A DOCS Education member seeks the faculty’s advice: I have a 54-year-old female patient who weighs 125 lb, is ASA II, has a high sugar diet and has smoked a pack a day for the past 40 years. She is not very fearful, just does not want to “deal with” the treatment. Her baseline pulse is 40, SaO2 97 percent, BP 140/97 (She had not taken BP meds yet that day). She reports sleeping only three hours per night. Her medications are Ambien® 12.5 mg, Xanax® 0.5 mg, both of which she takes occasionally, and Vicodin® 10/350 as needed for chronic pain from an auto accident four years ago. The patient reports she is trying to use ibuprofen as a substitute for Vicodin®. She also takes lisinopril 20 mg and melatonin. She reports being “totally awake” during IV sedation with an oral surgeon three weeks ago. Her dental treatment plan is as follows: two root canal treatments, two crowns, two extractions, four restoratives. Due to the patient stating she only needs the Ambien®, Vicodin® and Xanax® occasionally, my plan is to stop these medications the day before and the day of treatment, using 10 mg diazepam the night before, 0.25 mg triazolam one hour before, hydroxyzine 100 mg slurry and incremental dose from there. I think I have a probable hyporesponder. Is this a reasonable plan? Am I missing anything? Thank you! 
DOCS Education faculty member, Dr. Jerome Wellbrock, responds:
This patient is obviously not an endurance athlete, so I would be very concerned about a pulse of 40! I would contact the oral surgeon about the recent IV sedation and get information on the medications and dosages used as well as what they perceived the patient’s response to be. If this patient was "totally awake," I think she is most likely not a good candidate for oral sedation. Chronic pain, poor sleep habits, high sugar intake and smoking all make for a difficult sedation.
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