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TABLE 10-5 Guidelines for Blood Pressure (Adult)

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TABLE 10-5 Guidelines for Blood Pressure (Adult) PRINTED BY: Jafar Panahi <[email protected]>. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. deflation systems and readable printouts of both BP and heart rate. As with the aneroid manometer, automatic BP systems are somewhat fragile, requiring recalibration on a regular schedule or when bumped or dropped. Body movements may influence accuracy, and even the most accurate devices do not work on certain people. 34 TABLE 10-5 Guidelines for Blood Pressure (Adult) Blood Pressure, mm Hg, or ASA torr ClassificationDental Therapy Consideration <140 and 1 <90 1 Routine dental management 2 Recheck in 6 mo, unless specific treatment dictates more frequent monitoring. 140-159 2 and/or 90-94 1 Recheck BP before dental treatment for three consecutive appointments; if all exceed these guidelines, medical consultation is indicated. 2 Routine dental management 3 SRP as indicated 160-199 3 and/or 1 Recheck BP in 5 min. 95-114 2 If BP is still elevated, medical consultation before dental therapy is warranted. 3 Routine dental therapy 4 SRP 200+ and/or 4 115+ 1 Recheck BP in 5 min. 2 Immediate medical consultation if still elevated 3 No dental therapy, routine or emergency, * until elevated BP is corrected 4 Refer to hospital if immediate dental therapy is indicated. ASA, American Society of Anesthesiologists; BP, blood pressure; SRP, stress reduction protocol. * When the BP of the patient is slightly above the cutoff for category 4 and anxiety is present, inhalation sedation may be employed in an effort to diminish the BP (via the elimination of stress). Automatic BP monitors that fit on the patient's wrist are available and easy to use. However, BP measurements at the wrist may not be as accurate as those taken at the upper arm, and systematic error can occur as a result of differences in the position of the wrist relative to the heart (see later discussion).35 , 36 The technique of blood pressure monitoring is discussed in extensive detail in other textbooks. 37 For the adult patient with a baseline BP in the ASA 1 range (<140/<90 mm Hg), it is suggested that BP be recorded every 6 months unless specific dental procedures demand more frequent monitoring. Handbook of Local Anesthesia, 6th Edition Page 36 of 63 PRINTED BY: Jafar Panahi <[email protected]>. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. The parenteral administration of any drug (local anesthesia; IM, IV, or inhalation sedation; or general anesthesia) mandates more frequent recording of vital signs. Patients with BPs in the ASA 2, 3, or 4 category should be monitored more frequently (e.g., at every appointment), as outlined in Table 10 -5 . Patients with known HBP should have their BP monitored at each visit to determine whether BP is adequately controlled. It is impossible to gauge BP by “looking” at a person, or by asking, “How do you feel?” Routine monitoring of BP in all patients according to treatment guidelines will effectively minimize the occurrence of acute complications of HBP (e.g., hemorrhagic CVA). The normal range of BP in younger patients is somewhat lower than that in adults. Table 10 -6 presents a normal range of BP in infants and children. TABLE 10-6 Normal Vital Signs According to Age Age Heart Rate (beats/min) Blood Pressure (mm Hg) Respiratory Rate (breaths/min) 3-6 mo 90-120 70-90/50-65 30-45 6-12 mo 80-120 80-100/55-65 25-40 1-3 yr 70-110 90-105/55-70 20-30 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60-75 14-22 12+ yr 55-85 110-135/65-85 12-18 Modified from Hartman ME, Cheifitz IM: Pediatric emergencies and resuscitation. In Kliegman RM, Stanton BF, St. Geme JW III, Schor NF, et al, eds: Nelson textbook of pediatrics, ed 19, Philadelphia, 2011, Saunders. Heart Rate and Rhythm Technique Heart rate (pulse) and rhythm may be measured at any readily accessible artery. Most commonly used for routine measurement are the brachial artery, which is located on the medial aspect of the antecubital fossa, and the radial artery, which is located on the radial and ventral aspects of the wrist. Guidelines for Clinical Evaluation Three factors should be evaluated while the pulse is monitored: 1 The heart rate (recorded as beats per minute) 2 The rhythm of the heart (regular or irregular) 3 The quality of the pulse (thready, weak, bounding, full) The heart rate should be evaluated for a minimum of 30 seconds, ideally for 1 minute. The normal resting heart rate for an adult ranges from 60 to 110 beats per minute. It is often lower in a 143 well-conditioned athlete (physiologic [sinus] bradycardia) and elevated in the fearful individual 144 (sinus tachycardia). However, clinically significant disease may also produce slow (bradycardia [<60 per minute]) or rapid (tachycardia [>110 per minute]) heart rates. It is suggested that any heart Handbook of Local Anesthesia, 6th Edition Page 37 of 63 PRINTED BY: Jafar Panahi <[email protected]>. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. rate below 60 or above 110 beats per minute (adult) should be evaluated (initially via dialogue history). Where no obvious cause is present (e.g., endurance sports, anxiety), medical consultation should be considered. The healthy heart maintains a relatively regular rhythm. Irregularities in rhythm should be confirmed and evaluated via dialogue history and/or medical consultation before the start of treatment. The occasional premature ventricular contraction (PVC) is so common that it is not necessarily considered abnormal. Clinically, PVCs detected by palpation appear as a break in a generally regular rhythm in which a longer-than-normal pause (a “skipped beat”) is noted, followed by resumption of regular rhythm. PVCs may be produced by smoking, fatigue, stress, various drugs (e.g., epinephrine, caffeine), and alcohol. Frequent PVCs are usually associated with a damaged or an ischemic myocardium. Disturbances in the regularity of heart rhythm should be evaluated before the start of dental treatment, particularly when drugs (e.g., local anesthetics, sedatives) are to be administered. Table 10 -6 presents the range of normal heart rates in children of various ages. Administration of epinephrine-containing local anesthetics is relatively contraindicated in patients with ventricular dysrhythmias unresponsive to medical therapy. Dysrhythmias frequently are induced by an ischemic or irritable myocardium. Epinephrine and other catecholamines may provoke further irritability, leading to potentially more serious, possibly fatal dysrhythmias. Respiratory Rate Guidelines for Clinical Evaluation Normal respiratory rate for an adult is 14 to 18 breaths per minute. Bradypnea (abnormally slow rate) may be produced by, among other causes, opioid administration, whereas tachypnea (abnormally rapid rate) is seen with fever, fear (hyperventilation), and alkalosis. The most common change in ventilation noted in the dental environment is hyperventilation, an abnormal increase in the rate and depth of respiration. It is also seen, but much less frequently, in diabetic acidosis. The most common cause of hyperventilation in dental and surgical settings is extreme psychological stress, which is not infrequent during local anesthetic administration (e.g., “the shot”). Any significant variation in respiratory rate should be evaluated before treatment. Table 10 -6 presents the normal range of respiratory rates at different ages. BP, heart rate and rhythm, and respiratory rate provide information about the functioning of the cardiorespiratory system. It is recommended that they be recorded as part of the routine physical evaluation for all potential dental patients. Recording of the remaining vital signs—temperature, height, and weight—although desirable, may be considered optional. However, when parenteral drugs are to be administered, including local anesthetics, especially in lighter-weight, younger, or older patients, actual recording of a patient's weight becomes considerably more important. Handbook of Local Anesthesia, 6th Edition Page 38 of 63 PRINTED BY: Jafar Panahi <[email protected]>. Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted. TABLE 10-7 Acceptable Weight (in Pounds) for Men and Women * AGE Height 19-34 Years 35 Years and Older 5 ft 0 in 97-128 108-138 5 ft 1 in 101-132 111-143 5 ft 2 in 104-137 115-148 5 ft 3 in 107-141 119-152 5 ft 4 in 111-146 122-157 5 ft 5 in 114-150 126-162 5 ft 6 in 118-156 130-167 5 ft 7 in 121-160 134-172 5 ft 8 in 125-164 138-178 5 ft 9 in 129-169 142-183 5 ft 10 in 132-174 146-188 5 ft 11 in 136-179 151-194 6 ft 0 in 140-184 155-199 6 ft 1 in 144-189 159-205 6 ft 2 in 148-195 164-210 Department of Health & Human Services (HHS) and Department of Agriculture (USDA): Dietary guidelines for Americans, Washington, DC, 2005, HHS/USDA. * Weights based on weighing in without shoes or clothes. Height and Weight Technique Patients should be asked to state their height and weight. The range of normal height and weight is quite variable and is available on charts developed by various insurance companies. New guidelines for range of normal height and weight have been published (Table 10 -7 ).
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