A member of DOCS Education writes:
My patient was a 50-year-old male weighing 239 pounds. He presented in a state of extreme anxiety and possessed a severe gag reflex—so much so I couldn’t even use the mirror to study the lingual of his anterior teeth without producing a response.
He takes the following medications each day: 1 mg ropinirole, 300 mg buprion and 12.5 mg losartan. He is being treated as well for high blood pressure, restless legs syndrome and sleep apnea. He smokes one-half pack of cigarettes a day and consumes moderate amounts of alcohol three or four days a week. His baseline pulse was 74; the SaO2 was 96 percent and blood pressure 146/94. He described the blood pressure reading as a reflection of “white coat syndrome,†and his general nervousness about the dental treatment.
The man took 10 mg Valiumâ„¢ the night before followed by 0.25 mg triazolam one hour prior to the treatment. His blood pressure that morning was 134/86 and all other vitals were also normal. I gave him the first dose of 0.5 mg triazolam sublingually and he was relaxed. The blood pressure stayed about the same. However, the patient remained more aware than he wanted to be, so after 45 minutes I gave him a second dose of 0.5 mg triazolam sublingually. Now the man was falling asleep and very comfortable but his blood pressure went up and down along with his SaO2 which at one time dropped to 88 percent. The alarm was constantly going off. When his blood pressure climbed to 146/105 I gave him Gatoradeâ„¢ and called his wife to come get him. I asked that an appointment be made with his medical doctor for an evaluation before any scheduling any further treatment. Naturally I had him remain in the office until he was ready to leave.
According to my patient, he followed up with his medical doctor. The patient told my front office his doctor thought I was “silly†to stop treatment and that he was fine to go forward. I’m waiting for a confirmation from the medical doctor. Was I being overly cautious? Should I refuse to treat this patient or try another protocol?
A DOCS Education member responds:
The diagnosis of sleep apnea is a big red flag here. I wouldn’t treat this patient without more information. His blood pressure is also a concern and you are not being too cautious. At your pre-op evaluation he is Stage 1 hypertensive at 146/94. He’s prehypertensive at the sedation appointment (134/86) but later spikes to Stage 2 hypertension: 146/105. You note that his pre-op 02 saturation is 96 percent, which isn’t bad for a smoker. However, he drops to 88 percent during treatment with the alarm constantly going off.
My thought here is that you have a patient with sleep apnea who is over sedated. Your patient isn't breathing, his sympathetic nervous system is kicked into high gear, and he is the man who could die in your chair.
Patients with either COPD or sleep apnea (obstructive and/or central) are patients we really need to consider whether we are qualified to treat in our offices or not. Without more information about this particular patient I would most likely refer him where a separate anesthesia provider does the anesthesia and you or another dentist can performs the dental care.
I personally would not give a patient with either COPD or sleep apnea any sedative to take at home (certainly not at bedtime the night before). Your patient had a pretty good load of sedative with 10 mg diazepam the night before followed by 0.25, 0.50 and 0.50 mgs of triazolam the day of treatment. I appreciate your posting this case. It is a great one for all of us to consider regarding our patients.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
I completely agree. This patient has sleep apnea, mild COPD and borderline blood pressure at baseline.
Sleep apnea needs special attention since sedation will slow down his breathing and lead to desaturation. He certainly carries the diagnosis and behaved exactly as would be expected for a patient with sleep apnea. With desaturation, blood pressure usually goes up, particularly when it was borderline to start with.
This is not a patient who can be easily sedated, regardless of what his medical doctor says (he is probably not familiar with sedation dentistry). You did the right thing. Had you continued to push with sedation he might have retained CO2 and gotten into a lot of trouble.
Although this patient needs sedation for his dentistry, he should be treated in an environment where airway can be managed expertly (intubation if necessary). I would refer this patient.
