A DOCS Education member writes:
Our patient experienced triple-bypass cardiac surgery recently. Before this operation we successfully sedated the man twice. His other medical conditions include diabetes, high blood pressure and high cholesterol, all of which involve daily medication. He is 61 years old and taking the following prescription drugs: 325 mg aspirin, 1000 mg metformin, 50 mg metoprolol, 100 mg sertraline, 1 tab garlic, 60 mg Starlix®, 180 mg diltiazem, 600 mg gabapenten, 50 mg feosol, 1 tab Foltx, 100 mg losartan, 4 mg doxazonsin and SLO niacin.
The man has expressed great fear of dentistry.
We let the man's cardiologist know we were using triazolam and diazepam. He commented that the patient's weight—244 pounds for a height of 5'9"—likely presented a difficult airway management problem.
The Lexicomp® program showed a D interaction with diltiazem, which the patient takes for high blood pressure.
We planned to perform a hemisection on number 30 with a buildup and crown.
Due to the history of the heart-bypass operation and the number and type of medication taken, we want to know whether you feel it is safe to proceed with sedation.
Dr. Leslie Fang, DOCS Education Faculty responds:
Unless an urgent indication presents I would wait a full 6 months following the cardiac bypass before performing elective surgery.
As for diltiazem this medication is a serious D interaction—you must avoid both diazepam and triazolam because of the CYP3A4 inhibition.
This fact should have raised a very bright red flag with the cardiologist.
After the 6 months have passed you should use lorazepam as your sedating drug.
For the following reasons this is not a simple patient.
- Recent cardiac bypass
- Hypertension
- Diabetes mellitus
- BPH
- Diabetic neuropathy
- Obesity
- Anemia on iron and folate
- Hyperlipidemia
- Hypertriglyceridemia
At present this patient is an ASA IV. In six months he will be an ASA III.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
I agree with Dr. Fang's assessment of the risks associated with treating this patient. Any practitioner taking on this patient now or in the future should have advanced training and experience.
Even though I have both, I would only provide emergency care to this man during the next several months. And I would do so only at a surgery center with a dedicated anesthesiologist and a medical team able to deal with emergency situations.
The areas of greatest concern are the airway, the potential for low oxygenation generally and the impact low oxygenation could have specifically on this patient's compromised heart condition.
Finally, the diltiazem interaction with benzodiazepines metabolized by CYP3A4 is significant enough to substitute the benzodiazepine.
