A DOCS Education member writes:
Am I undersedating? That's my question and I would welcome your advice. The following are some recent examples of sedation appointments in my office.
An 18-year-old female indicated that she had an anxiety disorder but was otherwise in good health. The night before the sedation appointment the woman took 5 mg diazepam, and she followed this with 0.25 mg triazolam at 7 a.m. the next morning. The patient arrived at the office at 8 a.m. After an assessment at 8:15 a.m. she received 0.5 mg triazolam sublingually.
Because the patient appeared very comfortable I started treatment at 9 a.m. However, she cried when I placed a mirror in her mouth; during local and again once she heard the hand piece. I quickly put equipment down and retreated to a corner of the operatory. The woman then turned over and appeared to be asleep.
Restorative work and hygiene were completed around noon. The pattern exhibited by the woman throughout the appointment was periods of restfulness and/or sleep followed by arousal and crying. These emotional outbursts did not appear to result from anything we were doing. Tears streamed down her face even at the end of the appointment. When we spoke with the woman the next day she reported feeling "in and out" during treatment. She said she was aware of her surroundings but experienced no pain. She said the next time she would consider being "totally out."
Recently I sedated another patient who was not on any medications. This 32-year-old man took 10 mg diazepam the night before his appointment and 0.25 mg triazolam at 7 a.m. the next morning. We assessed him at 8 a.m. and gave him 0.5 mg triazolam SL. By 9 a.m. the patient seemed ready and we administered nitrous oxide as needed for local. The man seemed to be resting comfortably during the appointment. However at a follow up call the next day he said he remembered everything and everything went well. He would recommend oral sedation to others but wasn't sure that he would choose this option again himself.
Finally, we sedated another young man with lorazepam (triazolam wasn't available during a shortage in Canada). This 19-year-old patient was seriously fighting the sedation. He took 10 mg diazepam the night before; 2 mg lorazepam at 7 a.m. and 2 mg lorazepam SL at 8 a.m. He was still wide awake at 8:30 a.m. when we administered another 2 mg of lorazepam and at 9 a.m. when we gave him another 3 mg lorazepam SL. He was finally comfortable and ready for treatment at 9:15 a.m. However, it was a shorter appointment and be vomited in the car on the way home.
Based on these experiences do you think I am undersedating? I understand we don't wish patients to sleep (which seemed to be the case with the young woman, between the bouts of tears).
Dr. Anthony Feck, Dean of DOCS Education Faculty responds:
My impression is that yes, you have a tendency to undersedate. While this is certainly better than oversedating it does lend itself to challenging appointments.
Think of the patient's CNS depression in terms of different planes. In one the patient is neither stimulated nor threatened. In the other you stimulate them with touch or feel in a threatening environment. This speaks to the changing plasma concentration required for effective sedation. I speak of this frequently in the DOCS Education seminars. It explains how a patient can actually become more sedated at home after the appointment.
We need to achieve a happy medium between these two planes. Even if the patient appears adequately sedated when not stimulated, they may need more medication to address their lessened level of CNS depression while treatment is occurring.
A few other points to consider:
- Patients with an underlying anxiety disorder will often act unusually.
- While patients often say they "remembered everything" this is highly unlikely, even if their level of sedation was light. They remember bits and pieces, but the amnesic effect of triazolam is quite significant and predictable. I will often respond by saying, "did you remember snoring"? This usually causes the patient to laugh and reply that apparently they didn't remember everything.
- By the way you describe them, it sounds as if you had three successful sedation experiences. The definition of a successful sedation appointment is twofold: the patient received the treatment they were appointed for, and they were safe and comfortable in the process.
