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NERVE BLOCKS AND ITS COMPLICATIONS
- 1. Nerve Blocks
- 2. Techniques of Injection • Basic points- Use a Sterile Sharp Needle Check The flow of Solution Position the patient Dry the tissue/ wipe once. Apply topical anesthetic
- 3. Topical antiseptic /optional Communicate with patient apply firm hand rest Inject few drops of soln, communicate with patient, Advance to the target slowly ,aspirate , inject Withdraw the needle slowly Observe the patient & check for anesthetic symptoms
- 4. Technique for Maxillary Block • Supra periosteal injection: – Anaesthetize buccal soft tissue & hard tissue – Nerves anaesthetized – large terminal branches – Indication : • 1 or 2 teeth need to be anaesthetized / small area
- 5. – Contra-indication : • Infection • Dense bone covering – Target area : • Behind apices of tooth – Landmarks : • Muco-buccal fold • Crown & root length
- 7. • Posterior Superior Alveolar Nerve Block – Area anaesthetized: • Maxillary 3rd, 2nd & 1st molar (except mesio- buccal root of 1st molar • Bone & periodontium over these – Indication: • Treatment of 2 or more molars required • Supra-periosteal injection – ineffective • Acute inflammation
- 8. – Contra-indication: • Pt with bleeding disorders – Disadvantage: • More of soft tissue landmarks used • 2nd injection for 1st molar – Landmarks: • Mucobuccal fold • Zygomatic process of maxilla • Infratemporal surface of maxilla • Anterior border and coronoid process of mandible • Tuberosity of maxilla
- 9. – Complications: • Hematoma – – Non visible - pterygoid plexus posteriorly – Visible – buccal aspect • Accidental mandibular Anaesthesia • Orbital contents – anaesthetized accidentally • Accidental - parotid gland facial nerve affected
- 11. • Anterior superior alveolar nerve block – Areas anaesthetized • Pulp of maxillary C.Is – Canine • Buccal periodontium, lower eyelid, lateral aspect of nose • Upper lip – Indications • More than 2 anterior teeth – Contraindications • Discreet treatment areas • Hemostasis of localized area – not adequately achieved
- 12. – Landmarks • Mucobuccal fold, infra-orbital notch, infra-orbital foramen • 2 methods: – Intra-oral • Premolar approach • Incisal approach – Extra-oral
- 14. Palatal Anaesthesia • Pressure Anaesthesia – Slow deposition – Small quantity – Effect only a very small area • Greater palatine nerve block – Areas anaesthetized • Palatal soft tissue – posterior aspect • Palatal hard tissue
- 15. – Indication • Surgical procedures posterior portion of hard palate • Palatal Anaesthesia in conjunction with posterior superior alveolar nerve block. – Landmarks • Greater palatine foramen – junction of the maxillary alveolar process & palatine bone • Between the 2nd & 3rd molars – 1-1.5cms away from gingival margin
- 17. • Nasopalatine nerve block – Areas anaesthetized • Anterior portion of Hard palate and over lying structures back to the bicuspid area. – Indications • Anterior palatal procedures supplementing infraorbital nerve blocks • Anaesthesia of nasal septum – Landmarks • Central incisor & incisive papilla
- 18. – Complications • Hematoma • Necrosis – Technique • Single needle penetration • Multiple needle penetration Usually most discomforting block for patient – very painful
- 19. • Maxillary nerve block – Areas anaesthetized • Pulpal Anaesthesia • Maxillary teeth – 1 side • Periodontium / soft tissue – 1 side – Indications • Extensive oral / periodontal / endodontal procedures • Other regional nerve blocks not possible • Therapeutic procedure to diagnose neuralgias
- 20. – Contra-indications • Pediatric patients • Infection / inflammation • Hemorrhage – anticipated • Greater palatine canal approach not possible – bony obstr. – Landmarks • Mucobuccal fold distal to maxillary 2nd molar • Maxillary tuberosity • Zygomatic process • Greater palatine foramen
- 21. – Complications • Hematoma • Penetration into orbit – Volume – displaces orbital structures, periorbital swelling, proptosis, 6th nr block – diplopia, transient loss of vision, optic nerve blocked, retrobulbar block / hemorrhage, opthalmoplegias (common) • Penetration into nasal cavity – Patient complains – LA running down the throat – to prevent keep mouth wide open – Technique • High tuberosity approach • Greater palatine canal approach
- 23. • Maxillary nerve block – Extra Oral – Areas anaesthetised • Anterior temporal & zygomatic region • Lower eyelid • Side of nose • Anterior cheek • Upper lip • Maxillary teeth / alveolar bone & overlying structures – 1side • Hard & soft palate • Tonsils – parts of pharynx • Nasal septum – floor of nose
- 24. – Indications • Extensive surgery – 1 half of maxilla • Others blocks not possible • Therapeutic purposes – Technique • mid point of zygomatic process • Needle gently contact lateral pterygoid plate • Maximum length of 4.5cms directed slightly upward & forward – Note: • In final position – internal maxillary artery – inferior to needle • Temporal vessels on either sides • Posteriorly foramen ovale with mandibular nerve & foramen spinosum with middle meningeal artery • Anteriorly pterygomaxillary fissure
- 26. Mandibular Nerve Blocks • Inferior alveolar nerve block – Areas anaesthetised • Mandibular teeth upto midline • Body of mandible • Inferior portion of ramus • Buccal periosteum & mucous membrane • Lingual soft tissue • Anterior 2/3rd of tongue – Indications • Multiple mandibular teeth – procedures • Buccal / Lingual soft tissue anaesthesia
- 27. – Contraindications • Infection / acute inflammation • Young children / mentally handicapped – Landmarks • Coronoid notch • Pterygomandibular raphe • Occlusal plane of posterior mandibular teeth – Complication • Hematoma • Trismus • Transient facial paralysis (parotid gland)
- 28. • Anatomical structures - final position • Superiorly – – Inferior alveolar nerves & vessels – Insertion of medial pterygoid – Mylohyoid nerves & vessels • Anteriorly – – Deep part of parotid gland • Laterally – – Lingual nerve – Internal pterygoid – Spehnomandibular ligament • Medially- ramus of mandible.
- 31. • Closed mouth/ Akinosis technique (1977)— – Nerves anesthetized - – Area anesthetized • one half of mandible upto mid line including lingual tissue and inferior portion of the ramus of the mandible. – Land mark- • occluding plane of the teeth. • Muco gingival junction maxillary teeth. • Antr border of ramus. • Orientation of bevel must be oriented away from the bone of mandibulaar ramus (bevel faces toward mid line). – More popular now • Land marks easy • One prick – mandibular, buccal, lingual n anesthetised. • Patient more comfortable.
- 33. • Advantages Atraumatic, pats. with restricted mouth opening. fewer post op complications. Disadvantages Difficult to visualize the path of needle and depth of insertion. Complications hematoma, transient facial n. paralysis.
- 34. • Gow gates technique– 1973 (mandibular n. block) Nerves anaesthetised – inferior alveolar, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal. – Area –all mandibular hard and soft tissue Upto mid line. – Indications- multiple procedures on mandibular teeth, buccal soft tissue anaesthesia from third molar to midline, conventional inf. alv. n. block is unsuccessful. – Contraindications – infection or acute inflammation in the area of infection, pats. with restricted mouth opening.
- 35. – Land marks- – Extraoral- corner of mouth, lower border of the tragus, intertragic notch – Intraoral – height of injection established by placement of needle tip just below the mesiolingual cusp of max. 2nd molar, penetration of soft tissue distal to 2nd molar at the same height. – Final position needle is just inferior to condyle and insertion of lateral pterygoid. Gained popularity – single needle penetration, relies on soft tissue landmarks – differ from patient to patient
- 37. • Lingual nerve block – – Area anaesthetised – • Anterior 2/3rd tongue, floor of mouth, lingual mucoperiosteum Only used singly to operate on tongue, floor of mouth • Buccinator / long buccal nerve block – Area anaesthetised – • Buccal mucosa & mandibular molar – mucoperiosteum – Land marks • External oblique ridge, retromolar triangle
- 39. • Mental nerve block – Areas anaesthetised • Lower lip, mucous membrane – anterior to mental foramen – Landmarks • Mandibular bicuspids – Indications • Surgery of lower lip or mucous membrane
- 41. Extra Oral Technique • Mandibular nerve – Area anaesthetised • Temporal region with auricle of ear & external auditory meatus • TMJ, salivary glands • Anterior 2/3rd of tongue • Mandible – hard & soft tissue – midline – Landmarks • mid point of zygomatic arch • Zygomatic notch • Cornoid process of mandible • Lateral pterygoid plate
- 42. – Indications • When need to anaesthetise entire mandibular nerve • Infection / trauma – makes terminal anaestheisa not possible • Diagnostic / therapeutic The needle is pointed posteriorly & to a greater depth of 5 cms
- 44. • Mental & Incisive nerve block – Area anaesthetised • Mandibular hard & soft tissue – labial aspect with lower lip – Landmarks • Bicuspid teeth, lower ridge of body of mandible • Supra & infra orbital notch • Pupil of the eye 2 inch 22 gauge needle used & introduced slightly anteriorly & downwards
- 46. Complications • Definition – An anaesthetic complication may be defined as any deviation from the normal expected pattern during or after securing regional anaesthesia – 2 types • Local • Systemic
- 47. • LOCAL COMPLICATIONS – Needle breakage – Pain on injection – Burning on injection – Persistent anaesthesia or paresthesia – Trismus – Hematoma – Sloughing of the tissue / soft tissue injury – Facial nerve paralysis
- 48. • SYSTEMIC COMPLICATIONS – Toxicity – Idiosyncracy – Allergy – Anaphylactoid reaction – Syncope
- 49. • Classification – Primary / secondary • Primary – caused & manifested at time of anaesthesia • Secondary – manifested later – Mild / severe • Mild – exhibit slight change from normal expected pattern - reverses itself without treatment • Severe – manifests itself – pronounced deviation - requires specific treatment
- 50. – Transient / permanent • Transient – is one that is severe at occurrence – no residual effects • Permanent – residual effect; lasts for a life time even though it is mild Complications could be a combination of any of the above mentioned types Majority are either Primary Mild & Transient or Secondary Mild & Transient
- 51. • Complications – Attributed to solutions – toxicity, allergy, idiosyncrasy, anaphylactoid reaction, local irritation – Attributed to technique / needle – syncope, muscle trismus, pain, edema, hematoma
- 52. Needle breakage • Cause – – Unexpected movement – patient (if patient movement is opposite to path of needle insertion) – Multiple used needle – Defective manufacture of needles/barbed needles – smaller gauge – more likely to break
- 53. • Prevention – Correct gauge – 25 gauge – Long needles – prevent penetration till hub – Not to redirect when in tissue • Management – Patient – not to move – hand in the mouth – mouth open – Fragment visible – remove it – Fragment not visible – inform patient – not necessary for intervention immediately – Radiograph suggested
- 54. • Precautions – Avoid bony contact – Avoid heavy pressure – Avoid movement of needle and patient
- 55. Pain on injection • Causes – • Careless injection technique • Multiple used needle • Rapid deposition • Problems – – Pain – patient anxiety – unexpected movements • Prevention – – Proper technique – sharp needles – Enter topical anaesthetics – Inject slowly – solution sterilized – Check temperature of solution
- 56. Burning on injection • Causes – Due to pH of solution 5 (LA) – 3 (LA+VC) – Rapid injection – Contamination – Warm solution • Problems – pH disappears upon LA action – no residual effect – Contaminated solution other complications – trismus, edema, paraesthesia
- 57. • Prevention – Slow injection – 1ml / minute – Cartridge stored at room temperature – away from containers with alcohol / other agents
- 58. Persistent anaesthesia / paresthesia • Causes – Direct trauma to nerve – bevel of needle – LA solution containing neurotoxic substance – alcohol – Injection of wrong solution – Hemorrhage / infection – near to nerve • Problem – Persistent anaesthesia – usually rare – Biting / thermal / chemical insult – without patient awareness – When lingual nerve is involved – taste impaired
- 59. • Prevention – Proper care & handling of dental cartridge – Adherence to injection protocol • Management – Usually resolve in 8 weeks – Periodic recall & check up of patients – Persistence – consult neurosurgeon – TENS – Recall patient every 2 months for check up
- 60. Trismus • Definition – “difficulty in opening the jaws due to muscle spasm” • Causes – Trauma – muscle / blood vessel – Irritating solution – hemorrhage – Infection – Multiple needle punctures – LA have been known to have slight myotoxicity – Excessive volume – distension of tissues • Problems – Pain / hypomobility
- 61. • Prevention – Use of sharp, sterile, disposable needle – Aseptic technique – Practice atraumatic methods – Avoid repeated injections – Use minimum volume – Control infection
- 62. • Management – Heat therapy • Warm saline rinses, moist hot packs – Analgesics • Aspirin, Codeine (30-60mg), muscle relaxants – Initial physiotherapy • Thrice a day – Antibiotic regime • Possibility of infection
- 63. Hematoma • “effusion of blood into extra-vascular spaces” • Causes – Arterial & venous puncture – common in PSA & Inf. Alv. nerve blocks – Patients with bleeding disorders • Problem – Bruise – may / may not be visible extra-orally – Complications – pain & trismus – Swelling & discoloration • Prevention – Knowledge of normal anatomy – proper technique – Shorter needle – PSA, minimize the number of penetration – Discard defective needles- barbed needles
- 64. • Management – Immediate – apply firm pressure 5-10minutes • Inf. Alv. Nr. Block – medial aspect of ramus • Infra orbital, Mental, Incisive block – directly over foramen • PSA – pressure on soft tissue with finger as posteriorly as tolerated by patient – medial superior direction • Patient to be reviewed after 24 hours, advice analgesics, cold application upto 4-6 hours, warm- pack application next day
- 65. Infection • Comparitively rare complication • Instrument needle solution to be as aseptic as possible • Area & operative hands – cleaned • Avoid passing needle through infected area • Use disposable syringes
- 66. Edema • Causes – Trauma during injection – Infection, hemorrhage – Allergy (Angioedema) – Injection of irritating solution • Problems – Pain & dysfunction – Airway obstruction
- 67. • Prevention – Proper care & handling of armamentarium – Atraumatic injection technique – Complete medical evaluation prior to injection • Management – Trauma – resolve in few days without therapy – Hemorrhage – resolve slowly 7-14 days – Allergy – life threatening, airway impairment – basic life support, call medical help, Epinephrine – 0.3mg, Antihistamine, Corticosteroids – Total airway obstruction – Tracheostomy / Cricothyroidectomy
- 68. Sloughing of tissue • Causes – Epithelial desquamation – topical anaesthesia – long time, heightened sensitivity to LA – Sterile abscess – secondary to prolonged ischemia – VC in LA site – hard palate • Problems – Pain & infection • Prevention – Topical – for not more than 1-2 minutes – VC – minimal concentration in solution
- 69. • Management – Symptomatic – pain – analgesia – Epithelial desquamation – resolve few days – Sterile abscess resolve 7-10 days
- 70. Soft tissue injury • Causes – Trauma occurs – frequently mentally / physically challenged children – Primary cause – significantly longer duration of action • Problem – Pain & swelling – Infection of soft tissue • Prevention – Cotton roll between lip & teeth – Patient – guarded against eating / drinking – Warning sticker
- 71. Facial nerve paralysis • Cause – LA solution into parotid gland – usually while giving Inf Alv Nr. Block, Akinosis technique • Problem – Ipsilateral loss of motor control – Buccinator muscle – Inability to raise the corner of Mouth, close Eye lid • Prevention – Needle tip to contact bone, redirection of needle to be done only after complete withdrawal
- 72. • Management – Reassure the patient – Resolves after action of LA is over – Eye patches to the affected – eye drops – Contact lenses if any – removed
- 73. Systemic complications • Toxicity / toxic overdose – “Signs and symptoms that result from an overly high blood level of a drug in various target organs and tissues” – Predisposing factors • Age – any age • Weight – greater the body weight greater is the amount of dose tolerated before overdose reaction • Sex – during pregnancy – renal function disturbed – females more affected at this time • Diseases – hepatic & renal dysfunction reduced breakdown • Congestive heart failure – less liver perfusion • Genetics – pseudocholinesterase deficient – toxicity - Ester LA
- 74. • Drug factors – Vasoactivity – vasodilation – increase in blood concentration • More concentration – greater risk • Dose- smaller dose should always be preferred • Route of Administration – Intravascular – increased toxicity • Rate of injection – slower rate preferred • Vascularity of injection site – more vascular – greater absorption • Presence of Vasoconstrictor – with VC less absorption
- 75. – Causes of toxicity – • Biotransformation usually slow • Drug – slowly eliminated by kidney • Too large a total dose • Absorption from injection site - rapid • Accidental intra-vascular injection – Symptoms – • CNS – cerebral cortical stimulation – talkative, restless, apprehensiveness, convulsions • Cerebral cortical depression – lethargy, sleepiness, unconsciousness • Medullary stimulation – increased B.P, Pulse rate, Respiration
- 76. – Medullary depression – mild fall in B.P– severe cases drops to 0 , Pulse , Respiration – similar effect • Treatment – Mild overdose reaction – slow onset reaction – > 5 mins administer Oxygen (prevent acidosis), monitor vital signs, in case of convulsions – anti-convulsants (diazepam/midazolam infusion) – Slower onset - >15 mins – same procedure – Severe overdose reaction – rapid onset – 1 minute – unconsciousness with or without convulsion, patient in supine position, convulsions – protect hand, leg, tongue, BLS, administer anti-convulsant,use of vasopressor(phenyl ephrine) i.m if hypotensiom presists. – post seizure – CNS depression usually present
- 77. Idiosyncrasy • “It is an adverse response that is neither an overdose nor an allergic reaction” • Common cause – some underlying pathology/psychological /genetic mechanism • Psychotherapy may be helpful • Treatment – symptomatic ..remember ABC’s!
- 78. Syncope • “transient loss of consciousness that is caused due to cerebral ischemia (neurogenic shock)” • Anxiety – increased blood supply to muscles, sitting position 2mm Hg, less pressure – cerebral arteries • Clinically pallor, light headedness, dizziness, tachycardia & palpitation – may further lead to Unconsciousness • Treatment – discontinue procedure, supine position- (trendelenburg position), deep breathing, O2 administration if required, BLS
- 79. Allergy • “hypersensitive state acquired through exposure to a particular allergen reexposure to which produces a heightened capacity to react” • 1 % of all reaction in LA is allergy • Predisposing factors – Hyper sensitivity to ester more common-procaine – Most of patients allergic to methyl paraben – Recently allergy to sodium meta bi sulfide is also increasing Precautions--- Ho of allergy to be recorded Ho any asthmatic attack to be noted. Always better to test the patient for allergy before treatment.
- 80. – Consultation and allergy testing • Refer doubtful cases for allergic skin test – sub cutaneous test most sensitive. • Informed consent that includes cardiac arest end death to be included. – Signs and symptoms of allergy. • Dermatological------ urticaria –wheal and smooth elevated patch seen, ------angio oedema—localised swelling – face hands, common • Respiratory– broncho spasm, respiratory distress, – dysnea, wheezing, flushing, tachycardia etc.
- 81. –Laryngeal edema – type of angio neurotic oedema- life threating. •Edema upper air way – laryngeal edema • Lower air way affect bronchioles- small.
- 82. –Management •skin reactions- –Delayed – non life threatening - oral histamine blockers- 50 mg diphenhidramine,10 mg chlorpheniramine 3-4 days. –Immediate reaction—with conjunctivitis rhinitis- vigorous management. – 0.3 mg epinephrine. IM – 50 mg diphenhydramine Im – medical help summoned.
- 83. – Observe patient for minimum of 60 min – Oral histamine blockers for 5 days. – Respiratory reaction – • patient in comfortable position. • administer - oxygen • Admn epinephrine- bronchodilator • Observe for 60 min , advise anti histamines to prevent relapse. • Histamine blockers Im – Laryngeal edema- • Patient position ,oxygen, broncho-dilator, iv anti histamines. • If condition not improving cricothyrotomy - achieve patent air way if necessary give artificial ventilation.
- 84. • Patient with confirmed allergy status- – if patient allergic to any one type of anesthetic ester / amide use the other. – Use histamine blocker like diphenhydramine as anesthetic. – General anesthesia – alternative method of pain control – • electric anesthesia / hypnosis.