LOCAL ANESTHETICS AND REGIONAL ANESTHESIA

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES

Local Anesthetics- History

1860 - cocaine isolated from erythroxylum coca Koller - 1884 uses cocaine for topical anesthesia Halsted - 1885 performs peripheral nerve block with local Bier - 1899 first spinal anesthetic

Local Anesthetics - Definition

A substance which reversibly inhibits nerve conduction when applied directly to tissues at non-toxic concentrations

Local anesthetics - Mechanism

Limit influx of sodium, thereby limiting propagation of the action potential.

Local Anesthetics - Classes

Esters

Local anesthetics - Classes (Rule of is)

Esters Cocaine Chloroprocaine Procaine Tetracaine Amides Bupivacaine Lidocaine Ropivacaine Etidocaine Mepivacaine

Local anesthetics - Formulation

Biologically active substances are frequently administered as very dilute solutions which can be expressed as parts of active drug per 100 parts of solution (grams percent)
Ex.: 2% solution =

_2 grams__ = _2000 mg_ = __20 mg__ 100 ccs 100 ccs 1 cc

Local Anesthetics - Allergy

True allergy is very rare Most reactions are from ester class - ester hydrolysis (normal metabolism) leads to formation of PABA - like compounds Patient reports of allergy are frequently due to previous intravascular injections

Local Anesthetics - Toxicity

Tissue toxicity - Rare Can occur if administered in high enough concentrations (greater than those used clinically) Usually related to preservatives added to solution Systemic toxicity - Rare Related to blood level of drug secondary to absorption from site of injection. Range from lightheadedness, tinnitus to seizures and CNS/cardiovascular collapse

Local anesthetics - Duration

Determined by rate of elimination of agent from site injected Factors include lipid solubility, dose given, blood flow at site, addition of vasoconstrictors (does not reliably prolong all agents) Some techniques allow multiple injections over time to increase duration, e.g. epidural catheter

Local anesthetics - vasoconstrictors

Ratios
Epinephrine is added to local anesthetics in extremely dilute concentrations, best expressed as a ratio of grams of drug:total ccs of solution. Expressed numerically, a 1:1000 preparation of epinephrine would be
1 gram epi 1000 ccs solution

1000 mg epi
= 1000ccs solution =

1 mg epi 1 cc

Local anesthetics - vasoconstrictors

Therefore, a 1 : 200,000 solution of epinephrine would be

1 gram epi

1000 mg epi

200,000 ccs solution

=
or

200,000 ccs solution

5 mcg epi
1 cc solution

Local anesthetics - vasoconstrictors

Vasoconstrictors should not be used in the following locations Fingers Toes Nose Ear lobes Penis

REGIONAL ANESTHESIA

Regional anesthesia - Definition

Rendering a specific area of the body, e.g. foot, arm, lower extremities, insensate to stimulus of surgery or other instrumentation

Regional anesthesia - Uses

Provide anesthesia for a surgical procedure Provide analgesia post-operatively or during labor and delivery Diagnosis or therapy for patients with chronic pain syndromes

Regional anesthesia - types

Topical Local/Field Intravenous block (Bier block) Peripheral (named) nerve, e.g. radial n. Plexus - brachial, lumbar Central neuraxial - epidural, spinal

Topical Anesthesia
Application of local anesthetic to mucous membrane - cornea, nasal/oral mucosa Uses :
awake oral, nasal intubation, superficial surgical procedure

Advantages :
technically easy minimal equipment

Disadvantages :
potential for large doses leading to toxicity

Local/Field Anesthesia
Application of local subcutaneously to anesthetize distal nerve endings Uses:
Suturing, minor superficial surgery, line placement, more extensive surgery with sedation

Advantages:
minimal equipment, technically easy, rapid onset

Disadvantages:
potential for toxicity if large field

IV Block - Bier block

Injection of local anesthetic intravenously for anesthesia of an extremity Uses
any surgical procedure on an extremity Advantages: technically simple, minimal equipment, rapid onset

Disadvantages:
duration limited by tolerance of tourniquet pain, toxicity

Peripheral nerve block

Injecting local anesthetic near the course of a named nerve Uses:
Surgical procedures in the distribution of the blocked nerve

Advantages:
relatively small dose of local anesthetic to cover large area; rapid onset

Disadvantages:
technical complexity, neuropathy

Plexus Blockade
Injection of local anesthetic adjacent to a plexus, e.g cervical, brachial or lumbar plexus Uses :
surgical anesthesia or post-operative analgesia in the distribution of the plexus

Advantages:
large area of anesthesia with relatively large dose of agent

Disadvantages:
technically complex, potential for toxicity and neuropathy.

Central neuraxial blockade - Spinal

Injection of local anesthetic into CSF Uses:
profound anesthesia of lower abdomen and extremities

Advantages:
technically easy (LP technique), high success rate, rapid onset

Disadvantages:
high spinal, hypotension due to sympathetic block, post dural puncture headache.

Central Neuraxial Blockade - epidural

Injection of local anesthetic in to the epidural space at any level of the spinal column Uses: Anesthesia/analgesia of the thorax, abdomen, lower extremities Advantages:
Controlled onset of blockade, long duration when catheter is placed, post-operative analgesia.

Disadvantages:
Technically complex, toxicity, spinal headache