek additional expertise.
Thank you.
A DOCS Education Member responds:
I would not treat this patient without a physician consultation. His pulmonary function would be my greatest concern. RADS is an irritation-induced asthma in patients who have never had asthma symptoms previously. At least a hundred New York City firefighters have been diagnosed with RADS following 9/11. Many cases of RADS heal over time, but if your patient is still symptomatic, I would suspect serious pulmonary damage. Don't proceed without knowing his status.
Also, you note a mitral valve repair. It would help to know if it was repair or replacement, and the type of repair or replacement, as well as his current cardiac risks—cholesterol, elevated BP, etc.
Open-angle glaucoma is okay for sedation, but watch out for closed- or narrow-angle glaucoma. None of his listed meds are an interaction greater than a "C." Reduce his dosage by half because of his age.
After consulting with his physician and receiving approval for sedation, if you decide to treat him, then proceed with caution and carefully monitor your patient—especially his oxygen stats and respiration. Supplemental oxygen is possibly indicated. If you have capnography capability in your monitoring, I think it would be an excellent idea to monitor his CO2 levels.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
There are obviously a number of issues to be addressed:
- By far the most important is an assessment of the extent of involvement of RADS. Since this is triggered by irritants, nitrous may or may not be problematic. It’s important to know his current pulmonary function tests and whether there is any tendency to retain CO2. He is on multiple medications for reactive airway disease.
- Mitral valve repair: this is where the valve is repaired without replacement. The patient is therefore not on anticoagulation. It is still prudent to ask his cardiologist about antibiotic premedication.
- Open-angle glaucoma is not an issue, whereas close-angle glaucoma is.
There are no significant drug-drug interactions of his medications with sedation drugs.
