Pharmacology Of Local Anaesthesia

By: Dr. Alshaimaa Ahmed Lecturer of Oral & Maxillofacial surgery

What is local anesthetics?

Local anesthetics are drugs that block nerve conduction when applied to a nerve fiber in appropriate concentrations.

Transient

completely reversible

Characteristics of an ideal local anesthetic

Reversible anesthesia. Effective.

Rapid onset and sufficient duration.

Stable in solution. Stable for sterilization.

Easy metabolism and excretion.

Not allergic Should not have any systemic side effect. Should not be expensive.

Where do Local anesthesia work?

Nerve Membrane is the site at which local anaesthetics exert its pharmacological action

Remember >>>>> Nerve cell

Remember >>>>> Cell Membrane

Remember >>>>> Nerve Conduction

How Local anesthetics work??? Theories of action of local anaesthesia:

Acetyl choline theory

Theories of action of local anaesthesia:

Calcium displacement theory

Theories of action of local anaesthesia:

Surface Charge theory

Theories of action of local anaesthesia:

Membrane expansion theory

Theories of action of local anaesthesia:

Specific receptor theory

Chemical structure of local anesthetics

R
------------------- O
Aromatic portion Ester Or Amide

R
Amine portion

Chemical structure of local anesthetics

Classification of local anaesthetics:

The classification is based on the chemical structure of the intermediate chain.
Commonly used amides include: lidocaine, Mepivacaine. Commonly used esters include: tetracaine, procaine, cocaine. There are third group know as Quinoline.

Chemical structure of local anesthetics

Chemical structure of local anesthetics

In Laboratory >>>>> local anaesthetics is poorly soluble in water and unstable on exposure to air >>>>>in this form it is on no clinical value. For injection >>>>> local anaesthetics are dispensed as acid salts most commonly as hydrochloride salts dissolved in sterile water or saline

Dissociation of Local Anesthetics

Dissociation of Local Anesthetics & PH

The proportion of each ionic form in the sol varies with the PH of the sol or surrounding tissue

In the presence of high conc. Of H ion (low PH), the equilibrium shifts to the left and most of anesthetic sol exists in cationic form

RNH+> RN+H+
As hydrogen ion decreases ( higher pH) the equilibrium shifts to the free base form

RNH+ < RN +H+

Action on Nerve Membrane

PH7.4

Outside the cell RNH+ RN++ H

750 250

Sodium channel

Lipid bilayer

H + RN RNH Inside the cell

Action on Nerve Membrane

PH 6

Outside the cell RNH+ RN++ H

990 10

Sodium channel

Lipid bilayer

H + RN RNH Inside the cell

When will it start?? onset

Onset of action It is the time required for the local anesthetics to develop adequate anesthesia. It is affected by: The pH of the tissues and pKa of the agent. Diffusion to the site ( anatomical barrier). Concentration.

Dissociation constant pKa

It measures the affinity of a molecule for hydrogen ions A drug with lower pKa will have a rapid onset than that of higher pKa

Diffusion

Keep in Mind:
Nerve Fiber.single nerve cell Endoneurium covers each nerve cell Fasculi..bundles of 500 to 1000 nerve Perinurium.. Cover fasculi Perilemma.. Inner most layer of perinurium Epineurium alveolar connective tissue supporting fasculi and carrying nutrient vessels

Epinural sheath . Outer most layer of epinerium

How deep my anaesthesia potency?

The potency of a local anesthesia is its ability to provide complete analgesia under almost all circumstances.

The potency of a local anesthetic depend on:

1. Lipid solubility

2. Concentration.

How long will it stay? Duration

The duration of action of local anesthetics depends primarily on the redistribution of the drug away from the site of action. Redistribution can be altered by: 1. Protein binding. 2. Vasodilator activity 3. Individual variation in response to the drug.

Duration of action
Short acting L.A (5-40 min.): Without Vasoconstrictors: Lidocaine 2%. Prilocaine 4%. Mepivacaine 3%.

Duration of action
Medium Acting (45- 90 min.) Lidocaine 2% with epinephrine.

Mepivacaine 2% with epinephrine

Prilocaine 4% with epinephrine.

Duration of action
Long Acting (> 90 min.) Bupivacaine 0.5% with epinephrine.

Etidocaine 1.5% with epinephrine.

Recovery from local anaesthesia

By Diffusion>>>> in slower rate than onset

Readministration of Local anesthetics

Recurrence of immediate profound anesthesia Difficulty reachieving profound anesthesia (Tachyphylaxis .increased tolerance to the drug that administrated readetly) Tachyphylaxis caused by: edema localized hemorrhage clot formation decreased ph of the tissue)

 the local anaesthetic >>>> absorbed from the site of administration into circulation. The presence of a local anaesthetic drug in the circulatory system means that drug will be transported to every part of the body.

What does body do to the drug ? What the drug do to the body?

Pharmacokinetics

Uptake
Local Action: All local anesthetics posses a degree of vasoactivity, mostly vasodilatation except Cocaine which causes vasoconstriction.

Oral Route: All local anesthetics are poorly absorbed from the GIT except cocaine Most LA undergo hepatic first-pass after administration where 72% of the drug is transformed into inactive metabolites

Topical Route
Application to mucous membranes

the tracheal mucosa

Intact skin

Injection
The rate of uptake of local anesthetic after parental administration (subcutaneous, intramuscular or iv) is related to vascularity of the site and vasoactivity of the drug

Distribution
Local anesthetic absorbed and distributed to all tissues in the body. Intravascular injection results in a sequential distribution first to the lung then rapidly distributed to other organs with large blood supplies, especially the brain, heart, liver, kidneys, spleen and then to muscle and fat.

Biotransformation
Esters
Metabolized In plasma by the enzyme pseudocholine esterase Amides Metabolism In the liver by microsomal enzymes

Excretion
Kidneys are excretory organs for ester & amide anesthetics and their metabolites Patients with renal dysfunction may be unable to eliminate local anesthetics

Pharmacodynamics of Local anesthetics

LA are chemicals that reversibly block action potentials in all excitable membranes Most of the systemic actions are related to their blood or plasma level, the higher the level the greater will be the clinical action

Central nervous system

All local anesthetics cross the blood-brain barrier

At low therapeutic ,non toxic doses no CNS effects of any clinical significance is manifested
At higher toxic overdose levels the primary clinical manifestations is generalized tonic-clonic convulsions Between these two extremes there are preconvulsive signs and symptoms

Preconvulsive stage
Signs(objectively observable) Slurred speech Shivering Muscle twitches Visual disturbance

Drowsiness
Disorientation Symptoms (Subjectively felt) Numbness of tongue and circumoral region Warm flushed feeling of skin

Convulsive stage
Further elevation of LA blood levels leads to signs and symptoms of Tonic conic convulsive episode further increase will lead to depression

pre- convulsive & convulsive stages

Dose releated Mechanism

Inhibitory impulses

Faclitatory impulses

Central nervous system

Analgesia Mode elevations

Cardiovascular system
Action on myocardium : local anesthetics produce a myocardial depression that is related to drug blood level Decrease cardiac excitability Decrease conduction rate Decrease force of contraction Used for treatment of cardiac dysrhythmias

Cardiovascular system
Direct action on peripheral vasculature:

All Local anaesthetics cause vasodilatation except cocaine which is a vasoconstrictor

all except cocaine cause hypotension

Respiratory System
Has dual effect on respirations

At non overdose level they have a direct relaxant action on bronchial smooth muscle
As a result of CNS depression respiratory arrest may occur

Vasodilatation effect of local anesthesia

Increase rate of absorbtion Higher plasma levels of local anaesthesia Decrease in both depth and duration of local anesthesia Increased bleeding at the site of treatment

Vasoconstrictors

vasoconstrictors constrict blood vessels It counteract vasodilating effect of the local anesthetics.

Vasoconstrictors
Advantages:
Increase the concentration of drug at the site: Prolong anesthetic duration. Produces more profound anesthesia. Decrease the blood level of the drug, thus reduce the risk of toxicity. Decrease bleeding at site.

Vasoconstrictors
Systemic effects of vasoconstrictors: Vasoconstrictors are sympathomimetic i.e. they mimic the action of norepinephrine on sympathetic effector organs where they bind to specific receptors called adrenergic receptors. These receptors are divided into alpha () and beta ( ) receptors.

Vasoconstrictors
Alpha () receptors

Alpha 1 (1)
Smooth muscles of the BVs vasoconstriction

Alpha 2 (2)
Inhibitory receptors

Vasoconstrictors
Beta ( ) receptors

Beta 1 ( 1)
In the heart increase rate and force of contraction

Beta 2 ( 2)
In bronchi bronchodilation In coronaries vasodilation.

Vasoconstrictors

Nor-epinephrine excites mainly alpha receptors and to slight extent beta receptors.

Epinephrine excites both receptors predominant effect on beta ones.

with

slight

Vasoconstrictors
Mode of action: In the small amounts commonly used in dentistry,

vasoconstrictors stimulate alpha receptors located in

the walls of the arterioles in the area of injection causing vasoconstriction which in turn slowing the

removal of the anesthetic

Vasoconstrictors
Disadvantages:

Local anesthetic molecules are relatively stable and

degrade very slowly. As a result, the shelf life of local anesthetic depends mostly on the stability of the vasoconstrictor. For this reason, sodium metabisulphite is used a s a

preservative or stabilizer for the vasoconstrictor

molecule. Systemic effect

Vasoconstrictors
Dilution of vasoconstrictors: The dilution of vasoconstrictors is commonly referred to as a ratio (e.g. 1:1000) this ratio can

be interpreted and converted as the following:

1:1000 means that there is one gram (1000mg) of the drug in 1000 ml (1 litre) of solution, or 1.0 mg/ml of solution.

What is meaning of 1:100.000 epinephrines?

1: 1000 = 1 mg / ml 1: 50.000 = 0.02 mg / ml 1: 100.000 = 0.01 mg / ml 1: 20.000 = 0.05 mg / ml Content of carpule contain 1: 100.000 epinephrine. 0.01 mg x 1.8 ml
----------------------= 0.018 mg / carpule.

1:100.000 = 0.01 mg / ml ?

1 ml 1.8 ml

Vasoconstrictors
Epinephrine:

Nature:
Known as adrenaline. Most commonly used due to its strong action. Stability: Unstable, undergo oxidation by heat. Sodium bisulphite preservative used to delay oxidation

 Epinephrine (adrenaline):
Systemic effect: Increase blood pressure. Increase heart rate. Increase cardiac output. Increase myocardial oxygen consumption. Vasculature Hemostasis: vasoconstriction followed by vasodilatation

Termination : reuptake inactivated in blood by COMT & MAO.

Available concentration: 1:50.000- 1: 100.000 (in Canada) and 1:80.000- 1:300.000 in other countries

 Maximum permeable dose: For healthy patient 0.2mg in appointment:

10 ml of 1:50,000 dilution (5 crtridges).

20 ml of 1:100,000 dilution (11 cartridges). 40 ml of 1:200,000 dilution (22 cartridges). For cardiac patient 0.04 mg/appointment: 2ml of 1:50,000 dilution (1 cartridge). 4ml of 1:100,000 dilution (2 cartridges). 8ml of 1:200,000 dilution (4 cartridges).

Vasoconstrictors
Norepinephrine (levarterenol): Nature: Known as noradrenaline . Stability:

Undergo deterioration on exposure to light.

Systemic effect: Increase blood pressure. Decrease heart rate. Decrease cardiac output.

It is 1/8 as effective in raising the blood sugar as epinephrine.

 The norepinephrine act almost on potent as epinephrine.

receptors . It is one fourth as

That will lead to severe vasoconstriction in the peripheral circulation (ischemia in the palate ) Available consentration 1:300.000 Norepinephrine:
Maximum permeable dose:
For healthy patient 0.34 mg/appointment. For cardiac patient 0.14 mg/appointment.

Vasoconstrictors
Levonordefrin:
Nature:
It is synthetic vasoconstrictor. It has direct action on the 15% as potent as epinephrine receptors(75%) & it is

Stability:
Unstable, undergo oxidation and deterioration. Sodium bisulphite used to delay oxidation.

Systemic effect:
Less effective in contrating blood vessels and in raising blood pressure than epinephrine. It is 1/10 as active as epinephrine in increasing blood sugar.

 Levonordefrin:
Concentrations in L.A:
1:20,000.

Maximum permeable dose:

Maximum dose is 1 mg/appointment (11 cartridges).

Vasoconstrictors
Phenylephrin:
Nature:
Synthetic. It has direct action on the epinephrine receptors(95%) & it is 5% as potent as

Stability:
Most stable vasoconstrictor used in dentistry.

Concentrations in L.A:
Used in dental practice with 4% procaine in 1:2500 dilution.

 Phenylephrin:
Maximum permeable dose:
For healthy patient 4 mg/appointment. Far cardiac patient 1.6 mg/appointment.

Vasoconstrictors
Felypressin:
Nature:
Synthetic analogue of the antidiuretic hormone vasopressin. Act directly on the smooth muscles in the wall of the blood vesseles It is non sympathomimetic amine, so it has no effect on adrenergic nerve transmission safe for hyperthyroid patients.

Systemic effect:
It has oxytoxic action so it is contraindicated in pregnant women.

Concentration in L.A:
Used in dental practice with 3% prilocaine in a 0.03 IU/ml dilution.

Maximum permeable dose:

For cardiac patients is 0.27 IU

What we will find in the market ????

Ester Types Local Anesthesia

Procaine (Novocain) Propoxycaine Tetracaine (topical anaesthesia)

Procaine ( Novocain)
Nature ester types L.A. Metabolism in plasma by pseudocholinestrases enzymes. Excretion Via kidney. Onset: 6-10 min Dental concentration 2% or 4% conc. 2% solution gives from 12-15 minutes of anesthesia The addition of 1:100.000 adrenaline prolong the duration to 30-45 minutes

The addition of 1:50.000 adrenaline prolong the duration to 60-90 minutes.

Propoxycaine HCL
Nature ester types L.A. Metabolism in plasma by pseudocholinestrases enzymes. Excretion Via kidney. Onset: rapid 2-3 min Dental concentration 0.4% conc. It is combined with procaine to provide more rapid onset and a more profound anaesthesia

Amides Local Anesthesia

Lidocaine. Mepivacaine.

Articaine HCl.
Bupivacaine HCL Prilocaine HCL

Lidocaine (Lingospan, octocaine, Xylocaine)

Amide. Metabolism: liver. Excretions: kidneys. Duration of action: without V.C. 5 mins. Pregnancy classification: B Onset of action :2-3 min. Effective dental concentration: 2%

Maximum dose 300 mg without V.C & 500 mg with V.C

Mepivacaine HCl ( carbocaine, Isocaine, polocaine, scandanest) Amide.

Metabolism: liver. Excreation: kidneys. Vasodilating properties: produce slight V.D. Duration of action: without V.C. 20-40 min. Onset of action: rapid 1.5-2 min. Effective dental concentration: 3% without V.C.; 2% with a V.C. Pregnancy classification: C Concentrations of V.C.: 2% with levonordefrin (1:20,000), 2% with epinephrine (1:100,000).

Articaine HCl ( Articadent, orbbloc, septocaine)

Amide. Metabolism: it is the only amide-type local anesthetic that contains an ester group, so biotransformation occurs in both the plasma and liver. Excretion: kidneys. Onset of action: 1-3 min. Effective dental concentration: 4% with 1:100,000 or 1:200,000 epinephrine. Clinically it is claimed that maxillary buccal infiltration, on occasion, provides palatal soft- tissue anesthesia. It is also claimed that articaine can provide pulpal and lingual anesthesia when administered by infiltration in the adult mandible

Prilocaine (Citanest)
Nature Amides Local Anesthesia. Metabolism In liver, kidney & lung so it undergo biotransformation more rapidly than other amide. Excretion Via kidney faster than other amide. (most safe) Dental concentration 4% with or without V.C. V.C used with it is 1:200.000 Epinephrines. Onset of action Its onset of action is slightly slower than Lidocaine Maximum dose 6 mg/ kg body weight or 400 mg

Bupivacaine (Marcaine)
Nature Amides Local Anesthesia + long acting L.A. Metabolism In liver. Excretion Via kidney. Dental concentration 0.25% 0.5% conc. With 1:200.000 Epinephrine . Onset of action Rapid onset of action equal to lidocaine. Maximum dose 2 mg/ kg body weight for adult- 90 mg as maximum dose .

What is meaning of 2% xylocaine?

2% xylocaine = 20 mg / ml. Content of 2% xylocaine in one carpule = 20 mg x 1.8 ml = 36 mg/carpule.

20 mg / ml ?

1 ml 1.8 ml

Maximum doses of Local Anesthesia

The doses of local anesthetic drugs are presented in terms of milligrams of drug per unit of body weight.

The administration of a maximum dose based on body weight produces a local anesthesia blood level just below the threshold for an overdose (toxic) reaction.

Maximum doses of Local Anesthesia

Local anesthetic
Articaine
With V.C. 7.0 500

mg/Kg

MRD (mg)

Lidocaine

No V.C. With V.C.

4.4 4.4 4.4 4.4

300 300

Mepivacaine

No V.C. With V.C.

300 300

Maximum doses of Local Anesthesia

Local Anesthetic Percent concentration mg/ml X 1.8 ml = mg/ cartridge

Articaine

40

72

Lidocaine

20

36

Mepivicaine

2 3

20 30

36 54

Calculation of the max dose

Patient : 22 years old, Healthy , 50 kg Local Anaesthesia >>>> Lidocaine 2% epinephrine 1:100.000 Lidocaine 2% = 36mg/ cartilage Patient max dose= 50* 7 mg/kg = 350 mg (MRD)

Number of cartilage = 350/ 36 = 9 cartilage

What if the patient is cardiac ? What if the dentist use another local anaesthetic drug ?

Total dose of Both local anaesthetics should not exceed the lower of the two calculated dose.

What is maximum dose of V.C. in normal and cardiac patients?

Type of V.C. Maximum dose in normal patient Epinephrine 1:100.000 Norepinephrine 1: 30.000 Levonordefrine 1:20.000 Phenylephrin 1:2500 0.2 mg 0.34 mg Maximum dose in cardiac patient 0.04 mg 0.14 mg

1 mg
4 mg

0.2 mg
1.6 mg 0.27 IU,

Felypressin
0.03 IU

Factor in selection of a local anesthesia for a patient

Length of time pain control is necessary Potential need for posttreatment pain control Possibility of self mutilation in the post operative period

Requirment for hemostasis

Presence of any contraindication to local anaesthetic solution selected for administration

Topical anesthesia

Topical Anesthesia

Produce painless needle injection. Used for some procedures as removal of very loose primary teeth or suture removal or before gingival curettage. Reduce patient apprehension.

Topical Anesthesia
Characteristics: Can not penetrate intact skin. Its concentration is higher than injectable one to facilitate its diffusion through mucous membrane. Higher concentration increase its risk of toxicity because the topical anesthesia has no V.C.

Topical Anesthesia

Characteristics: The anesthesia is effective only on 2.3 mm depth of the tissues on which it is applied. Available in the form of spray or gel, the gel form is more preferred because it can be dispensed in a

premeasured doses.

Topical Anesthesia
Types of local anesthesia:

Benzocaine.
Lidocaine HCl.

Lidocaine base.
Tetracaine HCL. Cocaine HCl. EMLA (Eutectic Mixture of Local Anesthesia).