A DOCS Education member writes:
Recently I attempted to sedate a 54-year-old patient. The man reported a history of arthritis along with the diagnosis of melanoma in 2010. As a child he battled hepatitis. The patient takes one Vicodin® a day, smokes one pack of cigarettes a day and describes his alcohol consumption as occasional. He weighs 165 pounds.
The treatment plan includes extracting his remaining 23 teeth and placing 2 immediate mandibular anterior implants. I was limited to a single-dose protocol so administered the following: 10 mg diazepam to be taken the night before, followed by 3 mg lorazepam and 50 mg hydroxyzine on the day of the appointment. The man gave me the go-ahead to anesthetize him after 45 minutes. Nitrous was used for this purpose.
The man was lightly sleeping when the procedure started but after approximately 30 minutes he regained fuller consciousness and stayed quite alert. We finished the procedure because that was his wish, but the experience was miserable for both of us. He remembered everything about the appointment, by the way.
This is the second less-than-ideal experience I've had with lorazepam. Is this because of the particular medication or did this case just represent one of those patients who require more than the standard dose?
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
A number of reasons might account for the patient's dissatisfaction with the level of sedation in this case. They fall into two general categories:
- The patient is a hyporesponder (tolerance to CNS depressants from Vicodinâ„¢ and alcohol, smoking, high anxiety)
- Single-dose protocol (and the fact that lorazepam is not as efficacious as is triazolam)
One thing is certain: your chances for higher success rates on hyporesponders with sedation increase when you can incrementally dose. They approach 100 percent when you use IV sedation. Therefore, if you want to eliminate the occasional less-than-optimal sedation experience use triazolam in a single dose (and resign yourself to shorter appointments), or satisfy the requirements in your state for incremental dosing.
