Managing Persistently Elevated Blood Pressure and Heart Rate in Dental Patients

Sedation dentistry is a powerful tool for creating a comfortable and anxiety-free environment for patients undergoing dental procedures. However, even with careful preparation, scenarios can arise where a patient’s blood pressure (BP) and heart rate (HR) remain persistently elevated. These physiological changes can signal discomfort, stress, or underlying medical concerns, requiring the dentist’s immediate attention. Here's a step-by-step playbook for managing such situations effectively while ensuring patient safety.

Step 1: Evaluate Your Local Anesthesia

The first course of action is to assess your local anesthesia. Pain or discomfort can be a key driver of elevated BP and HR during sedation. Ensure that:

• The local anesthetic has been administered appropriately and in sufficient volume.
• You’ve used an adequate concentration to achieve profound anesthesia.
• You’re not relying solely on sedation to control pain during invasive procedures.

Reassess and top up the local anesthetic as needed, targeting full patient comfort before proceeding further.

Step 2: Check for a Full Bladder

Longer dental procedures can inadvertently cause bladder discomfort, especially when the patient is under sedation. A full bladder may result in sympathetic stimulation, increasing BP and HR. Ask the patient or pause the procedure to allow a restroom break if needed. Addressing this simple physiological need can often resolve elevated vital signs without further intervention.

Step 3: Reevaluate Patient Positioning

Improper positioning during a procedure can contribute to physical stress or discomfort. Check that:

• The patient’s head, neck, and back are properly supported.
• The chair is adjusted to n eminimize strain on the patient’s musculoskeletal system.
• The airway is unobstructed, and there are no signs of positional asphyxia or discomfort.

Adjust positioning as necessary to alleviate discomfort and ensure optimal circulation.

Step 4: Assess the Level of Sedation

Patients experiencing inadequate sedation may exhibit elevated BP and HR due to heightened stress, discomfort, or anxiety. Reevaluate the patient’s sedation level:

• Is the patient demonstrating signs of distress or restlessness?
• Has the current dose of sedative worn off?
• How much of my total max dose for the procedure have I given?

If necessary, administer a fresh dose of sedative, keeping within safe limits for the patient’s weight, respiratory stability, medical history, and overall condition.

Step 5: Pause and Monitor

If the above steps fail to resolve the issue, pause the procedure for 10 minutes. This break serves several purposes:

• It allows the patient’s autonomic system to recalibrate.
• It provides a window to reassess the patient’s condition and vital signs without external stimuli.

During this time, monitor the patient closely. If the heart rate and blood pressure decline to within acceptable limits, you may resume the procedure.

Step 6: Examine the Rhythm Strip

If the patient’s BP and HR remain elevated after pausing, it’s crucial to examine the rhythm strip for signs of arrhythmia. Persistent hypertension or tachycardia could indicate a more serious cardiac issue requiring intervention.

• Look for irregular heart rhythms or other abnormalities.
• Document your findings and be prepared to escalate care if needed.

Step 7: Know When to Stop

If the patient’s BP remains above a systolic of 180, diastolic of 110, or heart rate over 130 despite the above interventions, it’s time to stop the procedure if the readings did not lower after a 10 minute pause. Continuing under these conditions increases the risk of adverse outcomes and compromises patient safety. In such cases:

• Inform the patient or their caregiver about the situation.
• Refer the patient for further medical evaluation if necessary.
• Reschedule the procedure only once the patient’s condition has stabilized and any underlying issues have been addressed.

Conclusion

Managing elevated BP and HR during sedation requires a systematic approach to ensure patient safety and comfort. By addressing pain, positioning, sedation levels, and physiological needs, dentists can often resolve these issues promptly. However, knowing when to pause or stop the procedure is just as critical as recognizing the early warning signs. Following this playbook ensures a structured, safe response to challenging scenarios and reinforces trust in your care.

Always document your observations, interventions, and outcomes thoroughly to guide future treatment plans and maintain clear communication with patients and their healthcare providers.

Have questions about topics in this blog? We can help you in our Sedation forum, or check out our website for course dates!