LOCAL ANESTHETICS

AND REGIONAL ANESTHESIA

SMF ANESTESIOLOGI & REANIMASI

INTENSIVE CARE
RSUD JAYAPURA
PAPUA
 Local Anesthetics- History
• 1860 - cocaine isolated from erythroxylum coca
• Koller - 1884 uses cocaine for topical anesthesia
• Halsted - 1885 performs peripheral nerve block
with local
• Bier - 1899 first spinal anesthetic
Local Anesthetics - Definition
A substance which reversibly inhibits nerve
conduction when applied directly to tissues
at non-toxic concentrations
 Local anesthetics - Mechanism
Limit influx of sodium, thereby limiting propagation of the
action potential.
 Local Anesthetics - Classes

Esters
Local anesthetics - Classes (Rule of “i’s”)

Esters Am”i”des
Cocaine Bupivacaine
Chloroprocaine Lidocaine
Procaine Ropivacaine
Tetracaine Etidocaine
Mepivacaine
 Local anesthetics - Formulation
Biologically active substances are frequently
administered as very dilute solutions which can be
expressed as parts of active drug per 100 parts of
solution (grams percent)

Ex.: 2% solution =

_2 grams__ = _2000 mg_ = __20 mg__

100 cc’s 100 cc’s 1 cc
 Local Anesthetics - Allergy

• True allergy is very rare

• Most reactions are from ester class - ester hydrolysis
(normal metabolism) leads to formation of PABA - like
compounds
• Patient reports of “allergy” are frequently due to previous
intravascular injections
 Local Anesthetics - Toxicity

Tissue toxicity - Rare Systemic toxicity - Rare

• Can occur if administered in
high enough concentrations
(greater than those used
clinically)
• Usually related to
preservatives added to
solution
• Related to blood level of drug
secondary to absorption from
site of injection.
• Range from lightheadedness,
tinnitus to seizures and
CNS/cardiovascular collapse
 Local anesthetics - Duration
• Determined by rate of elimination of agent
from site injected
• Factors include lipid solubility, dose given,
blood flow at site, addition of
vasoconstrictors (does not reliably prolong
all agents)
• Some techniques allow multiple injections
over time to increase duration, e.g. epidural
catheter
 Local anesthetics - vasoconstrictors

Vasoconstrictors should not be used in the following

locations
• Fingers
• Toes
• Nose
• Ear lobes
• Penis
REGIONAL ANESTHESIA
 Regional anesthesia - Definition

Rendering a specific area of the body, e.g.

foot, arm, lower extremities, insensate to
stimulus of surgery or other instrumentation
 Regional anesthesia - Uses

• Provide anesthesia for a surgical procedure

• Provide analgesia post-operatively or during labor
and delivery
• Diagnosis or therapy for patients with chronic
pain syndromes
 Regional anesthesia - types

• Topical
• Local/Field
• Intravenous block (“Bier” block)
• Peripheral (named) nerve, e.g. radial n.
• Plexus - brachial, lumbar
• Central neuraxial - epidural, spinal
 Topical Anesthesia
• Application of local anesthetic to mucous
membrane - cornea, nasal/oral mucosa
• Uses :
– awake oral, nasal intubation, superficial surgical
procedure
• Advantages :
– technically easy
– minimal equipment
• Disadvantages :
– potential for large doses leading to toxicity
 Local/Field Anesthesia
• Application of local subcutaneously to anesthetize
distal nerve endings
• Uses:
– Suturing, minor superficial surgery, line placement,
more extensive surgery with sedation
• Advantages:
– minimal equipment, technically easy, rapid onset
• Disadvantages:
– potential for toxicity if large field
 IV Block - “Bier” block
• Injection of local anesthetic intravenously for anesthesia
of an extremity
• Uses
– any surgical procedure on an extremity
• Advantages:
– technically simple, minimal equipment, rapid onset
• Disadvantages:
– duration limited by tolerance of tourniquet pain, toxicity
 Peripheral nerve block
• Injecting local anesthetic near the course of a
named nerve
• Uses:
– Surgical procedures in the distribution of the blocked
nerve
• Advantages:
– relatively small dose of local anesthetic to cover large
area; rapid onset
• Disadvantages:
– technical complexity, neuropathy
 Plexus Blockade
• Injection of local anesthetic adjacent to a plexus, e.g
cervical, brachial or lumbar plexus
• Uses :
– surgical anesthesia or post-operative analgesia in the
distribution of the plexus
• Advantages:
– large area of anesthesia with relatively large dose of agent
• Disadvantages:
– technically complex, potential for toxicity and neuropathy.
 Central neuraxial blockade - “Spinal”
• Injection of local anesthetic into CSF
• Uses:
– profound anesthesia of lower abdomen and extremities
• Advantages:
– technically easy (LP technique), high success rate, rapid onset
• Disadvantages:
– “high spinal”, hypotension due to sympathetic block, post dural
puncture headache.
 Central Neuraxial Blockade - “epidural”
• Injection of local anesthetic in to the epidural space at
any level of the spinal column
• Uses:
– Anesthesia/analgesia of the thorax, abdomen, lower
extremities
• Advantages:
– Controlled onset of blockade, long duration when catheter is
placed, post-operative analgesia.
• Disadvantages:
– Technically complex, toxicity, “spinal headache”