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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
Q

Mepivacaine
Onset of action:

A

Rapid (1.5 to 2 mins)

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26
Q

Mepivacaine
Anesthetic t ½ :

A

1.9 hours

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27
Q

Mepivacaine
Maximum Recommended Dose ( MRD):
(3)

A

 4.4mg/kg
 Absolute maximum 300mg
 5.5 cartridges will be maximum # used on a patient

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28
Q

Mepivacaine
 — vasodilating properties

A

Mild

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29
Q

Mepivacaine
duration

A

Longer duration vs other agent w/o vasoconstrictor

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30
Q

Mepivacaine
3% Mepivacaine plain provides

A

 20-40 mins pulpal anesthesia
 2-3 hours soft tissue anesthesia

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31
Q

Mepivacaine
Indication:

A

 When vasoconstrictor is NOT indicated
 Most often used in pediatric / geriatric patient

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32
Q

Mepivacaine
Types

A

 3% without vasoconstrictor (UMKC: Carbocaine)
 2% with vasoconstrictor ( Levonodefrin )

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33
Q

Prilocaine
Potency:

A

similar to Lidocaine

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34
Q

Prilocaine
Metabolism:

A

 Hydrolyzed to orthotoluidine and N-propylalanine
 Orthotoluidine induce methemoglobin
• May cause observable cyanosis

35
Q

Prilocaine
Onset of Action:

A

slightly slower (2-4 mins)

36
Q

Prilocaine
Anesthetic t ½ :

A

1.6 hours

37
Q

Prilocaine
Maximum Recommend Dose:

A

 6.0mg/kg
 Absolute Maximum 400mg
 5.5 cartridges will be the maximum # used on a patient

38
Q

Prilocaine
 Relatively contraindicated in
(5)

A

 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
Q

Prilocaine
Types:
(2)

A

 4% w/o vasoconstrictor
 4% w vasoconstrictor

40
Q

Bupivacaine
Potency:

A

4X lidocaine

41
Q

Bupivacaine
Metabolism:

A

Liver

42
Q

Bupivacaine
Onset of Action:

A

Longer 6-10 mins
 occasionally similar to lidocaine

43
Q

Bupivacaine
Anesthetic t ½ :

A

2.7 hours (Long Duration)

44
Q

Bupivacaine
Maximum Recommended Dose:
(3)

A

 1.3mg/kg
 Absolute maximum 90 mg
 10 cartridges is the maximum # used on a patient

45
Q

Bupivacaine
Available in U.S. since —

A

1983

46
Q

Bupivacaine
Primary indication

A

 Lengthy dental procedure >90 mins pulpal anesthesia is
needed
 Management of postoperative pain
• Reduce post-op opioid analgesics

47
Q

Bupivacaine
Not recommended on

A

 Younger patient
 Physically / mentally disabled person

48
Q

Effective Pain Management
 Preoperative

A

 pretreatment of 1 or 2 doses of NSAID

49
Q

Effective Pain Management
Perioperative
(2)

A

 Local anesthesia
 Long-duration local anesthesia given upon D/C

50
Q

Effective Pain Management
Postoperative

A

 Continue oral NSAID q X hours for Y days

51
Q

NSAID can be given within — of the start of the surgical procedure

A

1 hour

52
Q

Articaine
Potency:

A

1.5X lidocaine

53
Q

Articaine
Metabolism:

A

 Only amide type L.A. with ester group
• Plasma esterase hydrolysis
• Liver metabolism

54
Q

Articaine
Onset of Action:

A

1-2 mins infiltration

55
Q

Articaine
Anesthetic t ½ :

A

0.5 hours

56
Q

Articaine
Maximum Recommended Dose:

A

 7mg/kg

57
Q

Articaine
Available in Europe since 1976, Approved by FDA in —

A

2000

58
Q

Articaine
Claims:
(4)

A

 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
Q

Articaine
Contraindication:
(5)

A

 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
Q

Articaine
Why Man?
 FDA regulation stated

A

• Cartridges must state the preceding if it cannot be guaranteed that all
cartridges of the drug contain minimally 1.8ml or greater

59
Q

Articaine
Cartridges of articaine stated “minimum content of each :

A

1.7 mL

59
Q
A

1.8mL
72mg
68mg (1.7 X 40 = 68)

60
Q

What happen to the Volume

A

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
Q

Articaine
The Four Percent Solution

A

• an analogue of prilocaine
• in Germany since 1976
• in Canada since 1983
• in the U.S. since April 2000

62
Q

The down-side (4)

A

 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
Q

Is 4% too concentrated?
Animal studies show increased
neurological deficits with –%
lidocaine
Human studies show the same
with –% lidocaine

A

4
5

64
Q

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.

A

2
1:100,000

65
Q

Topical anesthesia is effective only on

A

surface tissue (2-3mm)
 This is sufficient to allow atraumatic needle
penetration

66
Q

How about the spray devices?

A

 Not recommended, Unable to deliver measured
doses !

67
Q

Benzocaine
(5)

A

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
Q

EMLA cream
content

A

 Lidocaine 2.5% + Prilocaine 2.5%

69
Q

ELMA
Provides

A

surface anesthesia of intact skin

70
Q

EMLA
Usage

A

 Circumcision, Leg ulcer debridement and GYN procedures

71
Q

EMLA
 Direction

A

 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
Q

EMLA
 Contraindicated

A

 Methemoglobinemia
 Infant <12 months old had other methemoglobin-inducing drugs
 Amide sensitive

73
Q

EMLA
Dental use

A

 Dental use is under study

74
Q

Lidocaine (Topical)
 Two forms

A

 Lidocaine base
• Poorly soluble in H2O
 Lidocaine hydrochloride
• Water soluble
• Better tissue penetration but systemic absorption is also greater

75
Q

Lidocaine (Topical)
Maximum recommend dose is

A

200mg
 Keep in mind for the “other” injection lidocaine !!!

76
Q

Lidocaine (Topical)
Types

A

 Aerosol, ointment, patch, solution

77
Q

Tetracaine Hydrochloride

A

Long-duration ester local anesthetic
 Injection or topical application

78
Q

Tetracaine Hydrochloride
Usage should limit to

A

small area
 Rapidly absorbed through mucous membrane

79
Q

Tetracaine Hydrochloride
Extreme caution urged b/c great potential for

A

systemic
toxicity

80
Q

Selection of Local Anesthetic (4)

A

 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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