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

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.