TOTAL RESISTANCE TO LOCAL ANESTHESIA: A CASE REPORT

Dr Venkata Ramana Murthy, MDS

Assistant professor, Maxillofacial Surgery
NRI Institute of Medical Sciences
Sangivalasa, Bheemunipatnma, Visakhapatnam-531162, A.P., India
murthymaxfac@gmail.com
Dr K C Sekhar, M.D., Assistant Professor
NRI Institute of Medical Sciences
Sangivalasa, Bheemunipatnam, Visakhapatnam-531162, A.P. India
globeshaker@gmail.com

KEY WORDS

Local anesthesia, resistance

ABSTRACT

Local anesthesia is the most commonly used technique for most dental procedures in our
country. We report a case of a 32 year old female who demonstrated total resistance to local
anesthetics. Prior to seeking dental consultation, she had undergone three obstetric surgical
interventions wherein spinal anesthesia had failed and the procedures had to be completed under
general anesthesia. This history was not volunteered or elicited during dental extraction, when
repeated local anesthetic blocks proved ineffective and exodontia had to be done under conscious
sedation.

CASE REPORT

A 32-year-old healthy female with impacted wisdom tooth was posted for dental extraction.
She was not a diabetic or hypertensive and gave no history of scorpion bite, drug reactions or
idiosyncracies. Her physical examination was normal and she had no features to suggest
hypermobility of joints of abnormal skin elasticity. Since her coagulation profile and basic
laboratory investigations were within normal limits, she was accepted for extraction of an
impacted molar under local anesthesia.

Adopting all aseptic precautions,with the patient in a semi recumbent position on the dental
chair, a left mandibular nerve block was performed after eliciting paraesthesia with a 26 gauge
Quincke's needle. After test aspiration, 3.5 mL 2.0% of lignocaine with adrenaline was injected.
In spite of waiting for 20 min, the patient did not show any signs or symptoms of sensory block.
Hence an equivalent dose of the same local anesthetic was repeated. Despite waiting for 20
minutes, she did not develop anesthesia.

At this point, upon specific inquiry into her past history, the patient gave history of three
previous surgeries for Caesarian sections for which she had been given spinal anesthesia without
success on all three occasions. Consequently, the surgeries had to be performed under general
anesthesia on all occasions.

Thereafter, it was decided to conduct the procedure under conscious sedation. The
anesthesiologist administered Inj. Glycopyrrolate 0.2 mg IV, followed by Inj. Propofol 60mg

and Inj. Diclofenac acqueous 75mg intravenously and a size 3 Igel laryngeal mask was inserted.
Anaesthesia was maintained with oxygen and two increments of 20 mg propofol until end of
procedure. The surgery lasted 12 min, and the immediate post-operative period and follow up in
the post-operative period for the next 6 h, was uneventful.

A fortnight post extraction, the patient was called for a review when, after explaining the
possibility of her having resistance to local anesthesia and need to evaluate her more
scientifically, local infiltration of the skin near the anatomical snuff box of the left arm using 2%
xylocaine with adrenaline (total volume 3 mL) was carried out. There was no sensory nor motor
block after these injections.

DISCUSSION

Local anaesthesia is not a 100% certain successful technique and inadequate analgesia despite
technically well performed injections have been known to occur. Failure rates of 0.72-16.0%
have been reported.(1,2,3) The causes of some failures may be due the following (4):

1. Successfully injected drugs that are maldistributed relative to the needs of the planned
surgery
2. Unrecognized failed injection of drug, partial or total
3. Technical failure
4. Drug errors, i.e. wrong drugs and inappropriate additives

5. Improper storage conditions

6. Shelf life expiry of drug
7. Local anaesthetic resistance. True local anaesthetic resistance is difficult to diagnose and
viewed with skepticism.(5)
8. Pseudo block failure due to excessive expectations for speed of block onset
9. Chemical incompatability caused by adjuvants.
According to one study into the prevalence of local anaesthetic resistance to mepivacaine,
lignocaine and bupivacaine, 7.5% of patients were found to be hypoesthetic to mepivicaine,
3.8% to lignocaine. while the rest were hypoesthetic to all or bupivacaine. (6)

In another study, central neuroplasticity has been implicated in response to local anaesthesia in
patients with phantom limb pain and in animal and human models of tachyphylaxis. Related
mechanisms may be involved in patients with apparent local anaesthetic resistance, and may
suggest future directions for therapeutic interventions. (7)

Patients with Ehler Danlos syndrome (Type III, hypermobility type) have been reported to
exhibit resistance to local anesthetics. (8)
The resistance to local anaesthetics has also been attributed to mutations in the sodium channels.

The normal sodium channel consists of alpha, beta-1 and beta-2 subunits. The alpha subunit

comprises of four homologous domains I-IV with each domain having six trans membrane segments

S1-6. Local anesthetics interact at the 6th segment of domain four at the alpha subunit.

Figure 1: Details of the sodium channel subunits, domains and segments. Local anesthetics act at the

S6 segment

Genetic variations at this locus results in atypical receptor sites, differing in the phenylalanine and

tyrosine amino acid residues. (9) Local anesthetics bind with the sodium channels in open, closed

and inactivated states to reach their binding sites via intra and extra cellular pathways. (Fig 2)

Figure 2: Local anesthetics and their binding with local anesthetics

Coupled movement of sodium and local anesthetics in the closed channel has been implicated in

causing resistance of local anesthetics. Outer pore mutations of the sodium channel affecting ingress

and egress of local anesthetics have been reported with tetrodoxin and -conotoxin binding at these

sites have been reported. (10)

Patients with scorpion evenomation with 8 months or history of multiple bites have been reported to

be completely resistant to local anesthetics, while others with history of scorpion bites one year or

more previously have been reported to exhibit delayed onset and peak of both sensory and motor

blocks. (11,12,13)

Conclusion

A patient with total resistance to the effect of local anesthetics, manifesting as failure of block during a dental

procedure has been described. In the absence of any contributing factors, it is presumed that she has a

congenital mutation of the sodium channel that needs further evaluation. Patients should be

taken more seriously when they complain of pain during a procedure despite what should be adequate local

infiltration. Perhaps the patients who complain that the injections dont help might benefit from a reassessment

of their response to various local anesthetics.

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Source of support: Nil

Conflict of interest: No financial conflicts or any dual commitments that represent any potential conflicts
of interest are present for any of the authors of this article.