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2. HTN
PART- II
DR HITESH MOTWANI
DEPT OF ORAL & MAXILLOFACIAL SURGERY

3. Activation of HPA
What happens Activation physiologically of SNS
in a ptn. Sitting on a
axis
operating chair just prior to surgery
+ (vasopressin)
▪ Psychogenic factors, such as fright, anxiety, emotional stress, and
receipt of unwelcome news.
▪ Two other factors are pain- sply. Sudden and unexpected pain and
the sight of blood or surgical/dental instrument.
▪ These factors lead to the development of “fright or flight” response.

4. How to know whether the ptn is hypertensive or not
1. Symptoms
2. History : a. family history
b. drug history
c. social history
Cause Examples
Drug causing Na+ retention indomethacine
Corticosteroids
3. Physical examination : a. general
Drug causing increased sympathetic
activity
Ephidrine
b. cardiovascular
c. fundus
Drugs containing oestrogen Oral contraceptives
Drug interaction with antiHTN drugs indomethacine

5. How to know whether the ptn is hypertensive or not
▪ Investigations are needed in all ptn with HTN to detect any underlying cause, assess for
the consequences of HTN, and test for other cardiovascular risk factor.
1. Urinalysis
2. Biochemistry: a. serum level of K+ ( 3.5-5.2 mEq/L)
b. level of Na+ ( 135-147 mEq/L)
c. level of urea and creatine ( 20-40 mg/dL) ( 0.5-1.4 mg/dL)
Sokolow-Lyon criteria
3. Lipids ( LDL= 100-160 mg/dL) (HDL >= 40 mg/dL)
4. ECG

6. How it affects US ( OMFS )
▪ The primary concern is that during the course of treatment, a sudden, acute
elevation in blood pressure might occur, potentially leading to a serious outcome
such as stroke or MI
▪ Two important questions should be answered before dental treatment is provided
for a patient with hypertension:
1. What are the associated risks of treatment in this patient?
2. At what level of blood pressure is treatment unsafe for the patient?

7. How it affects US ( OMFS )
▪ The American College of Cardiology and the American Heart Association have
jointly published practice guidelines for the perioperative evaluation of patients
with cardiovascular disease for whom noncardiac surgery of various types is
planned.
▪ determination of risk includes the evaluation of three factors:
(1) The risk Imposed by The patient’s Cardiovascular disease,
(2) The risk imposed by the surgery or procedure, and
(3) The risk imposed by the functional reserve or capacity of the patient.

8. How it affects US ( OMFS )
Class II recommendations are as follows:
Class I recommendations are as follows:
▪ The ACC/AHA guideline recommendation are classified as follows:
▪ Class I: Benefits >> risk
▪ Class II: Benefits >= risk, and scientific evidence incomplete
▪ Class III: Risks >>benefits
Dental Management and Follow-up Recommendations Based on Blood Pressure
• Patients with a functional capacity >4 METs and without symptoms should proceed
to surgery
• Patients who have a need for emergency noncardiac surgery should proceed to the
operating room
• Patients with active cardiac conditions should be evaluated by a cardiologist and treated
according to ACC/AHA guidelines
• Patients with a functional capacity <4 METs or those with an unknown functional
capacity scheduled for intermediate-risk surgery should proceed to surgery with heart
rate control
• Patients undergoing low-risk procedures should proceed to surgery
• Patients with a functional capacity <4 METs or those with an unknown functional
capacity who are scheduled for vascular surgery should proceed to surgery with heart
rate control
• * Little Patients and Falace’s with poor Dental exercise Management tolerance of the Medically (<4 metabolic Compromised equivalents Patient, 8th Edition
[METs]) and no known
risk factors should proceed to surgery

9. Drug HoVawsoc oints tiactofr ifnetercacttiosn UOSra l m( aOnifeMstatFionS ) Other considerations
Thiazide Diuretics None Dry mouth, lichenoid
reactions
Orthostatic hypotension; avoid
prolonged use of NSAIDs—
may reduce antihypertensive
effects
Nonselective Beta Blocker potential increase in blood
pressure (use maximum of
0.036 mg epinephrine)
Taste changes,
lichenoid reactions
Avoid prolonged use of
NSAIDs— may reduce
antihypertensive Effects
Combined Alpha and Beta
Blockers
Because both B1 - and B2 -
adrenergic receptor sites are
blocked, the potential for an
adverse interaction is present;
however, it is unlikely to occur
because of compensatory a-adrenergic
receptor blockade
Orthostatic hypotension; avoid
prolonged use of NSAIDs—
may reduce antihypertensive
effects
Angiotensin-Converting Enzyme
(ACE) Inhibitors
None Angioedema of lips,
face, tongue; taste
changes; oral
Burning
-- “--
a1-Adrenergic Blockers None Dry mouth -- “--
Direct Vasodilators None -- “--
Central a2 -Adrenergic Agonists None Dry mouth Orthostatic hypotension
Calcium Channel Blockers None Gingival hyperplasia

10. Choice of LA with/without vasoconstrictor
▪ Epinephrine has both beta 1 and beta 2 activity, it does not tend to dynamically
increase blood pressure owing in part to beta 2 vasodilation.
▪ The hemodynamic alterations epinephrine very short duration less than 1
minute.
▪ Multiple studies with regard to local anesthesia and epinephrine confirmed that even
though blood pressure and heart rate may have changed significantly, the mean
arterial blood pressure (MAP) is unchanged.
▪ In evaluating the relationship between systemic resistance, blood flow, and pressure,
it is the MAP that is important and not the diastolic or systolic blood pressure values.

11. Choice of LA with/without vasoconstrictor
▪ Epinephrine usually increases HR , Stroke Vol. , SBP , myocardial oxygen consumption,
and cardiac automaticity but reduces DBP. Therefore, the MAP is relatively unchanged.
▪ There is a theoretical increased risk of LA toxicity because beta blockers can retard the
hepatic oxidation of the local anesthetic by inhibiting hepatic enzyme activity. But, this
noted drug interaction involves only the local anesthetic and not epinephrine.
▪ Niwa et al, demonstrated that infiltration anesthesia with epinephrine (45 ug
epinephrine) and lidocaine can be carried out safely on patients with an exercise
capacity of more than 4 MET.

12. Choice of LA with/without vasoconstrictor
▪ From the preceding studies, 3.6 - 5.4 ml of 2% lidocaine with 1:100,000
epinephrine (36 to 54 ug of epinephrine) appears to be tolerated in most patients
with hypertension or other cardiovascular disease, and the benefits of the
vasoconstrictor appear to outweigh potential disadvantages or risks.
▪ Conclusion: recommended maximum dosage of epinephrine in normotensive ptn.=
0.2 mg and in htn (<=180/110 mm hg) = 0.04 mg.
▪ In ptn. With severe form of htn (> 180/110 mm hg) use of LA with vasoconstrictor
should be avoided.

13. Epinephrine conc. Conc./ ml Max. does in ptn with CVD Max. does in normal ptn
1:80,000 0.0125 mg epinephrine/ml 3.2 ml 16ml
1:10,00,00 0.01 mg epinephrine/ml 4 ml 20ml
1:20,00,00 0.005 mg epinephrine/ml 8 ml 40ml
NB: max permissible dose of lidocaine with vasoconstrictor should not exceed 500 mg and without vasoconstrictor
not more than 300 mg

14. Management of emergency cases
▪ In diagnosed htn cases:
▪ Relative complication: M.I., stroke, increased blood loss
▪ Under LA: postural hypotension, incr. blood loss controlled by local methods
▪ Under GA: use of HYPOTENSIVE ANESTHESIA and other drugs to control htn and
increased blood loss
▪ In undiagnosed case:
▪ Relative comp: M.I., stroke, increased blood loss via the surgical field
▪ If proper precautions are not taken while injecting la, may lead to inc. in BP, HR,
due to the stimulation of beta receptors by the vasoconstrictor. Also at toxic levels
of lidocaine, there is marked cvs depression and vasodilatation

15. Management of emergency cases
▪ Management of lidocaine toxicity :
▪ Most local anesthetic overdose self-limiting
▪ rarely any drugs other than oxygen be necessary to terminate a local anesthetic overdose.
▪ Management of epinephrine overdose
▪ Most instances of epinephrine overdose are of short duration little or no formal
management is necessary.
▪ Terminate the Procedure If possible, remove the source of epinephrine. Stopping the injection
does not remove epinephrine that has been deposited; however, release of anxiety induced
endogenous epinephrine and norepinephrine is lessened
▪ Oxygen may be administered if necessary. The patient may complain of difficulty breathing. An
apprehensive patient may hyperventilate. Oxygen is not indicated in the management of
hyperventilation because it can exacerbate symptoms, possibly leading to carpopedal tetany

16. Management of emergency cases
Antihypetensive agent Intravenous Dose
Preferred Parenteral Drugs for Selected Hypertensive Emergencies
Nitroprusside Initial 0.3 (ug/kg)/min; usual 2–4 ( ug/kg)/min;
Stroke Nicardipine, labetalol, nitroprusside
maximum 10 ( ug/kg)/min for 10 min
Nicardipine Initial 5 mg/h; titrate by 2.5 mg/h at 5–15 min
Myocardial infarction/unstable angina Nitroglycerin, nicardipine, labetalol, esmolol
intervals; max 15 mg/h
Acute left ventricular failure Nitroglycerin, enalaprilat, loop diuretics
Labetalol 2 mg/min up to 300 mg or 20 mg over 2 min, then 40–
80 mg at 10-min intervals up to 300 mg total
Postoperative hypertension Nitroglycerin, nitroprusside, labetalol, nicardipine
Esmolol Initial 80–500 ug/kg over 1 min, then 50–
300(ug/kg)/min
Nitroglycerin Initial 5 ug/min, then titrate by 5 ug/min at 3–5-min
intervals; if no response is seen at 20 ug/min,
incremental increases of 10–20 ug/min may be used