CC
A 61-year-old male undergoing extraction of carious teeth with deep sedation develops ventricular tachycardia (VT).
HPI
The patient, a 61-year-old male who denies any previous past medical history, was referred by his dentist for extraction of multiple carious teeth. He was seen for a consult during which time he was found to have carious teeth #2, #3, #4, and #5. At the time of his consultation, he was noted to be extremely anxious and in severe pain from his teeth, which have been symptomatically painful off and on for the past month.
The risks, benefits, options, and potential complications for removal of the carious teeth were discussed with the patient, as well as the anesthetic options for his proposed surgical extractions. The patient demonstrated a good understanding of the proposed procedure and anesthesia options; he elected to have them performed under deep sedation as soon as possible. He was scheduled for the next day. On the day of surgery, after confirming preprocedure protocols had been met (including patient factors [nothing by mouth status, consent, appropriate escort presence], procedure factors [room ready, radiography and necessary instruments ready], and emergency factors [verification that emergency equipment and supplies are available in case the need arises]), the patient was brought to the procedure room. He was positioned in the chair, and standard monitors were attached.
The use of dynamic electrocardiogram (ECG) monitoring is regarded as a standard of care during the provision any anesthetic and is recommended even in the absence of general anesthesia cases. (This device is variably referred to as an ECG or as an EKG, the latter based on the Greek term “kardia” for heart. Some providers prefer EKG to ECG because it is less likely to be confused verbally with EEG, the abbreviation for an electroencephalogram.) In addition to three-lead ECG monitoring, pulse oximetry and a blood pressure cuff were also applied. The patient was initially provided with 2 L/min of oxygen via nasal cannula with end-tidal CO 2 monitoring capability. Intravenous (IV) access was established with a 22-gauge IV needle in the left antecubital fossa. The patient was noted to be quite anxious but denied any additional concerns at this time. Initial blood pressure was 146/94 mm Hg, heart rate was 99 bpm, respirations were 20 breaths per minute, and oxygen saturation was 98% on 2-L/min nasal cannula oxygen. The patient was prepped and draped in the usual manner, and the procedure was about to commence after a hard stop timeout was agreed upon by the staff present. After completion of the time-out and before the initiation of any sedation, the patient reported feeling heaviness in his chest and some difficulty in breathing. Immediate review of his ECG tracing revealed VT (wide QRS with the absence of atrial waveforms).
The procedure was aborted, and immediate treatment for the patient’s arrhythmia and symptoms was initiated. Activation of the emergency medical services (EMS) system occurred, and continued assessment of the patient and treatment options were immediately evaluated.
PMHX/PDHX/medications/allergies/SH/FH
Upon further questioning, the patient, who is 5 feet, 10 inches tall and weighs 110 kg (body mass index, 34), denied any significant past medical history but did report that he had not seen his physician in some time. He only visited his dentist for evaluation of his dental pain. Of note, jaw and tooth pain along with retrosternal discomfort can be seen and are common during myocardial ischemia. Consequences of myocardial ischemia include silent ischemia, Prinzmetal angina, or acute coronary syndrome (unstable angina, non–ST-elevation myocardial infarction, ST-elevation myocardial infarction). He has smoked a half of cigarettes a pack per day for 30 years but has been trying to quit recently. He also reports drinking four or five beers every week. His activity is limited because he works as a computer programmer and sits behind a desk 8 to 10 hours per day. His wife of 34 years notes that he snores very heavily at night and sometimes seems to gasp for air.
Patients should be considered to have coronary artery disease (CAD) or coronary heart disease if they have at least two of the following risk factors: hypertension, diabetes, hyperlipidemia with cholesterol greater than 240 mg/dL, smoking, and age older than 60 years. Male gender, genetics, and other poor lifestyle choices such as a high-fat, high-cholesterol diet and a sedentary lifestyle, are additional risk factors ( Table 98.1 ).
| Six Independent Predictors of Major Cardiac Complications |
| High-risk type of surgery (e.g., vascular surgery and any open intraperitoneal or intrathoracic procedures) |
| History of ischemic heart disease (history of MI or a positive exercise test result, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present) |
| History of heart failure |
| History of cerebrovascular disease |
| Diabetes mellitus requiring treatment with insulin |
| Preoperative serum creatinine >2.0 mg/dL (177 μmol/L) |
| Rate of Cardiac Death, Nonfatal MI, and Nonfatal Cardiac Arrest According to the Number of Predictors |
| No risk factors: 0.4% (95% CI, 0.1–0.8) |
| One risk factor: 1.0% (95% CI, 0.5–1.4) |
| Two risk factors: 2.4% (95% CI, 1.3–3.5) |
| Three or more risk factors: 5.4% (95% CI, 2.8–7.9) |
| Rate of MI, Pulmonary Edema, Ventricular Fibrillation, Primary Cardiac Arrest, and Complete Heart Block |
| No risk factors: 0.5% (95% CI, 0.2–1.1) |
| One risk factor: 1.3% (95% CI, 0.7–2.1) |
| Two risk factors: 3.6% (95% CI, 2.1–5.6) |
| Three or more risk factors: 9.1% (95% CI, 5.5–13.8) |
Coronary artery disease is hardening, narrowing, or dysfunction of the blood vessels that supply oxygen to cardiac muscle, thus causing an imbalance between myocardial oxygen demand and supply. CAD is the most common type of heart disease and is the leading cause of myocardial infarction (MI). More than 550,000 deaths per year in the United States are attributable to CAD, making it the leading cause of death in both males and females. The American Heart Association (AHA) estimates that every minute, one American will die from a coronary event. The diagnosis of CAD can be quite challenging because many individuals go undiagnosed until they present with acute symptoms and heart attacks.
Sudden cardiac arrest (SCA) usually occurs in people with some form of underlying structural heart disease, most notably CAD. As many as 70% of SCAs have been attributed to CAD. Among patients with CAD, SCA can occur both during an acute coronary syndrome and in the setting of chronic, otherwise stable coronary disease. More than 50% of cardiac arrests occur as the initial manifestation of previously unknown or unrecognized cardiac disease. More than half of patients with SCA had some prodromal symptoms such as chest pain or dizziness.
Often, dental patients needing medical care do not access it, many times presenting with undiagnosed coronary disease. This underscores the importance of meticulous history taking as part of any risk assessment before scheduling a patient for any surgical procedure. An important component of this assessment is to review the patient’s activity level ( Tables 98.2 and 98.3 ).
| Activity | Weight |
|---|---|
| Can you . . . | |
|
2.75 |
|
1.75 |
|
2.75 |
|
5.50 |
|
8.00 |
|
2.70 |
|
3.50 |
|
8.00 |
|
4.50 |
|
5.25 |
|
6.00 |
|
7.50 |
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