A DOCS Education member writes:

I have a 48 year-old female patient with an allergy to penicillin who is scheduled for a crown preparation which should take approximately 60 minutes. The patient takes no OTC or prescription medications, but has experienced rash and itching symptoms while using most pain medications. I spoke with the pharmacist who recommended using Hydroxyzine in tandem with Diazepam to reduce these itching symptoms. I understand that both drugs have CNS effects, so is it advisable that I prescribe both in tandem? My other concern is my state's regulations; under the Minnesota anxiolysis guidelines and protocols can I prescribe both Diazepam and Hydroxyzine without issue?

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

I am not familiar with Minnesota regulations, so I will let my colleague John Bitting address that part of the issue.

More information is needed when properly recommending a protocol. Many factors play into what our eventual recommendation will be, for instance what is the patients height, weight, BP, pulse, airway evaluation, sleep habbits, etc. All these factors are important to properly assess the full situation on a patient by patient basis.

Most importantly in this case, does the patient have a problem taking diazepam or other benzodiazepines? If not, why is a pharmacist recommending an antihistamine for itching? Do you anticipate needing analgesics?

When presenting sedation questions, we as a faculty are happy to help, but we need all the information available to make a proper, safe recommendation.

DOCS Education regulatory counsel, John Bitting, esq, adds:

Minnesota doesn't use the definitions "anxiolysis" and "conscious sedation" anymore. They've upgraded to "minimal sedation" and "moderate sedation." Minimal sedation encompasses all of anxiolysis and most of conscious sedation as they were formerly known.

Minimal sedation does NOT require an IV permit. The MN board will allow you to use the two-drug protocol (benzo + antihistamine) and even exceed the MRD of the benzo AS LONG AS the patient remains in minimal sedation. This means they're responding to your verbal commands like a normal person would in light of the situation. I.e. they're conversing with you easily, but they're relaxed and comfortable.

The MN board doesn't have dosage restrictions, so a good rule of thumb would be to not exceed 1.5x the MRD (ADA guidelines). That would be 0.75mg Triazolam, which you would administer in three incremental doses. After you provide Dr. Wellbrock with the information he needs, he can guide you through the clinical aspects of this protocol.

However, if this is new or confusing, you may want to join us in Memphis on August 23-25. I will be there and happy to discuss the MN regulations with you as well.

Let me know if you have questions.

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The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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