A DOCS Education member writes:
My 41-year-old patient is a nonsmoker. She reports a 10-year history with a disorder I haven’t heard of: regional systemic dystrophy. She describes this condition as accompanied by near-constant pain migrating to different parts of her body.
She sucks on fentanyl lollipops (Actiqâ„¢) and continually wears duragesic patches. She states she takes dilaudid about twice a month. She also takes Lyricaâ„¢ (as an analgesic), Cymbaltaâ„¢, amitriptyline, depakote and Allegra-Dâ„¢.
Known drug allergies are vicodin and percocet. While she was diagnosed in the past with asthma, she says she hasn’t suffered an attack in many years. For what it’s worth, her doctor faxed me that there are no precautions or recommendations needed in regard to this patient. She has multiple teeth which are broken down, perhaps partially as a result of the fentanyl lollipops.
I plan on conducting a test sedation to last around 90 minutes and perform a root canal on an anterior tooth and evaluate her response to the IV midazolam.
From looking at her and speaking with her, you wouldn’t know she was on so many psychoactive medications.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
I have not heard of the disease you listed, either. Is it possible she has reflex sympathetic dystrophy? RSD is characterized by pain, swelling and vasomotor changes in a specific area, usually the limb. It’s often the result of trauma to that limb. The pain is localized and doesn’t travel.
RSD is indeed treated with narcotics (in her case apparently fentanyl, duragesic and dilaudid) and neuroleptics such as Lyricaâ„¢, Cymbaltaâ„¢, amitriptyline and depakote.
As you know, patients on multiple narcotics and neuroleptics are always complicated sedation cases.
DOCS Education member responds:
I'm sure she listed the disease as regional systemic dystrophy. Her companion of 15 years agreed that it travels. That being said, I’m sure you are correct Dr. Fang because of the medication match and your own extensive knowledge.
P.S. I am confident in my monitoring because I always monitor CO2-ET. I will tread slowly.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
I agree that careful monitoring is indeed the key.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
I would not use any oral premedication the night before with this patient. I would use .025 mg triazolam one hour before the appointment. I would consider another dose of oral sedation at presentation if the patient, as expected, is showing few signs of sedation. The reason for the oral sedation prior to the IV sedation is to lengthen the duration of action of the IV midazolam in a patient who is most likely to hyporespond. I would also consider a single dose of hydroxyzine.
Titrate to effect with IV midazolam. Obviously, the patient should be able to tolerate IV fentanyl as well for analgesia, but she’ll likely need larger than average doses.
In addition to monitoring your patient carefully, use local anesthetic judiciously due to the elavil.
I would run D5W fluids, and still watch for signs of hypoglycemia in this patient as she appears to have a high daily intake of sugar.
Obviously the patient has her own post-operative analgesics. However, caution the patient and her companion about use of these on the day of the sedation appointment.
This is indeed a patient who is a much better candidate for IV sedation.
DOCS Education member responds:
Thank you both, Dr. Feck and Dr.Fang. for your insights. One final question: How much of an effect do the TC antidepressants typically have on administered epinephrine?
Dr. John Hexem, a member of the DOCS Education faculty, responds:
The current name for her problem is complex regional pain syndrome. The Lyricaâ„¢, amitriptyline, dilaudid and fentanyl address the perpiheral and central components of that syndrome, though it is a little odd to be on both Cymbaltaâ„¢ and amitriptyline.
The woman is already narcotic-tolerant and may require two to three times the usual doses of narcotics to achieve the same effect. There may be cross-tolerances to benzodiazepines as well. So I echo that IV sedation is a good plan. Is there a family history of alcoholism or addiction? While actually rare, addiction in chronic pain patients on narcotics does happen. This would be manifest during your sedation as combativeness. From your description of her demeanor I doubt this will be a problem. Fentanyl patches are used in patients who do not tolerate the GI and prutitic effects of p.o. short-acting narcotics like vicodin and percocet. Let us know how it turns out. Some p.o. clonidine is an efficacious premedication for these patients.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
The local anesthetic with vasoconstrictor in patients taking TCAs will cause a transient increase in heart rate. I've seen blood pressure rise as well. The degree to which this effect occurs is related to concentration, volume and speed of administration of the vasoconstrictor. Certainly intravascular injections and the patient's cardiovascular heart condition must also be taken into consideration.
If the LA with vasoconstrictor is administered slowly, in judicious amounts, and the patient is carefully monitored, where the patient is ASA I or ASA II with controlled cardiovascular disease, then the procedure can be performed safely.
