The use of epinephrine-containing anesthetic solutions in cardiac patients: a survey

O uso de soluções anestésicas em pacientes cardiopatas: levantamento entre estudantes de Odontologia

Farmacologia

The use of epinephrine-containing anesthetic solutions in cardiac patients: a survey

O uso de soluções anestésicas em pacientes cardiopatas: levantamento entre estudantes de Odontologia

Raquel Fernanda GERLACH^*

José Eduardo Tanus dos SANTOS^**

Carlos Alberto Bazaglia ESCOBAR^***

GERLACH, R. F.; SANTOS, J. E. T.; ESCOBAR, C. A. B. The use of epinephrine-containing anesthetic solutions in cardiac patients: a survey. Rev Odontol Univ São Paulo, v. 12, n. 4, p. 349-353, out./dez. 1998.

A questionnaire survey of 150 last term dental students from four dental schools was performed to delineate their current opinion with regard to the use of epinephrine-containing anesthetic solutions for dental procedures in cardiac patients. The students provided their opinion as "contraindicated" or "not contraindicated" regarding the use of these solutions in eight cardiac patients with either stable or unstable heart diseases including ischemic heart disease, arrhythmia, hypertension, and heart failure. We found an overall 77% rate of right answers among all students. Mistakes occurred more frequently when treating patients with ischemic heart disease (68% of right answers). Although vasoconstrictors may offer many advantages and are not contraindicated to the majority of cardiac patients, graduating dental students sometimes do not comply with current guidelines.

UNITERMS: Epinephrine; Anesthetics; Cardiovascular diseases.

INTRODUCTION

The addition of epinephrine to local anesthetic solutions offers an indisputable advantage regarding the duration of anesthesia, local blood loss during surgery and systemic toxicity of the anesthetic^3;12;18. The proper use of such solutions remains controversial for cardiac patients, since adverse cardiovascular effects may follow systemic absorption of the drug in some of these patients¹³. A current and highly desirable praxis among dentists is to send their cardiac patients to physicians before beginning treatment. In what concerns our previous experience, physicians invariably recommend avoiding epinephrine-containing anesthetics in cardiac patients. Nevertheless, well designed studies failed to show significant hemodynamic effects associated with the increase in plasma epinephrine levels following the administration of local anesthetics containing epinephrine^2;6;7;8;19. The cautious use of epinephrine-containing anesthetics has many advantages over plain lidocaine when the cardiac condition of the patient is well established and does not preclude epinephrine use. In recent years, this view prompted the establishment of guidelines for the management of cardiac patients, so that some of these patients can also benefit from epinephrine-containing anesthetics¹⁶.

In order to evaluate dentists' current knowledge about the use of epinephrine-containing anesthetics in cardiac patients, we carried out a questionnaire survey, comparing our findings with the recommendations found in the literature.

MATERIAL AND METHOD

Questionnaires were given to 150 last term dental students from four Brazilian dental schools located in the states of Rio Grande do Sul and Santa Catarina. The students who responded to the questionnaires were present at the end of an usual class. The survey was designed to provide anonymity for the respondent. We chose last term students because we assumed that they represent a group that follows as close as possible the academic guidelines taught in dental schools. Furthermore, in a few months they would be making their own decisions as practitioners.

The questionnaire comprised eight easily understandable clinical cases describing patients with a cardiac disease, for which the students should provide their opinion as "contraindicated" or "not contraindicated" regarding the use of epinephrine-containing local anesthetic solution. There were three cases of ischaemic heart disease, one case of refractory arrhythmia, two cases of hypertension and two cases of congestive heart failure.

According to current guidelines, heart diseases that are absolute contraindications to the use of epinephrine-containing anesthetic solutions are: unstable angina, recent myocardial infarction (less than 6 months), recent coronary bypass surgery (less than 6 months), refractory arrythmias, untreated or uncontrolled severe hypertension and untreated or uncontrolled congestive heart failure. These absolute contraindications also preclude the use of other epinephrine-related vasoconstrictors, and in all of these cases, patients should be referred to a cardiologist before any dental procedure is undertaken. In the questionnaire (presented), questions 2, 3, 4, 5 and 8 are absolute contraindications that fit well the aforementioned group of heart diseases.

Questionnaires were collected after class. We then pooled all the answers together, without taking into account to which dental school each student belonged. The final results were compared with the guidelines set by PÉRUSSE et al.¹⁶ (1992).

RESULTS AND DISCUSSION

Eighty-three percent of the students (150-181) were present at class and responded to the questionnaire. Difficulties in answering the proposed questions were not reported.

Table 1 summarizes the number and percentage of correct answers given by students to each case.

Table 1
- Number and percentage of correct answers given by dental students (n = 150) regarding the use of epinephrine-containing local anesthetics for cardiac patients

Heart disease	Correct answers
	Number	%
Stable angina pectoris	105/150	70
Recent (4 months) mycardial infarction	93/150	62
Unstable angina pectoris	110/150	73
Refractory arrhythmia	128/150	85
Uncontrolled severe hypertension	123/150	82
Controlled hypertension	128/150	85
Uncontrolled congestive heart failure	125/150	83
Controlled congestive heart failure	116/150	77

We found an overall rate of 77% (928/1.200) of correct answers among all students. The analysis of the answers by group of heart disease showed that students made mistakes more often when treating patients with ischaemic heart disease, with an average of 68% (308/450) of right answers to the cases 1 to 3, which described patients suffering from angina. Interestingly, mistakes occurred most frequently when considering a recent myocardial infarction (only 62% of right answers). The current recommendation for patients with a recent myocardial infarction is to postpone dental or surgical treatment for at least 6 months. It is well known that epinephrine has arrhythmogenic properties that could be life-threatening when interacting with the electrophysiological abnormalities of the infarcted myocardium. It is also important to note that a pathophysiological continuum is found between unstable angina and myocardial infarction. This fact precludes the use of epinephrine in both groups of patients because the hemodynamic changes observed in these patients may compromise their cardiovascular status¹⁶. However, stable angina pectoris patients may receive regional blockades with vasoconstrictors when administered carefully and with previous aspiration³. Only 70% (105/150) of the students correctly indicated epinephrine-containing anesthetic solutions for these patients.

Eighty-five percent of the students correctly contraindicated the use of epinephrine-containing solutions of local anesthetics in patients with a refractory arrhythmia. This condition puts patients at high medical risk and the use of local anesthetics with vasoconstrictors is therefore too risky¹⁶. This case seemed easy to identify as a formal contraindication to epinephrine.

When questioned about hypertensive patients, 82% (123/150) of the students gave right answers regarding uncontrolled severe hypertension and 85% (125/150) correctly indicated the use of vasoconstrictors in patients with controlled hypertension. The risk of severe cardiovascular or cerebrovascular complications appears too great in patients with severe or uncontrolled hypertension. Also, hypertensive patients whose blood pressure is only slightly or moderately elevated safely benefit from the use of local anesthetics with vasoconstrictors^8;16.

Uncontrolled heart failure is a condition that may reflect many other cardiac or non-cardiac diseases. Whatever the underlying disorder responsible for this condition, there is a high risk for morbid complications. Eighty-three (125/150) percent of the students correctly contraindicated the use of epinephrine-containing anesthetic solutions in these compromised patients. On the other hand, 77% (116/150) of the students correctly indicated these anesthetic solutions for controlled patients suffering from congestive heart failure.

We think that this study highlights the problems encountered in the selection of cardiac patients that could safely receive an injection of a local anesthetic solution with epinephrine for dental procedures. Several historic recommendations concerning its use were based on empirical information, which may be outdated, and often well thought empirical predictions are proven incorrect after scientific experimentation⁴. The advantages of using these solutions in patients with a stable and compensated heart disease are unquestionable^5;11;12 and vasoconstrictors are not contraindicated for the majority of cardiac patients¹⁶. Although the use of lidocaine with epinephrine causes an increase in epinephrine levels in the systemic circulation, and alters other physiologic parameters as heart rate, cardiac output, and plasma norepinephrine⁷, its use is considered save for normotensive and controlled cardiac patients^{2;6;7;8;10;13;17;19}. Some authors go even further, stating that the combination of epinephrine and local anesthetic is especially important in patients suffering from cardiovascular diseases, since ineffective pain control complicates dental treatment and considerably increases such patients' risk^12;13. It has also been demonstrated that the effects of epinephrine on the cardiovascular system are either eliminated or reversed at certain concentrations of epinephrine and lidocaine in the blood¹⁴. Even though this survey has specifically focused on epinephrine-containing anesthetics, it is worthy to mention that other sympathomimetic amines (norepinephrine, levonordephrine, and phenylephrine¹) follow the same rules established for epinephrine^15;18. In addition, sympathomimetic amines have potentially harmful effects in patients with other systemic conditions such as uncontrolled diabetes mellitus or hyperthyroidism. Furthermore, clinically significant drug interactions may occur when vasoconstrictors are used in patients taking tricyclic antidepressants or b-blockers, but these issues are beyond the scope of this study. Felypressin, a vasoconstrictor commonly used in combination with prilocaine, is chemically similar to vasopressin (antidiuretic hormone). Because of its less intense cardiovascular effects⁹, its use is more appropriate in patients with relative contraindications to epinephrine-containing anesthetics.

Finally, dentists should not expose patients to additional risk factors related to epinephrine use when treating a patient with suspected cardiac disease or poorly diagnosed condition. However, when patients' cardiac state is known, there is no more reason to avoid the benefits of epinephrine-containing anesthetics. This survey has demonstrated that graduating dental students frequently comply with current recommendations, but not always. Dental schools should probably introduce some general guidelines into their courses concerning medically compromised patients. Furthermore, the advance of medicine has given a significant contribution to the increase of life expectancy and more people with chronic diseases will be visiting their dentists in the future.

QUESTIONNAIRE

The use of epinephrine-containing anesthetic solutions in cardiac patients.

All questions should be answered as "contraindicated" or "not contraindicated" regarding the use of epinephrine-containing anesthetics in cardiac patients. It is assumed that all security guidelines are observed in routine dental procedures (careful administration with preliminary aspiration, maximal anesthetic dose, etc )

1. A patient reports mild chest pain (angina pectoris) associated with moderate to intense physical activity or emotional stress. There are no other complaints. The patient is presently using effective antianginal agents.

2. A patient had a myocardial infarction four months ago. The patient takes antianginal drugs and reports chest pain only after moderate to intense physical activity. There are no other complaints.

3. A patient suffers from stable angina pectoris for a long time. His antianginal drugs have always been effective and the last appointment with his cardiologist was two months ago. He has noticed that usual physical activity has been associated with chest pain (angina pectoris) and increasing breathlessness on exertion over the last two weeks.

4. A patient presents a cardiac arrhythmia that was not abolished by pharmacological therapy. The patient is unable to precisely describe his condition.

5. A patient has arterial hypertension and is under clinical treatment. There are no other specific problems. His present arterial blood pressure is 190/120 mmHg.

6. A patient has arterial hypertension and is under specialized therapy. There are no other problems. His present arterial blood pressure is 130/80 mmHg.

7. A patient suffering from congestive heart failure is under irregular clinical therapy. The patient complains of breathlessness during ordinary physical activity and presents peripheral edema. Those complaints were the same that urged him to see a cardiologist.

8. A patient with congestive heart failure is under regular follow-up with a cardiologist. He has no new complaints as a result of a successful therapeutic management of his condition.

GERLACH, R. F.; SANTOS, J. E. T.; ESCOBAR, C. A. B. O uso de soluções anestésicas em pacientes cardiopatas: levantamento entre estudantes de Odontologia. Rev Odontol Univ São Paulo, v. 12, n. 4, p. 349-353, out./dez. 1998.

Foi realizado um levantamento de dados através de questionário entre 150 alunos que estavam no último ano do Curso de Odontologia de quatro faculdades para delinear a sua atual opinião quanto ao uso de soluções anestésicas contendo epinefrina em pacientes cardiopatas. Os alunos tinham duas opções: "contra-indicado" ou "não contra-indicado", e deveriam escolher uma delas para os oito casos de pacientes com doenças cardiacas estáveis e instáveis, entre as quais doença cardíaca isquêmica, arritmia e hipertensão. Encontraram-se, em média, 77% de acertos quando analisadas as respostas de todos os alunos. Os erros foram mais freqüentes quando as perguntas diziam respeito a doença cardíaca isquêmica (68% de respostas corretas). Embora os vasoconstritores possam oferecer muitas vantagens e não sejam contra-indicados para a maioria dos pacientes cardiopatas, os alunos muitas vezes não observam as determinações atuais para o uso apropriado desses medicamentos nesses pacientes.

UNITERMOS: Epinefrina; Anestésicos locais; Doenças cardiovasculares.

BIBLIOGRAPHIC REFERENCES

1. ANTONIAZZI, J. C.; BOMBANA, A. C. Estudo comparativo em endodontia de duas lidocaínas com vasoconstritor e de diferentes procedências. Rev Bras Odontol, v. 46, n. 4, p. 16-26, 1989.

2. BARBER, W. B.; SMITH, L. E.; ZAGOLA, G. P. et al. Hemodynamic and plasma catecholamine responses to epinephrine-containing perianal lidocaine anesthesia. Anesth Analg, v. 64, p. 924-928, 1985.

3. BROWN, R. S. Local anesthetics. Dent Clin North Am, v. 38, n. 4, p. 619-632, 1994.

4. BROWN, R. S.; LEWIS, V. A. More on the contraindications to vasoconstrictors in dentistry: letter. Oral Surg Oral Med Oral Pathol, v. 76, n. 1, p. 2-3, Jan. 1993.

5. CARUANA, P.; PATEROMICHELAKIS, S.; ROOD, J. P. The effects of adrenaline on lignocaine nerve block anesthesia. J Dent, v. 10, n. 2, p. 140-143, Feb. 1982.

6. CHERNOW, B.; BALESTRIERI, F.; FERGUSON, C. D. Local dental anesthesia with epinephrine. Arch Intern Med, v. 143, p. 2143, 1983.

7. CIOFFI, G. A.; CHERNOW, B.; GLAHN, R. P. et al. The hemodynamic and plasma catecolamine responses to routine restaurative dental care. J Am Dent Assoc, v. 111, p. 67-70, 1985.

8. DAVENPORT, R. E.; PORCELLI, R. J.; IACONO, V. J. et al. Effects of anesthetic containing epinephrine on catecholamine levels during periodontal surgery. J Periodontol, v. 61, p. 553-558, 1990.

9. GOLDMAN, R. S.; AJL, M.; SELEGHINI, N. M. Avaliação da eficácia e dos efeitos cardiovasculares da associação prilocaína + felipressina em procedimentos odontológicos. Rev Bras Odontol, v. 50, n. 4, p. 40-47, 1993.

10. HASSE, A. L.; HENG, M. K.; GARRETT, N. R. Blood pressure and electrocardiographic response to dental treatment with use of local anesthesia. J Amer Dent Assoc, v. 113, p. 639-642, 1986.

11. KABAMBE, W. M.; ROOD, J. P.; SOWRAY, J. H. A comparison of plain 2 per cent lignocaine and 2 per cent lignocaine with adrenaline in local analgesia for minor oral surgery. J Dent, v. 10, n. 2, p. 136-139, 1982.

12. KNOLL-KÖHLER, E.; FÖRTSCH, G. Pulpal anesthesia dependent on epinephrine dose in 2% lidocaine. Oral Surg Oral Med Oral Pathol, v. 73, p. 537-540, 1992.

13. KNOLL-KÖHLER, E.; FRIE, A.; BECKER, J. et al. Changes in plasma epinephrine concentration after dental infiltration anesthesia with different doses of epinephrine. J Dent Res, v. 68, p. 1098-1101, 1989.

14. KNOLL-KÖHLER, E.; KNÖLLER, M.; BRANDT, K. et al. Cardiohemodynamic and serum catecholamine response to surgical removal of impacted mandibular third molars under local anesthesia: a randomized double-blind parallel group and crossover study. J Oral Maxillofac Surg, v. 49, p. 957-962, 1991.

15. NEIDLE, E. A.; YAGIELA, J. A. Farmacologia e terapêutica para dentistas. Rio de Janeiro : Guanabara-Koogan, 1991. v. 1.

16. PÉRUSSE, R.; GOULET, J. P.; TURCOTTE, J. Y. Contraindications to vasoconstrictors in dentistry: Part I: cardiovascular diseases. Oral Surg Oral Med Oral Pathol, v. 74, p. 679-686, 1992.

17. PÉRUSSE, R.; GOULET, J. P.; TURCOTTE, J. Y. Letter to the editor. Oral Surg Oral Med Oral Pathol, v. 76, n. 1, p. 4-5, 1993.

18. SISK, A. L. Vasoconstrictors in local anesthesia for dentistry. Anesth Prog, v. 39, p. 187-193, 1992.

19. TOLAS, A. G.; PFLUG, A. E.; HALTER, J. B. Arterial plasma epinephrine concentrations and hemodynamic responses after dental injection of local anesthetic with epinephrine. J Am Dent Assoc, v. 104, p. 41-43, 1982.

Recebido para publicação em 06/01/98

Reformulado em 21/05/98

Aceito para publicação em 08/08/98

*

Cirurgiã-Dentista e

**

Médico Anestesiologista - UNICAMP.

***

Cirurgião-Dentista da Universidade Federal de Santa Maria - RS.

Publication Dates

• Publication in this collection
  19 Nov 1999
• Date of issue
  Oct 1998

History

• Received
  06 Jan 1998
• Reviewed
  21 May 1998
• Accepted
  08 Aug 1998