A member of DOCS Education asks:

Hello. I have a patient who was treated with oral conscious sedation in August of 2014. The dental treatment itself went well, with two extractions and bone grafting. The sedation portion however, was not as smooth. The patient expressed unusual amounts of emotional strain due to personal issues and requested more sedation. The protocol used was diazepam 5 mg the night before with triazolam the day of. To summarize: Diazepam 5 mg hs, then triazolam 0.25 mg one hour prior. At 1:55 p.m., additional traizolam 0.25 mg. At 2:29 p.m., additional 0.25 mg traizolam At 2:40 p.m., additional 0.25 mg triazolam. Nitrous used during bouts of high stress. The patient feels that her pain was controlled very well during treatment and after; however, her anxiety was still very high and she remembers everything. We were hoping for more of an amnesic effect. She does not want to go to the trouble of IV sedation and would like to try the oral sedation again, so we are attempting another procedure. Would the lorazepam protocol be more effective for this patient, especially since the next procedures will result in a longer appointment? Her treatment plan includes veneers, crowns and extractions on #18, 31 with possible implant placement at #3, 14. It's a great treatment plan that I look forward to doing, but it is pretty big one that will take a decent amount of time. Any suggestions you can provide will be greatly appreciated. Thank you.

Dr. Jerome Wellbrock, DOCS Education faculty, responds:

Triazolam typically would have the best amnesic effect. You could use a larger dose of diazepam the night before and start with 0.5 mg as your first dose at the office if her level of sedation seemed inadequate. The addition of hydroxyzine to your protocol could also prove to be very helpful. Take another look at the patient's BMI, height and weight. You've already mentioned a high level of anxiety, which may have affected the sedation outcome. Also take note of any medications or herbals, tobacco habit, sugar intake—all which can affect your sedation.

Dr. Anthony Feck, DOCS Education faculty, adds:

Your patient was under sedated, and while it is very likely she remembers some things, it's doubtful that she remembers everything like she states. If she was anxious during the appointment, why didn't you give her more medication? Was it because you had reached her TOP Dose? Lorazepam is not a more efficacious sedative than triazolam, so that is not the answer. The answer is in giving the patient the appropriate dose of medication at appropriate intervals. If she is not comfortable and you have not reached TOP Dose, then give your patient more, monitoring her level of consciousness appropriately. If you have reached TOP Dose and she is still not comfortable, then your patient needs IV sedation.

The member replies:

The patient weighs 155 lb, making the TOP dose for the triazolam 1.55 mg. While we did not exceed the TOP does, we were not far off at 1.25 mg. She is a half a pack a day smoker, so that does have bearing. I am thinking her sugar intake is probably high, which you mentioned—all will have to be taken into account. I will make adjustments for her second appointment. Thank you for the feedback.

Disclaimer

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.

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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 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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