LOCAL ANESTHESIA

Achmad Assegaf,dr., Sp.An.

Anesthesia
General
I.V I.M Inhalation

Local
Topical Infiltration Field Block Nerve Block Spinal Epidural Intra Venous
COMBINATION

GENERAL ANESTHESIA : Impulse still reach to CNS

Cortisol Catecholamine Tachycardia Blood sugar

REGIONAL ANESTHESIA : Impulse less/not reach to CNS Segmental blockade T5 L1 Block sympathetic system
Cortisol N / less Catecholamine N / less

General Anesthesia All sensation loss Unconscious

sensory cortex cerebral

Subarachnoid

Local/Regional Anesthesia Partial sensation loss Conscious

Epidural

Nerve Ending Medulla Spinalis

ADVANTAGES :
Simple, Cheap Non explosive No pollution Post op care relative easy Conscious aspiration risk (-) Blood loss Autonomic & endocrine response

DISADVANTAGES :
Patient prefer unconscious Not practical if several injection are needed Fear that the effect of drug vanished the surgery not finished Side effect so severe death

Local Anesthetic Agent

1. Ester Compound
Cocaine Procaine / Novocaine Tetracaine / Pontocaine

2. Amide Compound
Xylocaine / Lidocaine Prilocaine / Citanest Bupivacaine / Marcaine Etidocaine / Duranest Ropivacaine Levo Bupivacaine

Agent Cocaine Procaine

Concent: Clinical use 4-10% Topical Infiltration 1% Epidural 2% Plexus block 2% Spinal 10% Infiltration 1% Epidural 2% Plexus block 2% Topical 0,5-1% Infiltr 0,1-0,2% Epidrl 0,4-0,5% Spinal 1%

Onset & Duration Slow 30 Slow 30-45

Max:Single dose 150 Mg 500 Mg EPI 600 Mg + EPI 1012 Mg/Kg

Potency Low

Chloro procaine

Rapid 45-60

600 Mg EPI Interme 650 Mg + EPI diate 10-15 Mg/Kg 100 Mg 2 Mg/Kg High

Tetracaine

Slow 180-300

Agent Xylocaine

Concent: Clinical use Infiltr 0,5-1% Epidural 1-2% N.block 1-1,5% Topical 4% Spinal 5% sda

Onset & Duration Rapid 60-120

Max:Single dose

Potency

300 Mg EPI Interme diate 500 Mg + EPI 7-8 Mg/Kg

Prilocaine

Slow 60-120 Slow >180>300 Rapid >180 >300

175 Mg EPI Interme diate 250 Mg + EPI 3-4 Mg/Kg 175 Mg EPI 250 Mg + EPI 3 4 Mg/Kg 300 Mg EPI 400 Mg + EPI 4-5 Mg/Kg High

Bupivacaine

Infilt 0,25-0,5% N.blok 0,5-0,75% Spinal 0,5% Infiltr 0,5% N.blok 0,5-1% Epidrl 1-1,5%

Etidocaine

High

Metabolism

Allergy

ESTER.C Hydrolyzed in Plasma (Ps.Choline) AMIDE.C Degradation in the Liver

(+) PABA

(-)

Anesthetic Profile of Local Anesthetic is depend on : Lipid solubility intrinsic potency

The Higher lipid sol Higher potency Procaine L.S. = 1 Bupivacaine L.S. = 30 Etidocaine L.S. = 140 90 % Axolemma consist of lipid

Protein binding
Higher Protein binding Longer duration Procaine P.B. = 5 Bupivacaine P.B. = 95 10 % axolemma consist of protein

 p Ka
P Ka as pH at which its ionized and non ionized are in complete equilibrium L.A. with pKa closer to tissue pH more rapid onset p Ka lidocaine = 7,7 Bupivacaine = 8,3

Intrinsic vasodilator activity

Influence potency and duration of action Degree of vascular absorption is related to blood flow through the area All local anesthetic vasodilation except Cocaine

Base upon potency and duration of action

1. Low Potency & short duration o.a.
Procaine chloroprocaine Lidocaine Mepivacaine Prilocaine Bupivacaine Tetracaine Etidocaine

2. Intermediate potency & duration o.a.

3. High potency & long duration o.a.

Toxicity of local anesthetic (0,2 1,5%)

1. Systemic toxicity Excitation CNS Depression Hypotension CVS CV collaps

 Local irritation Neural damage Miscellanous Allergy Met.Hb.emia Addiction

Chloroprocaine

Ester compound Prilocaine Cocaine

Systemic toxicity
L.A. agent are relatively free of side effect, if :
1. In appropriate dosage toxic excessive dose 2. In appropriate anatomical location toxic reaction following :

- accidental i.v. injection - subarachnoid inj. of large dose

Systemic toxicity
CNS is more susceptible than CVS Adverse effect involving CVS tend to be more serious and more difficult to manage

CNS toxicity
CNS is more susceptible to the systemic actions of L.A. than CVS

Tinnitus Light headedness Confusion Circumoral numbness Drowsiness unconscious Twitching & tremors muscles of face & distal extremities convulsion Respiratory arrest

 Bupivacaine : Etidocaine : Lidocaine = 4 : 2 : 1 Convulsive threshold is inversely related to the PaCO2 level. PaCO2 pH convulsive threshold convulsive threshold

CVS toxicity
Cardiac : - Negative inotropic action
more potent more depress contractility more difficult to resuscitate

- Ventricular fibrillation
bupivacaine

Vascular : biphasic action - Lower dose vasoconstriction - increase dose vasodilatation No correlation between L.A. potency and vascular smooth muscle effect

 Hypotension initially as a result of decrease in SV CO Later on vasodilatation CV collaps

Neurological Blockade
Peripheral : - Topical - Infiltration - Field block - Nerve block - I.V. Regional Anesthesia Central : - Spinal - Epidural

Spinal Anesthesia
L.A Subarachnoid space
Anterior horn blockade Posterior horn blockade

Small nerve fiber large fiber Autonom Sensoris (pain) Temperature Motoric Proprioceptic

Autonomic blockade 2 3 segments above analgesic level Motoric blockade 2 3 segments under analgesic level

Indication
Abdominal surgery esp. lower abdomen Hernia Inguinalis Lower extrimities surgery Vesica urinaria and prostatic surgery Obgyn surgery

Contraindication
Absolute : - refusal of the patients - local infection - coagulopathy Relative : - Sepsis - Neurological disease - Technical problems - Hypovolemia

Advantages
Conscious Relaxation (+) Pulmonary post. op. complication << Blood loss

Disadvantages
Hypotension Durante & post op nausea & vomiting Post op headache Disturb respiration high level Urinary retention

Technique
Lateral / sitting position Approach : midline / lateral
Level of injection : iliac crest L R L4-5 Needle is advanced until duramater is pierced CSF flow back The higher the dose the greater the height of block Lower abdominal surgery T 8-10 1,8 2 cc Higher abdominal surgery T 4-5 2 2,5 cc

Management
Fluid : 0,5 1 L Post injection : - Test analgesic - Respiratory monitor O2 by mask assist. ventilation

- Hypotension fluids ephedrine 5 10 mg i.v - High risk patients early ephedrine drips If necessary : - diazepam / midazolam - Hypnotic - N2O/O2 - Light G.A

Post Spinal Headache

Due to leakage of CSF smaller the needle less PSH G.N 25 3,5% ; 27 1% ; 29 < 1% Th/ : Laid flat 24 hrs Analgesic agent Autolog epidural blood patch

Epidural Analgesia
Thoracal, lumbar, caudal Indication / contraindication = spinal

Anatomy
Duramater is begine from foramen magnum and end at S2 level Posterior to the dura lies lig. Flavum Diameter 0,5 cm at L2 Content of epidural space : - fat - vascular vessel - lymph vessel - areolar tissue - spinal nerve roots

Detection of epidural space using tuohy needle :

- Loss of resistance - Hanging drop Dose : 1 1.5 ml / segment Injection begin with 3 ml of test dose consist of lidocaine 2 % + adrenaline 1 : 200.000

Complication
Penetrate duramater
Post spinal headache Total spinal

Systemic reaction

Spinal advantages
Less time to perform eq. technique easier Less doses More rapid onset Better quality sensory & motor block

Epidural advantages

Segmental block No PS Hypotension is not abrupt Less motoric block Can be used for post op. pain catheter

Epidural disadvantages
More difficult Larger doses Systemic reaction Total spinal if not in proper place

Caudal Block
Indication : perineal surgery Contraindication = epidural Technique :
1. 2. 3. 4. Prone position Cornu sacralis Hiatus sacralis Penetrate sacrococcygeal membrane

Disadvantages
Difficult to reach higher level of analgesia Systemic reaction could be (+)

Brachial plexus block

Supraclavicular Axillary

Nerve block at the elbow

N. ulnaris N. medianus + N. radialis Wrist block