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Dental Anesthesia

IV Sedation Ineffective

05/05/2010

Question:

Historically avoided much dental care due to dental needle phobia (vaso vagal). Researched and found highly published Periodontist (have learned that was not the most salient characteristic for which to look). In August 2010, had an extraction and 3 bone graphs, upperleft under IV sedation (Versed). No problems except an itchy nose. Local anesthetic and Versed wore off completely within an hour to everyone`s amazement. October 2010, had an extraction and 5 bone graphs, upper right. IV Sedation (Versed). Became fully conscious at moment of 1st intra oral injection; extreme panic, blood pressure spiked to 152/117 (normally about 112/70). Nurse Anesth. made dentist stop. I don`t remember the rest, but surgery eventually completed. Again, itching and rapid wearing off of both local and IV sedation. April 26th, 2010 Phobia at epic proportions. Scheduled for root canal, upper right, 2 implants upper right and upper left, each. Valium one hour before surgery - mello. Started Versed and immediately started intra oraql injection. Panic. Versed had very little effect. Fully conscious for all other injections, drilling, suturing. Arms are velcroed down. Total freak out. No anestesia. Total recall of entire process, conversations. Nurse Anesth has acknowledged problem; never seen before, "we need to figure out what happened". I feel like a war survivor. Taking no weird meds; none different any of the three times. Have had Versed three times before , over a seven year period for ortho surgery and colonoscopy, although w/Ketamine. Never had any problems what so ever. Also, Nitrous has always worked in the past, but has very little effect for me now. Can my level of anxiety be causing all of this? Do I need to see a physician or have an Anesthesia consult? Could the dentist have gotten a bad or expired lot of Versed? I am suppose to go back in 10 days and I can not until this is resolved and I find some help. Oh, the rest of my life is normal, fun, professional, active...

Answer:

Thank you for your question. I do not have your age, medical history, medications, allergies/adverse drug reactions etc that may have an impact on my understanding of the cause of your events. I will assume you are healthy and middle aged. I can, then, give you some general information.

 

 Moderate (conscious) sedation is not always effective for oral or other surgery. The intensity and duration of effect is highly variable and affected by patient fear and anxiety. Your history is not unusual and it is not your fault that the sedation is not working well. Your other sedations with Versed and Ketamine are what are called "deep sedation" and it appears that you need this deeper level of sedation or general anesthesia, which can be done intravenously and without a breathing tube, such as in the dental office. In most states, if a true nurse anesthetist is supervised by a dentist, they may only provide sedation (or general anesthesia) to the level of training of the dentist. Thus, if your periodontist has an IV conscious sedation permit from the dental board, this is the level of sedation that the nurse can be provide. This makes sense since the dentist is supervising the nurse's sedation and can not supervise a level of anesthesia that he or she is not licensed to provide. I said "true nurse anesthetist" as in many dental offices, dental assistants assist the dentist with sedation. The nurse anesthetist, as opposed to the dental assistant, is usually very highly trained.

 

However, you do have some options. You can have a dentist anesthesiologist come to your doctor's office and provide either deep sedation or general anesthesia, which sounds best. Alternatively, you may need a different set of medications, such as IV Valium rather than Versed, or a combination, based on your mellowness with Valium. There are also other medication choices. Still, with your level of anxiety and short lived local anesthesia, having a separate anesthesiologist who can control your blood pressure and heart rate if needed, as well as provide for an adequate depth of anesthesia sounds best. You may locate a dentist anesthesiologist at www.asdahq.org<http://www.asdahq.org> Good luck.

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Response by:

Steven I Ganzberg, SB, DMD, MS Steven I Ganzberg, SB, DMD, MS
Formerly, Clinical Professor of Dentistry
College of Dentistry
The Ohio State University