A member seeks Dr. Wellbrock’s advice on patient’s allergic reaction

A DOCS Education member seeks the faculty’s advice:

Dear DOCS,

Our patient recently underwent General Anesthesia (GA) in the Operating Room (OR) for Oral Sedation (OS) and received the following pre-operation medications:

• Midazolam 4 mg
• Ketamine 20 mg
• Glycopyrrolate 0.2 mg
• Dexmedetomidine 8 mcg

Post OS, the patient experienced a mild rash extending from her chest and neck to her back. This completely resolved following the administration of Benadryl 50 mg, and the procedure was continued under GA in the OR without any complications.

For previous appointments we have managed the patient with lorazepam 3 mg.

Because of the mild rash allergic response to the listed OR medications which includes a benzodiazepine, we are not planning on using lorazepam and are tentatively reviewing the use of zaleplon 15 mg, and possibly hydroxyzine 50 mg for her next oral conscious sedation operative (caries) appointment. The appointment is scheduled for one hour.

Medical History:

• Obese, female
• DOB: 3-12-94
• Height: 5'8 Weight: 271 lbs
• Autism
• Self-Injurious Behavior
• Non-Verbal
• Other Allergies: Septra®, fentanyl (no info)
• Medications: Prozac®, risperidone, clonidine, apri, MD prescribed lorazepam 2 mg PRN

QUESTION:

Are zaleplon and hydroxyzine a safe alternative to lorazepam (due to the listed potential allergy)?

Please advise. Thank you for your time.

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

Why do you suspect the lorazepam to be the cause of the allergic reaction? You list lorazepam as a medication the patient is taking as prescribed by her physician. I would inquire as to how often she is taking the lorazepam and if there is any problem when she takes it.

Lorazepam would have a much longer duration of action since it has a longer half life and it has a greater amnesic effect than does zaleplon. Zaleplon is a good choice for a one hour appointment but I would not add the hydroxyzine. I suggest digging deeper into her history with the previous GA appointment.

The member responds:

Hi, thank you.

We have been unsuccessful determining the use of the medical Rx: lorazepam since the patient’s OR GA case and listed allergic reaction. We had advised the patient to contact and inform the PCP prior to any continued use of the lorazepam as a precaution. Obtaining information and response(s), this patient has proven difficult at best.

This is why we are considering zaleplon as an alternative.

Any potential problems with zaleplon? Specifically the potential medications that might have caused the rash in the OR?

Dr. Wellbrock responds:

Zaleplon is a non-benzodiazepine sedative-hypnotic. Lexicomp reports no studies that relate to any cross sensitivity as far as an allergy is concerned between zaleplon and the other benzodiazepines. Zaleplon does work at the gaba-receptors and is reversible with flumazenil.

The member responds:

Update: As per the patient’s mother, she has utilized the lorazepam for two medical visits without incident or any signs of allergic reaction. So, we will be utilizing lorazepam, as we have for appointments in the past.

Thank you so much for your time; it is always appreciated.