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Hypertension: Classification,
Pathophysiology, and Management
During Outpatient Sedation and Local
Anesthesia
Stephen Wilford Holm, DMD,*
Larry L. Cunningham, Jr, DDS, MD, Eric Bensadoun, MD,
and Matthew J. Madsen, BS
Hypertension is defined as a systolic blood pressure 29% of patients with hypertension are treated, and
(SBP) higher than 140 mHg or a diastolic blood pressure only 45% of those treated with antihypertensive med-
(DBP) higher than 90 mmHg; the diagnosis is based on ications have controlled disease.7,8
the average of 2 or more readings taken at each of 2 or This paper reviews and summarizes the new clas-
more visits after an initial screening.1,2 When deter- sification system based on the Seventh Report of the
mined by these criteria, hypertension affects 20% to Joint National Committee on the Prevention, Detec-
30% of the adult population in most developed coun- tion, Evaluation and Treatment of High Blood Pres-
tries, and its prevalence appears to increase with the sure (JNC-7). In addition, it reviews the guidelines,
age of the patient.3-5 Recent publications have shown pathophysiology, clinical symptoms, and diagnosis of
that the lifetime risk of hypertension for patients who hypertension. Finally, it reviews treatment recom-
are normotensive at age 55 is 90%.1 African Americans mendations for common local anesthetics, conscious
are affected by hypertension nearly twice as often as sedative agents, and general anesthetics as they per-
whites and seem to be more vulnerable to its compli- tain to hypertensive patients undergoing oral and
cations.5,6 Hypertension is an important risk factor for maxillofacial surgery.
cardiovascular accidents, coronary heart disease, car- Oral and maxillofacial surgeons will frequently
diac hypertrophy with heart failure (hypertensive encounter patients with undiagnosed or poorly
heart disease), aortic dissection, and renal failure. controlled hypertension. The recent JNC-7 report
Hypertension can also accelerate atherogenesis and addressed the following issues: 1) the publication
can induce changes favorable for aortic dissection and of many new hypertension observational studies
cerebrovascular hemorrhage.7 Despite the prevalence and clinical trials; 2) the need for a new, clear, and
of hypertension and its associated complications, only concise guideline that would be useful for clini-
cians; 3) the need to simplify the classification of
blood pressure; and 4) the clear recognition that
*Resident, Oral and Maxillofacial Surgery, Carle Foundation Hos- previous JNC reports were not being used to their
pital, Urbana, IL. full potential.1
Assistant Professor and Residency Director, Oral and Maxillofa-
cial Surgery, University of Kentucky College of Dentistry, Lexing-
JNC Review
ton, KY.
Associate Professor, Division of Pulmonary and Critical Care JNC-7 is summarized by the following key points
Medicine, University of Kentucky, Lexington, KY. and alterations: 1) for patients older than 50, SBP
Dental Student, University of Kentucky College of Dentistry, higher than 140 mmHg is a much more important
Lexington, KY. cardiovascular risk factor than DBP; 2) the risk of
Address correspondence and reprint requests to Dr Cunning- cardiovascular disease (CVD) doubles with each in-
ham: University of Kentucky College of Dentistry, Oral and Maxil- crement of 20/10 mmHg above a baseline of 115/75
lofacial Surgery, 800 Rose Street, D-508, Lexington, KY 40536- mmHg; 3) the lifetime risk of hypertension for pa-
0297; e-mail: llcunn2@email.uky.edu tients who are normotensive at age 55 is 90%; 4)
2006 American Association of Oral and Maxillofacial Surgeons patients with SBP of 120 to 139 mmHg or DBP of 80
0278-2391/06/6401-0019$32.00/0 to 89 mmHg should be considered pre-hypertensive
doi:10.1016/j.joms.2005.09.023 and require health-promoting lifestyle modifications
111
112 HYPERTENSION DURING OUTPATIENT SEDATION AND LOCAL ANESTHESIA
clude ventricular hypertrophy (based on electrocardi- ing oral and maxillofacial surgery is to reduce the
ography), hematuria, proteinuria, heart failure, morbidity and mortality rates associated with surgical
angina, renal failure, or blindness. Secondary hyper- procedures that involve local anesthetics, conscious
tension can be caused by diseases of hormonal dys- sedation, or general anesthesia. JNC-7 recommends
regulation, such as primary aldosteronism, Cushings guidelines for the general management of hyperten-
syndrome, and pheochromocytoma.15 sion; its recommendations include single or combina-
Hypertension varies with the age of the patient. It is tion therapy with diuretics, -blockers, or both for
interesting to note that younger adults are more likely uncomplicated hypertension. The treatment of com-
to have elevated DBP, whereas older adults are more plicated hypertension may require various combina-
likely to have elevated SBP; DPS plateaus or even tions of medication, including ACE inhibitors, angio-
decreases with age.10,13 tensin II receptor blockers, -blockers, /-blockers,
Renal failure is a leading cause of secondary hyper- -blockers, calcium antagonists, and diuretics.1,16,17
tension.5 Hypertension resulting from renal dysfunc- When multiple drugs are used to achieve a target
tion develops primarily through the action of renin blood pressure of approximately 130/80 mmHg, the
and angiotensin II. Abnormalities in these systems possibility of adverse drug interactions increases.18
contribute to essential and secondary hypertension. Clinicians should become aware of the side effects
Diseases or conditions that may alter blood flow and interactions of these medications and should
through the kidneys include diabetes, renal arterial know when the use of these agents is an appropriate
stenosis, and pheochromocytoma. Another systemic treatment option.
contributor to hypertension is cardiac disease.5 Car- Effective perioperative management of the hyper-
diac output and total peripheral resistance work in tensive patient requires controlling stress and anxiety
combination to control arterial pressure. Cardiac out- and knowing the uses and adverse interactions of
put is affected by blood volume, which is regulated by antihypertensive drugs.13 The greatest concern for
systemic sodium levels. Total peripheral resistance is the oral and maxillofacial surgeon is the perioperative
regulated by the diameter of arteriolar vessels, which management of acute and emergent hypertension.
are under hormonal and neuronal regulation. Parenteral drugs outlined in Table 8 can be used for
hypertensive emergencies and urgencies. Preopera-
tive and postoperative pain control have been shown
Therapy and Anesthesia for
to be important factors contributing to blood pres-
Hypertensive Patients Undergoing Oral
sure management for oral and maxillofacial surgery
and Maxillofacial Surgery
patients.12,19
Hypertension is associated with increased morbid-
ity and mortality rates among patients with CVD LOCAL ANESTHETICS
and/or renal disease.16 One of the goals of antihyper- In 1986, a joint report of the American Heart Asso-
tensive therapy for the hypertensive patient undergo- ciation and the American Dental Association stated
114 HYPERTENSION DURING OUTPATIENT SEDATION AND LOCAL ANESTHESIA
that vasoconstrictors should be used only when the or nervous patient likely has increased levels of en-
procedure would be shortened or when the depth of dogenous epinephrine. Because plasma levels of epi-
anesthesia would be more profound.20 Local anesthet- nephrine are dose dependent, administration of epi-
ics are recommended for patients with hypertension nephrine to the nervous or apprehensive stage 2
because they can decrease pain and increase comfort. patient would be contraindicated. The type of injec-
True allergy is the only contraindication for the use of tion that is administered (block versus infiltration) as
such anesthetics.21 The selection of a local anesthetic well as vascularity of the area where the local anes-
solution is based primarily on the duration of the thetic is being deposited is also a factor.
procedure, the need for hemostasis, and the required Norepinephrine or levonordefrin should be avoided
degree of pain control.21 Vasoconstrictors are added because of their unopposed activation of 1-receptors in
to local anesthetics to aid in hemostatic control and to the hypertensive patient.12,23 This activation could lead
increase the duration of the drugs effect. A solution to uncontrolled increases in blood pressure. Other con-
of 2% lidocaine with 1:100,000 epinephrine is the traindications to local anesthetics containing vasocon-
formulation most commonly used to achieve the nec- strictors include severe uncontrolled hypertension, re-
essary degree of anesthesia for most dental situa- fractory arrhythmia, myocardial infarction or stroke
tions.22 Bupivacaine is the longest-acting local anes- within 6 months, unstable angina, coronary bypass graft-
thetic agent generally used. The maximum doses for ing within 3 months, uncontrolled congestive heart fail-
injectable local anesthetics given to healthy adult and ure, and uncontrolled hyperthyroidism.13 Clinicians
pediatric patients are listed in Table 4. should be cautious when administering local anesthetics
A risk in the administration of local anesthesia for at dosages higher than recommended; they should also
the hypertensive patient is the inclusion of epineph- be aware of the potential interactions between com-
rine and its sympathomimetic effect on cardiac 1- monly used local anesthetics and antihypertensive drugs
receptors. The current maximum recommended dose such as tricyclic antidepressants, adrenergic neuron
of local anesthetic solution for a patient with hyper- blockers, nonselective -blockers, and inhalation anes-
tension (poorly controlled ASA Class III or all class IV) thetics. Table 4 lists the most recent dosing recommen-
is two 1.8-ml cartridges (for a total dose of 3.6 ml) dations for commonly used local anesthetics.
with 1:100,000 epinephrine per appointment 12,13,23
If lengthy procedures are anticipated, the epineph- CONSCIOUS SEDATION
rine should be diluted to a ratio of 1:200,000.23 Niwa An inherent difficulty exists when comparing the
and colleagues24 showed that patients with mild CVD effects on hypertension of unrelated drugs used for
can withstand a dose of 1.8 ml of 2% lidocaine with conscious sedation. The doses and titrations of drugs
1:80,000 epinephrine without cardiovascular hemo- used for conscious sedation differ for each patient,
dynamic complications. and reports of morbidity and mortality rates can be
The side effects of absorbed epinephrine in a stage conflicting.22,25 Many studies have been performed
2 hypertensive patient must be weighed against the with healthy subjects, who can be significantly differ-
benefits. Many clinical situations will contraindicate ent from hypertensive patients. The outcomes of drug
the use of epinephrine. The apprehensive, sweating, administration will vary on the basis of health status.
HOLM ET AL 115
Surgeons and educators may use different techniques cardiac dysrhythmias, and bradycardia, these agents
when administering anesthetics, and several different should be used with caution for patients with conges-
approaches may be safe and effective. tive heart failure21 (Table 5).
Drugs commonly administered for conscious seda- Propofol is a sedative-hypnotic agent; its clinical
tion include benzodiazepines, given alone or in com- use is comparable to that of barbiturates. It causes a
bination with a barbiturate, propofol, an opioid, an decrease in cerebral metabolism, blood flow, and in-
antihistamine, ketamine, and/or droperidol.25 These tracranial pressure. It has been shown to cause pro-
drugs have been shown to be effective in relieving found hypotension when given as a bolus; this effect
pain and anxiety, which are important factors in the is most likely due to direct myocardial depression and
management of hypertension.19 a decrease in systemic vascular resistance. Its admin-
Benzodiazepines, when given at sufficient dosages, istration to patients of advanced age has been associ-
cause a generalized depression of the central nervous ated with alterations in the cardiovascular response26
system and a loss of muscular coordination. It has such as inotropic effects or a decrease in systemic
been suggested that benzodiazepines function by in- blood pressure because of decreased peripheral resis-
creasing the inhibitory activity of the neurotransmit- tance.
ter -aminobutyric acid (GABA), an important inhibi- Ketamine is a general anesthetic that provides pro-
tory transmitter in the brain.26 Rodrigo and co- found analgesia and amnesia. It causes an excitatory
workers27 reported that the incidence of unifocal dissociative state that is not associated with the use of
ventricular ectopic dysrhythmias is increased during other anesthetic drugs.26 Ketamine is the only intra-
conscious sedation with midazolam. Roelofse and van venous anesthetic that routinely produces an increase
der Bijl28 reported that the administration of midazo- in heart rate, arterial blood pressure, and cardiac
lam with a local anesthetic can increase the incidence output. It causes the release of endogenous cat-
of cardiac dysrhythmias; however, they pointed out echolamines and is therefore contraindicated for pa-
that this finding is contradicted by those of other
tients with hypertension. Ketamine is commonly and
researchers, who found that the incidence of dys-
effectively administered to pediatric patients (Ta-
rhythmias was decreased when certain benzodiaz-
ble 5).
epines were used in conjunction with local anesthet-
Opioids can produce profound analgesia. The ef-
ics. These authors argued that the incidence of
fects of these drugs include analgesia, drowsiness,
dysrhythmias is so common that this complication
mood swings, and mental confusion. There are 3
should be considered a normal sequelae of dental
groups of opioid analgesics: opioid agonists, which
surgery among healthy patients.28
interact with central nervous system receptors to pro-
A study by van der Bijl and colleagues22 found that
the various benzodiazepines differentially increase duce a physiologic response; opioid antagonists,
mean arterial pressure and average heart rate; other which occupy a receptor site without a physiologic
researchers found that changes in blood pressure or response; and opioid agonists/antagonists, which pos-
heart rate are usually insignificant when these drugs sess properties of both groups. Research has shown
are carefully titrated.25 It is generally agreed that the that the anticholinergic effects of opioids can lead to
benzodiazepines rarely cause adverse cardiovascular increases in heart rate because of the vagolytic prop-
effects, even among patients with substantial cardiac erties of these agents.26 When used as conscious sed-
disease.26 There are no significant contraindications ative agents, opioids have been associated with hypo-
for the use of these agents in dental practice21 (Ta- tension, peripheral circulatory collapse, and cardiac
ble 5). arrest.21 However, hypertension does not contraindi-
Barbiturates act by enhancing metabolic enzyme cate the use of opioids.
function and depressing ascending neuronal conduc- Droperidol (a neuroleptanesthetic) is an effective
tion to the cerebral cortex and to the limbic and tranquilizing agent, especially for pediatric patients.
reticular activating systems. These drugs can achieve Its effects are seen in its ability to alter the action of
a wide range of depression, from light sedation to dopamine in the subcortical levels of the central ner-
hypnosis, general anesthesia, coma, and death.21 Bar- vous system, thereby inducing a sedative state.
biturates have unpredictable effects on analgesia and Droperidol causes a sleepy, psychologically detached
can render patients restless and difficult to treat when state in which the patient can still respond to com-
they are in pain.21 The effects of these agents are mands. Its use is contraindicated for patients with
proportional to their accumulation and excretion. CVD because it blocks the vasopressor activity of
The cardiovascular system is generally resistant to the epinephrine. Orthostatic hypotension is also a contra-
physiological changes induced by these agents.26 indication for the use of this agent. Table 5 lists
However, because some researchers have found that common conscious sedative agents and their maxi-
the use of barbiturates is associated with hypotension, mum recommended dosages.
116
Table 5. INTRAVENOUSLY ADMINISTERED CONSCIOUS SEDATIVE AGENTS AND RECOMMENDED DOSES
Drug Class Generic Name Maximum Adult Dose Maximum Pediatric Dose Onset/Duration Hypertensive Complications
Benzodiazapenes
Diazepam 30 mg NE 015 min/45120 min Minimal hemodynamic changes
Midazolam 60 yr, unpremedicated: 6 mo: NE 15 min/30 min Minimal hemodynamic changes
5 mg IV 6 mo5 yr: 6 mg IV
60 yr, debilitated, or 6 12 yr: 10 mg IV
chronically ill: 3.5 mg
IV
Opioids
Meperidine NE 50 mg 5 min/46 hr Mild hypotension, decreased vascular
resistance, orthostatic hypotension,
Drug Class Generic Name Maximum Adult Dose Maximum Pediatric Dose Onset/Duration Hypertensive Complications
Muscle relaxants
Tubocurarine Initial: 69 mg 1 mo: 0.5 0.6 mg/kg 25 min/2090 min Hypotension; reactions more common
Maintenance: 0.1 mg/kg in patients with preexisting
PRN cardiovascular disease
Succinylcholine Initial: 0.31.1 mg/kg 0.12 mg/kg PRN Immediate/10 min Bradycardia, cardiac arrest, especially
Maintenance: 0.31.0 mg/ in children; after second dose,
kg PRN atropine should be administered
Inhalational agents
Halothane Initial: 0.53% Individualized Rapid/rapid Preexisting cardiovascular disease or
Maintenance: 0.51.5% pheochromocytoma: cardiovascular
effects such as dysrhythmias,
hypotension, myocardial depression,
and peripheral vasodilation
Sevoflurane Initial: individualized Same as adult Rapid/rapid
Maintenance: 0.53%
Isoflurane Initial: 0.53% Individualized Rapid/rapid Decreases mean arterial pressure,
Maintenance: 0.51.5% increases heart rate, transient
sympathetic activation
Desflurane Initial: 0.53% Not recommended for Very rapid/very Preexisting cardiovascular disease or
Maintenance: 2.5 8.5% induction rapid pheochromocytoma: cardiovascular
Maintenance: 5.210% effects such as dysrhythmias,
hypotension, myocardial depression,
and peripheral vasodilation,
tachycardia, hypertension
Nitrous oxide Induction: 70% and 30% O2 Individualized Very rapid/very 80% N2O20% O2 causes increased
Maintenance: 30%70% rapid response of vascular smooth muscle
with O2 to norepinephrine
Abbreviation: PRN, as needed.
Holm et al. Hypertension During Outpatient Sedation and Local Anesthesia. J Oral Maxillofac Surg 2006.
117
118 HYPERTENSION DURING OUTPATIENT SEDATION AND LOCAL ANESTHESIA
I. Hypertensive emergencies (1% Evidence of end organ damage in brain, Lower blood pressure to level normal for
of all hypertensive patients) heart, kidneys that patient within 3060 min in a
controlled, graded manner
II. Hypertensive urgencies (Usually Elevation of blood pressure levels to a Reduce blood pressure gradually within
115 mmHg DBP) state that may be potentially harmful 2448 hr; rapid reductions are
without evidence of end organ potentially harmful and should be
damage avoided
III. Uncomplicated hypertension No signs of end organ damage Treated acutely and aggressively with
(Blood pressure 115 mmHg follow-up care
DBP)
IV. Transient hypertension Resulting from underlying disease or Treatment includes resolution of the
disorder, such as anxiety, underlying condition, rather than
pancreatitis, stroke, epistaxis, etc. antihypertensive medication
Abbreviation: DBP, diastolic blood pressure.
Holm et al. Hypertension During Outpatient Sedation and Local Anesthesia. J Oral Maxillofac Surg 2006.
When drugs are combined, the likelihood of cross- Neuromuscular blocking agents can relax skeletal
reactive complications must be considered. The ad- muscle and facilitate mechanical ventilation during
vantage of drug combinations is that the administered general anesthesia. Neuromuscular blocking agents
amount of either drug can be reduced, thereby reduc- are classified as nondepolarizing drugs because of
ing associated morbidity rates and increasing the abil- their ability to bind to motor end plate acetylcholine
ity to control the agents effects. Dionne25 reported receptors, thereby preventing further depolarization.
that midazolam, used alone or in combination with Because of its ability to mimic the effects of acetyl-
other agents, can effectively relieve anxiety. Likewise, choline, succinylcholine, which consists of 2 acetyl-
the combination of midazolam and fentanyl or of choline molecules linked end to end, is frequently
midazolam and methohexital can substantially reduce used for general anesthesia. The use of succinylcho-
patients perceptions of pain. These combinations line can be associated with profound bradycardia be-
also have various effects on respiratory rate, oxygen cause the drug excites the myocardial acetylcholine
saturation, and mean arterial pressure.22,24,27,28 receptors. The complications associated with succi-
Most studies agree that the most effective treatment nylcholine are bradycardia, dysrhythmia, and cardiac
for patients at risk of a hemodynamic event during arrest.21 The risk of cardiovascular reaction associated
conscious sedation is careful monitoring of respira- with succinylcholine is higher when patients have
tion, oxygen saturation, and cardiovascular homeo- experienced hyperkalemia, severe burns or trauma,
stasis (by electrocardiography).22,24,27,28 Malamed29 spinal cord injury, or neuromuscular disease.21
noted that episodic increases in blood pressure were Inhalational anesthetics are commonly used after
most commonly caused by light anesthesia or seda- induction agents to produce and maintain general
tion and by the patients experience of pain during anesthesia. Inhalational agents are contraindicated for
treatment. patients with coronary artery disease, congestive
heart failure, other forms of CVD, or pheochromocy-
GENERAL ANESTHETICS toma. Complications associated with these agents are
General anesthetic agents can have various effects dysrhythmia and myocardial depression leading to
on the hypertensive patient. Common general anes- hypotension with or without peripheral vasodilation.
thetic drugs include intravenous induction agents, Special care should be used when halothane or des-
opioids, neuroleptanesthetics, ketamine, muscle re- flurane is administered to patients with cardiovascular
laxants, and inhalational anesthetics. Intravenous in- conditions, because these agents are more likely than
duction agents include the benzodiazepines, barbitu- others to result in cardiovascular stimulation.21 Des-
rates, ketamine, and propofol. The contraindications flurane has been shown to cause increases in cate-
for these drugs and those for opioids and neuro- cholamine release; its administration may cause hy-
leptanesthetics such as fentanyl and droperidol are pertensive episodes among healthy patients.29
the same as those for conscious sedation (Table 5). Nitrous oxide has anesthetic properties and can
The complications that may be associated with barbi- also interact with endogenous opioid receptors.
turates and ketamine, when these drugs are used as When nitrous oxide is used at a ratio of 80% N2O to
general anesthetics, are dysrhythmia and tachycardia; 20% O2, myocardial contraction is depressed because
in contrast, propofol is associated with bradycardia.21 of the drugs direct action on the heart and the re-
HOLM ET AL 119
It is an excellent drug for the management of peri- intervals during the first hour after administration
operative hypertensive emergencies. Its effects are and at 30-minute intervals during the second
immediate, and its half-life is 1 to 4 minutes. It is the hour.30
drug of choice for treating hypertension that com- The new guidelines for the classification of hyper-
plicates angina, myocardial infarction, or pulmo- tension and the list of cardiovascular risk factors pro-
nary edema. vided by JNC-7 are more helpful to oral and maxillo-
facial surgeons than previous such documents related
HYDRALAZINE to diagnosing hypertension and treating patients with
Hydralazine has direct effects as an arteriolar this condition. Cardiovascular hypertensive disorders
dilating agent with little to no effect on the venous affect the use of anesthetic treatment regimens for
system. It has a moderate onset of action, but its patients undergoing oral and maxillofacial surgery.
effects can last for 2 to 6 hours. Its use as a sole agent The majority of the cases that are treated by the oral
is contraindicated except for younger patients who and maxillofacial surgeon are in settings that are elec-
can handle increases in output without experiencing tive, acute, or emergent. Therefore, clinicians should
ischemia.30 become aware of drug interactions and of the clinical
classification of hypertensive stages. Prompt diagnosis
DIAZOXIDE
and treatment can mean the difference between life
and death for patients undergoing procedures that
Diazoxide inhibits the release of insulin from the involve local, conscious sedative, or general anes-
pancreas and produces direct relaxation of smooth thetic agents.
muscle. Peripheral arteriolar dilation results in de-
creased total peripheral resistance, which causes
reflex tachycardia and increased cardiac output. References
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