systemic complications of LA

1. SYSTEMIC COMPLICATIONS IN LOCAL
ANESTHESIA
Handbook of Local Anesthesia by
Stanley . F. Malamed

2. COMPLICATIONS IN LOCAL ANAESTHESIA
LOCAL COMPLICATIONS
1. Needle breakage
2. Facial nerve paralysis
3. Trismus
4. Soft tissue injury
5. Hematoma
6. Pain on injection
7. Burning on injection
8. Infection
9. Edema
10.Sloughing of tissues
11.Postanesthetic intraoral lesions
SYSTEMIC COMPLICATIONS
1. ADVERSE DRUG REACTION
a. Overdose/Toxicity reactions
b. Allergy
c. Idiosyncrasy

3. SYSTEMIC COMPLICATIONS

4. SYSTEMIC COMPLICATIONS
GENERAL PRINCIPLES OF TOXICOLOGY
1. NO DRUG EVER EXERTS A SINGLE REACTION
2. NO CLINICALLY USEFUL DRUG IS ENTIRELY DEVOID OF
TOXICITY
3. THE POTENTIAL TOXICITY OF THE DRUG RESTS IN THE
HANDS OF THE USER
So important to know the medical history of the patient
In ideal circumstances the right drug in the right dose is
administered via the right route to the right patient at the right
time for the right reason will not produce any unwanted effects.

5. OVERDOSE REACTION
 Most common of the all adverse reactions accounting to about 99% in studies
 There is overly high level of the drug
PREDISPOSING FACTORS
PATIENT FACTORS
1. Age
2. Weight
3. Other drugs-
phenetoin,cimetidine,desipramine
4. Sex- pregnancy- renal funtion
5. Presence of disease
6. Genetics
7. Mental attitude- larger dose
requirement & low seizure threshold
DRUG FACTORS
1. Vasoactivity
2. Concentration
3. Dose
4. Route of administration
5. Rate of injection
6. Vascularity of the injection site
7. Presence of vasoconstrictors

6. SYSTEMIC ACTION OF LA

8. SIGNS
 Talkativeness
 Excitability
 Slurred speech
 Sweating
 Elevated BP, HR, RR
SYMPTOMS
 Lightheadedness and dizziness
 Visual disturbances inability to focus
 Auditory disturbance - Tinnitus
 Nervousness
 Metallic taste
 Loss of conciousness.
SYSTEMIC ACTION OF LA
CNS MINIMAL TO MODERATE DOSES
Preconvulsive Signs and Symptoms of Central Nervous System Toxicity

9. SYSTEMIC ACTION OF LA
CVS EFFECTS IN SUMMARY
 At nonoverdose levels there is a slight increase or no change in BP
 At levels yet still below, overdose a mild degree of hypotension is
noted; this is by direct relaxant action on the vascular smooth muscle.
 At overdose levels there is profound hypotension caused by decreased
myocardial contractility, cardiac output, and peripheral resistance.
 At lethal levels cardiovascular collapse is noted due to massive
peripheral vasodilation, and decreased myocardial contractility and
heart rate (sinus bradycardia).

10. OVERDOSE REACTIONS
Most of the serious overdose reactions have occurred in children
Usually the 2-6 year old < 40 KG.
CAUSES
1. Often treated on all 4 quadrants at the same appointment.
2. Exceeding maximum dose based on patients weight.

11. SYSTEMIC ACTION OF LA
INTRA-VASCULAR INJECTION
BLOCK POSITIVE ASPIRATION RATE
1. Inferior alveolar 11.7%
2. Mental or incisive 5.7%
3. Posterior superior alveolar 3.1%
4. Middle superior alveolar 0.7%
5. Long buccal 0.5%

12. SYSTEMIC ACTION OF LA
INTRA-VASCULAR INJECTION

13. Management of LA overdose reactions
D – DEFINITIVE CARE
1. Monitor vital signs
2. Adequate ventilation – O2
3. Anti convulsive treatment
IV diazepam 5mg/min
OR
Midazolam 1mg/min
4. Post seizure Management:
IM or IV Vasopressure for hypotension.
IV fluids for hypotension

14. SUPINE POSITION
Management of LA overdose reactions

15. Management of LA overdose reactions

16. Management of LA overdose reactions

17. ALLERGY
Allergy is a hypersensitive state, acquired through exposure to a particular
allergen, reexposure to which produces a heightened capacity to react.
Predisposing Factors:
Incidence reduced significantly with amide group
Local Anaesthetic agent
Lignocaine 2%- 20 mg/ml
Mepivacaine 3% - 30 mg/ml
Vasoconstrictor - Epinephrine (1:80,000) – 0.0125 mg/ml
Anti-Oxidant - Sodium metabisulphite
Sodium Chloride - Isotonicity
Sterile Water - Diluent
Preservative - Methylparaben, caprylhydrocuprienotoxin
Fungicide - Thymol

18. ALLERGY
Allergy is a hypersensitive state, acquired through exposure to a particular
allergen, reexposure to which produces a heightened capacity to react.
Predisposing Factors:
Incidence reduced significantly with amide group
Local Anaesthetic agent
Lignocaine 2%- 20 mg/ml
Mepivacaine 3% - 30 mg/ml
Vasoconstrictor - Epinephrine (1:80,000) – 0.0125 mg/ml
Anti-Oxidant - Sodium metabisulphite
Sodium Chloride - Isotonicity
Sterile Water - Diluent
Preservative - Methylparaben, caprylhydrocuprienotoxin
Fungicide - Thymol
Now a days LA comes with out the preservative and
bacteriostatic agent

19. ALLERGY
ALLERGIC REACTIONS
1. Dermatological Reaction : Urticaria, angioedema, skin itching, rashes.
2. Respiratory Reactions : Respiratory distress, dyspnea, flushing, wheezing
Laryngeal edema (life threathening).
3. Generalized Anaphylaxis : (5 – 30 minutes)
• Skin reactions.
• Smooth muscle spasm of GIT, GUT and respiratory smooth
muscle(broncospasm).
• Respiratory distress.
• Cardiovascular collapse.
• Discuss with the Dr with whom the episode occurred.
• Send the patient for allergy testing.
• If truly allergic tell the patient the GENERIC name of the drug.

20. ALLERGY

21. ALLERGY

22. ALLERGY
Precautions
1. Allergy Testing:
Deposite 0.1 ml of plain LA subcutaneously into the patient’s forearm.
2. Intraoral challenge Test:
0.9 ml of solution injected intraorally via supraperiosteal infiltration
above a maxillary right or left premolars or anterior tooth.

23. ALLERGY
Dental Treatment in the presence of alleged LA allergy:
1. Elective Dental Care : Postponed until through evaluation of pt for
allergy is completed.
2. Emergency Dental Care:
1. If allergic to ester administer amide LA.
2. Inhalation sedation with N2O + O2.
3. General Anesthesia.
4. Histamine blockers as LA can be injected.
Dipehenhydramine in 1% solution with 1:100000 adrenaline –
Burning sensation.
5. Electronic dental anesthesia.

24. Electronic Dental Anesthesia

25. Works on TENS
- Trans-Cutaneous Electric Nerve Stimulation
Gate Control Theory
- Ronald Melzack and Patrick Wall
Electronic Dental Anesthesia

26. ALLERGY
MANAGEMENT:
1. Skin Reaction :
1. Delayed skin reaction – after 60 minutes.
• Not considered life–threatening.
• P-A-B-C
• D – Oral Histamine Blockers – 50 mg Dipenhydramine or
10 mg chlorpheniramine
2. Immediate skin reaction
• Administrate epinephrine 0.3 mg IM or SC.
• IM Histamine Blockers – 50 mg Dipenhydramine or
10 mg chlorpheniramine

27. ALLERGY
MANAGEMENT:
2. Respiratory Reaction :
1. Bronchospasm – lower respiratory obstruction
• Considered life–threatening.
• P-A-B-C
• D – Administrate oxygen via full mask 5-6 litres/min
- Epinephrine IM/SC 0.3 mg
- Oral Histamine Blockers – 50 mg Dipenhydramine or
10 mg chlorpheniramine
- Hydrocortisone 100 mg IM/IV
IV

28. ALLERGY
MANAGEMENT:
2. Respiratory Reaction :
2. Laryngeal edema – upper respiratory obstruction movement
of air through pt’s nose and mouth cannot be heard and felt.
• Considered life–threatening.
• P-A-B-C
• D – Administrate oxygen via full mask 5-6 litres/min
- Epinephrine IM/SC 0.3 mg
- Oral Histamine Blockers – 50 mg Dipenhydramine or
10 mg chlorpheniramine
- Hydrocortisone 100 mg IM/IV
• Perform cricothyrotomy.
IV

29. Thank You