Local Anesthetic Systemic Complications and Treatment

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Local Anesthetic Systemic Complications and
Treatment
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Adverse Drug Reactions

• 1) Side effects
• 2) Overdose reactions
• 3) Local toxic effects (most common)
• 4) Allergic reactions

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Toxicity caused by alteration in the recipient of
the drug

• 1) Disease process
• 2) Emotional disturbances
• 3) Genetic aberrations
• 4) Idiosyncrasy

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Signs and Symptoms Toxic Reaction to Local
Anesthesia

• Talkativeness
• Slurred speech
• Dizziness
• Nausea
• Depression
• Euphoria
• Excitement
• Convulsions

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Overdose Reactions

• Clinical signs and symptoms that
• develop as a result of an
• over-administration of a drug

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Overdose Contributing Factors

• Age
• Weight
• Other medications
• Presence of disease
• Genetics
• Mental wellbeing

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Drug Factors

• Vasoactivity
• Concentration
• Dose
• Route of administration
• Rate of injection
• Vascularity of the injection site
• Presence of vasoconstrictors

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Mild Overdose Reaction

• Slow onset
• Reassure patient
• Administer oxygen
• Monitor vital signs
• Allow patient to recover as long as necessary

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Slower Onset of Overdose

• Reassure patient
• Administer oxygen
• Monitor vital signs
• Administer anticonvulsant
• Call 911
• After reaction, have patient examined by a
  physician
• Do not let patient leave alone

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Severe Overdose Reaction

• Rapid onset (within one minute)
• Remove syringe (if in the process of an
  injection)
• Protect patient for trauma if convulsions are
• present
• Call 911
• Basic life support
• Administer anticonvulsant
• Allow patient to recover
• Do not let patient leave alone

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Epinephrine Overdose

• Very rare for patient to experience an
  epinephrine overdose

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Signs and Symptoms of Epinephrine Overdose

• Fear, anxiety
• Tenseness
• Restlessness
• Throbbing headache
• Tremor
• Perspiration
• Weakness
• Dizziness
• Pallor
• Respiratory difficulty
• Palpitations

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Management of Epinephrine Overdose

• Terminate dental procedure
• Sit patient upright in the dental chair
• Reassure patient
• Monitor blood pressure
• Administer oxygen

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Allergic Reactions to Local Anesthetic Agents

• Hypersensitive state as a result of exposure to
  an allergen
• Re-exposure can heighten the initial reaction

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Clinical Manifestations of an Allergy

• Fever
• Angioedema
• Urticaria
• Dermatitis
• Depression of blood-forming organs
• Photosensitivity
• Anaphylaxis

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Angioedema
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Urticaria (hives)
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Allergy

• Incidents of allergy are low
• Often allergic reaction is to one of the
  ingredients within the cartridge, not the local
  anesthesia itself

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How to Prevent An Allergic Reaction

• Take a thorough medical history
• Dialogue the medical history with the patient

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Common Questions to Ask the Patient

• Allergic to any medications?
• Have you ever had a reaction to local anesthesia?
• If yes, describe what happened
• Was treatment given? If so, what?

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Allergic Responses to local anesthetic

• Dermatitis (hives)
• Bronchospasm
• Systemic anaphylaxis
• Hypersensitivity to esters
• (atypical pseudo cholinesterase, PABA)

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Latex Allergy

• The cartridge opening into which the needle is
  inserted is aluminum with a very thin diaphragm
  of latex in the middle
• Though patients with a latex allergy are at an
  increased risk, there are no known cases or
  reports of an allergic response from the latex on
  a local anesthetic cartridge

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Asthma Patient

• Thorough medical and dental history
• Avoid use of anesthesia that contain epinephrine
  or levonordefrin because of sulfites (may cause
  wheezing)
• Asthma patient that is steroid dependant may
  develop brochospasms
• Establish rapport and calm environment

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Renal Disease

• Common diseases associated with renal failure are
  diabetes mellitus, hypertension, or systemic
  lupus erythematosus (SLE)
• Kidneys are compromised

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Drugs Metabolized by the Liver

• Lidocaine (Xylocaine)
• Prilocaine (Citanest)
• Mepivacaine (Carbocaine, Polocaine)
• Bupivacaine (Marcaine)
• Appear to be safe for use on patients with liver
  disease when used in appropriate amounts

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Pregnancy

• Anesthesia crosses the placenta and could be
  toxic to the fetus, but is not a known teratogen
• No drug should be administered during pregnancy
  especially the first trimester
• If treatment is necessary, local anesthetics with
  epinephrine are considered relatively safe for
  use during pregnancy check with patients
  physician
• Educate patients to the potential risks (document)

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FDA Category of Prescription Drugs
Drug Category Use During Pregnancy Risk
Lidocaine B Yes -
Prilocaine B Yes -
Mepivacaine C Use with caution- Consult physician Fetal bradycardia
Bupivacaine C Use with caution- Consult physician Fetal bradycardia
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Hypertension

• Stress and anxiety may raise the patients blood
  pressure (gt160/100)
• Thorough medical, dental and patient history
• Norepinephrine and levonordefrin should not be
  used because of alpha1 stimulation
• (2 Mepivacaine with 120,000 levonordefrin)
• Up to two cartridges of 2 lidocaine with
  1100,000 epinephrine is safe

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Contraindication for Local Anesthetic with
Epinephrine

• Uncontrolled hypertension
• Myocardial infarction (within 6 months)
• Unstable angina
• Coronary artery bypass graft (gt 3 months)

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Quiz

• 1. Local anesthetics and vasoconstrictors do
  cross the placenta in pregnant women local
  anesthetics and vasoconstrictors are known
  teratogens (cause birth defects).
• a. The first part of the statement is true,
  the second
• part is true.
• b. The first part of the statement is true,
  the
• second part is false.
• c. The first part of the statement is false,
  the second
• part is false.
• d. The first part of the statement is false,
  the second
• part is true.

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• 2. What should you do when using local anesthesia
  on a patient with
• controlled hypertension?
• a. Take the BP before the injection and use
  Mepivacaine only
• b. Take the BP before the injection and use
  an anesthetic without a
• vasoconstrictor
• c. Take the BP before the injection and use
  anesthetic with a
• vasoconstrictor judiciously
• d. Local anesthetics should not be used on
  patients with hypertension

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• 3. Since local anesthetics are excreted through
  the
• kidneys, what is true concerning giving local
  
• anesthesia to a patient with renal
  dysfunction?
• a. Consult patients physician
• b. Potential for overdose
• c. Use anesthetics in minimal doses
• d. All of the above

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• 4. What is the most common reason for allergies
  to
• local anesthetic solutions?
• a. Asthma
• b. The anesthetic solution itself
• c. The other added ingredients to the
  solution
• d. The vasoconstrictor

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• 5. To prevent an overdose, what should the
• maximum safe doses of anesthetic be based
  on?
• a. The patients age
• b. The patients weight
• c. The patients physical status
• d. The patients health
• e. All of the above