Patient's Query
Hello doctor,
I am a 79-year-old male in good health, aside from hypothyroidism, for which I have been taking bioidentical T3 and T4 for the past 18 years. I am 5 feet 10 inches tall and weigh 165 pounds. My blood pressure and pulse rate are in the low-normal range, and my oxygen saturation is consistently near maximum. I am scheduled to undergo all-on-four maxillary and mandibular implant surgery to replace all my teeth due to extensive bone loss.
The prescribed twilight sedation includes Propofol, Fentanyl, Precedex, and Versed. Based on my research and consultation with my general practitioner, this combination appears to be excessive and potentially risky. Additionally, if deep maxillary implantation is required, there is a possibility that I will need to be intubated and placed under general anesthesia. I would appreciate an opinion on the safety and appropriateness of this anesthetic plan.
Please help.
Hello,
Welcome to icliniq.com.
I understand your concern.
First of all, thank you for your detailed notes. I will walk you through this carefully because your concerns are valid.
The planned sedation regimen: The combination of drugs that you mentioned is given for deep sedation, but it is quite aggressive in elderly and hypothyroid patients, as they may have deranged sensitivity to anesthetic drugs.
General anesthesia with intubation is preferred over deep sedation in this case, provided preoperative evaluation and close monitoring are done. An anesthetist may prefer (Propofol and Fentanyl ) or (Propofol and low-dose Midazolam ) for most dental implant surgeries.
What you can do:
Talk to your dentist and anesthetist.
Ask for a preoperative evaluation with an anesthetist.
If deep maxillary implants are likely to require general anesthesia with intubation, you should ask:
Will this be done by an anesthesiologist, not just a sedation-trained dentist?
Will there be full monitoring and immediate airway control?
What is the expected length of the procedure?
I hope this helps.
Kindly follow up if you have more concerns.
Patient's Query
Hello doctor,
Thank you so much for your detailed reply. Your point regarding the thyroid issue is especially salient, as it appears to have been completely overlooked. I am currently preparing a request for a preoperative evaluation by the anesthesiologist and would appreciate your further input.
Based on your statement, "General anesthesia is preferred with intubation rather than deep sedation in this case, provided preoperative evaluation and close monitoring are done." I realize I may not have been entirely clear about the treatment plan. What I was told (though only verbally) is that the four drugs, propofol, fentanyl, Precedex, and Versed, would be administered for “twilight sleep,” which I understand to mean light sedation. Intubation and general anesthesia would only be used if deep implant placement beyond the maxilla is required, which will not be known until the time of surgery.
I do not tolerate medications well and have multiple allergies, including gluten, dairy, eggs, citrus, and cashews. The prospect of receiving a cocktail of unfamiliar drugs with unclear interactions is of great concern to me. I have also conducted some online research, initially prompted by the response I received from Google AI—which supports my concern. I quote below from that response:
Combined use of propofol, Precedex, fentanyl, and Versed for twilight sedation is generally avoided due to the significant risk of respiratory depression.”
Why the combination is concerning:
Synergistic effects: These drugs, when combined, may have an additive or even multiplicative effect, leading to deeper sedation and a significantly increased risk of respiratory depression.
Increased risk of adverse effects: This combination is associated with a higher risk of serious complications, including hypoxia, hemodynamic instability, and respiratory suppression.
Difficult to reverse: If an adverse reaction occurs, managing and reversing the effects of multiple sedatives can be challenging, increasing patient risk.
Generally, it is recommended to use fewer agents or to carefully titrate doses when multiple sedatives are required. For example, one study suggested that combining midazolam, propofol, and fentanyl for colonoscopy sedation may reduce the total amount of propofol needed and improve patient satisfaction compared to using fentanyl and propofol alone. However, this combination still carries risks and requires close monitoring.
Another study evaluated the use of Dexmedetomidine (Precedex) with Propofol for monitored anesthesia care in high-risk patients undergoing certain surgeries. Although Precedex offered some benefits, such as reduced need for additional sedatives and minimal respiratory depression, it was also associated with a higher incidence of adverse cardiovascular effects like bradycardia and hypotension, particularly during loading doses.
In summary, while the combination of Propofol, Fentanyl, and Midazolam (Versed) is established in certain sedation protocols, the addition of Precedex introduces further complexity and potential risk. There is limited research on the safety and efficacy of using all four medications together for twilight sedation.
Given the potential for additive adverse effects and limited reversibility, this approach should be undertaken only with comprehensive preoperative evaluation and meticulous intraoperative monitoring by experienced anesthesia providers.
Please help.
Hello,
Welcome to icliniq.com.
I understand your concern.
Thank you for such an extremely thoughtful and well-researched response.
Hemodynamic instability, respiratory depression, and difficulty in reversal are valid concerns. The safest approach for you may be full general anesthesia, counterintuitive but important.
In full general anesthesia, you have a controlled airway (intubation), controlled ventilation, a predictable depth of anesthesia, and continuous anesthesiologist presence. From your detailed description of your condition, including your allergies and unpredictable response to drugs, I would advise you to get a full anesthesiology consultation, not just routine pre-operation.
Complete review of allergy history.
Trial of any new medications beforehand, if possible (e.g., dexmedetomidine) in a monitored setting.
Baseline cardiac evaluation (ECG (electrocardiogram), if any bradycardia or arrhythmias are suspected).
Consider alternative sedation protocols with fewer agents, such as:
Propofol and Remifentanil (short-acting opioids).
Dexmedetomidine alone (if light sedation is sufficient).
Total intravenous anesthesia (TIVA) with controlled airway.
I hope this helps.
Kindly follow up if you have more concerns.
Patient's Query
Hello doctor,
Thank you again for your prompt and comprehensive response. I have a further inquiry. To what extent do you believe postoperative cognitive dysfunction (POCD) is a relevant factor in this case, and in your estimation, what are the best options, if any, for avoiding or minimizing it, whether twilight sedation or general anesthesia is used?
Please help.
Hello,
Welcome to icliniq.com.
I understand your concern.
Your question is valid, considering your age and the major procedure involving anesthesia.
POCD (postoperative cognitive dysfunction) is a well-documented cognitive decline following anesthesia and surgery, particularly in adults.
You are in the low-risk category due to your good physical condition and normal thyroid levels on medication, but your age is an independent risk factor, and the use of multiple sedatives is another risk factor.
Best strategies to decrease the risk of POCD:
Avoid Midazolam and use Propofol and Fentanyl (low dose) combination or Precedex monotherapy.
Minimize the number and dose of sedatives.
Consider general anesthesia with intubation if deep surgery is required.
Avoid prolonged fasting or dehydration.
Early ambulation after surgery.
I hope this helps.
Kindly follow up if you have more concerns.
Was this conversation helpful?
Answered byDr. Sofia John
Medically reviewed byiCliniq medical review team
Same symptoms don't mean you have the same problem. Consult a doctor now!
Related Questions
Intravenous Sedation - Revolutionizing Comfort
Awake Under Anesthesia- Cause, Prevention, and Actions
Can Propofol cause an electric current sensation in lips?
Dental Implant Surface Modifications: An Overview of New Advancements
Propofol Injection: Properties, Applications, and Risks Associated
Dental Implant Failure
Disclaimer: No content published on this website is intended to be a substitute for professional medical diagnosis, advice or treatment by a trained physician. Seek advice from your physician or other qualified healthcare providers with questions you may have regarding your symptoms and medical condition for a complete medical diagnosis. Do not delay or disregard seeking professional medical advice because of something you have read on this website. Read our Editorial Process to know how we create content for health articles and queries.