One-Drug Oral Sedation

Transcription

1 One-Drug Oral Sedation Triazolam (Halcion) Oral Sedation 0.25 mg. taken one hour before procedure. Dental patient so scared, she begins clonic activity immediately upon placing an IV needle and goes into cardiac arrest. A cardioinhibitory effect of stressinduced vasovagal reaction -- (bradycardia, hypotension, sinus arrest). Vasovagal reaction: A reflex of the involuntary nervous system that causes the heart to slow down (bradycardia) and that, at the same time, affects the nerves to the blood vessels in the legs permitting those vessels to dilate (widen). As a result the heart puts out less blood, the blood pressure drops, and what blood is circulating tends to go into the legs rather than to the head. The brain is deprived of oxygen and the fainting episode occurs. The vasovagal reaction is also called a vasovagal attack. The resultant fainting is synonymous with situational syncope, 1

2 Treatment: Start CPR, call seconds later, a normal sinus rhythm returned Oxygen administered Pt. had no memory of the event Had 3 brief periods of emesis 1 hr. later, procedure performed Next time, pt. pre-medicated the night before and 1 hr. before Prevention: Know the patient (2-4% are really scared) Supine position Have a monitor available (pulse, BP) Administer oxygen Pre-medicate patients at risk EDs: Abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual s physical and mental health. Patients (on Coumadin) deemed appropriate to undergo treatment in a dental office should have an experience that minimizes stress and anxiety. Premedication with a shortacting benzodiazepine the night before the appointment and one hour before the appointment is appropriate. Supplementation with nitrous oxide oxygen inhalation also may be helpful but should be discussed with the patient s physician. Extrapolating the results of the survey of adults in Canada 400,000 people may not have visited the dentist last year due to fear or anxiety. More than 1.5 million may have cancelled or avoided an appointment sometime in their lives. 12.4% of those surveyed were definitely interested with another 42.3% interest if the cost were reasonable. 2

3 DOCS ad. Bottom Line with triazolam: 0.25 mg or 0.50 mg administered orally or sublingually one hour before the procedure will decrease: anxiety, the perception of pain, and postoperative recall of discomfort 0.25 mg. without significant adverse effects. Overdose symptoms develop with four times the maximum therapeutic dose (0.50 mg) or 2 mg. Case Report: Patient given twice the recommended amount. Case Report: Patient given twice the recommended amount. Triazolam Equivalency: From a DOCS brochure. Sonata: Non-benzodiazepine hypnotic from the pyrazolopyrimidine class. Vistaril: An antihistamine that also treats anxiety and tension mg triazolam with 40% nitrous oxide produced anxiety relief equal to 19.3 mg IV Diazepam. Kaufman, E, et al mg triazolam given orally 60 minutes prior to the procedure is equivalent to mg IV Valium for decreasing anxiety and producing amnesia. Baughman, VL, et al

4 Triazolam Characteristics: onset of hypnotic activity is in less than one hour the peak plasma level occurs between one and two hours return to normal psychomotor activity with 0.25 mg is about four hours there is a significant lack of respiratory depression or adverse cardiac effects Safety Precautions with triazolam: maintain and review a current health history use written informed consent during the procedure, check pulse, BP and oxygen saturation have a reversal agent (Romazicon) available use written postoperative instructions have them accompanied by a responsible adult before and after the procedure Recommend a higher quality brand for about $2000. A higher quality brand for about $2000. Pulse Oximeters: Starting at about $700. Pulse Oximeters: Starting at about $700. 4

5 Inherent Problems with triazolam: Contraindications: hypersensitivity to benzodiazepines; pregnancy; patients who are elderly (over 65) or debilitated; patients younger than 18, those who are suffering from depression, suicidal tendencies, or pulmonary insufficiency Dr. Silverman: DOCS educates dentists to judge if conscious sedation is appropriate for a patient, teaching them to include critical variables such as age, health history, and drug interactions to make an assessment. They also stress constant monitoring and never leaving a patient alone. Drug interactions: alcohol, nefazadine (Serzone), cimetidine (Tagamet) ulcer medication, and levodopa Parkinson disease medication. Dear Karl, It was a pleasure to see you and Niles in Arizona. I found a sedation course through Baylor University that costs a fraction of the DOCS course. Here is the link ($695). Thanks again for a great course and I look forward to hopefully seeing you again one of these days. Sincerely, Milad Bozorgnia Notes from Dr. Silverman s DOCS course, continued: Romazicon: 0.2mg (0.1mg/cc) initial dose ½ inch in tissue just off midline under tongue into venous plexus. 2 nd dose in 2-3 min. Can cause seizures (if on medications for seizures) or agitation. 10 cc max. Can have re-sedation. No smoking or caffeine 12 hrs. before Patient should always respond to verbal commands and physical stimuli. 5

6 Notes from Dr. Silverman s DOCS Course: Likes 6 hr. fast before appointment. Avoids erratic or incomplete absorption. Need to wake up more? Give some juice. Older person needs less medication. Contraindicatons: pregnancy, pt. who premeds with alcohol, erythromycin, Tagamet*, antacids, CNS depressants, AIDs patients on protease inhibitors, cyclosporin, grapefruit juice, St. John s Wort, anti-fungal meds patients under 18. faculty.washington.edu/quarn/ Sept/Oct 2004 Gen Dent Grenada 6