COMPLICATIONS OF LOCAL ANESTHESIAPART I
Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial Surgery2013
Complications
Any deviation from the normally Expected pattern during or after securing local
analgesia.
Classifications
Primary or Secondary Mild or Severe Transient or Permanent Attributed to solution or needle insertion
Complications from Local Anesthesia
I. Complications associated with the absorption of the solution used.
II. Complications associated with needle insertion
Complications associated with the absorption of the solution used.
1- Complications resulting from absorption of the anesthetic solution:
Systemic drug reactions due to the local anesthesia agent:
1. Toxicity2. Vasoconstrictor toxicity3. Allergy4. Anaphylactic reactions5. Idiosyncrasy
Local Reaction:6. Infection due to contaminated solution7. Local tissue irritation.
Complications associated with needle insertion1. Fainting and syncope
2. Muscle trismus3. Pain4. Edema5. Infection6. Broken needles7. Prolonged anesthesia8. Hematoma formation9. Sloughing and ulceration10.Bizarre Neurological Symptoms
Keep in Mind
A: Airway Clear Adequate respiration
B: Bleeding Stopped Achieve inlet to vessels
C: Circulation: Fluids if needed
D: Drugs To treat the present condition
Keep in Mind
Call the medical emergency service
The patient placed in horizontal position on his back
Tilt the patient in a slightly head down position or elevate the legs to help increase cerebral circulation
Adequate oxygenation is of prime importance because of the impaired respiratory mechanism
Check the patients cardiac and cardiovascular status
Keep in Mind
Starts I.V fluids should (e.g. 5% dextrose in H2O)
Drugs according to the condition
If complete circulatory standstill I.V injection of Atropine Stimulation of the heart by introducing a
needle directly into it Intracardiac injection of epinephrine 0.1
ml of 1.1000 solution
Complications due to Absorption of the Injected Solution
Systemic Complications1. Toxicity2. Idiosyncrasy3. Allergy4. Anaphylaxis
Definition Etiology Clinically Prevention Treatment
TOXICITY
Definition
It refers to the symptoms manifested as a result of overdosage or
excessive administration of the solution
Etiology
Large Dose of drug Accidental I.V injection High concentration of a drug Unusually slow detoxification as a result of
severe liver disease Slow elimination as a result of kidney trouble Use of highly toxic drugs whose margin of
safety is narrow Injection of solution in highly vascular area
without the addition of vasoconstrictor substance.
Clinically
Early CNS stimulation symptoms
Cerebral cortex Medulla
Talkative Lethargy
Restlessness Sleepiness
Apprehensive Unconscious
Excited Convulsive
Clinically
Late CNS Depression Symptoms
Cerebral Cortex Medulla
Increase BP Dropped BP
Increase pulse rate Decrease Pulse Rate
Increase RR Respiratory depression
Nausea and Vomiting Decrease HR
Unconsciousness
Death usually occur due to Respiratory
Depression and Hypoxia and its subsequent effect on
the CVS
prevention
1. Pre-analgesic evaluation of the patient2. Use the weakest possible concentration3. Use vasoconstrictor whenever possible 4. Use of the least possible volume5. Aspirate before injection6. Slow injection7. Monitor the patient carefully after
injection
Treatment
Mild stimulation -- No treatment -- Stop further injection
Moderate stimulation Convulsions phase Depression phase
Treatment
Mild stimulation
Moderate stimulation IV injection of Barbiturates -- 0.2% solution of sodium Thiopental -- Secobarbital (seconal)
Oxygen inhalation
Convulsions phase Depression phase
Treatment
Mild stimulation Moderate stimulation
Convulsions phase Anticonvulsent IV/IM -- Coramine (150-450 mg I.V) -- Metrazol (100 mg I.V) (Midazolam or
Diazepam) -- Wyamine (7.5 mg I.V or 15 mg I.M) or
neosynephrine Oxygen inhalation
Depression Phase
Treatment
Mild stimulation Moderate stimulation Convulsions phase
Depression phase -- Artificial respiration -- I.V fluids -- Sympathomemetic drugs
Thank You
COMPLICATIONS OF LOCAL ANESTHESIAPART II
Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial Surgery2013
VASOCONSTRICTOR TOXICITY
Definition Etiology Clinically -- Palpitation -- Tachycardia -- Hypertension -- Headache -- Apprehension -- Restlessness Prevention and treatment
IDIOSYNCRASY
Definition
Abnormal reaction to a drug or group of drugs exhibited when only a Small Amount or a Nontoxic Dose of the drug has been used
This means that the susceptible patient Reacts Adversely to a volume or concentration of the drug that would not affect the typical patient
Nontoxic – Non Allergic condition
Etiology
Unknown
Enzymopathy -- Congenital -- Acquired
psychogenic
Clinically
1. Pallor2. Tachycardia3. Hypotension4. Decrease heart rate5. Collapse
Prevention
Do not use any drug, which the patient gives you a history of previous reactions to it
Inject slowly and observe the patient closely during injection
Treatment
The same as the depression stage of toxic overdose (Artificial respiration, I.V fluids, Sympathomemetic
drugs) Barbiturates are ineffective in the treatment or
prevention of this condition
ALLERGY AND ANAPHYLAXIS
Definition
Allergy is a hypersensitivity reaction that occurs through exposure to an antigen (Ag) such as a drug (as L.A agent) which the patient has been previously exposed to it creating an Ag-Ab reaction
Anaphylaxis is a severe form of allergic reaction occurs suddenly and end fatally in which sudden violent loss of vasomotor tonus
Clinically
Allergy
1. Rashes2. Urticaria3. Fever4. Dermatitis5. Angioneurotic edema6. Bronchial asthma7. Anaphylaxis (Anaphylactic shock)
Clinically
Anaphylaxis
1. Drop in B.P2. Weak rapid pulse3. Inadequate respiration (RR)4. Death
Management
Epinephrine -- 1:1000 concentration -- 0.3 mg SC or IM Bronchodilator -- Via inhaler
Antihistaminic -- Benedryl 20-40 mg IV or IM Corticosteroids -- 100 mg IV hydrocortisone hemisuccinate
COMPLICATIONS OF LOCAL ANESTHESIAPART III
Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial Surgery2013
COMPLICATIONS DUE TO ABSORPTION OF THE INJECTED SOLUTION
Local reaction1. Infection 2. Tissue Irritation
Infection
Infection from contaminated L.A solution are uncommon due to high standard of asepsis
during manufacturing
Tissue Irritation
Local tissue irritation through the use of non isotonic L.A solutions are uncommon due to
high standard of manufacturing
COMPLICATIONS ASSOCIATED WITH NEEDLE INSERTION
Fainting or Syncope
Due to temporary cerebral ischemia as a result of the
splanchnic B.V and reduced cardiac output
Signs and Symptoms:1. Pallor2. Cold3. Sweaty4. Dizzy5. Nausea6. Loss of consciousness
Fainting or Syncope
Management:
1. Stop dental procedure2. Place patient in supine position with slight head down tilt or
elevate the legs (to increase cerebral circulation)Or
3. Place the hands of the patient behind his head and bend him forward until his head is in between the knee (to produce pressure on the splanchnic B.V to replace the blood that drained from the head
4. Reassure patient5. Aromatic spirit (ammonia) held under the nose of the patient
for several breath.
Muscle Trismus
Inability to normally open the mouth
Etiology:1. Injecting into muscles or ligaments2. Needle borne infection3. Contaminated/Irritating solutions4. Hematoma formation in the muscle
Muscle Trismus
Management:Depends on the cause
If its due to Trauma it necessitates slight muscle exercise and drug therapy to relieve pain if present
If due to Infection then it needs antibiotics.
1. Heat therapy2. Warm saline rinses3. Analgesics4. Muscle relaxant
Pain
Etiology:1. Injection into a muscle or ligament, parotid gland, TMJ2. Using a non-isotonic solution3. Very cold solution4. Contaminated solution5. Too rapid injection resulting in tissue distention6. Numerous needle punctures
Management:7. Assure the patient8. analgesics
Edema
It is usually a symptomEtiology:1. Trauma2. Infection3. Allergy4. Hemorrhage
Management:Depends on the cause
Infection
Etiology:1. Contaminated Non-sterile needles or solution2. Carrying surface bacteria from non-sterile mucous
membrane into the deeper structures with the tip of the needle are the causative factors
3. Injection into infected area
Management: Antibiotics Anti-Inflamatory drugs
Broken Needle
Do not use a needle of a too fine gauge
Do not use old or dull needle
Do not use short neeldle for nerve block
Do not attempt to force the needle against resistance
Do not change the direction of the needle while it is embedded in the tissues, always remove it and redirect it
Warn the patient against any movement during injection and ask him to stay still till you finish the injection
Do not surprise the patient with a sudden unexpected needle insertion
Do not insert the needle so far that it is out of sight in tissue
Needles should not be sterilized by flaming because the tamper of their alloy will be destroyed and they break easily
On most occasions accidental breakage takes place at the hub
This enables the operator to remove the broken needle by grasping the
portion remaining in view
Prolonged Anesthesia
Etiology: Contamination of the anesthetic solution with alcohol or
some other germicidal solution
Needle trauma to nerve tissue This is manifested at the time of injection, the patient
reports immediately feeling a hot sharp pain flushing to the terminal branches of the nerve trunk contacted
Trauma and swelling of the soft tissue in proximity to the nerve
Prolonged Anesthesia
Management:
Assure the patient It takes some time to disappear (8-12 weeks) Examine and map the patient Follow up and re-evaluate.
Hematoma and Ecchymosis
The effusion of blood into the tissues as a result of punctured B.V leading to hematoma formation
Common sites: Maxillary tuberosity region
Management: No attempt should be made to aspirate the contents of hematoma It will absorb with time usually within 7-14 days Ice packs may be applied initially to act as analgesic and a
vasoconstrictor to reduce size of hematoma Antibiotics can be prescribed in cases of large hematoma to
prevent secondary infection
Sloughing and Ulceration
Traumatic Ulcers: Appears on the palate from excessive amount of solution
injected into the dense mucoperiosteal tissue of the palate Chewing the lip following a mandibular injection Pinching of the lip between the forceps and the teeth Application of topical anesthetic may cause irritation to
M.M leading to sloughing and ulceration (epithelial desquamation)
Management: Usually resolves within a few days or one week without
any intervention.
Bizarre Neurological Symptoms
Very rare Facial paralysis Crossed eyes Muscular weakness Temporary blindness
The best method of preventing these complications is to follow closely the accepted
techniques described above
THANK YOU
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