Do you proceed with oral conscious sedation when a patient tells you she had to be intubated while having her wisdom teeth removed under IV sedation? What do the experts recommend?
A DOCS Education Member inquires:
A 43-year-old female patient presented with severe dental anxiety. She has a history of chemotherapy and radiation, as well as gallbladder and appendix surgery. She also has a history of scarlet fever. She is on Vicodin® and clindamycin for a dental abscess; otherwise she is taking no medication. She is allergic to phenothiazines.
She reported that many years ago when she had IV sedation for wisdom teeth removal, she woke up intubated for five minutes. She has since had anesthesia for surgeries and has taken Valium®.
My plan is 10 mg diazepam the night before treatment; 0.375 mg triazolam one hour prior to treatment and nitrous as needed.
Should I be concerned due to her reaction to the IV sedation when her wisdom teeth were removed?
Dr. Jerome Wellbrock, DOCS Education faculty member, responds:
Why was she intubated? Over sedated? Allergic reaction? Why the chemotherapy and radiation?
It would be helpful to have more information from your sedation workup, i.e. height, weight, BMI, HR, BP, pulse ox, tobacco use, any other meds (either Rx or OTC); sleep habits, snoring, OSA? Mallampati classification, ASA classification? What dental treatment is planned? Extraction—simple or surgical? Any other dental care? Expected length of time for care?
All of this is important when deciding on your sedation protocol.
DOCS Education Member follows up:
The patient was intubated due to an allergic reaction and her throat started to close. She reports that after epinephrine and Benadryl® she was fine, and that they are not sure what it was due to—possibly local anesthetic. However, she has had local anesthesia since for stitches, an epidural and IV sedation since.
She had chemo and radiation due to breast cancer, which is now in remission.
BP 121/88, Mallapati class IV. She does not use tobacco or take any other medications. The planned treatment is a root canal or extraction for #13 depending on the restorability of the tooth, as well as a comprehensive exam treatment; time about 1.5-2 hours.
Dr. Wellbrock advises:
At this point, I would not sedate this patient until you have detailed information on her allergic response during the previous event. If you do not get a definitive answer, then allergy testing may be warranted. You would not want to have a serious, life-threatening event dealing with her airway.
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.
