A DOCS Education member seeks advice concerning patient’s recent stomach surgery

A DOCS Education member seeks the faculty’s advice:

We have a 45-year-old female patient who recently had stomach reduction surgery. Before her surgery we did pre-med of (1) Valium® 10 mg at bedtime the night before dental appointment and (1) Halcion® 0.25 mg one hour prior to the dental appointment. Her upcoming appointment is the first one she has had since her surgery. What is the suggested dosage for pre-med for her?

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

The information on this patient is incomplete and I will need more details before I can offer you complete advice. Would you please clarify that by “stomach reduction surgery” you are referring to gastric bypass surgery? If so, please provide the specific bypass procedure as well as when it was performed. The patient’s height and weight, or BMI, is good information to have as well.

I will also need all other information on her medical history and any info from her most recent physical exam, her level of fear or anxiety, what dental procedures are planned, expected length of dental appointment, vital signs from her pre-sedation workup, sleep habits such as snoring, OSA, etc.

After we receive a more complete medical picture for this patient, including a complete listing of any prescription or OTC medications, we can more accurately assist you and everyone on the forum will have the opportunity to learn from this experience.

The member clarifies:

The patient is six weeks out from her surgery. She had a gastric sleeve inserted and half of her stomach removed. Her stomach is about 4 oz now. The patient is 5'7" and now weighs about 194 lb.

She sleeps well. She breathes through her mouth and does not—to her knowledge—snore. Her level of anxiety is low. She has a prescription for Xanax® 1 mg, three times per day, but she only takes half of a tablet when her stomach gives her trouble.

She does take OTC Centrum® vitamins. No other meds. She is scheduled for a crown on tooth #2. The procedure should last about 1.5 hours.

Dr. Jerome Wellbrock adds:

Thanks for the additional information. It is very helpful. The gastric sleeve surgery involves removing a large portion of the stomach and the remaining stomach is reconfigured to resemble a sleeve or a narrow tube.

Think of cutting a football in half and putting the remaining half back together. This results in the stomach having little room to store any food contents, and anything that enters the stomach including oral sedation meds will pass through the stomach and into the small intestine at a much faster than normal rate.

This will result in a faster onset time of sedation; however, the meds will also pass the small intestine at a faster rate allowing less time for absorption.

You can expect faster onset of sedation but may require more frequent dosing for a longer procedure. Since your appointment is for 90 minutes you most likely will not require additional dosing.

Your biggest concern here is airway and breathing. She is definitely obese and is a mouth breather! Keep your sedation as light as possible and closely monitor your patient. Thanks again for posting and for the additional information. I hope this is helpful.