A member of DOCS Education writes:
A 72-year-old male presents with a history of arthritis, high blood pressure and sleep apnea, as well as recurrent back and neck pain from an injury. The primary care physician "sees no reason" to avoid conscious sedation. The patient’s pain control doctor and dermatologist both deferred to the primary care physician for recommendations. The patient is extremely anxious. He is taking following medications:
- Percocet™ 10/325 tid
- Losartan and hydrochlorothiazide 100/12.5 once daily
- Omeprazole 20 mg bid
- Lovasatin 40 mg once daily
- Cyclobenzaprine 10 mg PRN
- Orphenadrine citrate 100 mg
- Lycopen
- Saw palmetto
- Fluticasone
- Green tea
- Grape seed
The patient also had a spinal injection in 2009 for back pain. His baseline pulse is 80; SpO2, 97 percent; BP, 29/73; and preop respiration rate, 13 breaths/min.
The patient states that he had IV sedation twice in the recent past for extractions and desires conscious sedation for the removal of five teeth. I recently completed DOCS Education’s Sedation Solutions course, and I feel this patient is outside the parameters of my certification. The patient, however, strongly feels he is not, especially with the approval from his primary care physician. Please advise me at your earliest convenience as he is now on antibiotics for dental infections.
Dr. Lesley Fang, Medical Director of DOCS Education Faculty, responds:
As I said in SS, I cannot make up some of the cases you guys are asked to see if I tried!
This is clearly a tough case:
- Age 72 – Obviously limits the amount of drugs we can use
- Sleep apnea – sleep apnea is a diagnosis governed by the number of periods of apnea (not hypopnea). It is like pregnancy: there is no such thing as "a little pregnant." He either has it or doesn't. Even mild sleep apnea, by our convention, can be problematic with desaturation.
- High-dose narcotic
- Muscular issues on muscle relaxants
Dr. Anthony Feck, Dean of DOCS Education Faculty, adds:
You have to draw a line somewhere.
We all have a line we should not cross when it comes to sedating patients. You have indicated that this patient is outside your certification. That should be enough for you to decline this patient. It doesn't matter that the primary care physician and the patient think otherwise.
I support your intuition in this matter. The regrets associated with an untoward event are greater than those associated with not treating the patient.
This patient has chronic pain coupled with severe anxiety. This means he requires higher than average doses with all other things considered equal. You don't indicate this, but I wouldn't be surprised if he had a high percentage of body fat.
At the same time this is an elderly patient with untreated sleep apnea taking a muscle relaxant. This means he is more sensitive and prone to the untoward effects of over-sedation.
In my practice I wouldn’t treat this patient until the sleep apnea is successfully treated. Even then I would only allow this patient a short appointment, titrated with an IV to the lowest effective dose of a short-acting sedative. I would also have airways handy and would not leave this patient's side, because this patient is very close to being on the wrong side of my own line.