The complications of local analgesia
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1 The complications of local analgesia Dr. Körmöczi Kinga Department of Oral, Dental and Maxillofacial Surgery SEMMELWEIS UNIVERSITY FACULTY OF DENTISTRY
2 Complications and untoward reactions of local analgesia General complications toxic reactions /overdosage/ Side effect of adrenaline allergic /anaphylactic/ reactions Local complications haematoma formation nerve injury trismus /limited mouth opening/ facial paralysis injury of soft tissues
3 The aetiology of complications of local analgesia General complications: due to the anaesthetic solution Local complications: due to the technique
4 General complications Toxic reactions /overdosage/ Side effect of adrenaline Allergic /anaphylactic/ reactions
5 Local anaesthetic solution = 1. anaesthetic agent 2. vasoconstrictor 3. preservative
6 The pharmacological properties of local anaesthetics Toxicity Therapeutical ratio = LD 50 ED 50 lethal dosage effective dosage Depends on the metabolism of the local anaesthetic agent
7 The metabolism of Lidocaine and Articaine CH 3 O NHC Amide CH 2 N C 2 H 5 CH 3 NHC O CH 2 N C 2 H 5 CH 3 Lidocaine C 2 H 5 CH 3 OH C 2 H 5 S O NHC CH N CH 3 COOCH 3 Ester Amide H < 10 % C 3 H 7 > 90 % S O NHC CH 2 OH CH 3 COOCH 3 O N H C 3 H 7 H Articaine S NHC CH CH 3 COOH + CH 2 OH N C 3 H 7
8 The symptoms of overdosage of local anaesthetic agents Dose Depression phase CNS Respiratory depression, loss of consciousness, coma CVS Fall of pulse rate and blood pressure, cardiac arrest Excitation phase Dose Excitement, nausea, tremor, convulsions, hyperventilation Elevation of pulse rate and blood pressure. Redness of skin.
9 The comparison of local anaesthetics Articaine Lidocaine Bupivacaine Relative toxicity /procaine = 1/ 1,5 2 8 Therapeutical ratio 3,3 2 2 Plasma half time 20 min 96 min 162 min Recommended maximum dosage /70 kg/ with Adrenaline 500 mg mg 90 mg
10 PROTEIN-BINDING OF LOCAL ANAESTHETICS (%) LIDOCAINE 64 ARTICAINE 95 BUPIVACAINE 96
11 The advantages of high proteinbinding of local anaesthetics In pregnancy, less anaesthetic enters into the foetal circulation Less CVS and CNS risks
12 Lidocaine 2% c. Adr. /local anaesthetic solution/ Anaesthetic agent: lidocainum hydrochloricum 20 mg/ ml Maximum dose: 7 mg/ kg ~ 500 mg 20 ml ~ 10 Ampulla Vasoconstrictor: epinephrinum /adrenaline/ 1 : ,01 mg/ ml Maximum dose: 0,20 mg
13 Ultracaine 4% DS forte /local anaesthetic solution/ Anaesthetic agent: articainum hydrochloricum 40 mg/ ml Maximum dose: 7 mg/ kg ~ 500 mg 12,5 ml ~ 6 Ampulla Vasoconstrictor: epinephrinum /adrenaline/ 1 : ,01 mg/ ml Maximum dose: 0,20 mg
14 General complications Toxic reactions /overdosage/ Side effect of adrenaline Allergic /anaphylactic/ reactions
15 Receptor stimulation of adrenaline (i.v. application) 1-2 g / min Beta-1 and Beta-2-stimulation 2-10 g / min Alpha, Beta stimulation g / min Alpha stimulation Maximum dose: mg/s.c./
16 The symptoms of overdosage of adrenaline
17 The concentration of Adrenaline in local anaesthetics 1 : : : :
18 The maximum doses of Adrenaline in local anaesthetic solutions/0.2mg/ ADRENALINE MAXIMUM DOSE CONCENTRATION mg/ml mg ml Cartridge/1.7ml/ 1 : 50, ½ 1 : 100, : 200,
19 Lidocaine containing local anaesthetic solutions in Europe /not complete/ Manufacturer Proprietary name Astra Chemicals GmbH Xylocain 2% Adrenaline Xylocain 2% Spezial Adrenaline Anaesthetic concentration 2% 2% Vasoconstrictor concentration (Adrenaline) 1: : ESPE GmbH Xylestesin-A 2% 1: Xylestesin cento 2% 1: Xylestesin-S special 2% 1:
20 Articaine containing local anaesthetic solutions in Europe Manufacturer Proprietary name ESPE GmbH Ubistesin Ubistesin forte Anaesthetic concentration 4% 4% Vasoconstrictor concentration (Adrenaline) 1: : Hoechst AG Ultracain D-S 4% 1: Ultracain D-S forte 4% 1:
21 Aspirating syringe equipment
22 The possible cause of intravasal injection at negative aspiration-test
23 General complications Toxic reactions /overdosage/ Untoward reactions of adrenaline Allergic /anaphylactic/ reactions
24 The incidence of allergic responses to local anaesthetic agents Procaine para-allergy Articaine Lidocaine Bupivacaine
25 Local anaesthetic solution = 1. anaesthetic agent 2. vasoconstrictor 3. preservative
26 Preservative agents in the local anaesthetic solutions Methylparaben: antimicrobal effect allergic reactions Sodium metabisulfite: reducing agent protects the stability of adrenaline allergic reactions at asthmatic patients
27 Risk-patients regarding to local analgesia cardiovascular diseases hyperthyroidism hepatic insufficiency polyallergy pregnancy anxiety from the dental treatment
28 Risk-patients regarding to local analgesia cardiovascular diseases Acute myocardial infarction Cardial decompensation
29 The advantages of high proteinbinding of local anaesthetics In pregnancy, less anaesthetic enters into the foetal circulation Less CVS and CNS risks
30 Risk-patients regarding to local analgesia cardiovascular diseases hyperthyroidism
31 Risk-patients regarding to local analgesia cardiovascular diseases hyperthyroidism hepatic insufficiency
32 Hepatic insufficiency: reduced metabolism of amid type of local anaesthetics Hypoproteinaemia: alcoholic disease, malnutrition, malabsorption, nephrosis-syndrome, enteropathia Repeated doses are to avoid!
33 Risk-patients regarding to local analgesia cardiovascular diseases hyperthyroidism diabetes hepatic insufficiency polyallergy
34 Risk-patients regarding to local analgesia cardiovascular diseases hyperthyroidism diabetes hepatic insufficiency polyallergy pregnancy
35 Risk-patients regarding to local analgesia cardiovascular diseases hyperthyroidism diabetes hepatic insufficiency polyallergy pregnancy anxiety from the dental treatment
36 The comparison of the amounts of adrenaline given at dental treatment, and the catecholamines secreting in the adrenal medulla: Dental treatment: 4 ml Lidocaine c. Adr. = 0,04 mg Stress situation; pain, anxiety: Adrenal medulla = cca. 0,30 mg/min.
37 Local complications Haematoma formation Nerve injury Trismus /limited mouth opening/ Facial paralysis Injury of soft tissues
38 The position of needle and blood vessels at tuberal analgesia
39 Haematoma formation at tuberal analgesia
40 Local complications Haematoma formation Nerve injury Trismus /limited mouth opening/ Facial paralysis Injury of soft tissues
41 THE DIFFERENT POSITIONS OF THE NEEDLE AT THE NERVE BLOCK ANALGESIA OF THE INFERIOR ALVEOLAR NERVE
42 Local complications Haematoma formation Nerve injury Trismus /limited mouth opening/ Facial paralysis Injury of soft tissues
43 Transitory facial palsy on the left side after mandibular nerve-block analgesia
44 Local complications Haematoma formation Nerve injury Trismus /limited mouth opening/ Facial paralysis Injury of soft tissues
45 TRAUMATIC ULCERATION DUE TO LOCAL ANALGESIA
46 Necrosis on the hard palate after infiltration analgesia
47 Thank you for your attention!
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