Safe Use of Local Anaesthetics - GP CME South/Sat_Room3_1100_Seigne...What you need to know about...
Transcript of Safe Use of Local Anaesthetics - GP CME South/Sat_Room3_1100_Seigne...What you need to know about...
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What you need to know about the safe use of
Local Anaesthesia
Richard Seigne
Anaesthetist
CDHB
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Disclosures
None
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What you need to know about the safe use of Local Anaesthesia
They’re safe
…..when left in the ampoule in a cupboard
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History & Background
Cocaine 1884 – eye drops, toxicity, deaths
Procaine 1904 - anaphylaxis
Lignocaine – 1943 amide
Coca leaves - Peru
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History & Background
Bupivacaine – 1963, late ‘70s early 80’s reports of deaths
Ropivacaine – 1996, less cardiotoxic
Procaine – late 1950s, low toxicity, low potency
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“Problems with Local Anaesthesia”
Toxicity
Intra-neural injection
Oral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
Adrenaline
Anaphylaxis
Faint
Pain on injection
Errors
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Acidic
Weak base
More acidic environment
Mechanism of action and pharmacokinetics
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“Problems with Local Anaesthesia”
Toxicity -
Intra-neural injectionOral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
AdrenalineAnaphylaxis – very rare
Faint
Pain on injection
very rare especially with local infiltration
Errors
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Faint
Adrenaline effect
LA toxicity
Toxicity - differentials
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Recognition – not following best practice
symptoms - communication
Toxicity
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Behavioural change, feeling odd, light headed, tinnitus, visual changes - communication
CNS – excitation then depression (fitting then coma)
CVS – excitation then depression, VF (acidosis)
Toxicity
Tingling lips, tongue (paraesthesia) - communication
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Toxicity – too much drug in blood
Plasma concentration –
Accidental direct IV or IA injection
Absorption from tissue
drug dose
proximity of vessels
number of vessels
vasoconstrictors
mass of tissue – patient weight
AspirationSpeed of injectionFractionation
concentrationvolume
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Blood factors - (protein binding)
acidosis, hypoxia
Plasma clearance – liver
Drug pharmacokinetics and pharmacodynamics
Toxicity – too much drug in blood
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Stop injecting, get help
ABC & CPR - prolonged
Toxicity management
Intra-lipid
Lie patient down, legs up
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70kg adult - 500ml Intralipid 20% + 50ml syringe
– Draw up 50ml IV - X2 stat
– Rest of Intralipid IV with giving set over 15 minutes
– Repeat initial bolus up to twice more – if spontaneous circulation has not returned
+ CPR
Toxicity management
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Drug dosing
Drug “Max” Dose (with adrenaline) Potency
Lignocaine (Lidocaine) 3mg/kg (7mg/kg) 0.25
Bupivacaine (Marcaine) 2mg/kg (2.5mg/kg) 1
Ropivacaine (Naropin) 3-4mg/kg 0.6
Prilocaine (Citanest) 6mg/kg (9mg/kg) 0.25
NB Doses of different drugs are additive
1% = 10mg/ml – move decimal point to right
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“Problems with Local Anaesthesia”
Toxicity
Intra-neural injectionOral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
AdrenalineAnaphylaxis
Faint
Pain on injectionErrors
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“Problems with Local Anaesthesia”
Toxicity
Intra-neural injectionOral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
AdrenalineAnaphylaxis
Faint
Pain on injectionErrors
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“Problems with Local Anaesthesia”
Toxicity
Intra-neural injection
Oral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
Adrenaline
Anaphylaxis
Faint
Pain on injection
Errors
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Methaemoglobinaemia
Prilocaine
> 600mg – 0.5% - 120ml1% - 60ml2% - 30ml
Cyanosis, O2 sats falsely high initially
Usually resolves in 2 hours, methylene blue 1mg/kg over 5 min
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“Problems with Local Anaesthesia”
Toxicity
Intra-neural injection
Oral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
Adrenaline
Anaphylaxis
Faint
Pain on injection
Errors
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Intra-neural injection
Anatomy
Pain on injecting
Difficulty in injecting
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“Problems with Local Anaesthesia”
Toxicity
Intra-neural injection
Oral use - loss of airway reflexes
Accidental injury
MethaemoglobinaemiaAnaphylaxis
Faint
Pain on injection
Errors
Adrenaline
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Acidic solution
+ AlkaliNaHCO3
More acidic environment
Mechanism of action and pharmacokinetics
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“Problems with Local Anaesthesia”
Toxicity -
Intra-neural injection
Oral use - loss of airway reflexes
Accidental injury
Methaemoglobinaemia
Adrenaline
Anaphylaxis – very rare
Faint
Pain on injection
Errors
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Additives
Drawing up
Labelling
Errors
Gloves and sharps
Aspiration
Incremental injection
Communication
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Distractions
Drawing up
Routine
Errors
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Additives
Drawing up
Labelling
Errors
Gloves and sharps
Aspiration
Incremental injection
Communication
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Additives
Drawing up
Labelling
Errors
Gloves and sharps
Aspiration
Incremental injection
Communication
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Additives
Drawing up
Labelling
Errors
Gloves and sharps
Aspiration
Incremental injection
Communication
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Local Anaesthetics reborn
Wound catheters
Local Infiltration Analgesia (LIA)
IV lignocaine infusions
Catheter (wound)
Reservoir – elastomeric ball
Liposomal delivery
(EMLA/AMITOP)
Ultrasound
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Summary
Infiltrative local anaesthesia generally very safe
Follow common sense rules – drug preparation and administration
Regional anaesthesia requires more expertise, CPR equipment
Bigger dose – bigger risk
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