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PHARMAC-05

LOCAL ANESTHESIA

LOCAL ANESTHESIA
PHARMA-05

Definition
PAIN: Defined as an unpleasant emotional experience usually initiated by a noxious stimulus and transmitted over a specific neural pathway to the CNS where it is interpreted as such. LOCAL ANESTHESIA: Defined as loss of sensation in a circumscribed area of the body caused by a depression of excitation in the nerve endings or an inhibition of conduction process in peripheral nerves.

Ideal requirements of a local anesthetic drug


1. 2. 3. 4. 5. 6. 7. 8. Reversible Stable in solution Non irritating to tissues Should not cause any permanent alteration in nerve Low systemic toxicity Rapid onset and enough duration of action Potent enough to give complete anesthesia without using harmful concentrations Relatively free from producing allergic reactions

Indications of regional analgesia


1. Conscious state of patient in minor oral surgical procedures desired 2. Diagnostic and Therapeutic purposes 3. For bloodless field during surgical procedures as an adjunct when used with vasoconstrictor

Contraindications
ABSOLUTE: RELATIVE: Allergy 1.Local infections 2.Uncooperative patient 3.Fear or apprehension 4.Major oral surgical procedures 5.Systemic conditions like renal or liver disease affecting the metabolism and excretion of drug

The Concept Of LA
They prevent both generation and conduction of a nerve impulse. LA sets up a chemical roadblock between the source of impulse and the brain. Thus, the aborted impulse, prevented from reaching the brain is not interpreted as pain.

Classification Of LA Drugs
1.BASED ON COMPOSITION A. Natural: cocaine B. Synthetic nitrogenous compounds: PABA Procain, Benzocain acetanilide- Lignocaine Quinoline- centbucridine C. Non nitrogenous compounds: Benzyl alcohol D. Miscellaneous: Clove oil, phenol.

2.ACCORDING TO CHEMICAL STRUCTURE

A.ESTER GROUP Cocaine Benzocaine Tetracaine Butaine Procaine Propoxycain 2-Chlorprocaine

B.NON-ESTER GROUP Lidocaine Mepivacaine Pyrocaine Bupivacaine Prilocaine

3.ACCORDING TO DURATION OF ACTION 1.Ultrashort acting(<30 minutes) a) Procaine without vasoconstrictor. b) 2% lidocaine without vasoconstrictor. c) 2% chlorocaine without vasoconstrictor. 2.Short acting(45-75 minutes) a) 2% lidocaine with 1:100000 epinephrine. b) 2% mepivacaine with 1:20000 levonordefrin. c) 4%prilocaine nerve block.

3.Medium acting a) 4% prilocaine with 1:200000 epinephrine. b) 2% lidocaine with vasoconstrictor 4. Long acting (180 minutes or long) a) 0.5% bupivacaine with 1:200000 epinephrine b) 0.5 %etidocaine with 1:200000 epinephrine.

Techniques
3 major types of local anesthetic injections: LOCAL INFILTRATION: LA deposited near small terminal nerve endings FIELD BLOCK: LA deposited near larger terminal nerve branches. NERVE BLOCK: LA deposited close to main nerve trunk.

Maxillary Injection Techniques


1.Anesthesia for Teeth and Buccal soft and hard tissues: a) Supra periosteal b) Posterior Superior alveolar c) middle superior alveolar d) Anterior superior alveolar 2.Palatal: a) Greater palatine b) Nasopalatine c) Local infiltration d) AMSA e) Palatal approach-ASA 3.Maxillary Nerve block

Mandibular Injection Techniques


REGIONAL ANESTHESIA TO PULPS OF SOME OR ALL TEETH: Inferior alveolar nerve block Gow-gates mandibular nerve block Incisive nerve block Vazirani-akinosi (closed mouth)

1. 2. 3. 4.

REGIONAL ANESTHESIA FOR SOFT TISSUES ONLY: 1. Buccal nerve block 2. mental nerve block

Anesthetic Complications
DEFINITION: Any deviation from the normally expected pattern during or after securing of local anesthesia.

CLASSIFIED AS: primary/secondary mild/ severe transient/permanent.

COMPLICATIONS: Toxicity Allergy Syncope Trismus Broken needles Hematoma Sloughing

Toxicity
CAUSES: 1.Overdosage 2. unusually rapid absorption intravascular injection 3. slow elimination or distribution. SYMPTOMS: 1.talkitiveness 6.sweating 2.apprehension 7.disorientation 3.exitability 8.elevated B.P. 4.sluttered speech 9.respiratory rate high 5.euphoria

1. 2. 3. 4. 5. 6. 7.
P

PREVENTION: Preanesthetic evaluation must. Select drug with care. Use least possible volume. Deposit solution slowly. Aspiration is must. Use vasoconstrictor if not contraindicated. Do not give LA beyond recommended doses. BASIC EMERGENCY MANAGEMENT: A B C D

Allergy
SYMPTOMS:
Rashes

TREATMENT: Antihistaminic agents Benadryl:20-50 mg Epinephrine-0.5ml of 1:1000 IM Aminophylline-0.5gm IV Oxygen

Urticaria Angioneurotic edema Mucous membrane congestion

rhinitis
asthmatic symptoms

Syncope
TREATMENT: Should be done before patient loses consciousness. Detect change in appearance-pallor. Discontinue any procedure. Semi-reclined position.

Conscious patient: instruct to take few deep breaths. Unconscious patient: check vitals if beyond normal limits give artificial ventilation.

Trismus
Prolonged tetanic spasm of jaw muscles Restricted mouth opening. Causes: Trauma Infection or irritating solutions.

Management:1.heat therapy 2.warm saline rinses 3.muscle relaxants 4.physiotherapy 5.antibiotics if symptoms persist. 6.surgery if chronic dysfunction exists.

Broken Needle
Most annoying and depressing complication. Causes: 1. bending before insertion. 2. sudden patient movement. 3. use of fine needles. Management: If visible: instruct patient not to move. remove with hemostat or Magill forcep. If lost: do not proceed with incision or probing refer patient for consultation. If in deeper tissues: let it remain without attempt at removal.

Clinical Aspects
Max dose of lidocaine without adrenaline is = 300mg Max dose of LA with adrenaline = 500mg Max safe dose of adrenaline =0.2mg/visit

2% Lignocaine= 2g in 100 ml 2000mg in 100 ml 20 mg in 1ml 1 mg= 1/20 500mg=1/20500= 25ml can be given safely for a normal pt

Adrenaline present in our vials is in conc. of 1:80,000 1ml=1/80,000=0.0125mg 0.0125mg-1ml As MRD-0.2mg , so for normal pt- 0.2 mg=1/0.01250.2=16ml of LA can be administered safely

THANK YOU

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