The woman suffers from a rare congenital abnormality called Wolff-Parkinson-White Syndrome. The syndrome is associated with supraventricular tachycardia (SVT). SVT is a general term referring to any rapid heart rhythm originating above the ventricular tissue. Under what conditions can she be treated for multiple restorations with sedation? A DOCS Education member writes:
My patient requires multiple restorations. She’s 42 and weighs 110 pounds. A one-pack-a-day smoker, the woman suffers from panic attacks and chronic back pain resulting from two auto accidents. She has also been diagnosed with Wolff-Parkinson-White Syndrome.
Current medications include 5 mg Ativan™ and 10 mg methodone (twice a day). Once a week she takes multivitamins and milk thistle. Her baseline vitals were pulse 62 bpm; oxygen saturation 97 percent and blood pressure 117/65. Obviously I’m concerned about possible arrhythmias and tachycardias.
Here’s my question: Should we rule out oral sedation or continue to obtain medical consults?
Dr. Anthony Feck, Dean of DOCS Education faculty responds:
Given that there is an X interaction according to Lexi-Comp with the sedation medications in the DOCS protocol, and that interaction involves substantial additive CNS depression, I recommend a sedation protocol that allows for titration of medications, i.e., IV sedation.
Dr. Leslie Fang, a member of the DOCS Education faculty, responds:
Wolff-Parkinson-White Syndrome is a congenital anomaly in which a re-entry circuit promotes supraventricular tachycardia. This is characterized on an electrocardiogram by a short PR interval and an early shoulder on the QRS complex signally pre-excitation. Patients with WPW can certainly go into tachyarrhythmias at rates >150 beats per minute.
The syndrome can produce results ranging from an electrocardiographic finding with no SVT to frequent and symptomatic SVT. In patients with frequent and symptomatic SVT, we almost always would go in and ablate the accessory pathway to stop the SVT.
This patient doesn’t appear to be taking any medication for WPW. I would think that means she either has very infrequent SVTs or has already been ablated.
From a sedation standpoint, your patient takes significant doses of Ativan™ on a standing order TID as well as methadone, both of which will need attention for sedation. I am less concerned about the WPW, albeit that syndrome creates an interesting issue.
