Patient Assessment and Preparation Flashcards

A patient presenting for oral surgery under deep sedation has a history of obstructive sleep apnea managed with CPAP at 10 cmH₂O. They arrive without their CPAP device. Which is the most appropriate course of action?

Answer: Reschedule the procedure until the patient can bring their CPAP device for potential intraoperative use

Patients with obstructive sleep apnea are at significantly elevated risk for airway obstruction and respiratory depression under deep sedation. The absence of their CPAP device — which may be needed during recovery — combined with the unpredictable airway dynamics of OSA patients under sedation warrants rescheduling. Proceeding without this critical device compromises patient safety, as even positioning and airway adjuncts cannot fully replicate CPAP-level airway support during deep sedation.

During pre-sedation assessment, a patient reports taking St. John's Wort daily for depression. Which specific concern should most influence your sedation plan?

Answer: Induction of CYP3A4 enzymes leading to significantly reduced midazolam efficacy

St. John's Wort is a potent inducer of CYP3A4, the primary enzyme responsible for metabolizing midazolam. Chronic use can reduce midazolam plasma concentrations by up to 50–60%, resulting in inadequate sedation depth despite standard dosing. While serotonin syndrome is a real concern with certain opioids and the herb does have mild antiplatelet effects, the most clinically significant and predictable concern for sedation planning is this enzyme induction effect on benzodiazepines.

A 68-year-old patient scheduled for sedation has a resting blood pressure of 162/94 mmHg at check-in, compared to their medical record baseline of 138/82 mmHg. They deny symptoms. Which response is most appropriate?

Answer: Delay the procedure for 15 minutes, recheck blood pressure, and consult with the treating dentist before proceeding

An acute elevation significantly above a patient's known baseline warrants a pause and recheck rather than immediate dismissal or immediate proceeding. A 15-minute recheck after allowing the patient to relax helps distinguish white-coat elevation from true uncontrolled hypertension. The treating dentist must make the final go/no-go decision. Sublingual nifedipine is contraindicated in this setting due to risk of precipitous hypotension and reflex tachycardia. Immediate cancellation without a recheck is overly conservative when symptoms are absent.

A patient with a history of malignant hyperthermia (MH) susceptibility confirmed by muscle biopsy is scheduled for IV sedation with midazolam and fentanyl. Which statement about this patient's management is correct?

Answer: IV sedation with midazolam and fentanyl can proceed safely, as neither agent is a known MH trigger

Malignant hyperthermia is triggered specifically by volatile halogenated inhalation anesthetics (e.g., sevoflurane, halothane) and succinylcholine. Neither midazolam, fentanyl, nor any other IV sedative/opioid is an MH trigger. Therefore, a well-planned IV sedation technique is not only acceptable but preferred in MH-susceptible patients — it avoids the triggering agents entirely. Dantrolene should be available in the facility but is not given prophylactically. Converting to inhalation anesthesia would be the opposite of the correct approach.

When evaluating a patient's airway using the Mallampati classification, a class III presentation is observed. In the context of sedation planning, this finding most specifically predicts:

Answer: A higher probability of difficult mask ventilation if rescue breathing becomes necessary

The Mallampati classification (Class I–IV) assesses the relative size of the tongue to the oropharyngeal space and is primarily used to predict difficulty with laryngoscopy and intubation. Critically for sedation assistants, a Class III or IV presentation also correlates with difficult bag-mask ventilation — meaning that if the patient becomes apneic or obstructed, manual rescue ventilation may be ineffective. This has direct implications for the sedation team's preparedness and escalation plan.

A patient taking warfarin for atrial fibrillation presents with an INR of 2.8 (therapeutic range 2.0–3.0) for a scheduled extraction under IV sedation. The patient's cardiologist has not been consulted. What is the most appropriate action regarding anticoagulation management?

Answer: Proceed without alteration, as the INR is within therapeutic range and bridging is not indicated for minor oral surgery in low-risk cardiac patients

Current evidence and guidelines support performing minor oral surgical procedures (including extractions) in anticoagulated patients whose INR is within therapeutic range (typically up to 3.5 for minor procedures) without altering warfarin therapy. The risk of thromboembolic events from stopping anticoagulation in an AF patient outweighs the manageable local bleeding risk, which can be controlled with local hemostatic measures. Bridging with LMWH is generally reserved for patients undergoing major surgery with high thrombotic risk, not for minor dental procedures with a therapeutic INR.