Local Anesthesia and Regional Anesthetics

Mark E. Schroeder, MD
Associate Professor University of Wisconsin !"#!#
Local Anesthesia and Regional Anesthetics $%&ectives
1. Name the two chemical classes of local anesthetics.
2. Describe the metabolism of the ester local anesthetics and how the metabolic product relates to
their allergenic potential.
3. Give the advantages of amide local anesthetics.
4. Name an intermediate and a long acting local anesthetic and generally accepted dose limits for
each to avoid systemic toxicity.
. !ist the reasons epinephrine is added to local anesthetic solutions.
". Give the signs and symptoms of local anesthetic systemic toxicity.
#. Describe the e$uipment and supplies that should be available where nerve bloc%s are performed.
&. 'xplain why local anesthetics will not cause numbness if in(ected into an abscess
). *dentify the nerves that transmit pain sensation.
1+. Describe three different methods to identify a nerve location prior to a bloc%.
11. 'xplain how to perform an intravenous or ,ier bloc%.
12. -ompare and contrast spinal and epidural anesthesia in terms of anatomy. drug doses re$uired.
rapidity of onset.
13. Describe the symptoms. pathophysiology and treatment of a postdural puncture headache.
14. !ist absolute and relative contraindications to regional anesthesia.
/he first local anesthetic was cocaine. a naturally occurring substance. isolated from cocoa
leaves by a German chemist 01riedrich Gaedc%e2 in1&. *n 1&&4. 3arl 3oller. an 4ustrian. used this
substance to produce topical anesthesia of the eye. !ater that year. two 4mericans. 5alsted and 5all
administered cocaine to each other to produce neural bloc%ade. presumably of peripheral nerves.
-orning described spinal anesthesia in 1&&. but his meticulous description did not mention the
efflux of cerebral spinal fluid. *t is thought he performed an epidural anesthetic. *nterestingly. the
techni$ue for lumbar puncture was reported six years later by 6uinc%e. 7ne type of cutting8bevel spinal
needle is %nown to this day as a 96uinc%e9 needle.
/he first spinal anesthetic was performed in 1&)& and is generally attributed to 4ugust ,ier. a
German physician 01&"181)4)2. ,ier was the sub(ect. 5is graduate student placed the needle and -:1
poured out. *t was only then that they discovered that the syringe did not mate to the needle. /he
experiment preceded the universal use of standardi;ed needles and hubs with what we refer to as !uer
loc%s. !uer. a German instrument ma%er. died in 1&&3.
,ier suffered from one of the se$uelae of spinal anesthesia that we warn our patients of today.
the post dural puncture headache. *mpressively. he attributed the headache to the loss of -:1 and
advocated the use of small gauge needles. 1ollowing his recovery. ,ier performed the procedure on his
assistant. /hey were ecstatic. when after the in(ection of cocaine. the young
man<s legs became numb. /hey proceeded to celebrate with wine and cigars. /he insensibility of his
legs was demonstrated with repeated blows and %ic%s. 4s you can imagine. his recovery was
complicated both by a headache and very sore shins.
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4nother German chemist. 'inhorn produced the first synthesi;ed local anesthetic in 1)+4.
=rocaine 0Novocaine2 is the first in the class of 9ester9 local anesthetics and is short acting. 7ther esters
still in use in our operating rooms are the long8acting tetracaine and 28chloroprocaine 0Nesacaine2.
which is ultra short acting. 4ll of the ester local anesthetics are metaboli;ed in the plasma by the en;yme
commonly referred to as plasma pseudocholinesterase. >ou may recall this is the same en;yme that acts
on succinylcholine.
/he metabolic product of the degradation of procaine is para8aminoben;oic acid 0=4,42. which
was a common ingredient in topical sunscreens. ?odern sunscreens use alternate @A light bloc%ers and
are fre$uently advertised as 9=4,4 free9 because =4,4 provo%es an allergic reaction. Bhile allergy to
local anesthesia is not a ma(or problem. when it does occur. it is most often seen with the ester local
anesthetics because of this metabolite.
/he other chemical class of local anesthetics is the amides. /he most commonly recogni;ed drug
in this class. lidocaine 0Cylocaine2. was synthesi;ed in 1)43. /orsten Gordh. a :wedish anesthesiologist.
0who incidentally received his anesthesia training at the @niversity of Bisconsin under our first
chairman. Dalph ?. Baters. ?D2 introduced it into clinical practice. /he amides have several
advantages over the esters. /hey are far less li%ely to produce allergic reaction and they can undergo
repeated high temperature sterili;ation without losing potency. ?ost of the local anesthetics in common
use today belong to the amide class. /hese include. in addition to lidocaine. bupivacaine 0?arcaine or
:ensorcaine2. mepivacaine. etidocaine. prilocaine. and the most recent. ropivacaine.
*f you choose two local anesthetics to learn to use. * suggest the intermediate acting lidocaine
and the long acting bupivacaine. !idocaine is supplied in many formulations. for example. for topical
use in anointment. a water8soluble (ell and a 4E solution. as a E solution for spinal administration. and
for in(ection as +.E.1E. l.E and 2E solutions. *t is also widely available in a 1E multi8dose vial. and
pre8prepared with epinephrine. 4 word of cautionF the multi8dose vials contain a preservative.
methylparaben. which should not be given in a spinal or epidural anesthetic because of concerns about
neuro toxicity. *nterestingly. the metabolite of methylparaben is =4,4 and may be the real culprit in
many cases of lidocaine allergy. 4lso. there have been reports of cauda e$uina syndrome and mono8
radiculopathies due to spinally administered lidocaine. causing a drastic reduction in its use for this
purpose. !idocaine dose limits to avoid systemic toxicity with nerve bloc% or infiltration are mgG3g of
plain solution or #mgG3g if the solution contains epinephrine.
-ommercially available solutions of local anesthetic containing epinephrine are prepared at a
low p5 to prevent degradation of the epinephrine. /his has implications for the onset time of the drug.
as we will discuss later. ?ost anesthesiologists will prepare local anesthetics containing epinephrine at a
concentration of 1F2++.+++ or mcg of epinephrineGml (ust before use. /he addition of epinephrine to
local anesthetic solutions can serve several purposesF
1. prolongs the action of the local anesthetic
2. blunts systemic upta%e and thereby limits systemic toxicity
3. decreases bleeding at the site of in(ection
4. serves as a mar%er of intravascular in(ection
. improves the $uality of spinal bloc%ade. probably on the basis of spinal alpha receptors.
,upivacaine is a long8acting local anesthetic. *t has an interesting characteristic in that it tends to
cause a longer sensory bloc% than motor bloc%. /his ma%es it ideal for post8operative analgesia.
,upivacaine is available as +.2E. +.E and +.#E. /he higher concentrations will lead to increased
motor bloc%. ,upivacaine is highly tissue bound and its action is not prolonged by the addition of
epinephrine. *f it is in(ected systemically it may result in cardiac asystole. -=D should be carried on for
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a prolonged period in this situation. Decently the use of 2+E fat emulsion or HintralipidI during
resuscitation from bupivacaine toxicity has been demonstrated to improve outcome. /he general
recommendation for dose limits for bupivacaine is 2 mgG3g plain and 3 mgG3g with epinephrine.
:ystemic toxicity of local anesthetics will be seen after intravascular in(ection or systemic
absorption of drug used for a nerve bloc%. :ome nerve bloc% sites have higher rates of absorption than
others generally related to blood flow. :ites are generally ran%ed intercostalJepiduralJbrachial
plexusJspinal. /he signs of systemic toxicity are peri8oral numbness. metallic taste in the mouth.
tinnitus. di;;iness. respiratory depression. coma. sei;ure. cardiovascular system depression. /he
important thing about this list is to notice that cardiovascular depression occurs only at very high blood
concentrations. /hus. if the earlier symptoms occur. as% the patient to hyperventilate. provide oxygen.
prepare to secure the airway and treat a sei;ure. *f you prevent hypercarbia. hypoxia. and aspiration of
stomach contents. then it is li%ely the patient will weather the insult without se$uelae.
-onsider what e$uipment and supplies you would provide in a location where nerve bloc%s are
to be performed. -ertainly you would wantF oxygen and a way to deliver it. laryngoscope. endotrachial
tubes. ventilation bag and mas%. suctionK drugs to treat hypotension. bradycardia. sei;ure. anxiety. and
painK local anesthetics. monitors. *A starting e$uipmentK a bed that can be ad(usted into various
positionsK and an assistant.
Bith the case report detailing the use of 2+E fat emulsion as a rescue medication from
bupivacaine toxicity. we are now stoc%ing this substance in our 7D pharmacy and bloc% rooms.
4s a general rule. particularly when using a 9stationary needle techni$ue9 0i.e. when the local
anesthetic is in(ected at one site2 always aspirate before in(ecting and aspirate repeatedly during the
in(ection. usually every 3 to ml. 4n exception to this rule is if the amount of local anesthetic is well
below the level of systemic toxicity.
!ocal anesthetics are wea% bases with p3a in the range of #.). /his of course means that at a p5
of #.) in a population of local anesthetic molecules is e$ually divided between a charged and uncharged
state. *n order to %eep the local anesthetic molecules in solution. hydrogen ions are added 0i.e. the
solution is made acidic2 or said another way the p5 of the solution is lowered. *f the local anesthetic
solution is made with epinephrine. the p5 is made even lower.
!etLs turn our discussion now to a consideration of nerves. 4s most (unior high school students
%now. nerve membranes are a lipid bilayer with protein channels. !ocal anesthetics act in the sodium
channel. entering from the internal aspect. Now you may have noticed a bit of a problem. =ositively
charged local anesthetic molecules soluble in an a$ueous solution will have trouble passing through a
lipid membrane. /his problem is overcome when the tissue surrounding the nerve accepts 0or buffers2
the hydrogen ions and the uncharged molecules are then free to pass through the axonal membrane.
7nce in the cell. the molecule must be recharged before they can affect a bloc% of the sodium channel.
73. so whatM Bhat difference does this ma%e clinicallyM !ocal anesthetics will not wor% in
tissue that is unable to buffer the excess hydrogen ions. /his is why local anesthetics in(ected into the
acidic environment of an abscess will not cause numbness. 7ccasionally anesthesiologists will add
Na5-73 to a local anesthetic to speed the onset of the drug effect. 5owever. this additive is not a
powerful enough base to overcome the acidity in abscessed tissue.
Nerves are classified in several ways. /here are motor. sensory and autonomic nerves. Nerves
are myelinated and unmyelinated. 4 common system categori;es nerves into 4. ,. and - with 4 further
divided into alpha. beta. gamma and delta. 7nly the - fibers are unmyelinated. 48delta and - fibers
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carry pain sensation. 48delta fibers. being myelinated. conduct at a very rapid rate and carry 9first pain9
or discriminative pain. - fibers are slower and carry Hsecond painI which is dull. aching and boring in
nature. !ocal anesthetics will act all along - fibers. but only at the brea%s in the myelin or the Nodes of
Danvier 01rench pathologist. 1&381)222 on the 48delta fibers. /ypically. three or more Nodes of
Danvier must be bloc%ed to stop transmission along the nerve.
Nerves may be bloc%ed wherever they can be found. -ertainly. there are some locations where it
may be unwise to attempt a bloc%. 'xamples of this are bony or fascial tunnels where the pressure of the
in(ected solution may cause pressure related nerve damage. /extboo%s describe nerve bloc%s in relation
to anatomic landmar%s. /hus. for example the median nerve may be bloc%ed at the wrist or elbow. *f
you are able to locate the median nerve in the forearm. it could be bloc%ed there.
:trategies to find nerves include loo%ing for the accompanying artery. see%ing a paresthesia
0recall the old saying. 9No paresthesia. No 4nesthesia92. using an 9electric nerve stimulator.9 or actually
visuali;ing the nerves and surrounding structures with an ultrasound. /he electric nerve stimulator is a
device that gives a short pulse of electrical current and is attached to an insulated needle and a grounding
pad on the patient. 4s a mixed function or motor nerve is approached with the needle the nerve will be
stimulated and a muscle twitch will result. /he closer the needle is to the nerve. the less current it ta%es
to cause a bris% muscle twitch. Generally. * start see%ing the nerve with a current of 2 m4 and in(ect
when * am able to dial down to +. m4. /witches at very low current may indicate the needle is resting
inside the nerve bundle. *n(ection in that position will be very painful. may result in nerve damage and
should be avoided.
@ltrasound guidance for nerve bloc%s is the most recently introduced techni$ue. 1re$uently
nerves will travel with veins and arteries. between fascial planes or muscle bundles. /hese anatomic
landmar%s help to indentify the nerve structure. Nerves may be hyper8echoic and are sometimes
described as Hgrape8li%eI when seen with ultrasound. -ombining ultrasound and the electric nerve
stimulator is helpful when a suspected nerve on ultrasound causes a HtwitchI with the stimulator.
/he simplest sort of local anesthetic bloc% is infiltration or field bloc%. :pecific nerves are not
sought. the local anesthetic is (ust in(ected into the s%in and tissue where the painful procedure will be
done. =lacing a s%in wheal prior to starting an *A is an example of this sort of infiltration.
=eripheral nerve bloc%s see% to bloc% individual nerves and include. for exampleF median. ulnar
and radial nerves at the wrist or elbowK the superficial and deep peroneal. saphenous. sural and tibial
nerves at the an%leK or even the intercostals nerves. 1re$uently the anesthesiologist would li%e to bloc%
the entire arm or a large portion of the leg with a single in(ection or an in(ection at a single site. *n this
situation a plexus bloc% is ideal. 4 single in(ection of local anesthetic onto the brachial plexus will result
in a bloc% of arm tissue innervated by several peripheral nerves. :everal approaches to the brachial
plexus have been describedF the axillary. infraclavicular. supraclavicular. and intrascalene approaches
each have advantages in certain situations.
4nother way to bloc% an extremity is the *ntravenous ,loc% first described by 4ugust ,ier. 4n
*A is inserted into a distal vein in the extremity and capped. 4 wide rubber band 0'smarch bandage.
'smarch 1&2381)+& was a friend of ,ier2 is tightly spirally8wrapped starting distally and wor%ing
proximally to exsanguinate the limb. 4 pneumatic tourni$uet is inflated to prevent arterial inflow to the
extremity and the 'smarch is removed. 1ifty to "+ ml of lidocaine +.E is in(ected through the distal *A
and held in the arm or leg by the tourni$uet. /he tourni$uet may remain inflated for up to two hours. but
the ischemic pain beneath the tourni$uet ma%es this a better techni$ue for shorter cases. 4t the end of
the case the tourni$uet is dropped and re8inflated repeatedly over several minutes to gradually wash out
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the local anesthetic and lessen the ris% of systemic toxicity. /he bloc% resolves within minutes of
releasing the tourni$uet.
Neuraxial nerve bloc%s include spinal. epidural and caudal bloc%s. 4 spinal is more precisely
called a subarachnoid bloc% 0:4,2. /he local anesthetic is in(ected into the cerebral spinal fluid 0-:12.
4s the nerves are unprotected hereK a very small amount of anesthetic will cause the rapid onset of a
dense bloc%. /he in(ectate may be hyperbaric. hypobaric or isobaric relative to -:1. ,y having a
different baricity from -:1. the anesthetic solution spread and the extent of the bloc% may be controlled
by positioning the patient. :pinal anesthesia is widely thought by non8anesthesiologists to be a safer
form of anesthesia for ill patients. /his is probably because patients don<t necessarily have to be
intubated or Hput to sleep9 when under spinal anesthesia. *n reality. the physiologic changes due to
bloc%ade of sympathetic fibers and the resultant decreased afterload. hypotension. bradycardia. and
respiratory depression 0depending on spinal segments bloc%ed2 may be more of a ris% and less
controllable than a well8monitored general anesthetic. Note that respiratory depression during a spinal
bloc% most often follows hypotension with resulting ischemia of the brain stem respiratory centers and is
rarely if ever due to paralysis of the spinal roots supplying the phrenic nerve 0-382.
?any patients worry about bac% pain. paralysis or other nerve damage. and infection following
:4,. ,ac% pain is about as common after a general anesthetic as a spinal. *t is probably due to stretch
on the ligaments in the bac% with flattening of the lumbar curve against the 7D table. Nerve damage and
infection occur very rarely. /he most common adverse se$uelae following spinal anesthesia is a post8
dural puncture headache 0=D=542. /his is related to low -:1 pressure due to lea% of the fluid from the
puncture hole in the dura made with the spinal needle. 4 very powerful diagnostic feature of the
headache is its positional nature. *t is worse when the patient is sitting or standing and better when the
patient is lying flat. =atients in the second and third decade and larger needles with cutting bevels are
associated with a higher incidence of =D=54. 7ur standard is to use 2 gauge pencil point 0Bhitacre2
needle with a reported headache incidence of less than 1E in the high8ris% age group. =D=54 is treated
with recumbency. hydration. caffeine. or more aggressively with an epidural blood patch of the lea%ing
dural hole.
4 needle headed for the epidural space ta%es a similar path to a spinal needle. but is stopped
before piercing the dura. /his is usually accomplished by using the loss of resistance techni$ue. 4 needle
is placed into the rather dense interspinous ligament between two spinous processes. /hen a syringe
containing saline or air 0saline is preferred2 is attached to the hub of the needle and an attempt to in(ect is
made. Desistance is noted. /he needle is advanced with repeated testing of resistance to in(ection. 4s
the bevel passes into the ligamentum flavum increased resistance may be noted. 7ften a pop is felt or
heard as the needle is advanced through the ligamentum flavum and then there is a loss of resistance to
in(ection. *f the needle is advanced too far. the dura will be punctured and -:1 will pour out when the
syringe is removed. 4 /uohy 02+th century 4merican anesthesiologist2 needle is most commonly used
for epidural anesthesia. *t has a curved bevel that will direct a catheter threaded through it into the
epidural space. *f a /uohy needle punctures the dura. both its large gauge and bevel design will result in
a large hole and a high ris% 0#+E2 of =D=54. *n well trained hands the ris% is between +.1 to 1 E or
less.
-audal bloc%s are an approach to the epidural space through the sacrococcygeal ligament. (ust
above the coccyx. -audal bloc%s are useful for perineal operations and may be used in children to thread
a catheter up the epidural space to thoracic levels.
'pidural anesthesia re$uires about ten times the dose of local anesthetic to achieve a bloc% as
compared to a spinal. /his raises the potential for systemic toxicity. /he bloc%s setup more slowly than
spinal bloc%s. /his is maddening if you are trying to get a case underway. but is good in terms of
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controlling blood pressure with fluid resuscitation. *t is far more common to perform a continuous
epidural bloc% by placing a catheter than a continuous spinal. 4 continuous epidural allows prolonged
operative anesthesia 0generally with *A sedation or as an 9over8under techni$ue9 with light general
anesthesia2 or postoperative epidural analgesia using dilute local anesthetics and opiates. 'pidurals are a
fre$uent method of labor analgesia for pregnant women because they produce good analgesia with little
neuropsychiatric depression of the newborn as compared to *A opioid analgesics. /here is an ongoing
debate as to the effect of epidural labor analgesia on the progress of labor and the incidence of forceps
delivery.
Not all patients are appropriate for regional anesthesia. /hose who refuse or have an infection at
the in(ection site are considered to have absolute contraindications. /he re$uirements are eyen more
stringent for neuraxial bloc%ade. -oagulopathy whether therapeutic or part of the patient<s pathology and
increased l-= are added to the list of generally accepted absolute contraindications when epidural or
spinal is considered. Delative contraindications include sepsis. hypovolemia. neurologic disease.
psychological instability. antiplatelet drugs. prolonged surgery. certain cardiac diseases 0idiopathic
hypertrophic subaortic stenosis. aortic stenosis2. and an uncooperative patient or surgeon.
Degional anesthesia is undergoing a renaissance. /his is fueled by exciting new concepts in pre8
emptive analgesia. which promise to decrease the post8operative pain experience and inhibit actual
physical changes in the spinal cord due to pain. New drugs and ad(uvant analgesics and a growing
%nowledge about how to use them will allow us to tailor our anesthetic approaches to specific patients.
4natomy is an old science. but surprisingly. new approaches to nerve bloc%s continue to be described.
/he recurrent challenge is to help an individual patient do better than they expected. to allay their
anxiety and to have less pain.
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