If a child weighs as much as a grown man, does that complicate his sedation planning? A dentist must perform an emergency root canal but wonders whether this 13-year-old’s medical situation—which includes taking the drugs clonidine, escitalopram and methyline—rules out certain protocols. A member of DOCS Education writes:
A 13-year-old patient will soon arrive for an emergency root canal. He needs sedation. I’m considering teen sedation number 5: 1 mg lorazepam, 1 mg hydroxyzine (2 mg/kg) and 50 mg meperidine.
This boy weighs 196 pounds—almost 90 kg—so physically his size is really that of an adult. Other medications he takes include 15 mg escitalopram for anxiety and 10 mg methylin for ADHD. In the evening, for sleep, he takes 0.01 mg clonidine. I’d appreciate your take given his circumstances and medical situation.
Dr. Kenji Saisho, DOCS Education faculty responds:
While your patient carries the physical characteristics of adulthood at 196 pounds, in the psychological and medicolegal sense he remains a child. And if he has a good, unobstructed airway he makes a good candidate for oral sedation.
The medications you list—methylphenidate, clonidine and escitalopram—reflect the severity and the significance of his medical condition. However, they do not complicate your sedation protocol. If the boy takes these meds 7 days a week, have him continue that course, even the night before you treat him.
If the child takes medications on weekdays only and not on weekends/vacations have him omit the methylphenidate on the day of your sedation procedure.
Make sure your patient is not on any benzodiazepines. The presence of these undermines your efforts at sedation and gives any of the teen protocols little chance for success.
On the other hand, if he does take benzodiazepines such as Xanax™, Valium™ or Ativan™, you will not sedate him with more Ativan™ or midazolam. In this case refer him to a doctor able to sedate under general anesthesia.
As much as you can, ensure that he is NPO, as the sedation meds will be much more efficacious. You will also run less risk of emesis/GI upset/aspiration.
Rather than using the lorazepam protocol, I would recommend midazolam, hydroxyzine and meperidine. The quick onset of midazolam is one of its most beneficial aspects. You will see effects within 10 to 15 minutes and will very likely be able to start your treatment at that time. Lorazepam, in contrast, will take 60 to 90 minutes to produce the same effects.
Twenty mg midazolam, 50 mg of hydroxyzine and 25 to 50 mg of meperidine provides more than enough sedation meds for your patient. It also affords you a couple of hours working time for his RCT. Should your treatment require more time than that consider adding another appointment.
