Questioning doctor: My first sedation case was challenging, to say the least. The patient was a 23-year-old female. She wasn’t currently taking any medications so I classified her as ASA I. I planned to use Protocol Number 1. She arrived at 8 a.m., having taken 10 mg diazepam at 1 a.m. and 0.25 mg triazolam at 7 a.m. She claimed not to have eaten since 9 p.m. the previous evening and reported feeling tired and very hungry. I administered 0.25 mg triazolam sublingually. I started the nitrous and anesthetized at 9 a.m. By 10 a.m. I had removed her third molars—uneventfully. Suddenly she became extremely agitated and complained of a terrible headache. Her blood pressure rose from 123/79 to 140/109. I responded with oxygen and administered 0.125 mg triazolam. The patient urged me to raise her to a sitting position. Finally, she calmed down, and her blood pressure returned to normal. I then performed a post and core and crown prep, but the same symptoms returned. This time they were worse than before, and now they were accompanied by weeping. I interpreted the situation as side effects from triazolam and discontinued further treatment. I administered Advil™ and Tylenol® and encouraged her to drink a bottle of Gatorade®. This was a long hour; however, all worked out well. Did I handle this properly? What else should have been done? I am left with the impression I overlooked something important.
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
Unusual behavior almost always results from one of two things: underlying psychotic condition on the part of the patient or, more commonly, hypoglycemia. Neither result is a side effect of triazolam. The following facts in your narrative lead me to believe hypoglycemia was the source of the reaction.
- “23-year-old female†– young women are more prone to hypoglycemia.
- “Complained of being very hungry†– this represents the typical response to low blood sugar.
- “Became very agitated and complained of a terrible headache†– the brain has a continual need for glucose, but lacks the ability to store glycogen, which is the repository for glucose. So the brain is dependent upon blood-glucose levels sufficient to sustain normal activities. When the blood-glucose level is depleted, abnormal brain activity exhibits itself through aberrant behavior.
- “Her blood pressure rose†– this is another typical response to low blood sugar. Patients with hypoglycemia may “pass out†temporarily. A key method for determining whether the loss of consciousness is a vasovagal response instead of the result of hypoglycemia is the patient’s blood pressure. When the blood pressure is depressed, the cause is vasovagal; if it’s elevated, the reason is hypoglycemia.
Feed a patient immediately who exhibits this behavior. This doesn’t have to constitute a three-course dinner. A couple of tablespoons of applesauce or yogurt will suffice (make sure no allergies exist). Wait five minutes, and you’ll likely be startled by the degree of improvement. When you treat patients who are susceptible to hypoglycemia, find a baseline blood-glucose level one hour after a meal. This can be extremely helpful in preventing and/or treating hypoglycemia during a procedure. I treat many diabetics under sedation, so measuring blood glucose is standard procedure in my practice. The information is easy to obtain and reliable. I also find having an IV in place with dextrose infusion and the ability to administer additional dextrose through the IV has eliminated the problem of hypoglycemia during sedation. (It’s my understanding that you don’t need an IV sedation permit to place an IV so long as no sedation drugs are administered through the IV. You certainly do not need an IV sedation permit to administer emergency drugs such as dextrose in the event of a hypoglycemic episode.)
