Systemic Complications Of Local Anesthesia 

1. Systemic ComplicationsSystemic Complications
Of Local AnesthesiaOf Local Anesthesia
By :- Ahmed Amer Ibraheem
Under the supervision of Dr. Emad Hamoody
Abdulla
Tikrit university
Collage of dentistry

2. ComplicationsComplications
 ComplicationsComplications :- Any deviation from the:- Any deviation from the
normally expectednormally expected pattern during or afterpattern during or after
securing localsecuring local analgesia analgesia

3. ClassificationsClassifications
 Primary or SecondaryPrimary or Secondary
 Mild or SeverMild or Sever
 Transient or PermanentTransient or Permanent
 Attributed to solution or needle insertionAttributed to solution or needle insertion

4. Complications from localComplications from local
AnesthesiaAnesthesia
 I. Complications associated to theI. Complications associated to the
absorption of the solution usedabsorption of the solution used
 II. Complications associated with needleII. Complications associated with needle
insertioninsertion

5. Complications associated withComplications associated with
absorption of the anestheticabsorption of the anesthetic
solutionsolution
1 Systemic reactions due to the local anesthetic1 Systemic reactions due to the local anesthetic
agent:agent:
1. Toxicity1. Toxicity
2. Allergy2. Allergy
3. Anaphylactic reactions3. Anaphylactic reactions
4. Idiosyncrasy4. Idiosyncrasy
5. syncope and fainting5. syncope and fainting
6. pregnancy6. pregnancy
7. Hypertension7. Hypertension
2. Local reactions:2. Local reactions:
11 ..Infections due to contaminated solutionsInfections due to contaminated solutions
2. Local tissue irritation 2. Local tissue irritation

6. Complications associated withComplications associated with
needle insertionneedle insertion
( local complication )( local complication )
1. Fainting and syncope1. Fainting and syncope
2. Muscle trismus2. Muscle trismus
3. Pain3. Pain
4. Edema4. Edema
5. Infection5. Infection
6. Broken needles6. Broken needles
7. Prolonged anesthesia7. Prolonged anesthesia
8. Haematoma formation8. Haematoma formation
9. Sloughing and ulceration9. Sloughing and ulceration
10. Bizarre Neurological symptoms10. Bizarre Neurological symptoms

7. Keep in mindKeep in mind
A: Airway » Clear » Adequate RespirationA: Airway » Clear » Adequate Respiration
B: Bleeding » Stopped » Achieve inlet toB: Bleeding » Stopped » Achieve inlet to
vesselsvessels
C: Circulation » Fluids if neededC: Circulation » Fluids if needed
D: Drugs to treat the present condition D: Drugs to treat the present condition

8. Keep in mindKeep in mind
•• Call medical emergency serviceCall medical emergency service••
The patient position – Placed in horizontal position on hisThe patient position – Placed in horizontal position on his
back – Tilt the patient in a slightly head down position orback – Tilt the patient in a slightly head down position or
– elevate the legs to help increase cerebral circulation– elevate the legs to help increase cerebral circulation
•• Adequate oxygenationAdequate oxygenation••
Check the patients cardiac and cardiovascular status•Check the patients cardiac and cardiovascular status•
Start I.V. fluids (e.g. 5% dextrose in H2O)•Start I.V. fluids (e.g. 5% dextrose in H2O)•
Drugs according to the condition•Drugs according to the condition•
If complete circulatory standstill – IV injection of atropine –If complete circulatory standstill – IV injection of atropine –
Stimulation of the heart by introducing a needle directlyStimulation of the heart by introducing a needle directly
into it – Intracardiac injection of epinephrine 0.1 ml ofinto it – Intracardiac injection of epinephrine 0.1 ml of
1.1000 solution 1.1000 solution

10. Complications due to absorption ofComplications due to absorption of
the injected solutionthe injected solution
– Systemic complicationsSystemic complications
 1. Toxicity1. Toxicity
 2. Idiosyncrasy2. Idiosyncrasy
 3. Allergy3. Allergy
 4. Anaphylaxis4. Anaphylaxis
 5. syncope and fainting5. syncope and fainting
 6. pregnancy6. pregnancy
 7. Hypertension7. Hypertension

11. DefinitionDefinition
•• EtiologyEtiology
•• Clinically (Signs & Symptoms)Clinically (Signs & Symptoms)
•• PreventionPrevention
•• TreatmentTreatment

12. ToxicityToxicity
 Definition It refers to the symptomsDefinition It refers to the symptoms
manifested as a result of over dosage ormanifested as a result of over dosage or
excessive administration of the solution excessive administration of the solution

13. EtiologyEtiology
•• Large dose of drugLarge dose of drug
•• Accidental intravenous injectionAccidental intravenous injection
•• High concentration of a drugHigh concentration of a drug
•• Unusually slow detoxification as a result ofUnusually slow detoxification as a result of
severe liver diseasesevere liver disease
•• Slow elimination as a result of kidney troubleSlow elimination as a result of kidney trouble
•• Use of highly toxic drugs whose margin of safetyUse of highly toxic drugs whose margin of safety
is narrowis narrow
•• Injection of solution in highly vascular areaInjection of solution in highly vascular area
without the addition of vasoconstrictorwithout the addition of vasoconstrictor
substance substance

14. ClinicallyClinically
I. Early C.N.S. stimulation symptomsI. Early C.N.S. stimulation symptoms
(1)Cerebral Cortex (2)Medulla(1)Cerebral Cortex (2)Medulla
1. Talkative 1. Lethargy1. Talkative 1. Lethargy
2. Restlessness 2. Sleepiness2. Restlessness 2. Sleepiness
3. Apprehensive 3. Unconscious3. Apprehensive 3. Unconscious
4. Excited4. Excited
5. Convulsive 5. Convulsive

15. II. Late C.N.S. Depression symptomsII. Late C.N.S. Depression symptoms
(3)Cerebral Cortex (4)Medulla(3)Cerebral Cortex (4)Medulla
1. Increased blood 1.1. Increased blood 1. Dropped bloodDropped blood
pressure pressurepressure pressure
2. Increase pulse rate 2. Decreased pulse rate2. Increase pulse rate 2. Decreased pulse rate
3. Increase respiratory rate 3. decrease heart rate3. Increase respiratory rate 3. decrease heart rate
4 Nausea & vomiting 4. Respiratory4 Nausea & vomiting 4. Respiratory
depressiondepression
5. Unconsciousness5. Unconsciousness

16. N.B. Death usually occur due to respiratoryN.B. Death usually occur due to respiratory
depression and hypoxia and itsdepression and hypoxia and its
subsequent effect on the cardiovascularsubsequent effect on the cardiovascular
system system

17. PreventionPrevention
1. Pre-analgesic evaluation of the patient1. Pre-analgesic evaluation of the patient
2. Use the weakest possible concentration2. Use the weakest possible concentration
3. Use vasoconstrictor whenever possible3. Use vasoconstrictor whenever possible
4. Use of the least possible volume4. Use of the least possible volume
5. Aspirate before injection5. Aspirate before injection
6. Slow injection6. Slow injection
7. Monitor the patient carefully after injection 7. Monitor the patient carefully after injection

18. TreatmentTreatment
•• Mild StimulationMild Stimulation
–– No treatmentNo treatment
–– Stop further injectionStop further injection
•• Moderate stimulationModerate stimulation
•• Convulsions phaseConvulsions phase
•• Depression phaseDepression phase

19. TreatmentTreatment
•• Mild StimulationMild Stimulation
•• Moderate stimulationModerate stimulation
–– IV injection of BarbituratesIV injection of Barbiturates
•• 0.2% solution of sodium thiopental0.2% solution of sodium thiopental
•• Secobarbital (Seconal)Secobarbital (Seconal)
–– Oxygen inhalationOxygen inhalation
•• Convulsions phaseConvulsions phase
•• Depression phaseDepression phase

20. TreatmentTreatment
•• Mild StimulationMild Stimulation
•• Moderate stimulationModerate stimulation
•• Convulsions phaseConvulsions phase
–– Anticonvulsent IV / IMAnticonvulsent IV / IM
•• Coramine (150-450 mg. I.V.)Coramine (150-450 mg. I.V.)
•• Metrazol (100 mg I.V.) (Midazolam or Diazepam)Metrazol (100 mg I.V.) (Midazolam or Diazepam)
•• Wyamine (7.5 mg I.V. or 15 mg I.M.) or neosynephrineWyamine (7.5 mg I.V. or 15 mg I.M.) or neosynephrine
–– Oxygen inhalationOxygen inhalation
•• Depression Depression

21. TreatmentTreatment
•• Mild StimulationMild Stimulation
•• Moderate stimulationModerate stimulation
•• Convulsions phaseConvulsions phase
•• Depression phaseDepression phase
–– Artificial RespirationArtificial Respiration
–– IV fluidsIV fluids
–– Sympathmemetic drugsSympathmemetic drugs

22.  Vasoconstrictor ToxicityVasoconstrictor Toxicity
DefinitionDefinition
EtiologyEtiology
ClinicallyClinically
–– PalpitationPalpitation
–– TachycardiaTachycardia
–– HypertensionHypertension
–– HeadacheHeadache
–– ApprehensionApprehension
–– RestlessnessRestlessness
–– N.B. Difficult to differentiate from those of L.A. AgentN.B. Difficult to differentiate from those of L.A. Agent
•• Prevention and treatmentPrevention and treatment

23. IdiosyncrasyIdiosyncrasy
DefinitionDefinition
•• Abnormal reaction to a drug or group of drugsAbnormal reaction to a drug or group of drugs
exhibited when only a small amount or aexhibited when only a small amount or a
nontoxic dose of the drug has been usednontoxic dose of the drug has been used
•• This means that the susceptible patient reactsThis means that the susceptible patient reacts
adversely to a volume or concentration of theadversely to a volume or concentration of the
drug that would not affect the typical patientdrug that would not affect the typical patient
•• Nontoxic – Non Allergic condition Nontoxic – Non Allergic condition

24. EtiologyEtiology
•• UnknownUnknown
•• EnzymopathyEnzymopathy
–– CongenitalCongenital
–– AcquiredAcquired
•• PsychogenicPsychogenic

25. ClinicallyClinically
1. Pallor1. Pallor
2. Tachycardia2. Tachycardia
3. Hypotension3. Hypotension
4. Decreased Heart rate4. Decreased Heart rate
5. Collapse5. Collapse

26. PreventionPrevention
1. Do not use any drug, which the patient1. Do not use any drug, which the patient
gives you a history of previousgives you a history of previous
reactions to itreactions to it
2. Inject slowly and observe the patient2. Inject slowly and observe the patient
closely during injectionclosely during injection
TreatmentTreatment
•• The same as the depression stage ofThe same as the depression stage of
toxic overdose• Barbiturates aretoxic overdose• Barbiturates are
ineffective in the treatment orineffective in the treatment or
prevention of this conditionprevention of this condition

27. Allergy and AnaphylaxisAllergy and Anaphylaxis
DefinitionDefinition
•• Allergy is a hypersensitive reaction that occursAllergy is a hypersensitive reaction that occurs
through exposure to an antigen (Ag) such as athrough exposure to an antigen (Ag) such as a
drug ( as L.A. agent) which the pt. has beendrug ( as L.A. agent) which the pt. has been
previously exposed to it creating an Ag - Abpreviously exposed to it creating an Ag - Ab
reactionreaction
•• Anaphylaxis is a severe form of allergic reactionsAnaphylaxis is a severe form of allergic reactions
occurs suddenly & end fatally in which suddenoccurs suddenly & end fatally in which sudden
violent loss of vasomotor tonusviolent loss of vasomotor tonus

28. ClinicallyClinically
AllergyAllergy
1. Rashes1. Rashes
2. Urticaria2. Urticaria
3. Fever3. Fever
4. Dermatitis4. Dermatitis
5. Angioneurotic edema5. Angioneurotic edema
6. Bronchial asthma6. Bronchial asthma
7. Anaphylaxis( anaphylactic shock)7. Anaphylaxis( anaphylactic shock)

29. Angioedema

30. Urticaria (hives)

31. Clinically AnaphylaxisClinically Anaphylaxis
1. Drop in B.P. (↓B.P.)1. Drop in B.P. (↓B.P.)
2. Weak rapid pulse2. Weak rapid pulse
3. Inadequate respiration (↓Respiratory rate)3. Inadequate respiration (↓Respiratory rate)
4. Death4. Death

32. ManagementManagement
1. Antihistaminic (benadryl 20 - 40 mg IV or1. Antihistaminic (benadryl 20 - 40 mg IV or
IM.)IM.)
2. Epinephrine 1:1000 concentration 0.3 mg2. Epinephrine 1:1000 concentration 0.3 mg
SC. or IM.SC. or IM.
3. Bronchodilator via inhaler3. Bronchodilator via inhaler
4. Corticosteroid 100mg IV. hydrocortisone4. Corticosteroid 100mg IV. hydrocortisone
hemisuccinatehemisuccinate

33. Fainting or SyncopeFainting or Syncope
•• It is due to temporary cerebral ischemia as aIt is due to temporary cerebral ischemia as a
result of dilation of the splanchnic B.V. &result of dilation of the splanchnic B.V. &
reduced cardiac outputreduced cardiac output
•• Signs &symptoms:Signs &symptoms:
1. Pallor1. Pallor
2. Cold2. Cold
3. Sweaty3. Sweaty
4. Dizzy4. Dizzy
5. Nausea5. Nausea
6. Loss of consciousness6. Loss of consciousness

34. ManagementManagement
•• Stop dental procedureStop dental procedure
•• Place pt. in supine position with slight head down orPlace pt. in supine position with slight head down or
elevate the legs ( to ↑ cerebral circulation)elevate the legs ( to ↑ cerebral circulation)
oror
•• Place the hands of the pt. behind his head and bend himPlace the hands of the pt. behind his head and bend him
forward until his head is in between the knee( to produceforward until his head is in between the knee( to produce
pressure on the splanchnic B.V. to replace the blood thatpressure on the splanchnic B.V. to replace the blood that
drained from the headdrained from the head
•• Reassure pt.Reassure pt.
•• Aromatic spirit (ammonia) held under the nose of the pt.Aromatic spirit (ammonia) held under the nose of the pt.
for several breath for several breath

35. PregnancyPregnancy
 Anesthesia crosses the placenta and could beAnesthesia crosses the placenta and could be
toxic to the fetus, but is not a knowntoxic to the fetus, but is not a known teratogenteratogen
 No drug should be administered duringNo drug should be administered during
pregnancy especially thepregnancy especially the firstfirst trimestertrimester
 If treatment is necessary, local anesthetics withIf treatment is necessary, local anesthetics with
epinephrineepinephrine are considered relatively safe forare considered relatively safe for
use during pregnancy; check with patient’suse during pregnancy; check with patient’s
physicianphysician
 Educate patients to the potentialEducate patients to the potential risksrisks
(document)(document)

36. HypertensionHypertension
 StressStress andand anxietyanxiety maymay
raise the patient’sraise the patient’s
blood pressure (>160/100)blood pressure (>160/100)
 ThoroughThorough medicalmedical,, dentaldental andand patientpatient historyhistory
 Norepinephrine and levonordefrin should not be usedNorepinephrine and levonordefrin should not be used
because ofbecause of alphaalpha11 stimulationstimulation
(2% Mepivacaine with 1:20,000 levonordefrin)(2% Mepivacaine with 1:20,000 levonordefrin)
 Up toUp to twotwo cartridges of 2% lidocaine with 1:100,000cartridges of 2% lidocaine with 1:100,000
epinephrine is safeepinephrine is safe

37. Contraindication for LocalContraindication for Local
Anesthetic with EpinephrineAnesthetic with Epinephrine
 UncontrolledUncontrolled hypertensionhypertension
 Myocardial infarction (withinMyocardial infarction (within 66 months)months)
 UnstableUnstable anginaangina
 Coronary artery bypassCoronary artery bypass graftgraft (> 3 months(> 3 months))

39. ReferenceReference
 www.elhawarydentalclinic.comwww.elhawarydentalclinic.com
 Complications of local anesthesiaComplications of local anesthesia
byby Umm Al-Umm Al-QuraQura
University Faculty of DentistryUniversity Faculty of Dentistry onon FebFeb
25, 201225, 2012