Local Anesthesia & Analgesia 1 of 18 Veterinary Surgery I, VMED 7412

Local Anesthesia & Analgesia

Lyon Lee DVM hD DA!VA
Intro"uction
Several features of local anesthesia render it particularly useful in veterinary practice.
Many surgical procedures can be carried out satisfactorily under local anesthesia (e.g., C-
section in cows).
Whether or not sedation is necessary as an adunct will depend on the species,
te!pera!ent and health of the ani!al, and on the !agnitude of the procedure.
"n adult cattle, !any operations are perfor!ed on standing ani!als and since sedation
!ay induce the ani!al to lie down, it is better avoided. #nabling operation in standing
ani!als also eli!inates the dangers associated with forcible casting and restraint, and
prolonged recu!bency.
"n other ani!als, sedation is often e!ployed to facilitate cooperation fro! ani!als by
reducing fear and an$iety. %he sedation also reduces the li&elihood of sudden !ove!ent
in ani!als.
'ree!ptive local anesthesia in ani!als undergoing general anesthesia will reduce the
a!ount of general anesthetic, !ini!i(ing the cardiopul!onary depression that !ay
acco!pany and also leading to )uic&er recovery. "t provides a useful pain relief, even
beyond the full recovery fro! general anesthesia.
"n so!e situations with e$tre!ely depressed ani!als when they will tolerate, perfor!ing
a surgical procedure under local anesthesia !ay be safer as well as !ore econo!ical.
%he techni)ues are not difficult to learn and do not involve the use of e$pensive or
co!plicated e)uip!ent.
Structure acti#ity relationshi$s
*ocal anesthetics (*+s) consist of a lipophilic and a hydrophilic portion separated by a
connecting hydrocarbon chain (see figure ,).
+n ester (-C--) or an a!ide (-./C-) bond lin&s the hydrocarbon chain to the lipophilic
aro!atic ring.
%he hydrophilic group is usually a tertiary a!ine, such as diethyla!ine, whereas the
lipophilic portion is usually an aro!atic ring, such as para-a!inoben(oic acid.
%he nature of this bond is the basis for classifying drugs that produce conduction
bloc&ade of nerve i!pulses as ester local anesthetics or a!ide local anesthetics.
So!e e$a!ples are0
o #sters1 procaine, cocaine, chloroprocaine, and tetracaine.
o +!ides1 lidocaine, bupivacaine
Amides drugs have i in generic preifx before caine. Exception is piperacaine, an
ester drug.
Figure 1. Chemical structure of local anesthetics.
Mechanis% of action
*+s bloc& nerve conduction by inhibiting influ$ of sodiu! ions through ion-selective
sodiu! channels in nerve !e!brane leading to i!pair!ent of the generation of action
potential.
%he sodiu! channel itself is a specific receptor for local anesthetic !olecules.
Figure 2. echanism of action of local anesthetics
2/
3
2 3 /
3
#$tracellular
.a channel
/
3
3 2
2/
3
"ntracellular
2/
3
1 ioni(ed for!, cation
/
4
- soluble
21 unioni(ed for!, free base
lipid soluble
*ipid bilayer
&actors affecting onset, intensity, an" "uration of neural 'loc(a"e
*ocal anesthetics in solution e$ist in a che!ical e)uilibriu! between the basic uncharged
for! (2) and the charged cationic for! (2/
3
).
+t a certain hydrogen concentration specific for each drug, the concentration of local
anesthetic base is e)ual to the concentration of charged cation. %his hydrogen
concentration is called the p5a.
%his relationship is e$pressed as,
p/ 6 p5a 3 log
728
72/
3
8
*ower p5a !eans greater fraction of the !olecules e$ist in the unioni(ed for! in the
body, so !ore easily cross nerve !e!branes leading to faster onset.
%he p5a of currently used local anesthetic co!pounds lies between 9.9 and :.;.
%he co!!ercially available solutions are always acid so that they contain !ore ioni(ed
!olecules.
+cidosis in the environ!ent into which the local anesthetic is inected (as is present in an
infected, pus tissue) further increases the ioni(ed fraction of drugs. %his is consistent
with slower onset and poor )uality of local anesthesia when a local anesthetic is inected
into an acidic infected area.
*ocal anesthetics with a higher degree of protein binding have a prolonged duration of
action. "ncreased dose increases the duration of the bloc&.
%he half-life of esters is only a few !inutes due to their rapid hydrolysis in the plas!a
and liver, whereas the half-life of a!ides is a few hours.
'atients with reduced cholinesterase activity (new born, pregnant) !ay have an increased
potential for to$icity fro! ester local anesthetics.
+!ong the resulting !etabolites fro! ester local anesthetics, the para-a!inoben(oic acid
is believed to be an antigen responsible for subse)uent allergic reactions.
+!ides are !ainly !etaboli(ed by the liver. 'atient with severe hepatic disease !ay be
!ore susceptible to adverse reactions fro! a!ide local anesthetics.
%hin nerve fibers are !ore easily bloc&ed than thic& ones. /owever, !yelinated fibers
are !ore readily bloc&ed than un!yelinated ones because of the need to produce
bloc&ade only at the node of <anvier.
"n general, autono!ic fibers (2 and C fibers), s!all un!yelinated (C fibers), and s!all
!yelinated fibers (2 and += fibers) will be !ore readily bloc&ed than thic&, !yelinated
fibers (+> and +? fibers).
%hus, a differential bloc& can be achieved where the s!aller pain and autono!ic fibers
are bloc&ed, while large touch and !otor fibers are spared.
%his difference is due to the fact that nerve fibers containing !yelin are relatively
i!pervious to local anesthetic solutions co!pared to those which contain little or no
!yelin.
%he lipid solubility and p5a of the local anesthetic are the pri!ary deter!inants of the
degree of differential bloc&ade.
Syste%ic an" to)ic effects of local anesthetics*
+ccidental intravenous inection of local anesthetics is the !ost co!!on cause of
adverse reaction associated with local anesthetic ad!inistration. "n severe cases it can
cause cardiac arrest.
When the plas!a concentration of *+s is e$cessive, sufficient cardiac sodiu! channels
beco!e bloc&ed so that conduction and auto!aticity beco!e adversely depressed. @or
e$a!ple, e$cessive plas!a concentration of *idocaine !ay slow conduction of cardiac
i!pulses through the heart, !anifesting as increased '< interval and widened A<S
co!ple$ on the #CB.
#ffects of *+s on calciu! and potassiu! ion channels and local anesthetic induced
inhibition of cyclic adenosine !onophosphate (c+M') production !ay also contribute to
cardiac to$icity. 2upivacaine is !ore cardioto$ic than *idocaine.
Al+ays "ra+ 'ac( on syringe to chec( not in #ein 'efore in,ecting local
anesthetics*
Beneral overdose depends on blood levels, therefore is influenced by total dose and
speed of upta&e fro! the tissues.
+s a very rough guide, the to$ic dose of *idocaine would be : !gC&g (!uch lower in the
cat, 4!gC&g) and D !gC&g of 2upivacaine. (.2, in very s!all ani!als such as do!estic
cats, s!all dogs, goat &ids, birds and s!all !a!!als this a!ount can be easily e$ceeded
using solutions of standard concentration, so dilute it carefully and use with caution).
Signs of overdose are initial sedation, followed with increasing dosage by twitching,
convulsions, co!a and death. <eports i!plicate prilocaine, ben(ocaine, lidocaine and
procaine as causative agents to produce !ethe!oglobine!ia in so!e ani!als.
!linically i%$ortant $oints to recogni-e are.
Spreading properties. Bood spreading properties !ean that specific nerve bloc&s need
less accuracy.
Speed of onset of action.
Euration of action (and !echanis!s li!iting this, which include speed of re!oval fro!
tissues and !etabolis! and re!oval fro! the body.).
#ffect on local blood vessels. Fasoconstriction (cocaine only) or vasodilation.
(epinephrine is often added to cause vasoconstriction, thus delay re!oval and lengthen
action).
*ocal irritation and swelling (particularly i!portant in horses)
%o$icity.
Local anesthetics in co%%on #eterinary use
Li"ocaine
%his is the !ost widely used general-purpose local anesthetic in veterinary use. "t
possesses reasonably rapid onset of action, with good spreading properties, being a good
Gall roundH useful local anesthetic.
"t !ay cause so!e local irritation and swelling, which is particularly a proble! in the
horse. "t is available in a variety of concentrations or inection0 with and without
epinephrine0 and in the for! of solutions, crea!s, ellies, sprays etc.
Euration of action is variable (depending on upta&e) but will be around , hour without
epinephrine, and 4 hours with epinephrine.
/u$i#acaine
%his drug has a prolonged duration of action0 up to eight hours when co!bined with
epinephrine.
"t is therefore used whenever long action is re)uired (post-op analgesia0 prolonged
surgery etc).
Me$i#acaine
%his is the !ost widely used drug in the horse as it causes very little swelling and ede!a
in the area of inection, possibly as it lac&s vasodilatory action.
-nset of action is faster and reliability of bloc& greater than with prilocaine.
rilocaine
"t has slower onset of action, and spreads less well co!pared to lidocaine.
%he uni)ue ability of prilocaine to cause dose-dependent !ethe!oglobine!ia li!its its
clinical usefulness.
%he !ain use is in the horse as it causes less swelling but great accuracy is needed when
doing specific nerve bloc&s.
0ther local anesthetics
'roparacaine is used to anestheti(e the cornea of the eye. When dropped on the cornea it
has a rapid onset of action (within , !inute) and lasts for about ,;-IJ !ins. "t is
nonirritant, and does not affect the si(e of the pupil.
+!ethocaine is well absorbed by surfaces and is used on !ucous !e!branes.
'rocaine, an older drug with slow onset of action and poor spreading powers has been
superseded by the !ore !odern drugs.
Cocaine the original local anesthetic is the only one to cause vasoconstriction. "t is now
not used as a local anesthetic because of its potential for abuse (Schedule "").
.ewer long acting local anesthetics with less cardioto$icity, e.g., ropivacaine or
lovobupivacaine, are now available for !an, but are currently very e$pensive for
veterinary use.
!o%%on %etho"s of $ro"ucing local anesthesia
Surface (topical) anesthesia
"ntrasynovial anesthesia
"nfiltration anesthesia
Spinal anesthesia
"ntravenous regional local anesthesia
<egional anesthesia
Surface 1to$ical2 anesthesia
%his refers to the use of local anesthetics in solution sprays as well as in various crea!s
and oint!ents, on !ucous !e!branes0 drops into the eye0 sprays or brush in laryngeal
area, infuse into the nostrils, urethra, or rectu!.
Intrasyno#ial anesthesia
"n oints, bursa, and tendon sheaths.
Kseful for both diagnosis of la!eness, and for general pain relief.
%he local anesthetic chosen !ust cause !ini!al irritation, and great care in sterility is
necessary as infection in these sites occurs easily.
Infiltration anesthesia
2y this !ethod the nerve endings are affected at the actual site of operation.
Most !inor surgery can be done this way, e$cluding surgery on teats in cattle or s!all
ani!al digits.
'roble!s occur through infection (never inect local analgesic through infected tissues),
irritation, distortion of the wound, swelling and so!e delay in post-operative healing.
+ variation of infiltration anesthesia designed to !ini!i(e these effects is field
anesthesia. /ere, walls of anesthesia are !ade by infiltrating the tissues around (rather
than at) the surgical site.
+dvantages include absence of distortion of the anato!ical features in the line of
incision0 !uscle rela$ation and no interference to healing. +n e$a!ple of a field
anesthesia techni)ue which is widely used in cattle is the L"nverted * or 9 bloc&M for
anesthesia of the abdo!inal fossa.
<ing bloc&s whereby the tissue all around a distal organ is infiltrated with local
anesthetic, is another for! of field anesthesia 1 e$a!ples of where this is used is on the
teats of cattle (do not use epinephrine here, as vasoconstriction could lead to ische!ic
necrosis and sloughing of tissue) or around the li!b of cattle.
S$inal anesthesia
Spinal anesthesia is the inection of local anesthetic around the spinal cord.
When local anesthetics such as lidocaine or bupivacaine are used, all the seg!ental
nerves (sensory and !otor) which pass through the anesthetic are paraly(ed, although
when opioids are used only sensory bloc& occurs.
Spinal anesthesia is divided into two types0 GepiduralH and Gtrue spinalH.
o #pidural (or e$tradural) anesthesia refers to depositing of local anesthetics into the
e$tradural space. %he needle enters the spinal canal, but does not penetrate the
!eninges. %he anesthetic is therefore li!ited to the canal outside the dura !ater.
o %rue spinal anesthesia refers to the subarachnoid access (usually &nown as GspinalH
anesthesia) in which the needle penetrates the dura !ater, and the analgesic is
inected into the cerebrospinal fluid (CS@).
Effects of su'arachnoi" an" e$i"ural anesthesia
%he re)uire!ents fro! these techni)ues is paralysis of sensory nerves to the area in
which surgery is going to be perfor!ed.
Muscle rela$ation can be an added bonus or a disadvantage.
Muscle rela$ation of the li!bs causes recu!bency0 and of the thoracic region li!its
respiratory !ove!ent.
"f local analgesic reaches the cervical region and affects the phrenic nerves, then
respiration ceasesN
%hus !ost spinal and epidural anesthesia is inected in the caudal regions of the ani!al,
although there are several variations in ter!inology used, generally where inection of
drug is in the coccygeal region and the dose of drug is such that the hind li!bs are not
affected, it is ter!ed Lcaudal anesthesiaM where a higher dose of drug is given, still at the
coccygeal area, so the hind li!bs !ay be ust affected, the ter! Lepidural anesthesiaM is
used, and where the bloc& e$tends to the abdo!inal region, either because of the volu!e
used, or because the inection is carried out at the lu!bosacral space, the ter! used is
Lanterior epiduralM.
Autono%ic effects of e$i"ural anesthesia
Many of the spinal nerves also carry fibers of the autono!ic nervous syste!, which will
also be bloc&ed.
Most i!portant to the anesthetist are the sy!pathetic fibers, responsible for vaso!otor
tone. %hus spinal and epidural anesthesia always causes hypotension0 and if the bloc& is
sufficiently anterior to bloc& the splanchnic outflow, this hypotension can be severe, even
life threatening.
"F fluid line is essential prior to perfor!ing an epidural bloc& to treat a potentially
dangerous hypotension.
3he area 'loc(e" 'y e$i"ural anesthesia +ill "e$en" on
%he site of inection. Co!!on sites used in veterinary !edicine (depending on the
species) are the sacrococcygeal or interco$ygeal space, and the lu!bosacral space.
/owever, it is possible to carry out Lseg!entalM bloc&s using other points of inection
(widely used in !an0 develop!ent in veterinary use only ust under way).
Auantity, volu!e of and specific local anesthetic inected. (Well e$a!ined in !an0 in
veterinary use wor& dates fro! ,ODJHs0 no recent wor& with newer anesthetics).
Si(e of the spinal canal. %his varies not only between species of the sa!e weight, but
between breeds0 with age0 and with condition of the ani!al (e.g., fatCthin etc.).
'osition of ani!al (effects of gravity on spread).
<e!oval of the anesthetic fro! the canal. +gain this depends on !ultiple factors,
including age (influences si(e of LholesM in the dura around the nerves), condition, blood
flow etc. %he use of vasoconstrictors (epinephrine) will delay re!oval.
%hus epidural or spinal anesthesia is not a very precise techni)ue, and it is difficult to
esti!ate the e$tent of bloc& which will occur, or its duration.
Dangers of s$inal an" e$i"ural 'loc(
"nfection- Careful sterile precautions (good clipping and scrubbing)
"rritation causing spinal da!age (!ost li&ely with subarachnoid).
/indli!b !otor paralysis (proble! in large ani!als, acceptable in s!all).
/ypotension - !ost li&ely with an anterior bloc&. Where this is being done fluid therapy
or inotropes should be available to !aintain blood pressure.
<espiratory paralysis (only if !assive overdose of local analgesic used).
E$i"ural anesthesia in the Dog an" !at*
%he epidural inection site in dogs and cats is located at the lu!bosacral unction
between the seventh lu!bar (*-9) and the first sacral vertebra (S-,).
"n dogs the spinal cord ter!inates at around PC9
th
lu!bar vertebrae. +nterior epidural
anesthesia !ay therefore be safely and easily induced at the lu!bosacral unction.
"n cats, (and s!all ru!inants, cattle), however, the spinal cord ter!inates at the Ird
sacral vertebra (in ru!inants, it is in S-,), and both the spinal cord and subarachnoid
space are very close to the site of epidural inection.
%he spinal cord is supported, protected, and stabili(ed by vertebral colu!n, liga!ents
and !eninges.
%he epidural space is located i!!ediately below the liga!entu! flavu! separating the
dura !ater fro! the vertebral periosteu!, the lining of the spinal canal.
%o locate the site, identify the iliac pro!inences on either side, and ta&e an i!aginary
line between the! crossing the dorsal spinous process of the last lu!bar seg!ent.
%he site for the needle insertion is i!!ediately caudal to this, in the !idline.
<estrain laterally or in sternal recu!bency (personal preference). %he hair over
the lu!bosacral unction should be clipped and aseptically prepared.
Sterile surgical gloves should be worn during the procedure. + 4J-44 gauge, ,.;-4.;
inch spinal needle !ay be used0 depending on the si(e of the ani!al, a longer I.; inch
spinal needle is used for obese and large ani!als.
%o reach the epidural space, the needle !ust be passed in a ventral direction through
the s&in, subcutaneous fat, supraspinous liga!ent, interspinous liga!ent and
liga!entu! flavu! (yellow liga!ent).
"f the needle continues ventrally past the epidural space it will encounter the dura
!ater, arachnoid !e!brane, pia !ater and finally, the spinal cord. %he dura !ater,
arachnoid !e!brane and pia !ater constitute the three !eningeal !e!brane layers
that protect the spinal cord.
%he dura !ater, !eaning Ltough !otherM, is the outer!ost !eningeal layer. %he
arachnoid !e!brane, thin and avascular, lines the inner surface of the dura !ater.
%he inner!ost !e!brane layer, the pia !ater, closely appro$i!ates the spinal cord.
%his layer is a highly vasculari(ed !e!brane through which all blood vessels pass to
enter and leave the C.S. Cerebral spinal fluid (CS@) is located in the subarachnoid
space, which separates the arachnoid !e!brane and the pia !ater.
%o perfor! epidural anesthesia, the inection !ust be !ade only into the epidural
space, between the liga!entu! flavu! and dura !ater.
#pidural inection should be differentiated fro! spinal (or intrathecal) inection, in
which
the anesthetic is inected into the subarachnoid space, between the arachnoid !e!brane
and the pia !ater (this is also where the !yelogra! is perfor!ed in the disc proble!
dogs).
+nesthetic agents inected into the subarachnoid space (spinal inection) produce true
spinal anesthesia because of the lac& of protection provided by the dura !ater and
arachnoid !eninges. Conse)uently, the volu!e of the anesthetic solution !ust be reduced
by one third. /ypotension can be a !aor co!plication.
%his procedure should not be carried out unless there is an intravenous line in place so
fluids or anti-hypotensives can be given pro!ptly.
%he epidural space is identified by advancing the needle fro! an area of high
resistance
(liga!entu! flavu!) to an area of low resistance (epidural space).
%his is usually acco!plished using the Lhanging dropM or the Llac& of resistanceM
techni)ue during inection.
@or cranial laparoto!ies or hindli!b orthopedic procedures a dose of J., !gC&g of
!orphine withCwithout J.;Q bupivacaine of appro$i!ately , !l per ,J 5g is re)uired.
E$i"ural anesthetic techni4ues
3he 5hanging "ro$6 techni4ue
o %his involves re!oving the stylet of the spinal needle, filling the hub of the needle
with saline or anesthetic solution, and allowing one drop to hang fro! the hub.
o +s the needle is advanced through the liga!entous structures, the drop does not
!ove.
o /owever, upon penetration of the liga!entu! flavu!, the negative pressure in the
epidural space will draw the drop of solution into the needle, indicating proper
place!ent in the epidural space.
o + LpopM felt through the needle is usually encountered when the spinal needle is
passed through the liga!entu! flavu!.
o %he chance for a successful Lhanging dropM techni)ue is greater in large dogs than in
s!aller dogs and cats.
o "f the Lhanging dropM techni)ue fails, the Llac& of resistanceM techni)ue can be used.
3he 5lac( of resistance6 techni4ue
o %his indicates proper place!ent of the inection needle in the epidural space based on
the a!ount of resistance to the inection of air or saline.
o -nce in the epidural space, the inection of air, saline, or anesthetic solution will
encounter !ini!al resistance.
o + separate syringe of nor!al saline (I !l or air preferred by others) should be
prepared for the Llac& of resistanceM techni)ue.
o When !ini!al resistance to the saline inection is encountered, the saline syringe is
replaced with a syringe-containing anesthetic, and the inection is co!pleted.
o %o rule out the possibility of ad!inistering drugs into the venous sinus (presence of
the blood) or subarachnoid space (presence of CS@), it is i!portant to aspirate or
allow a few seconds to chec& bleeding before epidural inection.
Figure !. "iagram sho#ing various anatomic landmar$s and positions of needles to perform
epidural bloc$ techni%ue.
E$i"ural anesthesia in 'o#ine
"n the o$, the spinal cord ends in the region of the last lu!bar vertebra, but the !eningeal
sac goes to the IrdCDth sacral seg!ents.
@or caudal and epidural anesthesia the inection site used is between coccygeal C, and
C4 (located by raising tail in Lpu!p handleM fashion, the first obvious articulation behind
the sacru! being C, CC4).
@or a ;JJ &g bovine0 ;-,J !l 4Q lidocaine will give caudal anesthesia without causing
hind li!b ata$ia or paralysis.
-nset of paralysis of the tail should occur in ,-4 !ins. %he bloc& will last ,-4 hours.
*arger doses will produce increasingly anterior effects.
2y the ti!e ,JJ-,;J !ls 4Q lidocaine is inected, the bloc& will be sufficiently anterior
to allow surgery of the hindli!bs, !a!!ary tissue, flan&s and abdo!inal wall.
/owever, the bovine will be recu!bent. "nection of local anesthetics can be carried out
at the lu!bosacral unction in order to produce an anterior bloc& with less anesthetic.
/owever, there is a danger of accidental subarachnoid inection. Seg!ental epidural
anesthesia, where the anesthetic is inected into the epidural space at the region re)uired
can be used for analgesia of any Gseg!entH with less overall side effects. "t is !ore
difficult to perfor!0 penetration of the !eninges is li&ely, but in s&illed hands it is a very
useful techni)ue.
Figure &. 'ocation of (acral)Cocc*geal+,ntercocc*geal -unction for the epidural in-ection in
cattle. .ote the tail can be lifted up and do#n to *ield an indentation at the -unction.
/he shaded areas sho# the bloc$age of the caudal)epidural follo#ing lidocaine
in-ection. ,t induces both analgesia and motor bloc$ade 0From /hurmon et al. 11123
E$i"ural anesthesia in the shee$ an" goat
"n both sheep and goats, anterior epidural anesthesia, induced by inection at the
lu!bosacral unction is easily perfor!ed and provides e$cellent analgesia and !uscle
rela$ation for abdo!inal surgery.
<ecu!bency !ay occur but is not a proble! in these s!all ani!als. +s in cattle, there is
a ris& of subarachnoid inection.
Figure 2. "iagrams to sho# various epidural bloc$ing
sites. lumbosacral space, sacrococc*geal,
intercocc*geal. 4hat determines the site
depends on the area of operation and the
technical competence 0From /hurmon et al.
11123
E$i"ural anesthesia in the horse
/ind li!b ata$ia is a serious proble!, so only caudal epidural techni)ues are used. %hese
are useful for various obstetrical !anipulations and surgery on the rectu!, vagina and
tail.
%he techni)ue is less reliable than in cattle. Site of inection is usually sacrococcygeal
unction but can be between C, and C4. @or ;JJ &g horse, a !i$ture of ;J !g of
$yla(ine and P !l of 4Q !epivacaine (!ay be repeated for another dose) !ay prove very
effective.
Intra#enous regional local anesthesia 1/ier7s 'loc(2
"n this techni)ue, a li!b vein is catheteri(ed (see figure 9).
%he li!b is then e$sanguinated (#s!archs bandage), and a tourni)uet placed around the
li!b, at a pressure ade)uate to prevent arterial circulation (R ,;J !!/g).
*ocal anesthetic (preferably without epinephrine) is then inected into the vein.
+fter a period of ,; !inutes the area distal to the tourni)uet is anestheti(ed until the
tourni)uet is re!oved.
'otential proble!s are1
o Eifficulty in finding the vein once the li!b is e$sanguinated (this is why itHs best to
have a catheter in place first).
o Cardiac arrhyth!ias or even arrest. %his is due to an inade)uate tourni)uet (in !an
there have been !ore proble!s when bupivicaine was used than were found with
lidocaine).
o @ailure to ta&e effect. Co!!on reasons are inade)uate tourni)uet, inade)uate ti!e,
and lac& of e$sanguination (it does wor& without e$sanguination but not so well).
o Collapse when tourni)uet is re!oved. %his is because of ano$ic waste products
re-entering circulation. "t is preferable if the ani!al is recu!bent at this ti!e.
o Ea!age as a result of the tourni)uet being left on too long. %his is rare. "t can be left
on for ,-,.; hours on the li!b of cattle and dogs.
"ntravenous regional anesthesia is co!!only used in cattle for a!putation of a digit.
%he diagra!s below show so!e e$a!ples of veins available for inecting local
anesthetics.
%he analgesic techni)ue is particularly effective in the hind li!b. @or details of !ethods
see %hur!on et al. ,OOP pp ;JP-;J:.
"t is also used to a lesser e$tent for dogs to enable a!putation of the digit co!bined with
syste!ic sedation.
Figure 5. Easil* recogni6ed veins of the distal parts of the
limbs in cattle. 013 edial vie# of the right fore)
limb A, radial vein7 8, medial palmar digital
vein. 023 'ateral vie# of the right hind)limb9 C,
lateral branch of lateral saphenous vein7 ",
lateral plantar vein7 E, lateral plantar digital
vein.0From :all et al. 2;;;3
8egional anesthesia
%his ter! is used where specific nerves to the area concerned are bloc&ed.
#$a!ples include specific nerve bloc&s to the li!bs0 paravertebral bloc&s0 cornual bloc&
(for dehorning) and !any others.
+ list of the bloc&s widely used in veterinary !edicine, with suitable references, is given
as below.
ara#erte'ral anesthesia
'aravertebral anesthesia refers to the perineural inection of local anesthesia about the
spinal nerves as they e!erge fro! the vertebral canal through the intervertebral
fora!inae.
%he techni)ue !ay theoretically be carried out in any species, and at any level of the
spinal cord but in practice, its !ain use is to provide anesthesia of the lu!bar region in
ru!inants.
"ts advantage is that it provides analgesia and !uscle rela$ation of the whole area
covered by the seg!ental nerves bloc&ed.
Several different !ethods of achieving paravertebral anesthesia have been described.
+ll !ethods approaching fro! the dorsal surface are e)ually effective.
%he !ethod described whereby the needle is inserted ventral to the transverse processes
of the spine has the disadvantage that the dorsal branches of the seg!ental nerves are not
bloc&ed, thus so!e s&in sensitivity re!ains.
'aravertebral anesthesia is easy to carry out, and al!ost always effective, e$cept in the
very large beef breeds where it !ay be very difficult to locate the necessary land!ar&s.
+ description of one !ethod generally found to be effective for the cow is as follows0
ro)i%al $ara#erte'ral 'loc( 1&ar4uharson, 9all, or !a%'ri"ge 3echni4ue2
"ndicated for standing laparoto!y surgery such as C-section, ru!enoto!y, cecoto!y,
correction of gastrointestinal displace!ent, intestinal obstruction and volvulus.
%he dorsal aspect of the transverse processes of the last thoracic (%-,I) and first and
second lu!bar (*-, and *-4) vertebrae is the site for needle place!ent.
%he dorsal and ventral never roots of the last thoracic (%-,I) and ,st and 4nd lu!bar
spinal nerves e!erge fro! the intervertebral fora!ina are desensiti(ed. ,J-4J !l of 4Q
lidocaine is inected to each site onset occurs usually within ,J !inutes of inection
+nalgesia of the s&in, scoliosis toward the desensiti(ed side - due to paralysis of the
paralysis of the paravertebral !uscles, increased s&in te!perature due to vasodilation
(paralysis of cutaneous vaso!otor nerves) indicates effective bloc&. Euration of
analgesia lasts appro$i!ately OJ !inutes.
Distal $ara#erte'ral 'loc( 1Mag"a, !a(ala, or !ornell techni4ue2
"ndicated for sa!e as pro$i!al paravertebral bloc& above.
%he dorsal and ventral ra!i of the spinal nerves %,I, *, and *4 are desensiti(ed at the
distal ends of *-,, *-4 and *-D. + 9.;-c!, ,:-gauge needle is inserted ventral to the tips
of the respective transverse processes in cows where appro$i!ately ,J-4J !l of a 4Q
lidocaine solution are inected in a fan-shaped infiltration pattern.
%he needle is co!pletely withdrawn and reinserted dorsal to the transverse process,
where the cutaneous branch of the dorsal ra!i is inected with about ; !l of the
analgesic.
%he procedure is repeated for the second and fourth lu!bar transverse processes.
,J-4J !l 4Q lidocaine is used per site and onset and duration si!ilar to pro$i!al
techni)ue.
Figure <. /he proximal and distal
paravertebral bloc$ at the
/)1=, '1 and '2 in cattle.
/his techni%ue is one of the
most commonl* used
regional analgesia in cattle
for standing surger* 0C)
section, and laparotom*3.
0From /hurmon et al. 11123
Figure 1. 4hich side 0left or right3 of the co# is bloc$ed #ith
paravertebral techni%ue>
'eft side 0the muscles are relaxed on the bloc$ed side
and the muscle tone remains at the unbloc$ed side )
right side ) #hich pulled the co# to#ard this side and
#ith ade%uate #eight bearing3 0From :all et al. 2;;;3
/able 1. Advantages and disadvantages of four common local anesthetic techni%ues in cattle.
3echni4ues A"#antages Disa"#antages
'ro$i!al
'aravertebral
2loc&
,. S!all dose of analgesic,
4. Wide and unifor! area of
analgesia and !uscle rela$ation,
I. Mini!al intra-abdo!inal
pressure
D. "ncreased intestinal tone and
!otility
;. +bsence of local analgesic fro!
the operative wound !argins
,. %echnical difficulty
4. +rching up of the spine due to
paralysis of the bac& !uscles.
I. <is& of penetrating vital
structures such as the aorta
and thoracic longitudinal vein
on the left side and the caudal
vena cava on the right side.
Eistal
'aravertebral
2loc&
,. %he use of !ore routine si(e
needles, no ris& of penetrating a
!aor blood vessel.
4. *ac& of scoliosis !ini!al
wea&ness in the pelvic li!b and
ata$ia.
,. *arger doses of anesthetic are
needed.
4. Fariation in efficiency e$ists,
particularly if the nerves vary
in their anato!ical pathway.
"nfiltration
+nesthesia
,. #asiest and !ost co!!only used
,. #de!a and he!ato!a of the
!ultiple inections along the
incision site !ay interfere
with healing
4. "nco!plete analgesia and
!uscle rela$ation of the
deeper layers of the abdo!inal
wall
I. %o$icity after inecting
significant a!ounts of
analgesic solution
D. "ncreased cost due to large
doses and longer ti!e re)uired
for inection
"nverted L*M or
L9M 2loc&
,. Eeposition of the analgesic away
fro! the incision site, thus
!ini!i(ing ede!a, he!ato!a,
and possible interference with
healing.
,. "nco!plete analgesia and
!uscle rela$ation of the
deeper layers of the abdo!inal
wall
4. %o$icity after inecting
significant a!ounts of
analgesic solution
I. "ncreased cost due to large
doses and longer ti!e re)uired
for inection
Local Anesthesia & Analgesia 14 of 18 Veterinary Surgery I, VMED 7412
Veterinary Surgery I, VMED 7412 16 of 18 Local Anesthesia & Analgesia
Local ner#e 'loc(s of the hea"
!ornual ner#e 'loc(* !attle*
"ndicated for dehorning and treating horn inury.
-phthal!ic division of the fifth cranial nerve
"nected on the upper third of the te!poral ridge, about 4.; c! below the base of the horn.
%he nerve is relatively superficial, about J.9-, c! deep. I-; !l of 4 Q lidocaine is
inected.
-nset of analgesia occurs ,J-,; !inutes and duration of analgesia is appro$i!ately
one hour.
"n adult cattle with well-developed horns, a ring bloc& around the base of the horn !ay
be necessary.
Figure 1;. "iagrams of needle placement sites for cornual nerve bloc$ in a co#. 0From :all et
al. 2;;;3
!ornual ner#e 'loc(* :oats*
+gain for dehorning, not as easy as in the cow as there are two branches of the nerve
(lacry!al and infratrochlear branches).
Do not use in kids, as tend to use a total overdose of local anesthetics in these very s!all
ani!als.
Figure 11. "iagrams of needle placement sites for cornual nerve bloc$ in a goat. 0From
/hurmon et al 11123
Auriculo$al$e'ral 'loc(* !attle an" horses*
+uriculopalpebral nerve supplies !otor fiber to the orbicularis oculi !uscle.
"t runs fro! the base of the ear along the facial crest, past and ventral of the eye, giving
off its branches on the way
%he needle is inserted in front of the base of the ear at the end of the (ygo!atic arch and
is introduced until its point lies at the dorsal border of the arch. 4Q lidocaine ,J-,; !l at
inection site.
-nset of analgesia occurs ,J-,; !inutes and duration of analgesia is appro$i!ately one
hour. %his bloc& does not produce analgesia of the eye or the lids. "n conunction with
topical analgesia (4Q lidocaine), it is useful for the re!oval of foreign bodies fro! the
cornea and conunctival sac. +lso used, but less fre)uently in other species.
%his bloc& has no sensory effects but paralyses the !uscles of the eyelid. "t is used to
&eep the eye open, for e$a!ple, as an adunct in ophthal!ic surgery.
%his is one of the !ost co!!only used techni)ues to bloc& the !otor function of the
upper eye lid for ophthal!ic surgery. %o prevent eyelid closure during e$a!ination of
the eyeball
Figure 12. Auriculopalpebral bloc$ in a co# and a horse (@ro! /all et al. 4JJJ0 Muir et al.
,OOO)
8etro'ul'ar ner#e 'loc(* !attle*
Widely used in practice to enucleate the eye. May also be used in !any other species.
Figure 1=. ?etrobulbar needle placement through the
medial canthus 0A3 to the orbital apex 083
0From /hurmon et al. 11123
eterson7s eye 'loc(* !attle*
<e)uires !ore s&ill and specific anato!ic &nowledge than retrobulbar nerve bloc&, but
involves less ris& in da!aging surrounding anato!ic structure around the eye globe, and
less volu!e re)uire!ent reducing potential for syste!ic to$icity and e$pense.
%he point of inection is the notch for!ed by the supraorbital process cranially, the
(ygo!atic arch ventrally, and the coronoid process of the !andible caudally.
+n one inch, ,D gauge needle is inserted through a desensiti(ed s&in as far anterior and
ventral as possible in the notch.
"nsert a D-; inch, ,: gauge straight or slightly curved needle at the point of inection
!entioned above in a hori(ontal and slightly posterior direction until it hits the coronoid
process of the !andible.
Bently !anipulate the needle anteriorly until its point passes !edially around the
coronoid process, then advanced to the pterygopalatine fossa rostral to the solid bony
plate that is in close pro$i!ity of the orbitorotundu! fora!en. @ollowing aspiration, 9 S
,; !l of local anesthetics are inected.
-culo!otor, trochlear, abducens, and three branches of the trige!inal nerve (ophthal!ic,
!a$illary, and !andible) are desensiti(ed in ,J S ,; !inutes following inection.
&acial ner#es 1Infraor'ital, Man"i'ular, Mental an" Su$raor'ital2 ; Dog<9orse*
%hese nerve bloc&s !ay be used to allow surgery on the face. (%hur!on et al. ,OOP pages
DIJ-DI4, DDO-D;J).
Anesthesia of the li%'s
9orse*
"n the horse, very specific nerve bloc&s are used both for diagnoses of la!eness and to
allow surgery of the lower li!b.
"ntrarticular inections are also used.
Eetailed infor!ation of the specific digital nerve bloc& techni)ues is available in
%hur!on et al. (,OOP) pages D;4-DPJ.
!attle*
%he anato!y of the nerves to the li!bs of cattle is very co!plicated. (%hur!on et al.
pages ;J9-;,4).
+lthough very specific nerve bloc&s !ay be used to desensiti(e the lower li!b, it is !ore
co!!on to carry out the si!pler.
/rachial $le)us 'loc(
2rachial ple$us bloc& is suitable for inducing analgesia for the surgery on the front
li!b, any area below distal part of hu!erus.
%he techni)ue should be perfor!ed in a well-sedated or anestheti(ed ani!al.
%his bloc& can be used in dogs, cats, s!all ru!inants, calves, and foals.
2rachial ple$us bloc& is relatively si!ple and safe to perfor! and produces selective
anesthesia and rela$ation of the li!b and analgesia to the foreli!b.
%his techni)ue places a local anesthetic in close pro$i!ity to brachial ple$us nerves
that include the radial, ulnar, !edian, !usculocutaneous and a$illary nerves.
%he brachial ple$us nerves derived fro! C-P, C-9, C-: and %-, spinal nerves roots.
Bradual sensation and loss of !otor function occurs within ,J-IJ !inutes depending on
the type of drugs used.
+nesthesia lasts for appro$i!ately 4-P hours, and total recovery re)uires appro$i!ately
P-O hours.
Figure 1!. 8rachial plexus and nerve bloc$ing techni%ue.
9.;-c!, 4J-44 gauge spinal needle is inserted
!edial to the shoulder oint and directed
parallel to the vertebral colu!n toward the
costochondral unction.
"n larger si(e ani!al, if no blood is aspirated into
the syringe as the needle is withdrawn,
appro$i!ately ,J-,; !l of 4Q lidocaine or J.;
Q bupivacaine at I !gC&g with dilution up to 4J-
IJ !l is slowly inected.
*ocal anesthetics are inected to brachial
ple$us which would diffuse into the area to
effect.
'recise location is therefore usually less
i!portant than the spreading power of the drug
and inected volu!e. a1 CP, b1 C9, c1 C:, d1 %,,
f1 first rib, e1 /u!erus. (@ro! %hur!on et al.
,OOP)
Sources of reference
%hur!on, %ran)uilli and 2enson Feterinary +nesthesia Willia!s and Wil&ins ,OOP
/all, Clar&e, and %ri! Feterinary +nesthesia W2 Saunders 4JJJ
Muir, /ubbel and S&arda + handboo& of +nesthesia Mosby ,OOO