The hardest part of my job has nothing to do with teeth or gums. If you want to see me sweat, pull up a 20-page medical history. Poly-pharmacology is commonplace, and I cannot keep up. How can we make quick but smart choices to get our work done and keep our patients safe when providing local anesthetic injections? 

I choose to group patients by health and prescribe a cardiac dose for anyone ASA III or greater.   

A quick review of ASA Classifications

ASA 1 – picture of perfect health 
ASA 2 – controlled health issues  
ASA 3 – multiple uncontrolled health issues  
ASA 4 – very sick patients 
ASA 5 – end of life patients, hospice or hospital  

Who gets a cardiac dose?

I keep it simple. ASA 3 or greater gets a “cardiac dose.” The American Dental Association and the American Heart Association created this recommendation back in 1964. It limits anesthetic based on the milligrams of vasoconstrictors. For most of us this is synonymous with amount of epinephrine.  

It is important to remember the cardiac dose refers to the amount of vasoconstrictor NOT the amount of anesthetic, when administering local anesthetic injections. It is an absolute. It is not weight dependent.

Cardiac dose is 0.04 mg for Epinephrine and 0.2 mg for levonordefrin.   

This chart does not cover every circumstance. There will be patients that may not be able to have any epinephrine. But this is a great rule of thumb. Use it and make your life simple.  

To ensure your hygienist don't provide a cardiac dose have them take a local anesthesia course for dental hygienist.