MMR PRESENTATION Presenter : Dr Ahmad Jaihan Bin Ismail Moderator: Dr Aisai Abdul Rahman
HISTORY <ul><li>MJ </li></ul><ul><li>33 YEARS OLD MALAY MAN </li></ul><ul><li>ADMITTED 5/7 IN WARD FOR NECROTIZING FASCITI...
<ul><li>PRESENTED WITH </li></ul><ul><ul><li>FEVER FOR 2/7 PTA </li></ul></ul><ul><ul><li>RT LEG SWELLING </li></ul></ul><...
<ul><li>CARDIOVASCULAR </li></ul><ul><ul><li>HX OF SOB SINCE 3 YEARS AGO WHEN HE WAS  TOO EXHAUSTED </li></ul></ul><ul><ul...
<ul><li>RENAL </li></ul><ul><ul><li>DEVELOPED ARF 2 TO SEPSIS </li></ul></ul><ul><ul><li>UNDERGONE HD TWICE </li></ul></ul...
<ul><li>Drug therapy </li></ul><ul><ul><li>Completed iv unasyn 1.5g tds for 5/7 </li></ul></ul><ul><ul><li>Currently on iv...
examination <ul><li>General condition </li></ul><ul><ul><li>Alert, concious and pink </li></ul></ul><ul><ul><li>Mild dehyd...
<ul><li>Lung </li></ul><ul><ul><li>reduce air entry Rt side </li></ul></ul><ul><li>Musculoskeletal </li></ul><ul><ul><li>R...
INVESTIGATION <ul><li>FBC </li></ul><ul><li>COAGULATION PROFILE </li></ul><ul><ul><li>PTTK : 39.4 </li></ul></ul><ul><ul><...
<ul><li>BUSE/SE CREAT </li></ul>POST 1 ST  HD POST 2 ND   HD 6/2 7/2 8/2 8/2 9/2 UREA 34.9 41.1 46 33.9 20.6 Na 128 131 12...
<ul><li>ABG </li></ul><ul><ul><li>PH 7.37, PCO2 31, PA02 81, SAO2 95, HCO3 17,  BE  -7 </li></ul></ul><ul><li>ECG: SR, ISO...
<ul><li>PROBLEM LIST </li></ul><ul><ul><li>SEPSIS SECONDARY TO RT LL NECROTIZING FASCITIS </li></ul></ul><ul><ul><li>ARF S...
<ul><li>PLAN </li></ul><ul><ul><li>FOR ICU BACK UP </li></ul></ul><ul><ul><li>TO TRANSFUSE 2 UNIT PLATLET INTRAOP </li></u...
PROCEDURE <ul><li>UNDER ASEPTIC TECHNIQUE </li></ul><ul><li>WITH USG GUIDED </li></ul><ul><li>USING NERVE STIMULATOR </li>...
PROGRESS <ul><li>CLINICALLY NO EPISODE INADVERTENT OF INTRAVASCULAR INJECTION </li></ul><ul><li>HEMODYNAMICALLY STABLE THR...
AFTER 1 MINUTE <ul><li>C/O </li></ul><ul><ul><li>DIFFICULTY IN SWALLOWING </li></ul></ul><ul><ul><li>SWOLLEN AND NUMBNESS ...
PROGRESS <ul><li>HEMODYNAMICALLY STABLE </li></ul><ul><li>NO EPISODE OF HYPOTENSION OR BRADYCARDIA </li></ul><ul><li>PROCE...
LOCAL ANAESTHESIA <ul><li>DEFINITION </li></ul><ul><ul><li>A drug which reversibly prevents transmission of the nerve impu...
ester amides hydrophobic hydrophilic Molecule linkage is more easily broken less Less stable More stable- longer stored No...
Preparation of LA <ul><li>Available as solution for injection, sprays, cream and gels </li></ul><ul><li>Mostly prepared as...
Pharmacodynamic  <ul><li>MECHANISM OF ACTION </li></ul><ul><ul><li>2 theories </li></ul></ul><ul><ul><ul><li>Disruption of...
 
<ul><li>pKa  </li></ul><ul><ul><li>All local anesthetic agent is a weak base </li></ul></ul><ul><ul><li>At physiological p...
Pharmacokinetic  <ul><li>Absorption </li></ul><ul><ul><li>skin, subcuteneous tissue, intrathecal and epidural space </li><...
<ul><li>Metabolism & excretion </li></ul><ul><ul><li>Ester </li></ul></ul><ul><ul><ul><li>Rapidly metabolized by plasma es...
 
<ul><li>Degree of toxicity of the drug depend on protein bound </li></ul><ul><li>Therefore bupivacaine is > toxic than lid...
Procedure to do local/regional anaesthesia <ul><li>Explaination and consent </li></ul><ul><ul><li>Rule out any contraindic...
cont <ul><li>Performing block </li></ul><ul><ul><li>Under aseptic technique </li></ul></ul><ul><ul><li>Under usg guided </...
cont <ul><li>Use of nerve stimulator </li></ul><ul><ul><li>To locate the nerve </li></ul></ul><ul><ul><li>Preferable to us...
cont <ul><li>After block  </li></ul><ul><ul><li>Closed monitoring- BP, HR, saturation & amount of fluid </li></ul></ul><ul...
Potential problem with LA <ul><li>LA toxicity </li></ul><ul><li>Allergic reaction--- PABA </li></ul><ul><li>Methaemoglobin...
LA TOXICITY <ul><li>Factor predisposed to LA toxicity </li></ul><ul><ul><li>Overdosage </li></ul></ul><ul><ul><li>Type of ...
Clinical features <ul><li>CNS </li></ul><ul><ul><li>Tingling of lips </li></ul></ul><ul><ul><li>Slurred speech </li></ul><...
 
Management of LA toxicity <ul><li>Based on the Association of Anesthetist of Great Britain & Ireland 2010 </li></ul>
Prevention  <ul><li>Have adequate knowledge of pharmacokinetic and pharmacodynamic of the drugs </li></ul><ul><li>Use appr...
Reference  <ul><li>Toxicity from Local Anaesthetic Drugs Dr David A Conn,Consultant Anaesthetist, Royal Devon & Exeter Hos...
 
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Mmr presentation anaesth

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Mmr presentation anaesth

  1. 1. MMR PRESENTATION Presenter : Dr Ahmad Jaihan Bin Ismail Moderator: Dr Aisai Abdul Rahman
  2. 2. HISTORY <ul><li>MJ </li></ul><ul><li>33 YEARS OLD MALAY MAN </li></ul><ul><li>ADMITTED 5/7 IN WARD FOR NECROTIZING FASCITIS OF RT LOWER LIMB – PLAN FOR WD </li></ul><ul><li>ACTIVE IVDU </li></ul><ul><ul><li>LAST INJECTION 2/7 PTA </li></ul></ul><ul><ul><li>ADDICTED TO HEROIN </li></ul></ul>
  3. 3. <ul><li>PRESENTED WITH </li></ul><ul><ul><li>FEVER FOR 2/7 PTA </li></ul></ul><ul><ul><li>RT LEG SWELLING </li></ul></ul><ul><li>A/W </li></ul><ul><ul><li>CHILLS AND RIGORS </li></ul></ul><ul><ul><li>LETHARGIC AND POOR ORAL INTAKE </li></ul></ul><ul><ul><li>PROGRESSIVE WORSENING OF RT LEG SWELLING WITH REDNESS AND PAIN UPON WALKING. </li></ul></ul>
  4. 4. <ul><li>CARDIOVASCULAR </li></ul><ul><ul><li>HX OF SOB SINCE 3 YEARS AGO WHEN HE WAS TOO EXHAUSTED </li></ul></ul><ul><ul><li>ABLE TO LIE FLAT AND SLEEP WITH 1 PILLOW </li></ul></ul><ul><ul><li>NO PND, NO ORTHOPNOEA </li></ul></ul><ul><ul><li>NYHA CLASS II </li></ul></ul><ul><li>RESPIRATORY </li></ul><ul><ul><li>OLD PTB 2010- COMPLETED RX AT HOSP KAJANG </li></ul></ul><ul><ul><li>NO HX OF ICU ADMISSION </li></ul></ul>
  5. 5. <ul><li>RENAL </li></ul><ul><ul><li>DEVELOPED ARF 2 TO SEPSIS </li></ul></ul><ul><ul><li>UNDERGONE HD TWICE </li></ul></ul><ul><li>MUSCULOSKELETAL </li></ul><ul><ul><li>HX OF MVA TWICE </li></ul></ul><ul><ul><ul><li>2005 </li></ul></ul></ul><ul><ul><ul><ul><li>CALCANEUM FRACTURE </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ORIF WAS DONE UNDER SPINAL- UNEVENTFUL </li></ul></ul></ul></ul><ul><ul><ul><li>1/2/2012 </li></ul></ul></ul><ul><ul><ul><ul><li>RT ANKLE DISLOCATION WITH A/W </li></ul></ul></ul></ul><ul><ul><ul><ul><li>NO ADMISSION </li></ul></ul></ul></ul>
  6. 6. <ul><li>Drug therapy </li></ul><ul><ul><li>Completed iv unasyn 1.5g tds for 5/7 </li></ul></ul><ul><ul><li>Currently on iv cloxacillin 500mg qid </li></ul></ul>
  7. 7. examination <ul><li>General condition </li></ul><ul><ul><li>Alert, concious and pink </li></ul></ul><ul><ul><li>Mild dehydrated </li></ul></ul><ul><ul><li>Tachypnoea but able to talk in full sentence, not on oxygen therapy </li></ul></ul><ul><li>Vital sign </li></ul><ul><ul><li>T : 37 </li></ul></ul><ul><ul><li>BP : 100/65 </li></ul></ul><ul><ul><li>PR : 68 </li></ul></ul><ul><ul><li>RR : 25-30B/MIN </li></ul></ul><ul><li>Weght : estimated 60 kg. </li></ul><ul><li>Airway : normal </li></ul><ul><li>CVS : DRNM,S1S2 </li></ul>
  8. 8. <ul><li>Lung </li></ul><ul><ul><li>reduce air entry Rt side </li></ul></ul><ul><li>Musculoskeletal </li></ul><ul><ul><li>Rt LL swelling and erythematous up to mid thigh </li></ul></ul><ul><ul><li>Blackish discolouration dorsal of rt foot </li></ul></ul>
  9. 9. INVESTIGATION <ul><li>FBC </li></ul><ul><li>COAGULATION PROFILE </li></ul><ul><ul><li>PTTK : 39.4 </li></ul></ul><ul><ul><li>INR : 1.27 </li></ul></ul>6/2 7/2 8/2 9/2 TWC 26.8 34.9 42.6 37.8 Hb 11.2 10 9.46 10.7 PLT 184 107 93 80 HCT 24.1 23.1 22.9 24.3
  10. 10. <ul><li>BUSE/SE CREAT </li></ul>POST 1 ST HD POST 2 ND HD 6/2 7/2 8/2 8/2 9/2 UREA 34.9 41.1 46 33.9 20.6 Na 128 131 126 132 137 K 4.1 4.1 4.5 3.6 3.2 CL 98 97 98 97 98 CREAT 509 602 594 444 265
  11. 11. <ul><li>ABG </li></ul><ul><ul><li>PH 7.37, PCO2 31, PA02 81, SAO2 95, HCO3 17, BE -7 </li></ul></ul><ul><li>ECG: SR, ISOLATED T INVERSION AT AVL </li></ul><ul><li>CXR: FIBROTIC CHANGES > RT LUNG, NO CARDIOMEGALY </li></ul><ul><li>CARDIAC ENZYME </li></ul><ul><ul><li>CK 1934, LDH 1032, AST 264 </li></ul></ul><ul><li>HIV RAPID TEST: NEGATIVE </li></ul>
  12. 12. <ul><li>PROBLEM LIST </li></ul><ul><ul><li>SEPSIS SECONDARY TO RT LL NECROTIZING FASCITIS </li></ul></ul><ul><ul><li>ARF SEC TO SEPSIS </li></ul></ul><ul><ul><li>RHABDOMYOLISIS </li></ul></ul><ul><ul><li>ACTIVE IVDU </li></ul></ul><ul><ul><li>OLD PTB </li></ul></ul><ul><li>ASA CLASSIFICATION </li></ul><ul><ul><li>III,E </li></ul></ul>
  13. 13. <ul><li>PLAN </li></ul><ul><ul><li>FOR ICU BACK UP </li></ul></ul><ul><ul><li>TO TRANSFUSE 2 UNIT PLATLET INTRAOP </li></ul></ul><ul><ul><li>DECIDED FOR PERIPHERAL NERVE BLOCK IN OT </li></ul></ul><ul><ul><ul><li>SCIATIC NERVE BLOCK </li></ul></ul></ul><ul><ul><ul><li>FEMORAL NERVE BLOCK </li></ul></ul></ul>
  14. 14. PROCEDURE <ul><li>UNDER ASEPTIC TECHNIQUE </li></ul><ul><li>WITH USG GUIDED </li></ul><ul><li>USING NERVE STIMULATOR </li></ul><ul><li>TOTAL VOLUME </li></ul><ul><ul><li>SCIATIC NERVE: </li></ul></ul><ul><ul><ul><li>ROPIVACAIVE 0.75% 15CC ( 112.5 mg) </li></ul></ul></ul><ul><ul><ul><li>LIGNOCAINE 2% 15CC (300mg) </li></ul></ul></ul><ul><ul><li>FEMORAL NERVE: </li></ul></ul><ul><ul><ul><li>ROPIVACAINE 0.75% 10CC (75 mg) </li></ul></ul></ul><ul><ul><ul><li>LIGNOCAINE 2% 10CC (200 mg) </li></ul></ul></ul>
  15. 15. PROGRESS <ul><li>CLINICALLY NO EPISODE INADVERTENT OF INTRAVASCULAR INJECTION </li></ul><ul><li>HEMODYNAMICALLY STABLE THROUGHOUT PROCEDURE AND PT WAS WELL COMMUNICATED </li></ul>
  16. 16. AFTER 1 MINUTE <ul><li>C/O </li></ul><ul><ul><li>DIFFICULTY IN SWALLOWING </li></ul></ul><ul><ul><li>SWOLLEN AND NUMBNESS OF THE LIPS </li></ul></ul><ul><ul><li>IMMEDIATELY FOLLOWED BY JERKY MOVEMENT FOR A FEW SECONDS </li></ul></ul><ul><ul><ul><li>ABORTED SPONTENEOUSLY </li></ul></ul></ul><ul><ul><ul><li>NOT REGAIN CONCIOUSNESS POST FIT </li></ul></ul></ul><ul><li>IMP : LA TOXICITY </li></ul><ul><li>DECIDED FOR INTUBATION </li></ul><ul><ul><li>IV FENTANYL 100MCG, IV STP 200MG, IV SUXAMETHONIUM 100MG </li></ul></ul>
  17. 17. PROGRESS <ul><li>HEMODYNAMICALLY STABLE </li></ul><ul><li>NO EPISODE OF HYPOTENSION OR BRADYCARDIA </li></ul><ul><li>PROCEED WITH OP </li></ul><ul><li>INTRAOPERATIVELY NO COMPLICATION </li></ul><ul><li>ADMITTED TO ICU FOR FURTHER STABILIZATION AND WEANING </li></ul><ul><li>EXTUBATE AND T/O TO GEN WARD THE NEXT DAY. </li></ul>
  18. 18. LOCAL ANAESTHESIA <ul><li>DEFINITION </li></ul><ul><ul><li>A drug which reversibly prevents transmission of the nerve impulse in the region to which it is applied without affecting conciousness. </li></ul></ul><ul><ul><li>( hilary edgcombe, graham hocking) </li></ul></ul><ul><li>CLASSIFICATION </li></ul><ul><ul><li>Ester </li></ul></ul><ul><ul><ul><li>Lipid soluble & hydrophobic aromatic group </li></ul></ul></ul><ul><ul><li>Amide </li></ul></ul><ul><ul><ul><li>Hydrophilic group </li></ul></ul></ul>
  19. 19. ester amides hydrophobic hydrophilic Molecule linkage is more easily broken less Less stable More stable- longer stored Not heat-stable- cant Heat-stable- can be autoclave Metabolism mostly produces PABA >allergic reaction rare Short duration of action longer Rarely used Commonly used Eg: chloroprocaine cocaine dimethocaine procaine tetracaine/amethocaine Eg: bupivacaine cinchocaine/dibucaine levobupivacaine lidocaine/lignocaine mepivacaine prilocaine ropivacaine
  20. 20. Preparation of LA <ul><li>Available as solution for injection, sprays, cream and gels </li></ul><ul><li>Mostly prepared as the HCL salt----dissolved in water </li></ul><ul><li>Additive </li></ul><ul><ul><li>Adrenaline - vasoconstrict effect </li></ul></ul><ul><ul><li>- minimized vasodilator effect </li></ul></ul><ul><ul><li>- 1 : 200 000 </li></ul></ul><ul><ul><li>Sodium bicarbonate - 0.15ml of 8.4% </li></ul></ul><ul><ul><li>- ↑ pH– > ↑ unionised </li></ul></ul><ul><ul><li>Glucose – 80mg/ml for bupivacaine </li></ul></ul>
  21. 21. Pharmacodynamic <ul><li>MECHANISM OF ACTION </li></ul><ul><ul><li>2 theories </li></ul></ul><ul><ul><ul><li>Disruption of voltage gated Na channel function within neuron cell membrane </li></ul></ul></ul><ul><ul><ul><ul><li>Ionised form intracellularly </li></ul></ul></ul></ul><ul><ul><ul><li>Membrane expansion theory </li></ul></ul></ul><ul><ul><ul><ul><li>Unionised form extracellularly </li></ul></ul></ul></ul>
  22. 23. <ul><li>pKa </li></ul><ul><ul><li>All local anesthetic agent is a weak base </li></ul></ul><ul><ul><li>At physiological pH (7.4), all LA are more ionised than unionised </li></ul></ul><ul><ul><li>Proportions vary between the drugs </li></ul></ul><ul><ul><ul><li>Pka lidnocaine 7.9---- 25% unionised </li></ul></ul></ul><ul><ul><ul><li>Pka bupivacaine 8.1----15% unionised </li></ul></ul></ul><ul><ul><li>In infective tissue (abscess) </li></ul></ul><ul><ul><ul><li>More acidic environment </li></ul></ul></ul><ul><ul><ul><li>Fraction of unionised reduce---the effect delayed & reduced </li></ul></ul></ul><ul><ul><ul><li>Increase vascularity---increase systemic absorption----> reduce local effect on neuron </li></ul></ul></ul>
  23. 24. Pharmacokinetic <ul><li>Absorption </li></ul><ul><ul><li>skin, subcuteneous tissue, intrathecal and epidural space </li></ul></ul><ul><ul><li>Depend on </li></ul></ul><ul><ul><ul><li>Vascularity of the area </li></ul></ul></ul><ul><ul><ul><li>Intrinsic effect of the drug and its additives </li></ul></ul></ul><ul><li>Distribution </li></ul><ul><ul><li>Depend on the degree of tissue and plasma protein bound </li></ul></ul><ul><ul><li>>protein bound--->longer the duration of action </li></ul></ul>
  24. 25. <ul><li>Metabolism & excretion </li></ul><ul><ul><li>Ester </li></ul></ul><ul><ul><ul><li>Rapidly metabolized by plasma esterases--- short ½ life </li></ul></ul></ul><ul><ul><ul><li>Except cocaine is hydrolysed in the liver </li></ul></ul></ul><ul><ul><ul><li>Metabolite is excrete by the renal </li></ul></ul></ul><ul><ul><li>Amides </li></ul></ul><ul><ul><ul><li>Metabolised hepatically by amidase </li></ul></ul></ul><ul><ul><ul><li>Slow process---Longer ½ life </li></ul></ul></ul><ul><ul><ul><li>Can accumulate if given in repeated doses or by infusion </li></ul></ul></ul><ul><ul><ul><li>Except prilocaine is also metabolised extrahepatically </li></ul></ul></ul>
  25. 27. <ul><li>Degree of toxicity of the drug depend on protein bound </li></ul><ul><li>Therefore bupivacaine is > toxic than lidnocaine </li></ul>
  26. 28. Procedure to do local/regional anaesthesia <ul><li>Explaination and consent </li></ul><ul><ul><li>Rule out any contraindication </li></ul></ul><ul><ul><li>Explained to the pt regarding procedure and the effect of LA </li></ul></ul><ul><li>Preparation </li></ul><ul><ul><li>Familiar with the relevant anatomy, the technique and possible complication </li></ul></ul><ul><ul><li>Anaesthetic drugs ( thiopentone, ephidrine, atropine, suxamethonium) </li></ul></ul><ul><ul><li>Anesthetic and airway equipment </li></ul></ul><ul><ul><li>Pt monitoring- ecg, bp and pulse oxymeter </li></ul></ul><ul><ul><li>Running IV access </li></ul></ul><ul><ul><li>Adequate preload </li></ul></ul>
  27. 29. cont <ul><li>Performing block </li></ul><ul><ul><li>Under aseptic technique </li></ul></ul><ul><ul><li>Under usg guided </li></ul></ul><ul><ul><li>Short bevelled needle for peripheral nerve block </li></ul></ul><ul><ul><li>Use nerve stimulator to determine end point of paraesthesia </li></ul></ul><ul><ul><li>Always aspirate before injecting to reduce chance of inadvertent intravascular </li></ul></ul><ul><ul><li>Injected small amount of LA 1 st to avoid intraneural injection </li></ul></ul><ul><ul><li>Injection must be little or no resistance </li></ul></ul>
  28. 30. cont <ul><li>Use of nerve stimulator </li></ul><ul><ul><li>To locate the nerve </li></ul></ul><ul><ul><li>Preferable to use an insulated needle & connected to –ve electrode </li></ul></ul><ul><ul><li>Initially use single twitch with current strength 2.0-4.0 mA </li></ul></ul><ul><ul><li>Reduce the current strength to 0.2-0.5 mA when nerve approached, present of muscle twitching </li></ul></ul>
  29. 31. cont <ul><li>After block </li></ul><ul><ul><li>Closed monitoring- BP, HR, saturation & amount of fluid </li></ul></ul><ul><ul><li>Test the level of sensory block using needle(pain) or spirit swab(temperature) </li></ul></ul><ul><ul><li>Give adequate time to the block to take effect </li></ul></ul><ul><ul><li>Be prepared to convert to GA </li></ul></ul><ul><ul><li>Watch for complication- circumoral tingling sensation, nausea or vomiting, hypotension, bradycardia, respiratory distress and institute early treatment </li></ul></ul>
  30. 32. Potential problem with LA <ul><li>LA toxicity </li></ul><ul><li>Allergic reaction--- PABA </li></ul><ul><li>Methaemoglobinaemia--- prilocaine which is metabolised to O-toluidine </li></ul>
  31. 33. LA TOXICITY <ul><li>Factor predisposed to LA toxicity </li></ul><ul><ul><li>Overdosage </li></ul></ul><ul><ul><li>Type of the drugs used- bupivacaine > levobupivacaine> ropivacaine> lidnocaine </li></ul></ul><ul><ul><li>Types of peripheral nerve block- brachial plexus </li></ul></ul><ul><ul><li>Concentration of the drugs </li></ul></ul><ul><ul><li>Rate of administration </li></ul></ul><ul><ul><li>Pharmacokinetics of the drug are altered by comorbidity such as cardiac or hepatic failure </li></ul></ul><ul><ul><li>Alterations in plasma protein binding/ degree of protein binding </li></ul></ul><ul><ul><li>Interactions with other drugs </li></ul></ul>
  32. 34. Clinical features <ul><li>CNS </li></ul><ul><ul><li>Tingling of lips </li></ul></ul><ul><ul><li>Slurred speech </li></ul></ul><ul><ul><li>Reduce concious level </li></ul></ul><ul><ul><li>seizure </li></ul></ul><ul><li>CVS </li></ul><ul><ul><li>Arrythmias </li></ul></ul><ul><ul><li>Reduce myocardial contractility </li></ul></ul><ul><ul><li>Bradycardia and hypotension </li></ul></ul>
  33. 36. Management of LA toxicity <ul><li>Based on the Association of Anesthetist of Great Britain & Ireland 2010 </li></ul>
  34. 37. Prevention <ul><li>Have adequate knowledge of pharmacokinetic and pharmacodynamic of the drugs </li></ul><ul><li>Use appropriate dose for appropriate patient </li></ul><ul><li>Use correct technique as mention in a protocol of LA </li></ul><ul><li>Early recognition of complication </li></ul>
  35. 38. Reference <ul><li>Toxicity from Local Anaesthetic Drugs Dr David A Conn,Consultant Anaesthetist, Royal Devon & Exeter Hospital, Exeter, UK </li></ul><ul><li>Local anesthesia pharmacology, hillary edgcombe, graham hocking, consultant anaesthetist sir charles gairdner hospital perth, australia </li></ul><ul><li>Anaesthesia.uk </li></ul><ul><li>Manual of anaesthesia, Lee Choon Yee </li></ul><ul><li>Emergency medicine 7 th edition, Judith E. Tintinally </li></ul><ul><li>E- medicine </li></ul>

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