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I have a 45 year old male, 239 lbs. presents for exam and clearance prior to surgery to place an aortic mechanical valve. He requests sedation to allow treatment to be completed in one setting. Patient has moderate to advanced periodontal disease as well as several areas of decay that can be treated with composite restorations. Patient has Gitelman’s Syndrome which causes excess loss of magnesium and potassium as well as inadequate excretion of calcium from the kidneys, heart murmur since birth, and elevated cholesterol, portacath for biweekly infusions, does not smoke, no known allergies. Baseline pulse 94, O2 97%, BP 137/82. His meds are as follows: Mag-Oxide, Potassium Chloride, Amiloride, Inspra, Metoprolol, Lipitor, Cozar, and Magnesium infusions. In a medical consult his cardiologists nurse said he is OK for oral and/or IV sedation & did not have any contraindications. He would like us to just give him the Clindamycin IV day of apt. and follow with  PO Amoxil 2grams a day for about 4 days after the procedure. My initial thoughts for this patient was to treat him in a couple of unsedated appointments. Any input on this case would be appreciated.

Thx

Kevin Hayes D.M.D

Dear Kevin,

Thank you for yet another zebra of a case.  Gitelman's syndrome indeed!!!  I have 4 patients with this rare renal tubular disorder but none of them as profound as this case you are presenting.

Medical issues:

1.  Antibiotic prophylaxis is indeed necessary and antibiotic therapy after the procedure is dependent upon extent of bleeding and extent of pre-existing infection.  The regimen that he has listed is not unreasonable.  He has a portacath and obviously will need arrangement for the intravenous clindamycin made.

2.  Amoxicillin should be given as a 500 mg q6h regimen

3.  Based on the medication list, he has:

     a.  Hypertension

     b.  Hyperlipidemia

     c.  K depletion

     d.  Mg depletion

     e.  Obesity

4.  The K wasting and Mg wasting is very profound if he has to have intravenous repletion biweekly.   You absolutely have to be sure that you have a very recent K and Mg, Ca and Pi levels prior to any planned sedation.

5.  His weight is clearly going to pose airway concerns.

6.  I agree with you that you will have your hands full and it would be prudent to get to know the patient in one or two unsedated sessions before going on to doing extensive intervention under sedation.

 

Les

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lesfang

Kevin,

Thanks for the interesting case, and for doing your homework before presenting it.  It's also great to have a world-renown kidney specialist to lean on.

My two cents on the case is this: You've received advanced training. You can manage the patient's airway.  In a sick patient, I want an IV in and in nearly every case except the significant respiratory disease patient, the patient is better off sedated.

Go big blue,

Tony

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Anthony S. Feck, D.M.D.
Dean of Education, DOCS Education
Corporate Center Dental Care
Sunrise Dental Solutions
American Academy of Facial Esthetics

Les,

I hear a familiar Kenny Rogers song playing in the background!!  Unless I can grow a little more comfortable during these discussions, I will not sedate this nice zebra of a case.  It is still interesting (fun) to talk about just the same.  If you will indulge me a little further I'll expose my ignorance and maybe others can learn from my extended neck.

Can an IV sedation dentist be trained to use a portacath to inject medications?  Would I want to be if there was an indication?  Should I assume most of his veins are used up or are reserved for more serious medical procedures because he has a portacath?  What is the timing of the clindamycin if I can't deliver it iv or portacath prior to the appointment. 

 How "very recent" do you mean on the K, Mg,Ca,and Pi levels.  That day?  What are the ranges I'm looking for in a 1-2 hour treatment window?  Even if I don't sedate him these are all still very prudent questions aren't they?

 

You gotta know when to hold 'em..............

Thanx for the quick reply as always,

Kevin

Thanx Tony,

Great perspective.  You know, one of the most interesting things about this fellow is other than his weight is he has the look of a picture of health.  Some people just look sick and he doesn't.  I know as medical professionals continue to realize the need for good oral health to complement the healthy hearts we will seeing more and more patients seeking care prior to life saving medical interventions.

Go Big Blue Indeed,

Kevin

For you, Kenny seldom sings, since you have the training to get out of trouble.

1.  You can be trained to use the portacath since nurses can be trained to use the portacath.  Since this is a Lifeline, people do not like to have it used haphazardly.  If you are trained to so do, you would be able to use the portacath.

2.  If you are in trouble with the patient, you can violate the Lifeline.  However, you have to withdraw the heparin from the catheter prior to pushing anything in.  Otherwise, you will be pushing a big bolus of heparin into the patient.

3.  You can certainly start a peripheral line and treat this as an IV sedation case and leave the IV line alone.

4.  Clindamycin should be given at a dose of 600 mg IV or PO

5.  Labs done the week of or the week prior to planned procedure would be fine.

6.  K should be 4.0 to 4.5 mmol/dL

     Mg should be 2.5 to 3.0 mmol/dL

     Ca should be 8.5 to 10 mmol/dL

     Pi should be 4 to 4.5 mmol/L

 

 Les

 

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lesfang

The oral health aspect of this case is of critical importance since he will most likely have a prosthetic valve placement.  In this instance, it is almost like the oral management of the patient with head and neck cancer about to undergo radiation.  All questionable teeth ought to be removed and oral health should be optimized prior to the procedure since prosthetic valve endocarditis carries a 12-15% MORTALITY.

 

Les

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lesfang

Hello all,

 

Hello Kevin,

 

I have a few questions...

 

What is the patient's BMI?  If it is over 40 then he is automatically an ASA IV, and it would not be appropriate to do this case in a dental office on that note alone.

Do you have  the results of  the patient's airway evaluation?

Mallampati, thyromental distance and atlanto-occipatal joint measurements...

 

This is definitely a challenging case,. I agree that his dental needs need to be met prior to placement of the valve prosthesis.

 Please let us know how this turns out...

 

MM 

 

 

 

 

 

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Michael E. Mermigas, DDS, FAGD, RPh
Assistant Professor of Pharmacology/Toxicology
Director, Division of Continuing Dental Education
Duquesne University
Pittsburgh, PA

Hello indeed Dr M,

Hey, it's great to have you on board the forum!   I'm know your input will be exceptional and invaluable. 

We did go ahead and start this gentleman's treatment without conscious sedation but thanx for your input because that could change.  Here's most of what you asked for and a little more:

BMI-34, Class II Mallampati, Class III Mandible/thyromental, I haven't yet incorporated atlanto-occipital joint measurements into my airway evaluation, MIO of 46, no facial hair, a full set of teeth with slight mobility, normal neck mobility.

I'm working on a airway worksheet/form to standardize our airway evaluation on one sheet of paper.  Do you or anyone else out there have one they are already using?  "Hey man, just working on the systems" 

On a final note, it turns out that we had sedated this gentleman's spouse several times with great success and she wanted him to be sedated as well.  Upon final examination, we determined that we could provide multiple short appointments and he was just as happy with that approach.  Since his level of fear was not part of the equation the only disadvantage I saw in this approach was time and multiple antibiotic premedications.  What do you guys think?  Looks like the other card player blinked before I could fold.

Thanx again,

Kevin

 

Hey There Kevin,

 

Your approach sounds like a winner.  Actually it's probably  the textbook approach to handling such a patient. 

 

For pre-anesthetic evaluation, including airway, I use the AANA form.  After completing this form you will have very good documentation of the patients status and can assign an ASA class...

 I can email you a pdf of one or you can get it directly from the site  AANA.org

 

Take care,

 

Mike 

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Michael E. Mermigas, DDS, FAGD, RPh
Assistant Professor of Pharmacology/Toxicology
Director, Division of Continuing Dental Education
Duquesne University
Pittsburgh, PA