Intravenous sedation management for an outpatient with dental phobia and vasovagal reflex following an atrioventricular junctional rhythm: A case report

Abstract

Perioperative arrhythmias may be induced by an imbalance between sympathetic and parasympathetic activities owing to excessive mental and physical stress. To date, no studies have been conducted on intravenous sedation (IVS) during dental procedures in a serious dental anxiety patient with atrioventricular junctional rhythm (AVJR). We describe herein the management of IVS in an outpatient with dental phobia who experienced the AVJR followed by vasovagal reflex (VVR) during dental care. A 26-year-old woman with serious dental anxiety was scheduled for dental extraction under intravenous conscious sedation. A II-lead electrocardiogram revealed AVJR following sinus rhythm. Immediately afterwards, she experienced VVR with dimmed vision, cold sweat, hypotension, and bradycardia. She was made to relax in the supine position, which restored hemodynamics to normal, and sinus rhythm followed. She was optimally sedated with midazolam 4 mg and uneventfully treated under a preparation of intravenous atropine, and hemodynamic and respiratory statuses were closely monitored to ensure spontaneous breathing without any signs of AVJR or cardiorespiratory disorders. Finally, flumazenil 0.5 mg was administered, and she recovered without re-sedation or prolonged sedation. The autonomic nervous system and endocrine system are closely related in order to control the stress responses. The present case suggests that an electrocardiographic change such as AVJR is induced by an imbalance of autonomic activity owing to excessive psychosomatic stress and is considered as a possible prodromal sign of VVR as the dental procedures are likely to be stressful for some patients.

Transient asystole associated with vasovagal reflex in an oral surgery patient: A case report

“…We need to distinguish and diagnose the electrocardiographic changes that suggest the possible signs associated with VVR such as AVJR 12 or asystole resulting from parasympathetic hypertonia owing to painful stress of venipuncture for peripheral intravenous catheterization or local anesthetic injection to oral mucosa. On the contrary, it is also reported that the cerebral hypoperfusion causes unconsciousness approximately 6 to 8 s after asystole.…”

“…The preoperative general conditions such as hypovolemia due to dehydration, or anemia, which are involved in the systemic risk factors triggering cardiac events, should be recognized and improved before surgery. 3 Therefore, it is necessary to differentiate the underlying cardiovascular diseases as the possible causes of hemodynamic disorders or electrocardiographic changes including AVJR 12 or asystole.…”

A preliminary study on the assessment of pain using figures among patients administered with dental local anesthesia for mandibular third molar extraction

“…[4,5,7,8] Most dental and oral surgical procedures are performed under local anesthesia; therefore, failure to properly assess and control pain can lead to problems such as elevated blood pressure, vasovagal reflexes, and treatment interruptions. [14,15] For example, Gürler et al previously reported that acute dental pain can induce elevated stress hormone levels. [16] However, pain is difficult to assess as it is based on personal experiences influenced by biological, psychological, and social factors.…”

How should clinicians assess acute dental pain?: A review

“…However, during dental procedures with acute pain, blood pressure fluctuations and vasovagal reflexes may occur because of changes in the autonomic nervous system. [38,39] These conditions should be assessed and managed by dentists before, during, and after dental treatment. However, these are still important dental clinical problems because they are complex situations related to the subjective psychological state of the patient and acute dental pain.…”

“…However, these are still important dental clinical problems because they are complex situations related to the subjective psychological state of the patient and acute dental pain. [38,39] In light of this point of view, the authors listed and discussed the current status and issues in the development of acute dental pain assessment methods.…”