Local & Systematic Complications of LA

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Anaesthesia & Exodontia
Third Year

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Local & Systematic Complications of LA

  1. 1. LOCAL ANAESTHESIA Local and Systemic Complications of LA Dr. Adel I. Abdelhady BDS, MSC, (EG) PhD (EG,USA) Oral and Maxillofacial Surgery Dept. College of Dentistry, Dammam University, KSA. .
  2. 2. Unannounced Quiz What is the LA?  The lipid solubility determine the……….  The degree of protein binding of a local anesthetic agent determines the…………  The pKa of LA determines its…………… 
  3. 3. OBJECTIVS        The student shall be able to explain the signs and symptoms of side effects, and Localized and systemic complications , how to diagnose and the rational of their treatment. Systemic complications, how to diagnose and manage Doctor factor (wrong technique) and how to avoid Vasoconstrictor LA Needle Patient factor
  4. 4. Factors influencing injection discomfort?  The needle: Sharp & small gauge  The syringe: Aspirating to avoid local and systemic effects  The cartridge: Smooth bung to avoid judder and allow steady injection  The solution: Temperature: >15 – 37< is not detected by the patient. pH: (LA with VC is acidic (3.2)…..Painful, LA without VC is less acidic (6.8)……….Painless Rate of injection: faster injection is painful.
  5. 5. Complications of LA  Causes: • • • • • Doctor factor (wrong technique) Vasoconstrictor LA Needle Patient factor
  6. 6. Complications of LA I. Localised II. Systemic I. Localised complications:    Pain: during and postinjection Failure A Equipment failure:   Broken needle Cartridge failure.  Neurological problems:      Prolonged altered sensation Unilateral facial nerve paralysis Visual disturbances Aural disturbances Extensive paralysis: reversed flow to the brain
  7. 7. Needle Breakage Causes  Unexpected movement  Small needle size  Bent needles  Defective needles
  8. 8. Needle Breakage Prevention  Use large needles  Use long needles for deep injection,>18mm  Never insert to hub  Redirect only when adequately withdrawn
  9. 9. Rush Hour, Venice
  10. 10. Needle Breakage Management  Remain calm  Don't explore  Have the patient keep opening wide  If the needle is out remove it  Refer to an Oral Surgeon
  11. 11. Localised complications:  Vascular problems:        Intravascular injection Haematoma Sloughing of oral mucosa Self-inflicted trauma Trismus: due to bl. & LA Infection Interference with wound healing: adrenaline & dry socket
  12. 12. Failure anaesthesia • Causes • Wrong technique Anatomical variations: • • • • • • • • • Bifid or double nerve supply Nerve anastomosis Secondary supply by a soft tissue nerve: LN, LBN & GPN Inadequate dose Sepsis acidity Injection in BV Anxiety reduced patient pain threshold Patient immaturity
  13. 13. Management of failed local anaesthesia • • • • • Check anatomical landmarks Repeat injection Consider alternate or additional technique Consider whether anxiety may be contributory Settle pain and inflammation and try again about a week later
  14. 14. Pain on Injection Causes  Dull needles  Rapid deposit of solution  Needles with barbs  Careless technique
  15. 15. Pain during injection     Pain during injection: Intraepithelial injection leading to ballooning Subperiosteal injection cause discomfort due to injection into noncompliant tissues Too rapid injection a rate of 30 sec. per cartridge is ideal
  16. 16. Pain on Injection Prevention  Careful technique  Sharp needles  Topical anesthetic  Slow injections  Room temperature solutions
  17. 17. Burning on Injection Causes  PH of solution  Rapid injection  Contamination  Warmed solutions
  18. 18. Persistent Anesthesia or Paresthesia Causes  Trauma to nerve  Neurolytic agents (alcohol, phenol)  Intraneural injection  Hematoma
  19. 19. Persistent Anesthesia or Paresthesia Management  Patient counseling and reassurance  Documentation  Follow-up
  20. 20. Trismus A motor disturbance of the trigeminal nerve precipitating or resulting in spasm of the muscles of mastication
  21. 21. Trismus Causes  Trauma to muscles or blood vessels  Contaminated anesthetic solutions  Hemorrhage  Infection  Excessive anesthetic volume
  22. 22. Trismus Prevention  Sharp needles  Proper care and handling of cartridges  Aseptic technique and clean injection site  Atraumatic insertion  Minimal injections and volume
  23. 23. Trismus Management  Examination  Conservative therapy Passive ROM therapy Analgesics Heat Muscle relaxants    
  24. 24. Hematoma Due to needle accidentally penetrate a b.v. leading to effusion of blood into extravascular spaces Prevention  Care with needle placement  Minimize number of injections  Don't probe with needle  Modify technique o short needles o penetration depth o When hematoma is large prescribe antibiotics to prevent infection
  25. 25. Infection Causes  Needle contamination  Improper handling of armamentarium  Infection at injection site  Improper handling of tissue  Not following technique of asepsis
  26. 26. Infection Prevention  Disposable needles  Proper care of equipment  Aseptic technique
  27. 27. Infection Management  Usual sign is trismus  Trismus persists (1-3 day resolution )  Antibiotics, if suspicious
  28. 28. Cartridge failure L A cartridge may fail when subjected to high pressure during intraligamentary or palatal injection  To prevent this rate of injection should be slow 
  29. 29. Sloughing of Tissue Causes  Topical anesthetic  Prolonged ischemia Management  Observation  Documentation
  30. 30. Lip Chewing Management  Analgesics  Antibiotics  Saline rinses  Lip lubricants
  31. 31. Facial Nerve Paralysis Cause        Injection into the parotid capsule Anesthesia of peripheral Facial nerve branches Temporal Zygomatic Buccal Mandibular Cervical
  32. 32. Facial Nerve Paralysis Prevention  Bone contact when injecting  Avoid over penetration  Avoid arbitrary injection
  33. 33. Facial Nerve Paralysis      Management Reassure patient Cornea care Documentation Consider deferring dental care
  34. 34. Dolomite Mountains,
  35. 35. Complications of LA Systemic adverse effects complications:      Toxicity (due to LA & VC)  Methaemoglobinaemia:  General NS toxicity  Cardiovascular Toxicity (Haemoglobin contains iron in Ferric not Ferrous state leading Drug interactions to poor oxygenation and Allergic effects cyanosis (Treated by IV 1% Fainting/syncope methylene blue 1.5 mg/kg. oIdiosyncrasy toluidine (oxidise Iron) is a metabolic product of Prilocaine. Articaine, Benzocaine?
  36. 36. SYSTEMIC COMPLICATION Fainting     or syncope Fainting or syncope frequently occurs because of patient frightened at the thought of receiving an injection Predisposing factors: 1-Psychogenic factors: fear , anxiety and sight of unpleasant object as blood or surgical instrument 2-Non-psychogenic: factors as pain especially sudden unexpected, sitting in waiting area for a long period, hunger causing low glucose supply or exhaustion ,poor physical condition
  37. 37. Fainting Clinical features 1-Pre-syncope period : The patient feels faint and may feel nauseating. Paleness and coldness of hand, cold sweating over the forehead and hands, hypotension , tachycardia and deep irregular respiration
  38. 38. Syncope      Loss of consciousness: Hypotension , bradycardia and shallow irregular respiration. Possible muscular twitches (tremors) or convulsive movements of the extermities. Progression may occur into muscular relaxation and apnoea 2-Post-syncope period After regaining consciousness the patient feels weak, nauseating and mentally confused for few minutes.
  39. 39. Patho-physiology  Stress causes  Management secretion of adrenalin into the circulation this cause peripheral vascular resistance and blood flow to the muscle to prepare body to response to this stressful condition 1-Stop any dental procedure 2-Place patient in supine or trendelenberg position to facilitate venous return to the heart 3-Maintain patient airway , respiratory stimulants by aromatic spirit of ammonia 4-Oxygen administration might be needed 5-Keep the patient in this position under observation 6-For persistent bradycardia give atropine 0.4 mg i.v
  40. 40. LA Toxicity LA Toxicity Manifestations and management Manifestations and management Prevention
  41. 41. Cause of Overdose Levels      Total dose is too large Absorption is too rapid Intravascular injection Biotransformed too slowly Eliminated too slowly
  42. 42. Manifestations and management of LA toxicity a Manifestations •Mild toxicity: Talkativeness, anxiety, slurred speech, confusion Moderate toxicity: Stuttering speech, nystagmus, tremors, headache, dizziness, blurred vision, drowsiness Management • Stop administration of all local anaesthetics • Monitor vital signs • Observe in office for 1 hr • Stop administration of all local anaesthetics • Place in supine position • Monitor vital signs • Observe in office for 1 hr.
  43. 43. Manifestations and management of LA toxicity b Manifestations Management Sever toxicity: seizure, cardiac dysrhythmia or arrest. • Place in supine position • If seizure, protect from nearby objects and suction oral cavity if vomiting occurs • Have someone summon medical assistance • Monitor vital signs • Administer oxygen • Start IV • Administer diazepam 5-10 mg slowly or midazolam 2-5 mg slowly • Institute BLS if necessary • Transport to emergency care facility
  44. 44. General Principles       No drug exerts a single action No drug is non-toxic Potential toxicity is user dependent Adverse Drug Reactions Side effects Overdose
  45. 45. Adverse Drug Reactions Altered recipient  Disease process  Emotional disturbances  Genetic aberrations  Idiosyncrasy
  46. 46. Idiosyncrasy Reaction    Unexplained by any known mechanism of the drug’s action Neither overdose nor allergic reaction Unpredictable; treat symptoms
  47. 47. Predisposition - Overdose Patient factors  Age  Weight  Sex  Medications
  48. 48. Predisposition - Overdose Drug factors  Rate of injection  Vascularity of site  Vasoconstrictors
  49. 49. Adverse Drug Reactions Allergic reaction  Immediate - anaphylaxis  Delayed - contact dermatitis  Not dose related  May be systemic or localized  Unrelated to pharmacological effects  Exaggerated immune system response
  50. 50. Intravascular Injection Occurrence varies with type of injection: Nerve Block % positive aspirate  Inf. alveolar 11.7  Mental/Incisive 5.7  Post. sup. alv. 3.1  Ant. sup. alv./ Buccal <1
  51. 51. Prevention     Use aspirating syringe Use needle - 25 ga or larger Aspirate in 2 planes Inject slowly
  52. 52. Vasoconstrictor Overdose Clinical manifestations:   Sharply elevated BP (systolic)   Fear, anxiety   Tenseness   Restlessness   Tremor   Weakness  Throbbing headache Perspiration Dizziness Pallor Respiratory difficulty Palpitations Increased heart rate
  53. 53. Management - v/c overdose     Stop dental treatment Sit patient up Reassure patient, administer O2 Monitor BP and pulse until fully recovered
  54. 54. Allergic Reactions Type Mechanism Time Clinical Example I Antigen induc. sec/min Angioedema, Anaphylaxis IV Cell mediated 48 hrs Contact dermatitis
  55. 55. Allergens in Local Esters - usually to the Para-amino-benzoic-acid product  Na bisulfite or metabisulfite - found in anesthetics as perservative for vasoconstrictors  Methylparaben - no longer used as perservative in dental cartridges 
  56. 56. Management of Allergy Pts.  If the patient gives a history of allergy to local anesthetics - Assume that an allergy exists  Elective procedures Postpone until work-up is completed
  57. 57. Allergy - signs/symptoms Dermatologic:  Urticaria - wheals, pruritis  Angioedema  Minor rash
  58. 58. Allergy - signs/symptoms Respiratory:       Laryngeal edema Bronchospasm distress, dyspnea anxiety , cyanosis or flushing wheezing , tachycardia diaphoresis is the state of perspiring profusely, use of accessory muscles
  59. 59. Anaphylactic shock     Anaphylactic shock is anaphylaxis associated with systemic vasodilation which results in low blood pressure. It is also associated with severe vasoconstriction of the bronchioles to the point where the individual is unable to breathe Smooth muscle spasms (GI crampy abdominal pain, diarrhea, and vomiting ) Respiratory distress shortness of breath, wheezes or stridor Cardiovascular collapse
  60. 60. Management of Reactions Delayed skin reaction Benadryl - 50 mg stat & Q6H X 3-4 days Immediate skin reaction  Epinephrine 0.3 mg IM or SC  Benadryl - 50 mg IM  Observation, medical consultation  Benadryl - 50 mg Q6H X 3-4 days
  61. 61. Management of Reactions Bronchial constriction  Semi-erect position, O2 - 6 L/min  Inhaler or Epinephrine 0.3 mg IM or SC  Benadryl - 50 mg IM  Observation, medical consultation  Benadryl - 50 mg Q6H X 3-4 days
  62. 62. Mangement of Reactions Laryngeal edema  Place supine, O2 - 6 L/min  Epinephrine 0.3 mg IM or SC  Maintain airway  Benadryl - 50 mg IV or IM  Hydrocortisone - 100 mg IV or IM  Perform Cricothyrotomy
  63. 63. Management of Reactions Anaphylaxis  Place supine, on flat surface  ABCs of CPR, call for medical help  Epinephrine 0.3 mg IV or IM (Q 5 mins)  O2 - 6 L/min, monitor vital signs  Benadryl and Hydrocortisone
  64. 64. Methemoglobinemia      Methemoglobinemia (hemoglobin in Fe3+ oxidation state) 1. Amide-type agents (lidocaine, prilocaine) 2. Toxic metabolite (aromatic amine) 3. Cyanosis (brown blood, blue skin color) 4. Antidote: methylene blue
  65. 65. References 1. 2. SF Malamed: Pain and anxiety control for the conscious dental patient, 1997. Meechan, et al., Hand book of local anaesthesia, 1998.
  66. 66. Suggested maximum dosage of local anaesthetics Drug Common brand Concentration Percentage Maximum number of 1.8 ml cartridges Lidocaine Xylocaine 2% 10 Lidocaine + Epin. Xylocaine with epinephrine 2% lidocaine 1:100000 epinephrine 10 Mepivacaine Carbocaine 3% 6 Mepivacaine + norad. Carbocaine with neo-cobfrin 2% mepivacaine 1:20000 levonordefrin 8 Prilocaine Citanest 4% 6 Bupivacain + Adren. Marcaine with epinephrine 0.5% bupivacaine 1: 200 000 10 Etidocaine Duranest with 1.5% etidocaine 15
  67. 67. Church of Selva Di Cadore, Colle Santa Lucia

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