How about this case?

[Versed0101]

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22 yo male non verbal with CP, seizures once a month and on a full load of meds. Plan on dental rehab, some restorative, a few teeth to take out, etc... nothing major.

Here are his meds:

Phenobarbitol 20 mg TID
Lamictal 200mg TID
Keppra 100mg
Zonegram 100mg
Xopenex
Diastat 15mg

Is this a hospital case or ASC. Mom wants me to do conscious sedation in my office but I said no. I am going to call my anesthesia group on Monday and wanted some input before I talk with them.

 

[Noyac]

Personally, I feel these are better cases for the hospital arena.

 

[Planktonmd]

22 yo male non verbal with CP, seizures once a month and on a full load of meds. Plan on dental rehab, some restorative, a few teeth to take out, etc... nothing major.

Here are his meds:

Phenobarbitol 20 mg TID
Lamictal 200mg TID
Keppra 100mg
Zonegram 100mg
Xopenex
Diastat 15mg

Is this a hospital case or ASC. Mom wants me to do conscious sedation in my office but I said no. I am going to call my anesthesia group on Monday and wanted some input before I talk with them.

So this patient is on 5 different anticonvulsants and possibly has asthma.
On the other hand from your description: his seizures seem to be well controlled, and since you did not mention anything about a respiratory problem other than him being on Xopenex, I am going to assume that his asthma is well controlled as well.
So, why not, I am going to make Jet happy and say let's do it at the ASC.

 

[jetproppilot]

So this patient is on 5 different anticonvulsants and possibly has asthma.
On the other hand from your description: his seizures seem to be well controlled, and since you did not mention anything about a respiratory problem other than him being on Xopenex, I am going to assume that his asthma is well controlled as well.
So, why not, I am going to make Jet happy and say let's do it at the ASC.

Touche.

 

[Frank Rizzo]

non-verbal 22 yo male with CP, and crazy ****** strength, for dental rehab? F uck conscious sedeation. They go to sleep at the hospital.

 

[proman]

I'd say ASC, just may need to be watched a bit longer. Won't take much sevo to keep him still.

 

[drmwvr]

Won't take much sevo to keep him still.

Famous last words.

 

[Trisomy13]

non-verbal 22 yo male with CP, and crazy ****** strength, for dental rehab? F uck conscious sedeation. They go to sleep at the hospital.

as much as i enjoy the phrase "crazy ****** strength", remember that CP typically does not affect intelligence. not to say you can't have a dual diagnosis of MR and CP, but it's not the rule.

 

[proman]

Famous last words.

There's always more. And we always win.

 

[zippy2u]

Hold up Skippy... a little birdie just flew in the window and told me the dude's medicaid. We don't do medicaid at the ASC. Look at this way, dude didn't have to walk very far to get back out through the in door---got a cash register 3 feet from front door that plainly states no medicaid pts accepted. Next!! ---Regards, ---Zippy

 

[Planktonmd]

Hold up Skippy... a little birdie just flew in the window and told me the dude's medicaid. We don't do medicaid at the ASC. Look at this way, dude didn't have to walk very far to get back out through the in door---got a cash register 3 feet from front door that plainly states no medicaid pts accepted. Next!! ---Regards, ---Zippy

Excellent point Zippy 😀

 

[huktonfonix]

Hold up Skippy... a little birdie just flew in the window and told me the dude's medicaid. We don't do medicaid at the ASC. Look at this way, dude didn't have to walk very far to get back out through the in door---got a cash register 3 feet from front door that plainly states no medicaid pts accepted. Next!! ---Regards, ---Zippy

DAMMIT zippy, you almost made me choke on my drink.....funny as hell though

 

[huktonfonix]

as much as i enjoy the phrase "crazy ****** strength", remember that CP typically does not affect intelligence. not to say you can't have a dual diagnosis of MR and CP, but it's not the rule.

Yes, but non verbal and seizure disorder kinda adds up to a non favorable picture. higher probability of MR and poor cooperation.

 

[pgg]

as much as i enjoy the phrase "crazy ****** strength", remember that CP typically does not affect intelligence. not to say you can't have a dual diagnosis of MR and CP, but it's not the rule.

If this 22 year old had normal intelligence, he wouldn't need general anesthesia for dental work that is described as "nothing major" ... he'd sit still in the office, get local, and suck it up like the rest of us. 🙂

As one of my attendings used to put it, kids/adults who need GA for dental work usually fall into one of two categories: gorked or naughty. Neither type does well with conscious sedation (as the OP already rejected) and as for general anesthesia, my limited experience with these guys is that the near-obligatory premed and longer PACU stays aren't really optimal for an ASC where the goal is efficiency and fasttracking.

 

[zippy2u]

Ah right, the dude can get done at the ASC if 2 conditions are met: 1.) 5 benjamins float across my cherry desk. 2.) If IV access can be obtained in the holding area without causing harm to himself or others--he gets an IV induction in the OR. The IM dart induction game gets played at the hospital. Regards, ----Zip

 

[Noyac]

Ah right, the dude can get done at the ASC if 2 conditions are met: 1.) 5 benjamins float across my cherry desk. 2.) If IV access can be obtained in the holding area without causing harm to himself or others--he gets an IV induction in the OR. The IM dart induction game gets played at the hospital. Regards, ----Zip

Yep, everything sort of depends on the pt. If I had questions about this then it goes to the hospital from the start in order to avoid cancellations b/c "things were not as they were suspected". If the pt has a high likelyhood of accepting anesthesia then possibly an ASC case but cancellations are a hassle for everyone. I do my best to avoid them.

 

[urge]

Ah right, the dude can get done at the ASC if 2 conditions are met: 1.) 5 benjamins float across my cherry desk. 2.) If IV access can be obtained in the holding area without causing harm to himself or others--he gets an IV induction in the OR. The IM dart induction game gets played at the hospital. Regards, ----Zip

Assuming you cannot get the iv in holding, do you get to keep the 5 benjamins?

When I had my wisdom teeth taken out the dentist charged my mom $500 for conscious sedation. He game me pill. I assume it was xanax- maybe horse strengh- and that was it. No IV, no pulse ox, no nasal cannula. $500 for popping a pill. For all your troubles Zippy I think 20 benjamins should be involved.

 

[zippy2u]

5 benjamins go back the pts way if IV access is not obtained. I'm no crook! Regards, ---Zip

 

[Versed0101]

Assuming you cannot get the iv in holding, do you get to keep the 5 benjamins?

When I had my wisdom teeth taken out the dentist charged my mom $500 for conscious sedation. He game me pill. I assume it was xanax- maybe horse strengh- and that was it. No IV, no pulse ox, no nasal cannula. $500 for popping a pill. For all your troubles Zippy I think 20 benjamins should be involved.

Urge,

You probably went to one of those "Sleep Dentists" who took a weekend hotel course to do "enteral" conscious sedation. These guys are taught to "titrate" halcion in .125mg doses until the patient is "sedated". I liken that to my daughter "titrating" her chocolate milk with blocks of chocolate. I think it's a sham. In Texas if your DDS were doing this type of sedation, the minimum would be NIBP and pulse ox.

We don't even charge 500 for IV conscious sedation.

 

[Muadib]

As one of my attendings used to put it, kids/adults who need GA for dental work usually fall into one of two categories: gorked or naughty. Neither type does well with conscious sedation (as the OP already rejected) and as for general anesthesia, my limited experience with these guys is that the near-obligatory premed and longer PACU stays aren't really optimal for an ASC where the goal is efficiency and fasttracking.

and what if he's gorked AND naighty with "crazy ****** strength"? dude he could snap your neck. def the kid gets a general at the hospital. k-dart if he wont sit still for the iv.

 

[jennyboo]

The way I see it, if the patient would not be able to cooperate with any procedure awake, sedation will be trouble -- as you will have a noncooperative patient who is also disinhibited. Whoops.

So, general anesthesia it is. Doesn't matter where it's done (hospital or ASC) -- the patient ought to still be able to go home the same day.