A member of DOCS Education writes:
I’ve taken several DOCS Education courses in recent years including the ACLS training. So far I’ve performed around 26 cases, but I’m not sure whether this one is over my head or not. Here are the details. The patient is 64 and requires two crowns in addition to some fillings. His blood pressure is 128/60, heart rate 60 and oxygen saturation 96 percent. He had bypass surgery in 2009 and presently uses a CPAP machine on account of a diagnosis of sleep apnea.
The patient takes the following medications: amlodipine, atorvastatin, lisinopril, furosemide and carvedilol, plus aspirin.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
Whether you are in over your head or not depends upon the patient's ASA classification, and your level of training and/or experience. Occasionally, guidelines established by regulatory agencies governing how you practice may factor into the equation as well.
Our gateway or level one course trains dentists to treat patients who are ASA I and ASA II. Sedation Solutions is meant to expand the patient population the dentist can treat to include those who are classified as ASA III.
Before we can determine the patient's ASA classification and medical risk, we need more information. What is the patient's BMI? When was the date of the patient's last physical evaluation? What were the findings noted after that evaluation?
DOCS Education member replies:
His last physical exam took place in October, and the following problems were noted:
- Ischemic cardiomyopathy
- Remote anterior myocardial infarction (2009)
- History of coronary bypass surgery
- Mild chronic renal insufficiency
- Hypertension
- Obstructive sleep apnea
- Dyslipidemia
- Morbid obesity
The physician also gave this assessment: Patient takes Simvastatin™ and amlodipine. However, he tolerates this combination without side effects. We’ll continue this combination with an upcoming surveillance of a fasting Chem-12 and lipid profile. The patient is currently asymptomatic from a cardiac standpoint but remains morbidly obese. His blood pressure is at goal.
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
You’ve clearly done your homework. This is a concise but comprehensive look at the patient’s medical situation.
The patient satisfies the definition of ASA III in that he has severe systemic disease that may not be incapacitating but nevertheless limits activity. Because his medical condition doesn’t appear to represent an ongoing threat to his life (and thus placing him the category of ASA IV), he isn’t automatically eliminated as a prospect for outpatient sedation.
Although the patient's condition appears stable, the obesity and airway compromise render him a high risk for the low-oxygen tension potential posed by sedation, not to mention the physiological and psychological stress made possible by dental procedures.
You should have advanced sedation training before treating this patient.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
Neither the cardiac bypass in 2009 nor the possibility of drug interactions worry me. I am far more concerned about the fact he has sleep apnea. This largely predicts that the patients will hypoventilate when sedated and desaturate. In Sedation Solutions, Dr. Feck lectures on how to care for patients with sleep apnea, including how to evaluate and sedate them. I would not treat this patient without this expertise.
DOCS Education member replies:
Thank you. I will not sedate this case and instead offer the patient alternatives.
