A DOCS Education member conducts the perfect sedation appointment: the patient is sedated to a responsive but comfortable level, the procedure goes well, and the patient is discharged while alert enough to joke around with the staff. A few hours later, an urgent call comes into the office from the patient's wife who cannot keep him awake per the instructions. Was the patient over-sedated?
A DOCS Education member inquires:
Yesterday we had a patient in for treatment while under oral sedation. He was a model patient, responding to verbal commands and appearing relaxed throughout the procedure, which went perfectly. He was administered an at-home oral dose of 0.25 mg triazolam one hour prior to the dental visit, and an in-office sublingual dose of 0.50 mg triazolam and 100 mg hydroxyzine.
After the procedure, we began the dismissal protocol. As per our protocol, sugar in the form of a fruit drink was given to the patient, who was groggy but responsive. After drinking, he became much more alert. We went through our dismissal questioning, and found the patient very responsive. He even kidded a little bit with the dental assistant when asked questions about where he was and where he lived.
The patient was guided to the car by two assistants (which we do for all sedation patients who exceed the weight of one dental assistant), just to be extra careful of a misstep. Around three hours later, the patient's wife called my office, concerned that she couldn't keep the patient awake as instructed. According to her, he just seemed "over-sedated."
In hindsight, the pre-dismissal sugar dose might have led to an extremely short-term response quickly returning the patient to a sedated state that frightened his wife, who expected him to become more alert with the passage of time. Per our protocol, we stressed to his wife that the patient MUST be kept awake, and when she was unable do so she understandably became very nervous.
Thus, my questions are as follows:
- Should we consider changing the dismissal protocol of questions and answers to occur PRIOR to the sugar administration?
- We tell all caretakers that it is MANDATORY to keep the patient "awake" until bedtime. Is there a better way to state this? Is there less of a concern if the patient is allowed to sleep after a certain number of hours (half-life effect)?
- Is the effect of sedation on less-anxious patients more pronounced? Should we routinely go lower with our dosing even in cases necessitating a lengthy and complex procedure?
Dr. Jerome Wellbrock, DOCS Education faculty member, responds:
A couple of thoughts here: First, I do not feel it is necessary to keep your sedation patients awake for the remainder of the day until bedtime. It is important that there is a companion present to check the patient frequently to ensure they are easily awakened, but it is fairly normal for a patient to want to sleep after sedation.
Remember that as a patient returns to an environment causing him less anxiety, his minimum effective dose decreases, which raises level of sedation. It is also possible that your patient is somewhat of a hyper-responder, and you may want to consider a lower dose for any future appointments. You should make that decision based on the actual response of the patient in your office.
If you felt the patient was in a good place and not over-sedated then he was probably fine. However, you may want to consider reducing or skipping the dose of hydroxyzine unless there is a specific reason for adding that to your protocol.
Secondly, keep in mind that there is no such thing as a "standard protocol." DOCS Education has several protocols based on many factors, such as expected length of appointment, a patient’s age, height and weight or BMI, current medical conditions, any prescription or OTC drugs and/or herbals, tobacco, alcohol or recreational drug use.
It may be helpful to review the Oral Sedation Manual to look at current recommended protocols. If it has been some time since attending a DOCS Education program, a recertification class may be helpful. Again, it sounds like you have a good handle on this and a good team was there to assist you.
Please do not hesitate to email or call me if I can help in any way.
The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.