Complication of

local anestesia
Drg Yayun Siti Rochmah, SpBM
 Beberapa faktor yang dapat mempengaruhi
toksisitas obat anestesi lokal yaitu :

• Jenis obat anestesi lokal; baik sifat toksik

obat anestesi lokal maupun efek
vasodilatasinya.
• Konsentrasi obat anestesi lokal. Semakin
tinggi konsentrasinya semakin banyak
jumlah obat yang masuk ke dalam sirkulasi
darah.
• Injeksi intravaskuler.
• Kecepatan injeksi. Semakin cepat pemberian
semakin mudah cairan anestesi masuk ke
dalam sirkulasi darah.
• Vaskularisasi jaringan. Injeksi pada jaringan
dengan vaskularisasi yang tinggi, dan pada
daerah keradangan dan infeksi, akan
meningkatkan toksisitas sistemik.
• Berat badan penderita; semakin gemuk
seseorang semakin tinggi ambang toksistasnya
• Kecepatan metabolisme dan ekskresi obat. Obat
anestesi golongan amida akan terakumulasi
pada penderita penyakit liver sedangkan baik
obat golongan amida maupun ester terakumulasi
pada penyakit ginjal.
 Complication of local anestesia
• Pre operative complication
• Post operative complication
 Pre operative complication
• Needle breakage
1. Weakness of the alloy
2. Repeated injection with the same needle
cause fatique of the structure
3. False tehnique include aggressive insertion
of a needle into the tissue, sudden changes
in the direction inside the tissue or too deep
penetration broken hypodermic
needle.
4. Manufacturing defect
• Pain at injection
1. The solution is low pH value that may
irritated the tissue and temperature of
solution (warmer feeling more
comfortable than cold)
2. Aggressive insertion can tear soft
tissue, blood vessel, nerve or periosteum.
• Hypersensitivity and allergy
1. Rare, less than 1 %
2. Adrenalin can cause general symptoms,
including palpitation
3. Allergic reactions vary form a mild skin
irritation or rash to anaphylactic shock,
the main signs and symptoms of
anaphylactic shock are chest discomfort,
urticaria, stomach pain and dyspneu.
• Toxicity/Overdosage
• Predisposing factors, such as the patients : age,
weight, state of health, and other medications that
the patient may be taking (including meperidine,
phenytoin, quinodine and desipramine, which is a
tricyclic antidepressant) may cause increased free
local anesthetic blood levels due to a lack of plasma
proteins available for binding.
• During administration, both the rate of injection and
the route of administration can also have an impact
on the dosage effect, as rapid injection can lead to
increased plasma levels of local anesthetic.
• Overdosage. The concentration of the local
anesthetic in the blood supply may be
increased due to the vasodilating activity
of the local anesthetic; for this reason, a
vasoconstrictor is often present with many
of these agents.
• In addition, inadvertent intravascular
injections can also cause toxic
manifestations.
• Overdose symptoms may be minimal to
moderate, such as apprehension and
excitability; however, as the level of local
anesthetic in the blood increases, more
serious effects may result including CNS
depression, tonic-clonic seizures, and
possibly respiratory and cardiovascular
collapse. For a dosage of 40 to 160 mg of
local anesthetic administered, the blood
level rises to 1 mg/mL.
• CNS toxicity occurs at four times that
amount, so there is a good therapeutic
range. Fortunately most toxic reactions are
mild and are self-limited, as cerebral blood
levels of the anesthetic decrease over time
with redistribution. With the toxic side effects
of local anesthetics it is important to support
the airway when needed and to perform
basic life support as necessary.
• Post-anesthetic intraoral legions may also
develop, but will usually heal with time.
 Post operative complication
• Hematome
• Caused by penetrating the vessel with
needle or by intravascular injection
• Hematome formation can be avoided by
careful aspiration before injecting and by
gentle removal of the needle
• Trismus
• Caused by intramuscular injection of the
anaesthetic in the pterygomandibular space
• Occure even 2-5 days after inferior alveolar
nerve block.
• Anaesthetic solutions are usually cytotoxic
and cause inflamation inside the affected
muscle and trismus.
• Intramuscular injections can cause
hematome formation inside the muscle and
fibrosis, which lead to the trismus.
• Infection
• Infection, especially a needle track
infection, which manifests itself pretty
late, can occur. To prevent infection it is
recommend that needles not be reused in
a patient's mouth. Fresh needles should
always be used, and the area to be
penetrated should be cleaned prior to
insertion of the needle.
• Paresthesias/Anesthesias
• Persistent localized paresthias or
anesthesias may also occur, most
frequently as a result of direct trauma to
a nerve; injection of the local anesthetic
into the nerve sheath may result also in
trismus or possible hematoma formation.
• Complications from Nerve Block
• Facial nerve paralysis may occur
temporarily with a nerve block. Again,
reassure the patient that the condition will
disappear as the anesthetic agent is
metabolized.
Complications resulting from a maxillary
nerve block are rare, but may include:
• regional sixth nerve block, results in
temporary diplopia for the patient
• hematoma (rare)
• retrobulbar block (rare)
• optic nerve block, which can result in
temporary blindness (rare)
• In the study, 2731 patients receiving dental
anesthesia were evaluated by questionnaire
for risk factors, type and dosage of local
anesthetic applied, type and duration of
treatment, and complications associated with
the administration of the local anesthetic. Of
all patients, 45.9% had at least one risk
factor in their medical histories, with
cardiovascular diseases and allergies being
the most frequent.
• The overall incidence of complications was
4.5%. It was significantly higher in risk
patients (5.7%) than in nonrisk patients
(3.5%). The most frequently observed
complications (dizziness, tachycardia,
agitation, nausea, tremor) were transient
in nature and did not require treatment.
Severe complications (seizure,
bronchospasm) occurred in only two cases
(0.07%).
• Articaine was found to be administered in
over 90% of all dental anesthesias in
Germany despite the great variety of local
anesthetics available. Articaine 1:100,000
caused more sympathomimetic side effects
than did articaine 1:200,000. Additionally,
doses of local anesthetics proved not to be
strictly determined according to body weight,
especially for patients weighing less than 50
kg. In summary, it can be stated that dental
local anesthesia can be considered safe.
• Nevertheless, the incidence of complications
due to dental anesthesia can be expected to
be further reduced if (a) patients are
routinely evaluated for risk factors with an
adequate medical history prior to dental
treatment, (b) doses of local anesthetics are
strictly determined according to body weight,
(c) anesthetics with low concentrations of
epinephrine are used, and (d) the concept of
a differentiated dental anesthesia is applied.
 Reason of failure of dental local
anaesthesia
• Anatomical
• Pathological
• Psychological
• Poor injection technique
• Anatomical reason
• Accessory nerve supply, variation in
foramen location and abnormal course of
the nerve
• The teeth can be innervated by more than
one nerve
• Thick cortical plate of mandibular
• Pathological reason
• Trismus
• Infection
• Inflammation
• Trauma
• Psychological reason
• Anxiety Tx : benzodiazepine
• Poor technique
• Most common reason
• Inject the anaesthetics too soon on
anterior ascending ramus as the needle
point touches the lingual cortical bone
anterior to the lingula
• Inject inferior to the mandibular fomaren
• Inject too rapidly and forcefully
How to avoid complication ?