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BDS2 LA Symposium > Complications with LA > Flashcards

Complications with LA Flashcards

1
Q

what type of LA in lidocaine

A

amide

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2
Q

liddocaine strength

A

lidocaine HCl 2%

can also get 3% plain

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3
Q

types of vasoconstrictor available with lidocaine

A

plain (none)

1:80,000 adrenaline

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4
Q

ratio of adrenaline in lidocaine preparations

A

1:80,000

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5
Q

3 uses of lidocaine

A

infiltrations

blocks

others

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6
Q

pharmacology of lidocaine

A

greeted in kidney

metabolised in liver

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7
Q

citanest strength

A

Prilocaine HCl 3%

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8
Q

type of LA citanest is

A

amide LA

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9
Q

types of vasoconstricor available in citanest

A

plain

felypressin (octapressin)
- 1.2micogms

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10
Q

3 uses of citanest

A

infiltrations

blocks

others

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11
Q

3 common LA preparations

A

lidocaine

citanest

articaine

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12
Q

type of LA articaine

A

amide type LA

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13
Q

strength of articaine preparation

A

4% with adrenaline

1: 100,000
1: 200,000
1: 400,000

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14
Q

ratio of adrenaline in articaine

A

1: 100,000
1: 200,000
1: 400,000

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15
Q

2 uses of articaine

A

infiltration

blocks

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16
Q

pharmacology of articaine

A

greeted in kidney

metabolised in liver and plasma

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17
Q

block onset comparison of articaine and lidocaine

A

articaine more rapid block onset than lidocaine

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18
Q

potency comparison of articaine and lidocaine

A

articaine is 1.5x more potent than lidocaine

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19
Q

vasoconstrictor in Mepivacaine 3% plain

A

nil

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20
Q

vasoconstrictor in ligocaine HCl 2%

A

1:80,000 Adrenaline

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21
Q

vasoconstrictor in articaine HCl 4%

A

adrenaline

1: 100,000
1: 200,000
1: 400,000

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22
Q

vasoconstrictor in prilocaine HCl 3%

A

felypressin (octapressin)

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23
Q

infiltration time for pulpal anaesthesia for Mepivacaine 3% plain

A

20mins

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24
Q

infiltration time for pulpal anaesthesia for ligocaine HCl 2%

A

60mins

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25
Q

infiltration time for pulpal anaesthesia for articaine HCl 4%

A

up to 120mins

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26
Q

infiltration time for pulpal anaesthesia for prilocaine HCl 3%

A

30-45mins

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27
Q

block onset time for pulpal anaethesia for Mepivacaine 3% plain

A

40mins

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28
Q

block onset time for pulpal anaethesia for ligocaine HCl 2%

A

90mins

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29
Q

block onset time for pulpal anaethesia for articaine HCl 4%

A

75mins

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30
Q

block onset time for pulpal anaethesia for prilocaine HCl3 %

A

60mins

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31
Q

soft tissue anaesthesia onset time for Mepivacaine 3% plain

A

2hrs

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32
Q

soft tissue anaesthesia onset time for ligocaine HCl 2%

A

3-5hrs

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33
Q

soft tissue anaesthesia onset time for articaine HCl 4%

A

3-5hrs

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34
Q

soft tissue anaesthesia onset time for prilocaine HCl 3%

A

3-6hrs

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35
Q

6 systemic complications of LA

A

Psychogenic

Interaction with other drugs

Cross infection

Allergy

Collapse

Toxicity

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36
Q

complications of LA can be either

A

systemic or local

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37
Q

what is the most common complication of LA

A

systemic psychogenic/stress related reactions

especially in anxious patients

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38
Q

examples of psychogenic/stress related reactions as complications to LA

A

Fainting, palpitations (heart bounding), cold sweat, restlessness, excitation, trembling, weakness (natural response, oxygenated blood to central organs)

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39
Q

cause of psychogenic/stress related reactions as complications to LA

A

lack of oxygenated blood to the brain

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40
Q

clinical features of psychogenic/stress related reactions as complications to LA

A

Lightheadness

Pallor

Beads of sweat (lip, nose, temple)

Bradycardia (slow pulse)

Nausea

Pupil dilation

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41
Q

management of psychogenic/stress related reactions as complications to LA

A

lay flat and raise legs

loosen neck clothing

improve room ventilation

sweet drink potentially (glucose)

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42
Q

5 drugs that LA can systemically interact with

A

MAOI monoamine oxidase inhibitors

tri-cyclics

beta blockers

non potassium sparing diuretics

cocaine

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43
Q

Systemic interaction of LA with MAOI (monoamine oxidase inhibitors)

A

Most exogenous adrenaline is metabolised via catechol

- A-methyl transferase system. MAO system of lesser significance

44
Q

Systemic interaction of LA with tri-cyclics

A

Theoretical risk of hypertension due to inhibition of uptake of adrenaline at sympathetic nerve terminals

May be prudent to limit quantity to 2 cartridges of 1:80,000 (i.e. 50mcg)

45
Q

Systemic interaction of LA with beta blockers

A

pressor increase as vasodilatory Beta-2 adrenergic receptors blocked

again may be wise to restrict quantity

46
Q

Systemic interaction of LA with non potassium sparing diuretics

A

relatively low K+ may be further enhanced by adrenaline’s potassium lowering action

47
Q

Systemic interaction of LA with cocaine

A

increased adrenergic action

48
Q

systemic allergy reaction to LA

A

True allergy very rare
- Common physiological reaction to adrenaline misbelieved as

Historically due to latex bung

Most are now due to preservatives/antioxidant
- Methylparaben/sodium bisulphite

  • Skin rashes
  • Anaphylaxis

Go for patch testing if true allergy

Cannot be treated in GDP, go to special LA allergy services

49
Q

systemic toxicity reaction to LA

A

Convulsions

Loss of consciousness

Respiratory depression

Circulatory collapse
- Important to differentiate from fainting

50
Q

systemic reaction to certain LA if pregnant

A 
Avoid oxtapressin (vasoconstrictor in citanest) as this has the potential to induce labour 
- Same drug as oxytocin

Check MHx

51
Q

what is the max safe dose calculated base on

A

fit, healthy adult

  • if not suit to pt, change calculation accordingly

calculation should be made for each patient on an individual basis
- frail old lady with diseases compared to 70kg fit healthy individual

52
Q

max safe dose of LA presumes (2)

A

toxic effects can be reduced by use of an aspirating technique.

rate of introduction (injection) should be slow
- thereby decreasing chance of overload.

53
Q

max safe dose for LA preparation is in regards to

A

LA active component

vasoconstrictor can be just as dangerous - bear in mind

54
Q

example of max safe dose calculation for ligocaine 2% with adrenaline 5mg/kg for 70kg male

A

2% = 2g/1000ml = 20mg/ml

Each cartridge will have 44mg (2.2ml cartridge)

Safe dose = 5mg/kg  in a 70kg male =350mg

350/44 = approx. 7 cartridges

55
Q

example of max safe dose calculation for articaine 4% solution in 70kg male

A

4%=4g/100ml = 40mg/ml

Each cartridge will have 88mg (2.2ml cartridge)

Safe dose = 7mg/kg
In 70kg male = 490mg

490/88 = approx. 5 cartridges

56
Q

max dose for Mepivacaine 3% plain

A

3mg/kg

57
Q

Mgs within a cartridge of Mepivacaine 3% plain

A

66mg

58
Q

max number of cartridges (70kg adult) for Mepivacaine 3% plain

A

6

59
Q

max dose for lignocaine 2% Adr 1:80,000

A

5mg/kg

60
Q

Mgs within a cartridge of lignocaine 2% Adr 1:80,000

A

44mg

61
Q

max number of cartridges (70kg adult) for lignocaine 2% Adr 1:80,000

A

7

62
Q

max dose of articaine 4% Adr:1:100,000

A

7mg/kg

63
Q

Mgs within a cartridge of articaine 4% Adr:1:100,000

A

88mg

64
Q

max number o cartridges (70kg adult) for articaine 4% Adr:1:100,000

A

5

65
Q

max dose of prilocaine 3% octapressin

A

8mg/kg

66
Q

Mgs within a cartridge of prilocaine 3% octapressin

A

66mg

67
Q

max number of cartridges (70kg adult) prilocaine 3% octapressin

A

8

68
Q

4 areas of the body that adrenaline effects

A

heart

blood vessels

blood pressure

lungs

69
Q

4 effects of adrenaline on heart

A

increase rate
increase force
increase output
increase excitability

70
Q

what receptors in the sympathetic nervous system does adrenaline trigger in the heart to cause the 4 effects

A

beta 1

71
Q

3 effects of adrenaline on blood vessels

A

coronary dilation
skin contraction
muscle dilation

72
Q

skin contraction of BV by adrenaline is due to stimulation of which SNS receptors

A

alpha

73
Q

muscle dilation of BV by adrenaline is due to which SNS receptors

A

beta 2

74
Q

Effect of adrenaline on blood pressure

A

increase systolic and decrease diastolic

so overall little effect

75
Q

effect of adrenaline on lungs

A

bronchial muscle realaxation

76
Q

bronchial muscle relaxation in the lungs by adrenaline is die to stimulation of which SNS recpetors

A

beta 2

77
Q

4 dangers of adrenaline use

A

cardio-vascular disease
- best to avoid or use less than three 2.2ml cartridges if better LA available

hyperthyroidism (thyroid crisis)

pheochromocytoma (hypertension)

drug interactions

  • mono amine oxidase inhibitors
  • tricyclic antidepressants
  • Beta blockers
  • Non-potassium sparing diuretics
  • Halothane (G.A. Agent)
  • Cocaine
78
Q

6 drug interactions adrenaline has

A
  • mono amine oxidase inhibitors
  • tricyclic antidepressants
  • Beta blockers
  • Non-potassium sparing diuretics
  • Halothane (G.A. Agent)
  • Cocaine
79
Q

11 local complications of LA

A

failure to achieve anaesthesia

prolonged anaesthesia

pain during injection

trismus

Haematoma

intra-vascular injection

blanching

facial paresis

broken needle

infection of soft tissue damage

contamination

80
Q

why would a local failure to achieve anaesthesia be due to

A

variety of causes

- technique, swelling, infection

81
Q

local pain during or after injection can be due to

A

injecting too fast or pt has muscular spasm

82
Q

local trismus due to LA is because of

A

given LA and pt has muscular spasm in area so cannot open mouth wide
- frightening for pt

83
Q

haematoma local complication due to LA because of

A

hit BV when giving LA so bleed

- can lead to trimus

84
Q

local blanching due to LA due to

A

intra-vascular injection stops BV in the area

- can be frightening for pt

85
Q

how would you solve a broken needle from LA injection

A

unlikely but worrisome

- need surgery

86
Q

prolonged anaesthesia after IDB can be due to (4)

A

Direct trauma from needle

Multiple passes with same needle
- Tip becomes blunt when hit bone - Get a new needle if need to give second IDB

Chemical trauma for injection
- Directly injected into the nerve - Pt jumps, electric shock
—-Withdraw, aspirate and give LA
Don’t give straight away – force into nerve cause issues

Different depending on LA used

87
Q

presentation of trismus

A

Within a few hours of inferior dental block may severely restrict opening may last for weeks or months

88
Q

cause of trimus

A

probably damage to medial pterygoid

- injection too low or too forceful/rapid

89
Q

3 management techniques of trismus

A

Reassurance (after diagnosis)

Muscle relaxant

Anti-inflammatory

90
Q

true facial palsy

A

Tend to have bleed within the brain

Causes facial muscle fibres not to work properly

Right hand brain affects left hand face
- Cross inverting

Tend to get sparing of upper facial muscle (wrinkle forehead)

  • Upper spares upper
    Upper motor neuron defect spares upper facial nerve muscles
91
Q

LA facial palsy

A

LA cannot move any muscles on that side

Lower motor neuron – LA injury in parotid gland where CNVII branches pass

All paralysed

92
Q

how to differentiate upper facial palsy from lower facial palsy

A

True facial palsy
Tend to get sparing of upper facial muscle (wrinkle forehead)
- Upper spares upper
Upper motor neuron defect spares upper facial nerve muscles

LA cannot move any muscles on that side

  • Lower motor neuron – LA injury in parotid gland where CNVII branches pass
  • All paralysed
93
Q

presentation of LA facial palsy

A

Usually complete unilateral motor nerve paralysis within mixtures of INF dental blocks

94
Q

confirm LA facial palsy

A

Temporal branch affected i.e. lower motor neurone distribution

95
Q

cause of LA facial palsy

A

LA into parotid gland

- Injection too far posteriorly

96
Q

diagnosis of LA facial palsy

A

Test branches of CN VII (facial nerve)

97
Q

management techniques of LA facial palsy

A

Reassurance, apologise, better in a few hours

Cover with eye pad – until blink reflex returns (prevent dry out)

98
Q

features seen of intra-vascular LA injection

A

Adrenaline effect

- palpitation, anxiousness, restlessness, headache, sweating, pallor

99
Q

intra-arterial LA injection

A

rare

  • Profound Skin blanching
  • Visual disturbances
  • Aural (hearing) disturbances

All are transitory but persistence requires rapid specialised referral

100
Q

what type of LA injection is likely to breach intra-venous

A

block

  • most often IDB
101
Q

3 ways to avoid intra-vascular LA injections

A

Aspirating system

Slow drug introduction

Safe quantity

102
Q

risk rating of different brands of LA

A

articaine most risky

  • lidocaine is 1 in million
  • Prilocaine 1 in 600,00
  • Articaine 1:440,000
103
Q

standard LA used in GDH

A

lidocaine 2% with Adr is drug of first choice

- good anaesthesia levels with less risks

104
Q

where would inject for mental block

A

Apices of lower 4 and 5

Anaesthetise sensation to:

  • skin over chip and lip
  • buccal mucosa lower 4 to central
  • teeth
105
Q

where would inject for infraorbital block

A

Mid papillary line, beneath infraorbital ring below eye

Foramen comes out – termination of CV2

anaesthetise sensation to:

  • Lateral aspect of nose
  • Skin in area
  • Feeling to central, lateral and canine teeth
106
Q

posterior superior alveolar block

A

Block further back of CNV2

Anaesthetise to all teeth on right side, skin on nose, cheek and lip area

Difficult

107
Q

where inject for inferior alveolar block

A

Insert needle across premolar on contra lateral sign

BDS2 LA Symposium (4 decks)

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