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OS & Pain Management > Local Anesthesia pt. 3 > Flashcards

Local Anesthesia pt. 3 Flashcards

1
Q

History of Agents
 1980s

A

 Lidocaine, Mepivacaine, Prilocaine, Mixture of procaine and propoxycaine

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2
Q

History of Agents
 Next few years

A

 Bupivacaine 1983 (Long acting)
 Etidocaine 1985 (Long Acting)
 Articaine 2000 (intermediate duration)

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3
Q

History of Agents
 Presently

A

 Lidocaine, Mepivacaine, Prilocaine, Bupivacaine, and Articaine

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4
Q

Factors affecting both depth and duration of anesthesia

A

 Individual response to drug is a Bell shaped curve phenomenon
 Accuracy in deposition of local anesthesia
 Tissue status (vascularity, pH)
 Anatomical variation
 Types of injection administered (block or infiltration)

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5
Q

Maximum Recommended Dosages
Old days

A

 Different mg/kg MRDs dependent on inclusion of vasoconstrictor Manufacturer’s recommendation

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6
Q

Maximum Recommended Dosages
Now

A

 No distinction / adjustment made for inclusion of vasoconstrictor
 Council on Dental therapeutics of the American Dental Association
 United States Pharmacopeal Convention

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7
Q

Maximum Recommended Dosages
 Maximum calculated drug dose should — in medically compromised, debilitated, or elderly persons

A

decrease

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8
Q

Maximum Recommended Dosages
 What if I exceed MRD accidentally, do patient automatically OD?

A

 NO, when exceeding MRD, there is a greater likelihood of OD arising
• In fact OD may arise at the dosage below the calculated MRD (hyper-responders)

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9
Q

Maximum Recommended Dosages
 How to determine doses, if two drugs are used?

A

 The total dose of both local anesthetics not exceed the lower of the two
maximum doses for the individual agent.

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10
Q

Mix and Max

A

The total dose of both local anesthesia not exceed the
lower of the two max doses for the individual agent

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11
Q

Lidocaine
 Potency:

A

the standard

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12
Q

Lidocaine
Metabolism:

A

liver

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13
Q

Lidocaine
Onset of action:

A

rapid (2-3 mins)

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14
Q

Lidocaine
Anesthetic t ½ :

A

1.6 hours

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15
Q

Lidocaine
Maximum Recommended Dose (MRD)

A

 4.4mg/kg (Council on Dental Therapeutics of the ADA and USP convention)
 Absolute maximum 300mg
 8 Cartridges will be the maximum # used on a patient

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16
Q

Lidocaine
 Other limiting factors

A

 Healthy patient, maximum epinephrine is 0.2mg or 200mcg
 Cardio patient , maximum epinephrine is 0.04mg or 40mcg

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17
Q

Lidocaine
 Conclusion:

A

 Maximum dose is limited to
• First: maximum amount of epinephrine can be given
• Second: lowest possible dosage of lidocaine needed

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18
Q

First Amide to be marketed and replaced procaine (Novocain) as the drug of choice

A

Lidocaine
Synthesized in 1943 and in 1948

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19
Q

Lidocaine
onset

A

 Much faster onset
 (2-3mins, Lidocaine) vs (6-10mins, Procaine)

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20
Q

Lidocaine
allergy

A

Allergy to amide is virtually nonexist

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21
Q

gold standard

A

Lidocaine

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22
Q

Lidocaine
types (3)

A

 2% w/o vasoconstrictor
 2% w 1:50,000
 2% w 1:100,000

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23
Q

Mepivacaine
Potency:

A

similar to lidocaine

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24
Q

Mepivacaine
Metabolism:

A

Liver

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25
Mepivacaine Onset of action:
Rapid (1.5 to 2 mins)
26
Mepivacaine Anesthetic t ½ :
1.9 hours
27
Mepivacaine Maximum Recommended Dose ( MRD): (3)
 4.4mg/kg  Absolute maximum 300mg  5.5 cartridges will be maximum # used on a patient
28
Mepivacaine  --- vasodilating properties
Mild
29
Mepivacaine duration
Longer duration vs other agent w/o vasoconstrictor
30
Mepivacaine 3% Mepivacaine plain provides
 20-40 mins pulpal anesthesia  2-3 hours soft tissue anesthesia
31
Mepivacaine Indication:
 When vasoconstrictor is NOT indicated  Most often used in pediatric / geriatric patient
32
Mepivacaine Types
 3% without vasoconstrictor (UMKC: Carbocaine)  2% with vasoconstrictor ( Levonodefrin )
33
Prilocaine Potency:
similar to Lidocaine
34
Prilocaine Metabolism:
 Hydrolyzed to orthotoluidine and N-propylalanine  Orthotoluidine induce methemoglobin • May cause observable cyanosis
35
Prilocaine Onset of Action:
slightly slower (2-4 mins)
36
Prilocaine Anesthetic t ½ :
1.6 hours
37
Prilocaine Maximum Recommend Dose:
 6.0mg/kg  Absolute Maximum 400mg  5.5 cartridges will be the maximum # used on a patient
38
Prilocaine  Relatively contraindicated in (5)
 Idiopathic / congenital methemoglobinemia  Hemoglobinopathies (Sickle cell anemia)  Anemia  Cardiac / Respiratory failure evidenced by hypoxia  Patient taking Acetaminophen or Phenacetin • Produce elevations in methemoglobin level
39
Prilocaine Types: (2)
 4% w/o vasoconstrictor  4% w vasoconstrictor
40
Bupivacaine Potency:
4X lidocaine
41
Bupivacaine Metabolism:
Liver
42
Bupivacaine Onset of Action:
Longer 6-10 mins  occasionally similar to lidocaine
43
Bupivacaine Anesthetic t ½ :
2.7 hours (Long Duration)
44
Bupivacaine Maximum Recommended Dose: (3)
 1.3mg/kg  Absolute maximum 90 mg  10 cartridges is the maximum # used on a patient
45
Bupivacaine Available in U.S. since ---
1983
46
Bupivacaine Primary indication
 Lengthy dental procedure >90 mins pulpal anesthesia is needed  Management of postoperative pain • Reduce post-op opioid analgesics
47
Bupivacaine Not recommended on
 Younger patient  Physically / mentally disabled person
48
Effective Pain Management  Preoperative
 pretreatment of 1 or 2 doses of NSAID
49
Effective Pain Management Perioperative (2)
 Local anesthesia  Long-duration local anesthesia given upon D/C
50
Effective Pain Management Postoperative
 Continue oral NSAID q X hours for Y days
51
NSAID can be given within --- of the start of the surgical procedure
1 hour
52
Articaine Potency:
1.5X lidocaine
53
Articaine Metabolism:
 Only amide type L.A. with ester group • Plasma esterase hydrolysis • Liver metabolism
54
Articaine Onset of Action:
1-2 mins infiltration
55
Articaine Anesthetic t ½ :
0.5 hours
56
Articaine Maximum Recommended Dose:
 7mg/kg
57
Articaine Available in Europe since 1976, Approved by FDA in ---
2000
58
Articaine Claims: (4)
 Increased success rates ( don’t miss often)  Diffuse soft / hard tissue reliably  Infiltration of mandible resulted pulpal and lingual anesthesia  Controlled study failed to corroborate these claim !!!
59
Articaine Contraindication: (5)
 Patient allergic to amide type anesthesia (few to none)  Sulfite sensitivity  Caution with hepatic disease  Patient with significant impairments in cardiovascular function  Children < 4 y/o is not recommended due to insufficient data
59
Articaine Why Man?  FDA regulation stated
• Cartridges must state the preceding if it cannot be guaranteed that all cartridges of the drug contain minimally 1.8ml or greater
59
Articaine Cartridges of articaine stated “minimum content of each :
1.7 mL
59
Articaine actually DO contain --- or --- of drug not ---
1.8mL 72mg 68mg (1.7 X 40 = 68)
60
What happen to the Volume
All local anesthesia cartridges are labeled 1.7ml Robertson et al (2007)*  On Cartridge labeled 1.7ml • Average amount measured to be 1.76ml  On Cartridge labeled 1.8ml • Average amount comes to be....1.76ml  Based on 100 cartridge measurements
61
Articaine The Four Percent Solution
• an analogue of prilocaine • in Germany since 1976 • in Canada since 1983 • in the U.S. since April 2000
62
The down-side (4)
 Prior to introduction of articaine, prilocaine accounted for 51% of paresthesias in the US, while being used for 13 % of injections  Indicates potential for neuro- toxicity of articaine and prilocaine.  Ontario’s professional liability program 1983-1993.  Articaine and prilocaine resulted in more non-surgical paresthesias than all of the local anesthetics, despite being used for fewer injections.
63
Is 4% too concentrated? Animal studies show increased neurological deficits with --% lidocaine Human studies show the same with --% lidocaine
4 5
64
Is 4% too concentrated?  After 55 years of clinical use, --% lidocaine with --- epinephrine is still the closest to the ideal intermediate-duration local anesthetic in dentistry.
2 1:100,000
65
Topical anesthesia is effective only on
surface tissue (2-3mm)  This is sufficient to allow atraumatic needle penetration
66
How about the spray devices?
 Not recommended, Unable to deliver measured doses !
67
Benzocaine (5)
Ester local anesthesia Poor absorption into cardiovascular system Not suitable for injection Ester local anesthesia are more allergenic than amide Most commonly used topical anesthesia
68
EMLA cream content
 Lidocaine 2.5% + Prilocaine 2.5%
69
ELMA Provides
surface anesthesia of intact skin
70
EMLA Usage
 Circumcision, Leg ulcer debridement and GYN procedures
71
EMLA  Direction
 Apply 1 hour before the procedure  Satisfactory numbing of skin occurs 1 hour after application  Maximum comfort at 2 to 3 hours  Last 1 to 2 hours after removal
72
EMLA  Contraindicated
 Methemoglobinemia  Infant <12 months old had other methemoglobin-inducing drugs  Amide sensitive
73
EMLA Dental use
 Dental use is under study
74
Lidocaine (Topical)  Two forms
 Lidocaine base • Poorly soluble in H2O  Lidocaine hydrochloride • Water soluble • Better tissue penetration but systemic absorption is also greater
75
Lidocaine (Topical) Maximum recommend dose is
200mg  Keep in mind for the “other” injection lidocaine !!!
76
Lidocaine (Topical) Types
 Aerosol, ointment, patch, solution
77
Tetracaine Hydrochloride
Long-duration ester local anesthetic  Injection or topical application
78
Tetracaine Hydrochloride Usage should limit to
small area  Rapidly absorbed through mucous membrane
79
Tetracaine Hydrochloride Extreme caution urged b/c great potential for
systemic toxicity
80
Selection of Local Anesthetic (4)
 Procedure dependent  Postoperative pain control • Long duration local anesthesia ( Bupivacaine or Prilocaine) • Children / mentally disabled ( Mepivacaine )  Hemostasis • Use epi with 1:100,000 or 1:50,000  Any contraindications? • Absolute: true, documented reproducible allergy • Relative: find a better substitute (ex: amide for atypical pseudocholinesterase patient)

OS & Pain Management (8 decks)

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