how should I modify anesthetic protocol for a patient with cardiac disease undergoing dental surgery?

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Dogs with cardiac disease undergoing dental procedures are not at significantly increased risk for anesthetic complications when managed by trained personnel with careful monitoring. The key protocol modifications center on drug selection, balanced anesthesia to reduce volatile agent requirements, and hemodynamic support. 2 Premedication should favor opioids combined with midazolam rather than alpha-2 agonists. Midazolam and etomidate are used more frequently, and alpha-2 agonists less frequently, in cardiac patients compared to healthy controls undergoing dental procedures. 2 For patients with pulmonary hypertension or right-sided disease, methadone (0.2 mg/kg IM) combined with midazolam (0.3 mg/kg IV) and lidocaine (1 mg/kg IV) provides cardiovascularly stable premedication. 3 In ASA III–IV patients with coexisting disease, an opioid alone or an opioid-benzodiazepine combination is appropriate, avoiding the hemodynamic burden of acepromazine or dexmedetomidine. 1 Induction should use etomidate or a ketamine-propofol combination to preserve cardiovascular stability. Etomidate is preferred in cardiac patients. 2 A ketamine (1 mg/kg IV) plus propofol (2 mg/kg IV) combination has been used successfully in dogs with severe cardiac disease and pulmonary hypertension undergoing dental extractions. 3 All induction agents should be administered to effect to minimize cardiorespiratory depression. 1 Maintenance with isoflurane or sevoflurane should be kept at the lowest effective concentration using a balanced, MAC-sparing approach. High concentrations of volatile agents cause peripheral vasodilation, reduced myocardial contractility, and reduced cardiac output, which is poorly tolerated in compromised patients. 1 Continuous infusions of lidocaine (30–50 μg/kg/min) and remifentanil (10–30 μg/kg/h) serve as effective inhalant MAC-sparing adjuncts in cardiac patients. 3 Regional dental nerve blocks are a critical component of the cardiac dental anesthetic plan. Local anestheti