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Complications of local anesthesia

  1. 1. Complications Of Local Anesthesia ELHAWARY
  2. 2. Complications Of Local Anesthesia In the name of Allah, Most Gracious, Most Merciful ‫ﺑ م ﷲ ر ن رﺣ م‬ ِ ‫ِﺳْ ِ ا ِ اﻟ ﱠﺣْﻣ ِ اﻟ ﱠ ِﻳ‬ ‫َﺎ َ ﱡ َﺎ اﻟﱠﺎ ُ ِﱠﺎ ﺧﻠﻘْ َﺎ ُﻢ‬ ‫ﯾ أﯾﮭ ﻨ س إﻧ ََ ﻨ ﻛ‬ O mankind! We created you from a single (pair) of a male and a COMPLICATIONS‫ﻠْﻨ‬OF‫ﻣﱢﻦ ذَﻛَﺮٍ وَأُﻧﺜَﻰ‬ ْ‫ َ َﻌ َﺎ ُﻢ‬LOCAL ‫وﺟ َ ﻛ‬ female, and made you into nations and tribes, that ye may ‫ﺷﻌ ﺎ وﻗﺒ ﺋﻞ ﻟﺘﻌ َﻓ ِن‬ ‫ُ ُﻮﺑ ً َ َ َﺎ ِ َ ِ َ َﺎر ُﻮا إ ﱠ‬ know each other (not that ye may ANESTHESIA‫أَﻛْﺮَﻣَﻜُﻢْ ﻋِﻨﺪَ اﻟﻠﱠ‬ despise (each other). Verily the ‫ﮫ أ ﻘ ﻛ ِن‬ ‫ِ َﺗْ َﺎ ُﻢْ إ ﱠ‬ most honoured of you in the sight ‫ﻠﮫ ﻋﻠ ﻢ ﺧﺒ ﺮ‬ ٌ ‫اﻟﱠ َ َِﯿ ٌ َ ِﯿ‬ of Allah is (he who is) the most righteous of you. And Allah has full knowledge and is well acquainted (with all things). Dr. Hesham El-Hawary [13 : ‫]اﻟﺤﺠﺮات‬ Al Hujurât 13 Lecturer OMFS Faculty of Oral & Dental Medicine Cairo University ELHAWARY
  3. 3. Complications Of Local Anesthesia Complications Of Local Anesthesia Dr. Hesham El-Hawary Ass. Professor Oral and Maxillofacial Surgery ELHAWARY
  4. 4. Complications Of Local Anesthesia Complications Any deviation from the normally expected pattern during or after securing local analgesia ELHAWARY
  5. 5. Complications Of Local Anesthesia Complications Any deviation from the normally expected pattern during or after securing local analgesia Classifications  Primary or Secondary  Mild or Sever  Transient or Permanent  Attributed to solution or needle insertion ELHAWARY
  6. 6. Complications Of Local Anesthesia Complications from local Anesthesia I. Complications associated to the absorption of the solution used II. Complications associated with needle insertion ELHAWARY
  7. 7. Complications Of Local Anesthesia Complications associated with absorption of the anesthetic solution 1. Systemic drug reactions due to the local anesthetic agent: 1. Toxicity 2. Allergy 3. Anaphylactic reactions 4. Idiosyncrasy 2. Local reactions: 1. Infections due to contaminated solutions 2. Local tissue irritation ELHAWARY
  8. 8. Complications Of Local Anesthesia Complications associated with needle insertion 1. Fainting and syncope 2. Muscle trismus 3. Pain 4. Edema 5. Infection 6. Broken needles 7. Prolonged anesthesia 8. Haematoma formation 9. Sloughing and ulceration 10. Bizarre Neurological symptoms ELHAWARY
  9. 9. Complications Of Local Anesthesia 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 ELHAWARY
  10. 10. Complications Of Local Anesthesia Keep in mind • Call medical emergency service • The patient position – 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 • Check the patient's cardiac and cardiovascular status • Start I.V. fluids (e.g. 5% dextrose in H2O) • Drugs according to the condition • If complete circulatory standstill – IV 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 ELHAWARY
  11. 11. Complications Of Local Anesthesia Complications due to absorption of the injected solution Systemic complications 1. Toxicity 2. Idiosyncrasy 3. Allergy 4. Anaphylaxis ELHAWARY
  12. 12. Complications Of Local Anesthesia • Definition • Etiology • Clinically (Signs & Symptoms) • Prevention • Treatment ELHAWARY
  13. 13. Complications Of Local Anesthesia Toxicity ELHAWARY
  14. 14. Complications Of Local Anesthesia Definition It refers to the symptoms manifested as a result of overdosage or excessive administration of the solution ELHAWARY
  15. 15. Complications Of Local Anesthesia Etiology • Large dose of drug • Accidental intravenous 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 ELHAWARY
  16. 16. Complications Of Local Anesthesia Clinically I. Early C.N.S. stimulation symptoms 1)Cerebral Cortex 2)Medulla 1. Talkative 1. Lethargy 2. Restlessness 2. Sleepiness 3. Apprehensive 3. Unconscious 4. Excited 5. Convulsive ELHAWARY
  17. 17. Complications Of Local Anesthesia Clinically II. Late C.N.S. Depression symptoms 3)Cerebral Cortex 4)Medulla 1. Increased blood 1. Dropped blood pressure pressure 2. Decreased pulse rate 2. Increase pulse rate 3. Decreased heart rate 3. Increase respiratory 4. Respiratory depression rate 5. unconsciousness 4. Nausea & vomiting ELHAWARY
  18. 18. Complications Of Local Anesthesia N.B. Death usually occur due to respiratory depression and hypoxia and its subsequent effect on the cardiovascular system ELHAWARY
  19. 19. Complications Of Local Anesthesia Prevention 1. Pre-analgesic evaluation of the patient 2. Use the weakest possible concentration 3. Use vasoconstrictor whenever possible 4. Use of the least possible volume 5. Aspirate before injection 6. Slow injection 7. Monitor the patient carefully after injection ELHAWARY
  20. 20. Complications Of Local Anesthesia Treatment • Mild Stimulation – No treatment – Stop further injection • Moderate stimulation • Convulsions phase • Depression phase ELHAWARY
  21. 21. Complications Of Local Anesthesia Treatment • Mild Stimulation • Moderate stimulation – IV injection of Barbiturates • 0.2% solution of sodium thiopental • Secobarbital (Seconal) – Oxygen inhalation • Convulsions phase • Depression phase ELHAWARY
  22. 22. Complications Of Local Anesthesia 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 ELHAWARY
  23. 23. Complications Of Local Anesthesia Treatment • Mild Stimulation • Moderate stimulation • Convulsions phase • Depression phase – Artificial Respiration – IV fluids – Sympathmemetic drugs ELHAWARY
  24. 24. Complications Of Local Anesthesia Vasoconstrictor Toxicity ELHAWARY
  25. 25. Complications Of Local Anesthesia • Definition • Etiology • Clinically – Palpitation – Tachycardia – Hypertension – Headache – Apprehension – Restlessness – N.B. Difficult to differentiate from those of L.A. Agent • Prevention and treatment ELHAWARY
  26. 26. Complications Of Local Anesthesia Idiosyncrasy ELHAWARY
  27. 27. Complications Of Local Anesthesia 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 ELHAWARY
  28. 28. Complications Of Local Anesthesia Etiology • Unknown • Enzymopathy – Congenital – Acquired • Psychogenic ELHAWARY
  29. 29. Complications Of Local Anesthesia Clinically 1. Pallor 2. Tachycardia 3. Hypotension 4. Decreased Heart rate 5. Collapse ELHAWARY
  30. 30. Complications Of Local Anesthesia Prevention 1. Do not use any drug, which the patient gives you a history of previous reactions to it 2. Inject slowly and observe the patient closely during injection ELHAWARY
  31. 31. Complications Of Local Anesthesia Prevention 1. Do not use any drug, which the patient gives you a history of previous reactions to it 2. Inject slowly and observe the patient closely during injection Treatment • The same as the depression stage of toxic overdose • Barbiturates are ineffective in the treatment or prevention of this condition ELHAWARY
  32. 32. Complications Of Local Anesthesia Allergy and Anaphylaxis ELHAWARY
  33. 33. Complications Of Local Anesthesia Definition • Allergy is a hypersensitive reaction that occurs through exposure to an antigen (Ag) such as a drug ( as L.A. agent) which the pt. has been previously exposed to it creating an Ag - Ab reaction • Anaphylaxis is a severe form of allergic reactions occurs suddenly & end fatally in which sudden violent loss of vasomotor tonus ELHAWARY
  34. 34. Complications Of Local Anesthesia Definition • Allergy is a hypersensitive reaction that occurs through exposure to an antigen (Ag) such as a drug ( as L.A. agent) which the pt. has been previously exposed to it creating an Ag - Ab reaction • Anaphylaxis is a severe form of allergic reactions occurs suddenly & end fatally in which sudden violent loss of vasomotor tonus ELHAWARY
  35. 35. Complications Of Local Anesthesia Clinically Allergy 1. Rashes 2. Urticaria 3. Fever 4. Dermatitis 5. Angioneurotic edema 6. Bronchial asthma 7. Anaphylaxis( anaphylactic shock) ELHAWARY
  36. 36. Complications Of Local Anesthesia Clinically Anaphylaxis 1. Drop in B.P. (↓B.P.) 2. Weak rapid pulse 3. Inadequate respiration (↓Respiratory rate) 4. Death ELHAWARY
  37. 37. Complications Of Local Anesthesia Management 1. Antihistaminic (benadryl 20 - 40 mg IV or IM.) 2. Epinephrine 1:1000 concentration 0.3 mg SC. or IM. 3. Bronchodilator via inhaler 4. Corticosteroid 100mg IV. hydrocortisone hemisuccinate ELHAWARY
  38. 38. Complications Of Local Anesthesia Complications due to absorption of the injected solution Local Reactions 1. Infection 2. Tissue irritation ELHAWARY
  39. 39. Complications Of Local Anesthesia Infection Infection from contaminated L.A. solutions 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 ELHAWARY
  40. 40. Complications Of Local Anesthesia Complications associated with needle insertion ELHAWARY
  41. 41. Complications Of Local Anesthesia Fainting or Syncope • It is due to temporary cerebral ischemia as a result of dilation of the splanchnic B.V. & reduced cardiac output • Signs &symptoms: 1. Pallor 2. Cold 3. Sweaty 4. Dizzy 5. Nausea 6. Loss of consciousness ELHAWARY
  42. 42. Complications Of Local Anesthesia  Management: • Stop dental procedure • Place pt. in supine position with slight head down or elevate the legs ( to ↑ cerebral circulation) or • Place the hands of the pt. 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 • Reassure pt. • Aromatic spirit (ammonia) held under the nose of the pt. for several breath ELHAWARY
  43. 43. Complications Of Local Anesthesia Muscle Trismus • Inability to open the mouth normally • Etiology: – Injecting into muscles or ligaments – Needle borne infection – Contaminated irritating solutions – Haematoma formation in the muscle • Prevention: ELHAWARY
  44. 44. Complications Of Local Anesthesia  Management: Depends upon the cause – If it is due to trauma it necessitates slight muscle exercise and drug therapy to relieve pain if present – If due to infection this needs antibiotics 1. Heat therapy 2. Warm saline rinses 3. Analgesics 4. Muscle relaxant ELHAWARY
  45. 45. Complications Of Local Anesthesia Pain • Etiology: – Injection into a muscle or ligament, parotid gland, T.M.J. – Using a non-isotonic solution – Very cold solutions – Contaminated solutions – Too rapid injection resulting in tissue distention – Numerous needle punctures • Prevention  Management: 1. Assure the pt. 2. Analgesics ELHAWARY
  46. 46. Complications Of Local Anesthesia Edema • It is usually a symptom • Etiology: – Trauma – Infection – Allergy – Hemorrhage • Treatment and prevention depends upon the cause ELHAWARY
  47. 47. Complications Of Local Anesthesia Infections • Etiology: – Contaminated Non-sterile needles or solutions – Carrying surface bacteria from non-sterile mucous membrane into the deeper structures with the tip of the needle are the causative factors – Injection into infected area • Prevention  Management: – Antibiotics – Antinflammatory drugs ELHAWARY
  48. 48. Complications Of Local Anesthesia Broken needles • Do not use old or dull needles • Do not use short needles 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 • Do not use a needle of a too fine gauge ELHAWARY
  49. 49. Complications Of Local Anesthesia • 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 tissues • Needles should not be sterilized by flaming because the tamper of their alloy will be destroyed and they break easily ELHAWARY
  50. 50. Complications Of Local Anesthesia 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 ELHAWARY
  51. 51. Complications Of Local Anesthesia 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  Management: 1. Assure the pt. 2. It takes some time to disappear ELHAWARY
  52. 52. Complications Of Local Anesthesia Haematoma and Ecchymosis • The effusion of blood into the tissues as a result of punctured B.V. leading to haematoma formation • Common sites: maxillary tuberosity region  Management: 1. No attempt should be made to aspirate the contents of the haematoma 2. It will absorb with time (7 – 14) days 3. Ice packs may be applied initially to act as analgesic & a vasoconstrictor to reduce size of haematoma ELHAWARY
  53. 53. Complications Of Local Anesthesia Sloughing and Ulceration • Traumatic ulcers – Appear 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. lead to sloughing & ulceration  Management: Usually resolves within a few days or one week without any intervention ELHAWARY
  54. 54. Complications Of Local Anesthesia 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 ELHAWARY
  55. 55. ‫‪Complications Of Local Anesthesia‬‬ ‫ﺑ ﻢ ﷲ ﺮ ﻦ ﺮﺣ ﻢ‬ ‫ِﺴْ ِ ا ِ اﻟ ﱠﺣْﻤ ِ اﻟ ﱠ ِﯿ ِ‬ ‫ﯾ أﯾﮭ ﻨ س إﻧ ﺧﻠ ﻨ ﻛ ﻣ ذﻛﺮ‬ ‫َﺎ َﱡ َﺎ اﻟ ﱠﺎ ُ ِ ﱠﺎ ََﻘْ َﺎ ُﻢ ﱢﻦ َ َ ٍ‬ ‫وﺟﻌ ﻨ ﻛ ﺷﻌ ﺎ وﻗﺒ ﺋﻞ‬ ‫َُﻧ َﻰ َ َ َﻠْ َﺎ ُﻢْ ُ ُﻮﺑً َ َ َﺎ ِ َ‬ ‫وأ ﺜ‬ ‫ِ َ َﺎ َ ُﻮا ِ ﱠ َﻛْ َ َ ُﻢْ ِﻨ َ اﻟﱠ ِ َﺗْ َﺎﻛﻢْ‬ ‫ﻟﺘﻌ رﻓ إن أ ﺮﻣﻜ ﻋ ﺪ ﻠﮫ أ ﻘ ُ‬ ‫إن ﻠﮫ ﻋﻠ ﻢ ﺧﺒ ﺮ‬ ‫ِ ﱠ اﻟﱠ َ َِﯿ ٌ َ ِﯿ ٌ‬ ‫]اﻟﺤﺠﺮات : 31[‬ ‫‪ELHAWARY‬‬
  56. 56. Complications Of Local Anesthesia Thank You Hesham El-Hawary www.elhawarydentalclinic.com ELHAWARY

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