As oral and maxillofacial surgeons, we thrive on the complexity of full-arch reconstructions. Whether we are placing zygomatic implants or performing a standard full-arch rehabilitation, these cases represent the pinnacle of our restorative-driven surgical skill. However, the physiological demands on the patient—and the surgical team—are equally high.
One of the most common intraoperative challenges we face is acute hypertension. A sudden spike in blood pressure can transform a controlled surgical field into a management crisis, significantly increasing the risk of hematoma, persistent bleeding, and cardiovascular stress.
The Reality of the "Red Line"
Clinical judgment often dictates when a procedure moves from "routine" to "risk-heavy." I recently managed a case where a patient’s blood pressure spiked to over 180/100 mmHg intraoperatively. This was accompanied by heavy, difficult-to-control bleeding—a direct consequence of the high systemic pressure.
In this scenario, the priority shifted from completing the arch to ensuring patient safety. My management protocol included:
Pharmacological Control: Administered Labetalol to initiate a controlled reduction of the MAP (Mean Arterial Pressure).
Site Stabilization: Placed healing abutments to stabilize the surgical sites and facilitate closure.
The Decision to Abort: I made the call to stop the procedure.
The patient was subsequently managed by their primary care physician (PMD) to optimize their hypertensive regimen. By prioritizing medical stability, we were able to reschedule and successfully complete the procedure later under much safer conditions.
1. The "Pause and Assess" Protocol
Before reaching for the emergency kit, address the most likely physiological triggers:
Pain & Sympathetic Surge: Is the patient truly numb? A "top-off" of local anesthetic or a greater palatine nerve block can often resolve a spike caused by surgical stimulus.
Sedation Depth: If utilizing IV sedation, an acute BP rise often signals the patient is entering a lighter plane. Titrating your sedative (e.g., Midazolam or Propofol) can blunt the sympathetic response.
Cuff Artifact: Verify equipment. Ensure the cuff is sized correctly and positioned at heart level to avoid a "false high."
2. Pharmacological Intervention
When the BP remains elevated despite adequate anesthesia and sedation, a targeted approach is necessary:
Labetalol: 10–20 mg IV slow push. The "gold standard" for steady reduction via $\alpha$ and $\beta$ blockade.
Esmolol: 10–50 mg bolus. Ultra-short acting, ideal for brief spikes during high-stimulus maneuvers.
Hydralazine: 5–10 mg IV. Effective direct vasodilator, though one must watch for reflex tachycardia.
3. When to Pivot: Aborting for Safety
The decision to stop is a sign of clinical maturity, not a failure of technique. If a patient’s blood pressure is refractory or if you encounter heavy, non-anatomical bleeding, the goal is to stabilize, protect the sites, and collaborate with the patient's medical team. A "staged" approach is always preferable to a surgical complication.
Closing Thoughts
Full-arch surgery is as much about managing the patient’s physiology as it is about the "metal and bone." Having a clear, rehearsed protocol for hypertensive episodes—and the willingness to pause when the "red line" is crossed—ensures that we keep our patients safe and our surgical outcomes predictable.
Fellow surgeons: Have you ever had to abort a case due to hypertensive bleeding? How do you manage the conversation with the patient afterward? Let’s discuss in the comments.
References
AAOMS Parameters of Care: Clinical guidelines recommending the deferral of elective surgical procedures when blood pressure is $\ge$ 180/110 mmHg.
Little and Falace’s Dental Management of the Medically Compromised Patient: Established protocol for deferring elective care at the 180/110 threshold to mitigate risk of intraoperative bleeding and stroke.
AHA/ACC Perioperative Guidelines (2024): Framework for managing cardiovascular risk in non-cardiac surgery, emphasizing the importance of blood pressure optimization in elective settings.
Journal of Oral and Maxillofacial Surgery (JOMS): Studies correlating intraoperative hypertensive spikes with increased surgical site complications and impaired hemostasis.
