In a previous version of this post, the dosage of Triazolam was incorrectly listed as 25 mg one hour prior. This was incorrect and has since been changed to the correct dosage of 0.25 mg of Triazolam one hour prior.
A member of DOCS Education asks:
It seems I have an abundance of cops and nurses in the practice, and all seem to be taking some form of anti-anxiety meds or BP meds. Well, someone has to treat them and I have had great success with the DOCS protocol, but could use some suggestions here on an upcoming patient:
Patient is 5 9" / 220 lbs. He is a half pack a day smoker. No snoring, or so he says. BP today was 148/89, HR 86'. I have seen diastolic pressure at 95 on a previous visit. Meds are as follows:
- Tapentadol - 200 mg/d
- Metformin - 1000 mg/po. BID
- Lisinopril/hctz - 25 mg/d
- Bupropion - 300 mg/d
I am aware of the additive effects of triazolam with Tapentadol and Bupropion in the mix.
I would like to use the gold standard here as that seems to work well with my similar patients. 10 mg Valium® the night before followed by 0.25mg of triazolam at one hour prior, and small addition, prn.
Am I missing anything here? His physician was sent my conscious sedation request with vitals and I am waiting to hear back. All suggestions are appreciated, thank you.
Dr. Jerome Wellbrock, Live Patient Experience Director at DOCS Education, responds:
I would be cautious with this patient. At 5'9" and 220 lbs he is most likely obese unless he is extremely muscular. I would think he probably snores and has an airway concern. I would definitely not give him anything the night before because of airway and Tapentadol which is an opioid and a "D" interaction with all of the benzodiazepines. Definitely a medical consult is needed. I would even suggest a sleep study for this guy. Proceed slowly.
Dr. Anthony Feck, Dean of Faculty at DOCS Education, responds:
The Tapentadol is the problem as it has a [D] interaction with all of the DOCS sedation meds. If you prescribed this for acute pain, then change out the analgesic to something with less severe of an interaction. If the patient's physician has prescribed it, then consult with them regarding an alternative for the day before and day of the sedation appointment.
Once you have accomplished this, I recommend the Incremental Protocol 2. Determine the appropriate dose of hydroxyzine based on how the patient presents on the day of the sedation appointment. Your suggested dose of diazepam and loading dose of triazolam are good. Your patient will likely hyporespond. Pay close attention to the position of the airway and keep the sedation as light as possible while keeping them comfortable. You didn't list the age of the patient, but if they are under 50 they should have had a medical evaluation within the last two years.
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 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.
