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Cardiac Arrhythmias During Oral Surgery with Local Anesthesia
E le c tr o c a r d io g r a m s w e r e re co r d e d b e fo r e a n d d u r in g 7 7 o ra l s u r g e r y p r o c e d u r e s o n 6 5 p a t ie n t s . T w o p e r c e n t s o lu t io n o f lid o c a in e w ith 1 : 1 0 0 ,0 0 0 e p in e p h r in e w a s u se d fo r lo c a l a n e s t h e s i a . It w a s fo u n d t h a t o ld e r p a t i e n t s w ith c a r d io v a s c u la r d is e a s e h a d a g r e a t e r in c id e n c e o f p r e o p e r a tiv e a n d o p e r a t iv e a r r h y th m ia th a n t h o s e o f t h e s a m e a g e w ith c lin ic a lly n o r m a l c a r d io v a s c u la r s y s t e m s . T h e in c id e n c e o f a r r h y t h m ia in c r e a s e d w ith t h e d u r a tio n o f t h e p r o c e d u r e .
N o c o n s is te n t
r e la t io n s h ip
b e tw e e n
q u a n t it y o f a n e s t h e t i c a n d d e v e lo p m e n t o f a r r h y th m ia w a s n o te d .
C a r d ia c a r r h y t h m ia s d u r in g o ra l s u r g e r y w it h
lo c a l a n e s t h e s ia
Charles L. Hughes, DDS, Austin, Texas; John K. Leach, MD, Aibuquerque, N. Mex.
Robert E. A llen , DDS, MS, Kansas City, Mo.; Gordon O. Lambson, DDS, MS, Wadsworth, Kan.
The incidence of cardiac arrhythmia associated with general anesthesia and surgery has been the subject of many reports.113 Local anesthetics also have been associated with electrocardiographic changes in man and animals,14'16 but few studies have documented such changes during oral surgery. Burch and DePasquale17 recently pointed out the important relationship of dentistry to cardiology and emphasized the necessity of thorough evaluation of the cardiac patient before dental procedures.
The purpose of the present study was to investi gate further electrocardiographic changes during oral surgery with the patient under local anesthesia and to evaluate the clinical significance of these changes. Previous studies have indicated that vasocon strictor agents in the local anesthetic do not significantly increase the incidence of arrhythmia 1Si 19 and that epinephrine is not contraindicated in patients with cardiac disease if no more than 0.2 mg. is administered in any one operation.20 1095
Table 1 ■ Incidence of arrhythmia in relation to the
age of patient No. of potients developing arrhythmia
No. of arrhythmias
Age
During operation
Preoperatively
No. of procedures
No. of patients
proced % 13
30-39
13
16
O
2
40-49
13
18
1
2
6
50-59
12
14
3
4
14
60-69
14
10
53
12
15 13
3
70-79
4
7
38
80-89
1
1
0
0
0
65
77
11
25
Total
Table 2 ■ Incidence of arrhythmia in relation to quan
tity of anesthetic (2 per cent solution of lidocaine with epinephrine 1 :1 00,000) given to patient
Anesthetic (ml.)
No. of procedures
N °* of arrhythmias_______ During Preoperaoperation tively
No. of patients developing arrhythmia during procedure % 16 25 46
-1 . 8 1.9-3. 6 3.7-5.4 5.5-7.2 7.3-8. 8
32 24 15 5
4 4 3
9 7
0
0
0
1
O
1
100
Total
77
11
25
0 .8
8
Table 3 ■ Incidence of arrhythmia in relation to dura
tion of procedures
No. of arrhythmias Duration (m in.)
No. of procedures
Preoperatively
During operation
9 19
2
3
4 5
1
1
0
1
22
1-5 6-10
11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-48 Total
No. of patients developing arrhythmia during procedure %
.,
12 9
17
4
3 7
2
0
1
33 11
35 50 60
5
0
3
1
0
0
0
2
0
1
50
1
0
0
0
77
11
25
Since vasoconstrictors are usually desirable for good local anesthesia and since the recommended safe dose is seldom approached during oral surgery procedures, it was considered advisable to use the same anesthetic agent on all patients 1096 ■ JA D A , Vol. 73, Nov. 1966
in the study. Two percent lidocaine (Xylocaine) solution with 1:100,000 epinephrine was selected because of this agent’s widespread use.
M a t e r ia ls a n d m e t h o d s Seventy-seven procedures were carried out on 65 men. In this report, a procedure is defined as the total amount of oral surgery done at any one appointment. Ten patients were operated on twice; one patient, three times. Selection was made at random without regard to age, race, inpatient, or outpatient status, or the presence or absence of a cardiovascular or another disease. Fifty-six patients were Caucasian; eight were Negro, and one was Mexican. Patients ranged in age from 31 to 89 with a mean age of 55 (Table 1). Procedures consisted of minor oral surgery operations including single and multiple extrac tions, alveoloplasty, and biopsy. All patients were anesthetized with 2 percent solution of lidocaine (Xylocaine) with epinephrine 1:100,000 and operated on by one of us (C.L.H .). The volume of anesthetic ranged from 0.8 ml. to 8.8 ml. with a mean of 3.0 ml. (Table 2 ). No additional drugs were given at the time of surgery. Duration of the procedure was measured from the beginning of the injection until the completion of the operation. The duration ranged between 3 and 48 minutes with a mean of 17.5 minutes (Table 3 ). Preoperative electrocardiograms were obtained for all patients on a Sanborn Model 964, fourchannel, direct-writing recorder. Preoperative tracings consisted of the three standard limb leads, three unipolar limb leads, and seven pre cordial leads ( V4R, V i'V6). Injection of the anesthetic began 3 to 10 minutes after the control electrocardiogram was recorded. The operative electrocardiographic tracings that began just before the injection were terminated a few minutes after the completion of surgery. The tracings during the procedure were recorded on lead II at paper speeds of 10 or 25 mm./second. In the longer procedures, the electrocardiographic activity was monitored some of the time on the cathode-ray oscilloscope in lieu of a continuous tracing. All tracings were interpreted by one of us (J. K. L .). Preoperative electrocardiograms (ECG) were classified in the following way (Tables 4 and 5):
Group 1 included patients with normal ECG and no arrhythmia, a normal pattern with normal sinus rhythm. Group 2 patients had normal ECG and ar rhythmia. A normal pattern with arrhythmia is in itself not abnormal; it includes sinus arrhyth mia, supraventricular premature beats (atrial or nodal), and unifocal ventricular premature beats. Group 3 was comprised of patients with ab normal ECG and no arrhythmia, an abnormal pattern with normal sinus rhythm. These abnor malities may or may not be indicative of cardio vascular disease. Examples of ECG abnormalities which, by themselves, were inconclusive for cardiac disease included minor conduction defects and nonspecific ST and T wave changes. Tracings showing major conduction defects, ventricular hypertrophy, and patterns of old myocardial in farction indicated cardiac disease. Group 4 patients had abnormal ECG with arrhythmia. This group is similar to group 3 but with an arrhythmia. R e s u lts On reviewing the histories of the 65 patients, 40 (61 percent) were considered to have normal cardiovascular systems, whereas 25 (39 percent) had cardiovascular abnormalities. Three patients with minor preoperative electrocardiographic abnormalities were considered normal since history and physical examination indicated no evidence of cardiovascular disease.
Table 4 ■ incidence of arrhythmia in patients without
cardiovascular disease Preoperative ECG Preoperative group classification
No. of patients
Operative ECG
Operations Operations No. of without with procedures arrhythm ia arrhythmia
1.
Normal without arrhythmia 2 . Norma! with arrhythmia 3. Abnormal without arrhythmia 4. Abnormal with arrhythmia
35
2
3
0
40
46
36
10
procedures without development of arrhythmia. In addition, four others of this group had two operations without development of arrhythmia either time. ■ In group 2, two of the patients without cardio vascular disease had normal preoperative tracings with arrhythmia. One (patient 7) had rare VPC and the other (patient 8) had occasional supra ventricular premature beats. In neither patient was there an increased frequency of ectopic beats during the operation. ■ In group 3, of the three patients with abnormal preoperative tracings without arrhythmia, two (patients 9 and 10) developed occasional supra ventricular premature beats; the other showed no change. ■ In group 4, no patients without cardiovascular disease had an abnormal preoperative electro cardiogram and arrhythmia.
Patients without cardiovascular disease Tables 4 and 6 show the incidence of arrhythmia in patients without histories of cardiovascular disease. ■ In group 1, 35 of the 40 patients without cardiovascular disease had normal preoperative electrocardiograms (ECG) without arrhythmia. Six patients (patients 1, 2, 3, 4, 5, and 6) de veloped arrhythmias during operation. Four (patients 1, 2, 3, and 4) had infrequent unifocal ventricular premature contractions (V PC ), one (patient 5) a wandering pacemaker, and one (patient 6) occasional supraventricular prema ture beats. One of the four patients with ven tricular premature contractions (VPC) and the patient with the wandering pacemaker had second
Table 5 ■ Incidence of arrhythmia
in patients with
cardiovascular disease Preoperative ECG Preoperative group classification Normal without arrhythmia 2. Normal with arrhythmia 3. Abnormal without . arrhythmia 4. Abnormal with arrhythmia
No. of patients
Operative ECG
Operations Operations No. of without with procedures arrhythm ia arrhythmia
1.
9
3
9
5* 26
11
3
11
6
31
6
5
0
3
10
1
0
6
16
15
*One patient was in both preoperative group 3 and 4.
Hughes and others: CARDIAC AR R H Y T H M IA S AND LOCAL AN ESTHESIA ■ 1097
T ab le 6 ■ Types of arrhythmia in patients without cardiovascular disease Preoperative ECG Patient no.
Normal
6
X X X X X X
7
xt
1 2
3 4 5
8
Xt
Operative ECG
Arrhythmia
Other*
Normal Xi Xt Xt Xt Xt Xt
.., Unifocal VPC Supraventricular premature con tractions
9 10
Xt Xt Minor nonspecific ST & T wave changes Minor intraventricular conduction defect
Arrhythm ia Unifocal VPC Unifocal V P C Unifocal VPC Unifocal VPC Wandering pacemaker Supraventricular premature contractions Unifocal VPC Supraventricular premature contractions Supraventricular premature contractions Supraventricular premature contractions
*Other than normal or normal and arrhythmia. ^Normal pattern with arrhythmia which, in itself, was not abnormal.
Patients with cardiovascular disease Tables 5 and 7 show the incidence of arrhythmia in cardiovascular patients. The 25 patients with cardiovascular disease were in two categories. Eighteen had ischemic heart disease manifested by anginal syndrome or previous myocardial in farction; seven had hypertensive vascular disease with or without cardiac enlargement. ■ In group 1, nine patients had normal preopera tive electrocardiograms and no arrhythmia: Five of the nine showed no electrocardiographic changes during surgery (one of these five had two operations without an appearance of arrhythmia). The other four patients developed arrhythmia (patients 11, 12, 13A, 13B, and 14): one (patient 11) developed multifocal ventricular premature contractions; one (patient 12) a wandering atrial pacemaker, and two (patients 13A, 13B, and 14) occasional unifocal VPC. ■ In group 2, three patients with cardiovascular disease (patients 15, 16, and 17) had normal preoperative ECG with an arrhythmia. In each, arrhythmia was present during surgery. One patient (patient 15) had sinus arrhythmia in preoperative and operative tracings. Another (patient 16) with occasional unifocal VPC in the preoperative tracing, developed multifocal VPC during operation, and another (patient 17) with supraventricular premature beats preoperatively, had similar beats associated with episodes of nodal escape during surgery. The latter patient was re ceiving a digitalis preparation. ■ In group 3, nine patients had abnormal pre operative electrocardiograms and no arrhythmia. 1098 ■ JA D A , Vol. 73, Nov. 1966
One patient, receiving digitalis, had no operative arrhythmia. Another patient, also receiving digi talis, had three operations without the appearance of arrhythmia. Of the remaining seven, six did not develop arrhythmia, and one (patient 18) de veloped occasional supraventricular premature beats. ■ In group 4, five patients (patients 19, 20, 21A, 2 IB, 22, and 23) had abnormal preoperative electrocardiograms (ECG) and arrhythmia. One patient (patient 19) taking digitalis had unifocal VPC preoperatively and during the procedure (this patient was also in group 3 but had no oper ative arrhythmia). Another (patient 20) had atrial fibrillation and unifocal VPC in preoperative and operative tracings. One individual (patient 21 A, 2 IB) had two procedures. His first pre operative record showed occasional supraven tricular premature beats; his second, a wandering pacemaker. On neither occasion was there a significant change in the arrhythmia during surgery. Another patient (patient 2 3 ), taking digitalis, had occasional unifocal VPC in pre operative and operative tracings, whereas the third - (patient 2 2 ), not receiving digitalis, had unifocal VPC preoperatively but developed mul tifocal VPC during the operation.
D is c u s s io n Increased incidence of arrhythmia during general anesthesia and surgery is a common finding. Dodd and associates10 reported the appearance of arrhythmia in 92 of 179 patients (51 percent)
T ab le 7 ■ Types of arrhythmia in patients with cardiovascular disease Patient no.
Preoperative ECG Normal
11
X
12
X
13Af 13 B f
Operative ECG
Arrhythmia
Other*
X*
x$
X
14
X X*
X*
Sinus arrhythmia
16
X*
Unifocal VPC
17
Xt
Supraventricular premature contractions unifocal VPC
18
----
19
Arrhythm ia Supraventricular premature contractions, & multifocal VPC
X
15
Normal
Supraventricular premature contractions, shifting pacemaker Unifocal VPC Unifocal VPC
X$
Unifocal VPC
X*
Sinus arrhythmia
X*
Supraventricular premature contractions, nodal escape
Multifocal VPC
L e ft ventricular hypertrophy, old anterior wall infarction
Supraventricular premature contractions
Unifocal VPC
Old anterior wall infarction, ischemia, digitalis effect
Unifocal VPC
Unifocal VPC atrial fibrillation
Right bundle branch block
Unifocal VPC , atrial fibriljation
21 A f
Supraventricular premature contractions ✓
Right bundle branch block
Supraventricular premature contractions
21 B f
Supraventricular premature contractions, wandering pacemaker
Right bundle branch block
Supraventricular premature contractions, unifocal V P C , wander ing pacemaker
Unifocal V P C
Old multiple infarction
M ultifocal VPC
Unifocal VPC
Old anteroseptal infarction, left axis deviation
Unifocal VPC
20
22
23
....
....
♦Other than normal or normal and arrhythmia. f A and B indicates same patient undergoing two procedures. ¿Norm al pattern with arrhythmia which, in itself, was not normal.
with cardiovascular disease undergoing general anesthesia and in 78 of 390 patients (2 0 percent) without cardiovascular disease. In a similar study by Hurwitz,11 arrhythmia appeared in 72 of 190 patients (38 percent) with cardiovascular disease and in two of 30 normal patients (7 percent). In our study, the development of operative arrhythmia was greater in patients with cardio vascular disease. In 31 procedures on 25 patients with cardiovascular disease, no preoperative arrhythmia was present in 22 procedures. Opera tive arrhythmia occurred in six of these 22 pro cedures. Preoperative and operative arrhythmia was present in nine procedures. In four of these nine, the operative arrhythmia differed from the preoperative arrhythmia. Therefore, operative arrhythmia developed in ten of 31 procedures (33 percent). In 46 operations on 40 patients without cardio vascular disease, no preoperative arrhythmia was present in 44. Operative arrhythmia occurred in
eight of these 44. In two other instances, pre operative arrhythmia showed no chapge during surgery. Thus, in eight of 46 procedures (17 per cent), operative arrhythmia developed.’ None of the arrhythmias was considered significant. ■ Age and incidence of arrhythmias: Since the number of patients in each age group was small, it is difficult to draw conclusions regarding the in fluence of age on the appearance of arrhythmia. As noted in Table 8, however, the older patients were more susceptible to arrhythmia before and during surgery. As expected, older patients with cardiovascular disease had a greater incidence of preoperative and operative arrhythmia than those of the same age with clinically normal cardio vascular systems. These findings were consistent with those of Dodd,10 Hurwitz,11 and Calatayud.12 Silverblatt and others,9 however, noticed poor correlation of age with arrhythmia during surgical procedures.
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T ab le 8 ■ Incidence of arrhythmia in relation to the age and cardiovascular status of patient Absence of cardiovascular disease
Age 30-39 40-49 50-59 60-69 70-79 80-89
Presence of cardiovascular disease
Arrhythm ia present preopera tively
Arrhythm ia present during operation
14 13
0
2
0
1
5
1
1
8
1
1
6
2
3
7 4
1
4
8
2
6
0
2
9
4
5
0
0
9
15
No. of procedures
No. of procedures
Arrhythmia present preopera tively
Arrhythmia present during operation
2
0
0
0
0
0
1
46
2
10
31
■ Duration of procedure and incidence of ar rhythmia: The incidence of arrhythmia in creased with the duration of the procedure (Table 3 ). This increase was expected, as the longer pro cedures presented more time for arrhythmia to appear. Hurwitz11 noticed an increase in post operative ECG changes from 51 to 77 percent in procedures under 1 hour to over 2 hours, re spectively. A similar increase might have been noted if our procedures had been longer. ■ Quantity of anesthetic and incidence of arrhythmia: No consistent relationship between the quantity of anesthesia and arrhythmia was noticed (Table 2 ). The maximum quantity of anesthetic (2 percent lidocaine solution, 1:100,000 epinephrine) used was 8.8 ml. (176 mg. of lidocaine, 0.088 mg. of epinephrine). This was well within the maximum limits of 500 mg. of lidocaine as discussed by Adriani21 and of 0.2 mg. of epinephrine as recommended by the New York Heart Association.20 ■ Significance of arrhythmia: Most of the occur rences of arrhythmia observed during surgery were not considered clinically significant (Tables 6 and 7 ). Nine patients had infrequent, unifocal ventricular premature contractions (V PC ). Such an arrhythmia is benign.13 Averill22*23 found this arrhythmia in 0.65 percent of normal, healthy subjects but observed a threefold increase in this type of arrhythmia in persons over 45 years old. One instance of sinus arrhythmia was noticed postoperatively and during procedure. Sinus arrhythmia is a normal phenomenon with no clinical significance.13 24 Two patients having normal preoperative ECG developed an operative wandering supraventricu lar pacemaker. This arrhythmia is discussed under sinus arrhythmia by Katz 25 and has no clinical 1100 ■ JA D A , Vol. 73, Nov. 1966
*
significance. Graybiel and others26 reported a wandering pacemaker in 2.3 percent of 1,000 young, healthy aviators. He stated this unim portant arrhythmia had no pathological signifi cance. One patient, a 78-year-old Caucasian man with a history of myocardial ischemia, had a right bundle branch block, wandering pacemaker, and supraventricular premature contractions in a pre operative electrocardiogram. The oniy change during procedure was two unifocal ventricular premature contractions (V PC ). Six subjects had occasional unifocal supraven tricular premature contractions during procedure. Two of these had this arrhythmia preoperatively. Fosmoe27 noticed supraventricular premature con tractions occurring in 4 .9/1,000 subjects through all age groups (16 to 55 years). The vast majority of extrasystoles (premature contractions: atrial, nodal, or ventricular in origin) cause no complaints and require no therapy.28 Irving29 noticed that a single premature systole did not significantly reduce overall cardiac function. One patient, a 76-year-old Caucasian man with a history of ischemic heart disease and congestive heart failure, had unifocal supraventricular pre mature contractions preoperatively but, during the operative procedure, this arrhythmia was followed by atrioventricular nodal escape. This patient was not taking digitalis. Nodal escape is often observed in older age groups in association with sinus bradycardia and may occur because of digitalis intoxication30 but is usually of no clinical sig nificance.31 The most important type of arrhythmia de veloping during an operation was multifocal ventricular premature contractions (V PC ). Pre mature contractions from several areas within the same chamber indicate widespread myocardial irritability32 and may denote advanced myocardial
disease.29 Averill and others23 found that, in 67,375 asymptomatic subjects, only one had definite multifocal VPC. They concluded that multifocal VPC is evidence of heart disease. Although multifocal ventricular premature con tractions were not present in any preoperative tracing, three patients developed this arrhythmia during procedure. A brief review of these cases follows: Case 1 (patient 22): A 53-year-old Caucasian man had a history of multiple myocardial infarc tions. The preoperative electrocardiogram sug gested old inferior and anterolateral infarctions. Unifocal VPC with runs of bigeminal rhythm were present. Multifocal VPC developed during opera tion. His medications consisted of pentaerythritol tetranitrate (Peritrate) and nitroglycerin. Case 2 (patient 11): A 71-year-old Mexican man had a history of ischemic heart disease, evidence of cardiomegaly, and chronic pulmonary emphysema. His preoperative tracing showed a rate of 60 and a digitalis effect but no premature contractions; several premature supraventricular contractions and multifocal VPC developed during procedure. The patient was taking digitoxin (Purodigin), phenobarbital, sodium diphenylhydantoin (Dilan tin sodium), and hydrochlorothiazide (Esidrex). Case 3 (patient 16): A 63-year-old Caucasian man had a history of ischemic heart disease and diabetes mellitus. His preoperative electrocardio gram showed a rate of 100 with occasional uni focal VPC. These VPC continued but became multifocal near the completion of surgery. This patient was taking tolbutamide (Orinase). These three patients had (1 ) histories of signif icant cardiovascular disease and (2 ) development of multifocal VPC during surgery. It is apparent that in this study the develop ment of operative arrhythmia was significantly greater in patients with cardiovascular disease. Although none of our patients developed symptoms related to the arrhythmia, it is certainly conceivable that cardiac irregularities could lead to hypotension, syncope, and coronary insuffi ciency in this group of patients. This study, there fore, emphasizes the importance of thorough evaluation of the cardiac patient before oral surgery, as recently mentioned by Burch and DePasquale.17 These authors state that the
“hazards of frequent dental manipulations of short duration should be weighed against the hazards of more prolonged manipulation with fewer visits.” They also indicated that under certain circumstances the use of nitroglycerin or preoperative sedation might increase the tolerance of cardiac patients to oral surgery. Such decisions, of course, are of extreme importance to the cardiac patient and indicate the necessity of con sultation between the oral surgeon and the cardiologist. S um m ary Electrocardiograms were recorded before and during 77 oral surgery procedures on 65 patients. Two percent solution of lidocaine with 1:100,000 epinephrine was used for local anesthesia. Forty-six operations were performed on 40 patients without cardiovascular disease. In 44, no preoperative arrhythmia was present. Operative arrhythmia occurred in eight of these 44. In two other instances, minor arrhythmia, present in preoperative electrocardiograms, was unchanged during surgery. Therefore, operative arrhythmia developed during eight of 46 procedures (17 per cent) in this group of patients. Thirty-one procedures were performed on 25 patients with cardiovascular disease. No preopera tive arrhythmia was present in patients involved in 22 procedures. Operative arrhythmia occurred during six of these 22 procedures. In nine other procedures, preoperative and operative arrhyth mia occurred. In four of these nine, the op erative arrhythmia differed from the preopera tive arrhythmia. Therefore, in ten of 31 proce dures (33 percent), operative arrhythmia devel oped in the patient. N o multifocal VPC occurred preoperatively, but operative multifocal VPC de veloped in three of 31 procedures (10 percent). Older patients with cardiovascular disease had a greater incidence of preoperative and operative arrhythmia than those of the same age with clin ically normal cardiovascular systems. The inci dence of arrhythmia increased with the duration of the procedure. No consistent relationship be tween quantity of anesthetic and development of arrhythmia was noticed. Doctor Hughes was formerly a senior resident in oral surgery, Veterans Administration Center, W ad s worth, Kan. His present address is 1510 W est 34th Street, Austin, Texas 78703. Doctor Leach was formerly
Hughes and others: C A R D IA C A R R H Y T H M IA S A N D LO C A L A N E S T H E S IA
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1101
associate chief of staff at the Veterans Administration Center in Wadsworth, Kan. A t present, he is assistant professor of medicine at the University of New Mexico, School of Medicine, Albuquerque, N. Mex. Doctor Allen is professor and chairman of the department of oral surgery at the University of Missouri at Kansas City, School of Dentistry, Kansas City. Doctor Lambson is the chief of the oral surgery section at the Veterans Adm ini stration Center, Wadsworth, Kan. 1. Erlanger, H. Cardiac arrhythmias in relationship to anesthesia: past and present concepts. Amer. J . Med. Sci. 243:651 M ay, 1962. 2. Department of anesthesia, University of Pennsyl vania School of Medicine, Philadelphia. The heart and general anesthesia. Mod. Cone. Cardiov. Dis. 32:805 July, 1963. 3. Bellet, Samuel. Clinical disorders of the heartbeat, Philadelphia, Lea & Febiger, 1963, p. 696-712. 4. Rosner S.; Newman, W ., and Burstein, C. L. Electrocardiographic studies during endotracheal intu bation. V I. Effects during anesthesia with thiopental sodium combined with a muscle relaxant. Anesthesiology 14:591 Nov., 1953. 5. Arcuri, R. A .; Newman, W ., and Burstein, C. L. Electrocardiographic studies during endotracheal intu bation. V. Effects during general anesthesia and hexylcain e hydrochloride topical spray. Anesthesiology 14:46 Jan ., 1953. 6. Burstein, C. L.; LoPinto, F. J., and Newman, W . Electrocardiographic studies during endotracheal intuba tion. 1. Effects during usual routine technics. Anesthe siology. 1 1 :224, M arch, 1950. 7. Jacoby, J., and others. Cardiac arrhythmia: effect of vagal stimulation and hypoxia. Anesthesiology 16:1004 Nov., 1955. 8. Cannard, T. H., and others. The electrocardiogram during anesthesia and surgery. Anesthesiology 21:194 March-April, 1960. 9. Silverblatt, C. W ., and others. Factors associated with the development of ectopic rhythms during surgery. Amer. J . Surg. 103:102 Jan., 1962. 10. Dodd, R. B.; Simms, W . A ., and Bone, D. J. Cardiac arrhythmias observed during anesthesia and surgery. Surgery 51:440 April, 1962. 1 1. Hurwitz, M . M. Electrocardiographic changes following surgery. Geriatrics 17:275 M ay, 1962. 12. Calatayud, J . B.; Kelser, G. A ., Jr., and Caceres, C. A. Incidence of cardiac arrhythmias following non cardiac thoracic surgery. J . Thorac. Cardiov. Surg. 41 :498 April, 1961. 13. Buckley, J. J., and Jackson, J. A . Postoperative cardiac arrhythmias. Anesthesiology 22:723 Sept.-Oct.( 1961. 14. Foldes, F. F., and others. Comparison of toxicity of intravenously given local anesthetic agents in man. J A M A 172:1493 April 2, 1960. 15. Fraser, I. M ., and others. A comparative study of the effect of local anesthetics on the electrocardio gram of the dog. J . S. Calif. Dent. Assn. 30:228 July, 1962. 16. Sfewart, D. M ., and others. Effect of local anes thetics on the cardiovascular system of the dog. Anes thesiology 24:620 Sept.-Oct., 1963. 17. Burch, G. E., and DePasquale, N. P. Relationship of dentistry to cardiology. Amer. Heart J. 67:99 Jan ., 1964. 18. W illiam s, R. M ., and others. Electrocardiographic changes during oral surgical procedures under local anesthesia. Oral Surg. 16:1270 Oct., 1963. 19. Modica, R., and Olivero, S. Electrocardiographic
1102 ■ JA D A , Vol. 73, Nov. 1966
findings in dental surgery with local anesthesia. Minerva Anest. 22:97 March, 1956. 20. New York Institute of Clinical Oral Pathology: a report from the New York Heart Association. Is the use of epinephrine dangerous in connection wth procaine in dental procedures? Oral Surg. 8:225 M arch, 1955. 21. Adriani, J.; Campbell, D., and Yarberry, O. H., Jr. Influence of absorption on systemic toxicity of local anesthestic agents. Anesth. Analg. 38:370 Sept.-Oct., 1959. 22. A verill, K. H., and Lamb, L. E. Electrocardio graphic findings in 67,375 asymptomatic subjects. 1. Incidence of abnormalities. Amer. J . Cardiol. 6:76 Ju ly, 1960. 23. Hiss, R. G.; Averill, K. H., and Lamb, L. E. Electrocardiographic findings in 67,375 asymptomatic subjects. III. Ventricular rhythms. Amer. J. Cardiol. 6:96 July, 1960. 24. Phibbs, Brendan Pearse. The cardiac arrhythmias, a guide for the general practitioner. St. Louis, C. V. Mosby Co., 1961, p. 31. 25. Katz, Louis Nelson, and Pick, Alfred. Clinical electrocardiography. 1. The arrhythmias with an atlas of electrocardiograms. Philadelphia, Lea & Febiger, 1956, p. 69-70. 26. Graybiel, A ., and others. Analysis of the electro cardiograms obtained from 1,000 young healthy aviators. Amer. Heart J. 27:524. April, 1944. 27. Fosmoe, R. J .; Averill, K. H., and Lamb, L. E. Electrocardiographic findings in 67,375 asymptomatic subjects. II. Supraventricular arrhythmias. Amer. J. Cardiol. 6:84 Ju ly , 1960. 28. Scherf, D. The mechanism and treatment of extra systoles. Progr. Cardiov. Dis. 2:370 Jan ., 1960. 29. Irving, D. W . The significance and treatment of premature systoles. Dis. Chest 40:102 July, 1961. 30. Bellet, Samuel. Clinical disorders of the heartbeat. Philadelphia, Lea & Febiger, 1963, p. 400-401. 31. Katz, Louis Nelson, and Pick, Alfred. Clinical electrocardiography. 1. The arrhythmias with an atlas of electrocardiograms. Philadelphia, Lea & Febiger, 1956, p. 98. 32. Phibbs, Brendan Pearse. The cardiac arrhythmias, a guide for the general practitioner, St. Louis, C. V. Mosby Co., 1961, p. 42.
Definitions As the patient from the country walked the city-hospital corridor with his wife, he attempted to interpret the various signs for her: "Pharm acy— that's the drugstore. Pediatrics— that's for babies and children. Oral Surgery— that's where they talk you out of it."
Contributed by Hazel Prosser, Reader’s Digest, June, 1966, p. 172.
N o c o n s is te n t
r e la t io n s h ip
b e tw e e n
q u a n t it y o f a n e s t h e t i c a n d d e v e lo p m e n t o f a r r h y th m ia w a s n o te d .
C a r d ia c a r r h y t h m ia s d u r in g o ra l s u r g e r y w it h
lo c a l a n e s t h e s ia
Charles L. Hughes, DDS, Austin, Texas; John K. Leach, MD, Aibuquerque, N. Mex.
Robert E. A llen , DDS, MS, Kansas City, Mo.; Gordon O. Lambson, DDS, MS, Wadsworth, Kan.
The incidence of cardiac arrhythmia associated with general anesthesia and surgery has been the subject of many reports.113 Local anesthetics also have been associated with electrocardiographic changes in man and animals,14'16 but few studies have documented such changes during oral surgery. Burch and DePasquale17 recently pointed out the important relationship of dentistry to cardiology and emphasized the necessity of thorough evaluation of the cardiac patient before dental procedures.
The purpose of the present study was to investi gate further electrocardiographic changes during oral surgery with the patient under local anesthesia and to evaluate the clinical significance of these changes. Previous studies have indicated that vasocon strictor agents in the local anesthetic do not significantly increase the incidence of arrhythmia 1Si 19 and that epinephrine is not contraindicated in patients with cardiac disease if no more than 0.2 mg. is administered in any one operation.20 1095
Table 1 ■ Incidence of arrhythmia in relation to the
age of patient No. of potients developing arrhythmia
No. of arrhythmias
Age
During operation
Preoperatively
No. of procedures
No. of patients
proced % 13
30-39
13
16
O
2
40-49
13
18
1
2
6
50-59
12
14
3
4
14
60-69
14
10
53
12
15 13
3
70-79
4
7
38
80-89
1
1
0
0
0
65
77
11
25
Total
Table 2 ■ Incidence of arrhythmia in relation to quan
tity of anesthetic (2 per cent solution of lidocaine with epinephrine 1 :1 00,000) given to patient
Anesthetic (ml.)
No. of procedures
N °* of arrhythmias_______ During Preoperaoperation tively
No. of patients developing arrhythmia during procedure % 16 25 46
-1 . 8 1.9-3. 6 3.7-5.4 5.5-7.2 7.3-8. 8
32 24 15 5
4 4 3
9 7
0
0
0
1
O
1
100
Total
77
11
25
0 .8
8
Table 3 ■ Incidence of arrhythmia in relation to dura
tion of procedures
No. of arrhythmias Duration (m in.)
No. of procedures
Preoperatively
During operation
9 19
2
3
4 5
1
1
0
1
22
1-5 6-10
11-15 16-20 21-25 26-30 31-35 36-40 41-45 46-48 Total
No. of patients developing arrhythmia during procedure %
.,
12 9
17
4
3 7
2
0
1
33 11
35 50 60
5
0
3
1
0
0
0
2
0
1
50
1
0
0
0
77
11
25
Since vasoconstrictors are usually desirable for good local anesthesia and since the recommended safe dose is seldom approached during oral surgery procedures, it was considered advisable to use the same anesthetic agent on all patients 1096 ■ JA D A , Vol. 73, Nov. 1966
in the study. Two percent lidocaine (Xylocaine) solution with 1:100,000 epinephrine was selected because of this agent’s widespread use.
M a t e r ia ls a n d m e t h o d s Seventy-seven procedures were carried out on 65 men. In this report, a procedure is defined as the total amount of oral surgery done at any one appointment. Ten patients were operated on twice; one patient, three times. Selection was made at random without regard to age, race, inpatient, or outpatient status, or the presence or absence of a cardiovascular or another disease. Fifty-six patients were Caucasian; eight were Negro, and one was Mexican. Patients ranged in age from 31 to 89 with a mean age of 55 (Table 1). Procedures consisted of minor oral surgery operations including single and multiple extrac tions, alveoloplasty, and biopsy. All patients were anesthetized with 2 percent solution of lidocaine (Xylocaine) with epinephrine 1:100,000 and operated on by one of us (C.L.H .). The volume of anesthetic ranged from 0.8 ml. to 8.8 ml. with a mean of 3.0 ml. (Table 2 ). No additional drugs were given at the time of surgery. Duration of the procedure was measured from the beginning of the injection until the completion of the operation. The duration ranged between 3 and 48 minutes with a mean of 17.5 minutes (Table 3 ). Preoperative electrocardiograms were obtained for all patients on a Sanborn Model 964, fourchannel, direct-writing recorder. Preoperative tracings consisted of the three standard limb leads, three unipolar limb leads, and seven pre cordial leads ( V4R, V i'V6). Injection of the anesthetic began 3 to 10 minutes after the control electrocardiogram was recorded. The operative electrocardiographic tracings that began just before the injection were terminated a few minutes after the completion of surgery. The tracings during the procedure were recorded on lead II at paper speeds of 10 or 25 mm./second. In the longer procedures, the electrocardiographic activity was monitored some of the time on the cathode-ray oscilloscope in lieu of a continuous tracing. All tracings were interpreted by one of us (J. K. L .). Preoperative electrocardiograms (ECG) were classified in the following way (Tables 4 and 5):
Group 1 included patients with normal ECG and no arrhythmia, a normal pattern with normal sinus rhythm. Group 2 patients had normal ECG and ar rhythmia. A normal pattern with arrhythmia is in itself not abnormal; it includes sinus arrhyth mia, supraventricular premature beats (atrial or nodal), and unifocal ventricular premature beats. Group 3 was comprised of patients with ab normal ECG and no arrhythmia, an abnormal pattern with normal sinus rhythm. These abnor malities may or may not be indicative of cardio vascular disease. Examples of ECG abnormalities which, by themselves, were inconclusive for cardiac disease included minor conduction defects and nonspecific ST and T wave changes. Tracings showing major conduction defects, ventricular hypertrophy, and patterns of old myocardial in farction indicated cardiac disease. Group 4 patients had abnormal ECG with arrhythmia. This group is similar to group 3 but with an arrhythmia. R e s u lts On reviewing the histories of the 65 patients, 40 (61 percent) were considered to have normal cardiovascular systems, whereas 25 (39 percent) had cardiovascular abnormalities. Three patients with minor preoperative electrocardiographic abnormalities were considered normal since history and physical examination indicated no evidence of cardiovascular disease.
Table 4 ■ incidence of arrhythmia in patients without
cardiovascular disease Preoperative ECG Preoperative group classification
No. of patients
Operative ECG
Operations Operations No. of without with procedures arrhythm ia arrhythmia
1.
Normal without arrhythmia 2 . Norma! with arrhythmia 3. Abnormal without arrhythmia 4. Abnormal with arrhythmia
35
2
3
0
40
46
36
10
procedures without development of arrhythmia. In addition, four others of this group had two operations without development of arrhythmia either time. ■ In group 2, two of the patients without cardio vascular disease had normal preoperative tracings with arrhythmia. One (patient 7) had rare VPC and the other (patient 8) had occasional supra ventricular premature beats. In neither patient was there an increased frequency of ectopic beats during the operation. ■ In group 3, of the three patients with abnormal preoperative tracings without arrhythmia, two (patients 9 and 10) developed occasional supra ventricular premature beats; the other showed no change. ■ In group 4, no patients without cardiovascular disease had an abnormal preoperative electro cardiogram and arrhythmia.
Patients without cardiovascular disease Tables 4 and 6 show the incidence of arrhythmia in patients without histories of cardiovascular disease. ■ In group 1, 35 of the 40 patients without cardiovascular disease had normal preoperative electrocardiograms (ECG) without arrhythmia. Six patients (patients 1, 2, 3, 4, 5, and 6) de veloped arrhythmias during operation. Four (patients 1, 2, 3, and 4) had infrequent unifocal ventricular premature contractions (V PC ), one (patient 5) a wandering pacemaker, and one (patient 6) occasional supraventricular prema ture beats. One of the four patients with ven tricular premature contractions (VPC) and the patient with the wandering pacemaker had second
Table 5 ■ Incidence of arrhythmia
in patients with
cardiovascular disease Preoperative ECG Preoperative group classification Normal without arrhythmia 2. Normal with arrhythmia 3. Abnormal without . arrhythmia 4. Abnormal with arrhythmia
No. of patients
Operative ECG
Operations Operations No. of without with procedures arrhythm ia arrhythmia
1.
9
3
9
5* 26
11
3
11
6
31
6
5
0
3
10
1
0
6
16
15
*One patient was in both preoperative group 3 and 4.
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T ab le 6 ■ Types of arrhythmia in patients without cardiovascular disease Preoperative ECG Patient no.
Normal
6
X X X X X X
7
xt
1 2
3 4 5
8
Xt
Operative ECG
Arrhythmia
Other*
Normal Xi Xt Xt Xt Xt Xt
.., Unifocal VPC Supraventricular premature con tractions
9 10
Xt Xt Minor nonspecific ST & T wave changes Minor intraventricular conduction defect
Arrhythm ia Unifocal VPC Unifocal V P C Unifocal VPC Unifocal VPC Wandering pacemaker Supraventricular premature contractions Unifocal VPC Supraventricular premature contractions Supraventricular premature contractions Supraventricular premature contractions
*Other than normal or normal and arrhythmia. ^Normal pattern with arrhythmia which, in itself, was not abnormal.
Patients with cardiovascular disease Tables 5 and 7 show the incidence of arrhythmia in cardiovascular patients. The 25 patients with cardiovascular disease were in two categories. Eighteen had ischemic heart disease manifested by anginal syndrome or previous myocardial in farction; seven had hypertensive vascular disease with or without cardiac enlargement. ■ In group 1, nine patients had normal preopera tive electrocardiograms and no arrhythmia: Five of the nine showed no electrocardiographic changes during surgery (one of these five had two operations without an appearance of arrhythmia). The other four patients developed arrhythmia (patients 11, 12, 13A, 13B, and 14): one (patient 11) developed multifocal ventricular premature contractions; one (patient 12) a wandering atrial pacemaker, and two (patients 13A, 13B, and 14) occasional unifocal VPC. ■ In group 2, three patients with cardiovascular disease (patients 15, 16, and 17) had normal preoperative ECG with an arrhythmia. In each, arrhythmia was present during surgery. One patient (patient 15) had sinus arrhythmia in preoperative and operative tracings. Another (patient 16) with occasional unifocal VPC in the preoperative tracing, developed multifocal VPC during operation, and another (patient 17) with supraventricular premature beats preoperatively, had similar beats associated with episodes of nodal escape during surgery. The latter patient was re ceiving a digitalis preparation. ■ In group 3, nine patients had abnormal pre operative electrocardiograms and no arrhythmia. 1098 ■ JA D A , Vol. 73, Nov. 1966
One patient, receiving digitalis, had no operative arrhythmia. Another patient, also receiving digi talis, had three operations without the appearance of arrhythmia. Of the remaining seven, six did not develop arrhythmia, and one (patient 18) de veloped occasional supraventricular premature beats. ■ In group 4, five patients (patients 19, 20, 21A, 2 IB, 22, and 23) had abnormal preoperative electrocardiograms (ECG) and arrhythmia. One patient (patient 19) taking digitalis had unifocal VPC preoperatively and during the procedure (this patient was also in group 3 but had no oper ative arrhythmia). Another (patient 20) had atrial fibrillation and unifocal VPC in preoperative and operative tracings. One individual (patient 21 A, 2 IB) had two procedures. His first pre operative record showed occasional supraven tricular premature beats; his second, a wandering pacemaker. On neither occasion was there a significant change in the arrhythmia during surgery. Another patient (patient 2 3 ), taking digitalis, had occasional unifocal VPC in pre operative and operative tracings, whereas the third - (patient 2 2 ), not receiving digitalis, had unifocal VPC preoperatively but developed mul tifocal VPC during the operation.
D is c u s s io n Increased incidence of arrhythmia during general anesthesia and surgery is a common finding. Dodd and associates10 reported the appearance of arrhythmia in 92 of 179 patients (51 percent)
T ab le 7 ■ Types of arrhythmia in patients with cardiovascular disease Patient no.
Preoperative ECG Normal
11
X
12
X
13Af 13 B f
Operative ECG
Arrhythmia
Other*
X*
x$
X
14
X X*
X*
Sinus arrhythmia
16
X*
Unifocal VPC
17
Xt
Supraventricular premature contractions unifocal VPC
18
----
19
Arrhythm ia Supraventricular premature contractions, & multifocal VPC
X
15
Normal
Supraventricular premature contractions, shifting pacemaker Unifocal VPC Unifocal VPC
X$
Unifocal VPC
X*
Sinus arrhythmia
X*
Supraventricular premature contractions, nodal escape
Multifocal VPC
L e ft ventricular hypertrophy, old anterior wall infarction
Supraventricular premature contractions
Unifocal VPC
Old anterior wall infarction, ischemia, digitalis effect
Unifocal VPC
Unifocal VPC atrial fibrillation
Right bundle branch block
Unifocal VPC , atrial fibriljation
21 A f
Supraventricular premature contractions ✓
Right bundle branch block
Supraventricular premature contractions
21 B f
Supraventricular premature contractions, wandering pacemaker
Right bundle branch block
Supraventricular premature contractions, unifocal V P C , wander ing pacemaker
Unifocal V P C
Old multiple infarction
M ultifocal VPC
Unifocal VPC
Old anteroseptal infarction, left axis deviation
Unifocal VPC
20
22
23
....
....
♦Other than normal or normal and arrhythmia. f A and B indicates same patient undergoing two procedures. ¿Norm al pattern with arrhythmia which, in itself, was not normal.
with cardiovascular disease undergoing general anesthesia and in 78 of 390 patients (2 0 percent) without cardiovascular disease. In a similar study by Hurwitz,11 arrhythmia appeared in 72 of 190 patients (38 percent) with cardiovascular disease and in two of 30 normal patients (7 percent). In our study, the development of operative arrhythmia was greater in patients with cardio vascular disease. In 31 procedures on 25 patients with cardiovascular disease, no preoperative arrhythmia was present in 22 procedures. Opera tive arrhythmia occurred in six of these 22 pro cedures. Preoperative and operative arrhythmia was present in nine procedures. In four of these nine, the operative arrhythmia differed from the preoperative arrhythmia. Therefore, operative arrhythmia developed in ten of 31 procedures (33 percent). In 46 operations on 40 patients without cardio vascular disease, no preoperative arrhythmia was present in 44. Operative arrhythmia occurred in
eight of these 44. In two other instances, pre operative arrhythmia showed no chapge during surgery. Thus, in eight of 46 procedures (17 per cent), operative arrhythmia developed.’ None of the arrhythmias was considered significant. ■ Age and incidence of arrhythmias: Since the number of patients in each age group was small, it is difficult to draw conclusions regarding the in fluence of age on the appearance of arrhythmia. As noted in Table 8, however, the older patients were more susceptible to arrhythmia before and during surgery. As expected, older patients with cardiovascular disease had a greater incidence of preoperative and operative arrhythmia than those of the same age with clinically normal cardio vascular systems. These findings were consistent with those of Dodd,10 Hurwitz,11 and Calatayud.12 Silverblatt and others,9 however, noticed poor correlation of age with arrhythmia during surgical procedures.
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T ab le 8 ■ Incidence of arrhythmia in relation to the age and cardiovascular status of patient Absence of cardiovascular disease
Age 30-39 40-49 50-59 60-69 70-79 80-89
Presence of cardiovascular disease
Arrhythm ia present preopera tively
Arrhythm ia present during operation
14 13
0
2
0
1
5
1
1
8
1
1
6
2
3
7 4
1
4
8
2
6
0
2
9
4
5
0
0
9
15
No. of procedures
No. of procedures
Arrhythmia present preopera tively
Arrhythmia present during operation
2
0
0
0
0
0
1
46
2
10
31
■ Duration of procedure and incidence of ar rhythmia: The incidence of arrhythmia in creased with the duration of the procedure (Table 3 ). This increase was expected, as the longer pro cedures presented more time for arrhythmia to appear. Hurwitz11 noticed an increase in post operative ECG changes from 51 to 77 percent in procedures under 1 hour to over 2 hours, re spectively. A similar increase might have been noted if our procedures had been longer. ■ Quantity of anesthetic and incidence of arrhythmia: No consistent relationship between the quantity of anesthesia and arrhythmia was noticed (Table 2 ). The maximum quantity of anesthetic (2 percent lidocaine solution, 1:100,000 epinephrine) used was 8.8 ml. (176 mg. of lidocaine, 0.088 mg. of epinephrine). This was well within the maximum limits of 500 mg. of lidocaine as discussed by Adriani21 and of 0.2 mg. of epinephrine as recommended by the New York Heart Association.20 ■ Significance of arrhythmia: Most of the occur rences of arrhythmia observed during surgery were not considered clinically significant (Tables 6 and 7 ). Nine patients had infrequent, unifocal ventricular premature contractions (V PC ). Such an arrhythmia is benign.13 Averill22*23 found this arrhythmia in 0.65 percent of normal, healthy subjects but observed a threefold increase in this type of arrhythmia in persons over 45 years old. One instance of sinus arrhythmia was noticed postoperatively and during procedure. Sinus arrhythmia is a normal phenomenon with no clinical significance.13 24 Two patients having normal preoperative ECG developed an operative wandering supraventricu lar pacemaker. This arrhythmia is discussed under sinus arrhythmia by Katz 25 and has no clinical 1100 ■ JA D A , Vol. 73, Nov. 1966
*
significance. Graybiel and others26 reported a wandering pacemaker in 2.3 percent of 1,000 young, healthy aviators. He stated this unim portant arrhythmia had no pathological signifi cance. One patient, a 78-year-old Caucasian man with a history of myocardial ischemia, had a right bundle branch block, wandering pacemaker, and supraventricular premature contractions in a pre operative electrocardiogram. The oniy change during procedure was two unifocal ventricular premature contractions (V PC ). Six subjects had occasional unifocal supraven tricular premature contractions during procedure. Two of these had this arrhythmia preoperatively. Fosmoe27 noticed supraventricular premature con tractions occurring in 4 .9/1,000 subjects through all age groups (16 to 55 years). The vast majority of extrasystoles (premature contractions: atrial, nodal, or ventricular in origin) cause no complaints and require no therapy.28 Irving29 noticed that a single premature systole did not significantly reduce overall cardiac function. One patient, a 76-year-old Caucasian man with a history of ischemic heart disease and congestive heart failure, had unifocal supraventricular pre mature contractions preoperatively but, during the operative procedure, this arrhythmia was followed by atrioventricular nodal escape. This patient was not taking digitalis. Nodal escape is often observed in older age groups in association with sinus bradycardia and may occur because of digitalis intoxication30 but is usually of no clinical sig nificance.31 The most important type of arrhythmia de veloping during an operation was multifocal ventricular premature contractions (V PC ). Pre mature contractions from several areas within the same chamber indicate widespread myocardial irritability32 and may denote advanced myocardial
disease.29 Averill and others23 found that, in 67,375 asymptomatic subjects, only one had definite multifocal VPC. They concluded that multifocal VPC is evidence of heart disease. Although multifocal ventricular premature con tractions were not present in any preoperative tracing, three patients developed this arrhythmia during procedure. A brief review of these cases follows: Case 1 (patient 22): A 53-year-old Caucasian man had a history of multiple myocardial infarc tions. The preoperative electrocardiogram sug gested old inferior and anterolateral infarctions. Unifocal VPC with runs of bigeminal rhythm were present. Multifocal VPC developed during opera tion. His medications consisted of pentaerythritol tetranitrate (Peritrate) and nitroglycerin. Case 2 (patient 11): A 71-year-old Mexican man had a history of ischemic heart disease, evidence of cardiomegaly, and chronic pulmonary emphysema. His preoperative tracing showed a rate of 60 and a digitalis effect but no premature contractions; several premature supraventricular contractions and multifocal VPC developed during procedure. The patient was taking digitoxin (Purodigin), phenobarbital, sodium diphenylhydantoin (Dilan tin sodium), and hydrochlorothiazide (Esidrex). Case 3 (patient 16): A 63-year-old Caucasian man had a history of ischemic heart disease and diabetes mellitus. His preoperative electrocardio gram showed a rate of 100 with occasional uni focal VPC. These VPC continued but became multifocal near the completion of surgery. This patient was taking tolbutamide (Orinase). These three patients had (1 ) histories of signif icant cardiovascular disease and (2 ) development of multifocal VPC during surgery. It is apparent that in this study the develop ment of operative arrhythmia was significantly greater in patients with cardiovascular disease. Although none of our patients developed symptoms related to the arrhythmia, it is certainly conceivable that cardiac irregularities could lead to hypotension, syncope, and coronary insuffi ciency in this group of patients. This study, there fore, emphasizes the importance of thorough evaluation of the cardiac patient before oral surgery, as recently mentioned by Burch and DePasquale.17 These authors state that the
“hazards of frequent dental manipulations of short duration should be weighed against the hazards of more prolonged manipulation with fewer visits.” They also indicated that under certain circumstances the use of nitroglycerin or preoperative sedation might increase the tolerance of cardiac patients to oral surgery. Such decisions, of course, are of extreme importance to the cardiac patient and indicate the necessity of con sultation between the oral surgeon and the cardiologist. S um m ary Electrocardiograms were recorded before and during 77 oral surgery procedures on 65 patients. Two percent solution of lidocaine with 1:100,000 epinephrine was used for local anesthesia. Forty-six operations were performed on 40 patients without cardiovascular disease. In 44, no preoperative arrhythmia was present. Operative arrhythmia occurred in eight of these 44. In two other instances, minor arrhythmia, present in preoperative electrocardiograms, was unchanged during surgery. Therefore, operative arrhythmia developed during eight of 46 procedures (17 per cent) in this group of patients. Thirty-one procedures were performed on 25 patients with cardiovascular disease. No preopera tive arrhythmia was present in patients involved in 22 procedures. Operative arrhythmia occurred during six of these 22 procedures. In nine other procedures, preoperative and operative arrhyth mia occurred. In four of these nine, the op erative arrhythmia differed from the preopera tive arrhythmia. Therefore, in ten of 31 proce dures (33 percent), operative arrhythmia devel oped in the patient. N o multifocal VPC occurred preoperatively, but operative multifocal VPC de veloped in three of 31 procedures (10 percent). Older patients with cardiovascular disease had a greater incidence of preoperative and operative arrhythmia than those of the same age with clin ically normal cardiovascular systems. The inci dence of arrhythmia increased with the duration of the procedure. No consistent relationship be tween quantity of anesthetic and development of arrhythmia was noticed. Doctor Hughes was formerly a senior resident in oral surgery, Veterans Administration Center, W ad s worth, Kan. His present address is 1510 W est 34th Street, Austin, Texas 78703. Doctor Leach was formerly
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1101
associate chief of staff at the Veterans Administration Center in Wadsworth, Kan. A t present, he is assistant professor of medicine at the University of New Mexico, School of Medicine, Albuquerque, N. Mex. Doctor Allen is professor and chairman of the department of oral surgery at the University of Missouri at Kansas City, School of Dentistry, Kansas City. Doctor Lambson is the chief of the oral surgery section at the Veterans Adm ini stration Center, Wadsworth, Kan. 1. Erlanger, H. Cardiac arrhythmias in relationship to anesthesia: past and present concepts. Amer. J . Med. Sci. 243:651 M ay, 1962. 2. Department of anesthesia, University of Pennsyl vania School of Medicine, Philadelphia. The heart and general anesthesia. Mod. Cone. Cardiov. Dis. 32:805 July, 1963. 3. Bellet, Samuel. Clinical disorders of the heartbeat, Philadelphia, Lea & Febiger, 1963, p. 696-712. 4. Rosner S.; Newman, W ., and Burstein, C. L. Electrocardiographic studies during endotracheal intu bation. V I. Effects during anesthesia with thiopental sodium combined with a muscle relaxant. Anesthesiology 14:591 Nov., 1953. 5. Arcuri, R. A .; Newman, W ., and Burstein, C. L. Electrocardiographic studies during endotracheal intu bation. V. Effects during general anesthesia and hexylcain e hydrochloride topical spray. Anesthesiology 14:46 Jan ., 1953. 6. Burstein, C. L.; LoPinto, F. J., and Newman, W . Electrocardiographic studies during endotracheal intuba tion. 1. Effects during usual routine technics. Anesthe siology. 1 1 :224, M arch, 1950. 7. Jacoby, J., and others. Cardiac arrhythmia: effect of vagal stimulation and hypoxia. Anesthesiology 16:1004 Nov., 1955. 8. Cannard, T. H., and others. The electrocardiogram during anesthesia and surgery. Anesthesiology 21:194 March-April, 1960. 9. Silverblatt, C. W ., and others. Factors associated with the development of ectopic rhythms during surgery. Amer. J . Surg. 103:102 Jan., 1962. 10. Dodd, R. B.; Simms, W . A ., and Bone, D. J. Cardiac arrhythmias observed during anesthesia and surgery. Surgery 51:440 April, 1962. 1 1. Hurwitz, M . M. Electrocardiographic changes following surgery. Geriatrics 17:275 M ay, 1962. 12. Calatayud, J . B.; Kelser, G. A ., Jr., and Caceres, C. A. Incidence of cardiac arrhythmias following non cardiac thoracic surgery. J . Thorac. Cardiov. Surg. 41 :498 April, 1961. 13. Buckley, J. J., and Jackson, J. A . Postoperative cardiac arrhythmias. Anesthesiology 22:723 Sept.-Oct.( 1961. 14. Foldes, F. F., and others. Comparison of toxicity of intravenously given local anesthetic agents in man. J A M A 172:1493 April 2, 1960. 15. Fraser, I. M ., and others. A comparative study of the effect of local anesthetics on the electrocardio gram of the dog. J . S. Calif. Dent. Assn. 30:228 July, 1962. 16. Sfewart, D. M ., and others. Effect of local anes thetics on the cardiovascular system of the dog. Anes thesiology 24:620 Sept.-Oct., 1963. 17. Burch, G. E., and DePasquale, N. P. Relationship of dentistry to cardiology. Amer. Heart J. 67:99 Jan ., 1964. 18. W illiam s, R. M ., and others. Electrocardiographic changes during oral surgical procedures under local anesthesia. Oral Surg. 16:1270 Oct., 1963. 19. Modica, R., and Olivero, S. Electrocardiographic
1102 ■ JA D A , Vol. 73, Nov. 1966
findings in dental surgery with local anesthesia. Minerva Anest. 22:97 March, 1956. 20. New York Institute of Clinical Oral Pathology: a report from the New York Heart Association. Is the use of epinephrine dangerous in connection wth procaine in dental procedures? Oral Surg. 8:225 M arch, 1955. 21. Adriani, J.; Campbell, D., and Yarberry, O. H., Jr. Influence of absorption on systemic toxicity of local anesthestic agents. Anesth. Analg. 38:370 Sept.-Oct., 1959. 22. A verill, K. H., and Lamb, L. E. Electrocardio graphic findings in 67,375 asymptomatic subjects. 1. Incidence of abnormalities. Amer. J . Cardiol. 6:76 Ju ly, 1960. 23. Hiss, R. G.; Averill, K. H., and Lamb, L. E. Electrocardiographic findings in 67,375 asymptomatic subjects. III. Ventricular rhythms. Amer. J. Cardiol. 6:96 July, 1960. 24. Phibbs, Brendan Pearse. The cardiac arrhythmias, a guide for the general practitioner. St. Louis, C. V. Mosby Co., 1961, p. 31. 25. Katz, Louis Nelson, and Pick, Alfred. Clinical electrocardiography. 1. The arrhythmias with an atlas of electrocardiograms. Philadelphia, Lea & Febiger, 1956, p. 69-70. 26. Graybiel, A ., and others. Analysis of the electro cardiograms obtained from 1,000 young healthy aviators. Amer. Heart J. 27:524. April, 1944. 27. Fosmoe, R. J .; Averill, K. H., and Lamb, L. E. Electrocardiographic findings in 67,375 asymptomatic subjects. II. Supraventricular arrhythmias. Amer. J. Cardiol. 6:84 Ju ly , 1960. 28. Scherf, D. The mechanism and treatment of extra systoles. Progr. Cardiov. Dis. 2:370 Jan ., 1960. 29. Irving, D. W . The significance and treatment of premature systoles. Dis. Chest 40:102 July, 1961. 30. Bellet, Samuel. Clinical disorders of the heartbeat. Philadelphia, Lea & Febiger, 1963, p. 400-401. 31. Katz, Louis Nelson, and Pick, Alfred. Clinical electrocardiography. 1. The arrhythmias with an atlas of electrocardiograms. Philadelphia, Lea & Febiger, 1956, p. 98. 32. Phibbs, Brendan Pearse. The cardiac arrhythmias, a guide for the general practitioner, St. Louis, C. V. Mosby Co., 1961, p. 42.
Definitions As the patient from the country walked the city-hospital corridor with his wife, he attempted to interpret the various signs for her: "Pharm acy— that's the drugstore. Pediatrics— that's for babies and children. Oral Surgery— that's where they talk you out of it."
Contributed by Hazel Prosser, Reader’s Digest, June, 1966, p. 172.