COMPLICATIONS OF LOCAL ANESTHESIAPART I

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial Surgery2013

Complications

Any deviation from the normally Expected pattern during or after securing local

analgesia.

Classifications

Primary or Secondary Mild or Severe Transient or Permanent Attributed to solution or needle insertion

Complications from Local Anesthesia

I. Complications associated with the absorption of the solution used.

II. Complications associated with needle insertion

Complications associated with the absorption of the solution used.

1- Complications resulting from absorption of the anesthetic solution:

Systemic drug reactions due to the local anesthesia agent:

1. Toxicity2. Vasoconstrictor toxicity3. Allergy4. Anaphylactic reactions5. Idiosyncrasy

Local Reaction:6. Infection due to contaminated solution7. Local tissue irritation.

Complications associated with needle insertion1. Fainting and syncope

2. Muscle trismus3. Pain4. Edema5. Infection6. Broken needles7. Prolonged anesthesia8. Hematoma formation9. Sloughing and ulceration10.Bizarre Neurological Symptoms

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

Keep in Mind

Call the medical emergency service

The patient 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 is of prime importance because of the impaired respiratory mechanism

Check the patients cardiac and cardiovascular status

Keep in Mind

Starts I.V fluids should (e.g. 5% dextrose in H2O)

Drugs according to the condition

If complete circulatory standstill I.V 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

Complications due to Absorption of the Injected Solution

Systemic Complications1. Toxicity2. Idiosyncrasy3. Allergy4. Anaphylaxis

Definition Etiology Clinically Prevention Treatment

TOXICITY

Definition

It refers to the symptoms manifested as a result of overdosage or

excessive administration of the solution

Etiology

Large Dose of drug Accidental I.V 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.

Clinically

Early CNS stimulation symptoms

Cerebral cortex Medulla

Talkative Lethargy

Restlessness Sleepiness

Apprehensive Unconscious

Excited Convulsive

Clinically

Late CNS Depression Symptoms

Cerebral Cortex Medulla

Increase BP Dropped BP

Increase pulse rate Decrease Pulse Rate

Increase RR Respiratory depression

Nausea and Vomiting Decrease HR

Unconsciousness

Death usually occur due to Respiratory

Depression and Hypoxia and its subsequent effect on

the CVS

prevention

1. Pre-analgesic evaluation of the patient2. Use the weakest possible concentration3. Use vasoconstrictor whenever possible 4. Use of the least possible volume5. Aspirate before injection6. Slow injection7. Monitor the patient carefully after

injection

Treatment

Mild stimulation -- No treatment -- Stop further injection

Moderate stimulation Convulsions phase Depression phase

Treatment

Mild stimulation

Moderate stimulation IV injection of Barbiturates -- 0.2% solution of sodium Thiopental -- Secobarbital (seconal)

Oxygen inhalation

Convulsions phase Depression phase

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 Phase

Treatment

Mild stimulation Moderate stimulation Convulsions phase

Depression phase -- Artificial respiration -- I.V fluids -- Sympathomemetic drugs

Thank You

COMPLICATIONS OF LOCAL ANESTHESIAPART II

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial Surgery2013

VASOCONSTRICTOR TOXICITY

Definition Etiology Clinically -- Palpitation -- Tachycardia -- Hypertension -- Headache -- Apprehension -- Restlessness Prevention and treatment

IDIOSYNCRASY

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

Etiology

Unknown

Enzymopathy -- Congenital -- Acquired

psychogenic

Clinically

1. Pallor2. Tachycardia3. Hypotension4. Decrease heart rate5. Collapse

Prevention

Do not use any drug, which the patient gives you a history of previous reactions to it

Inject slowly and observe the patient closely during injection

Treatment

The same as the depression stage of toxic overdose (Artificial respiration, I.V fluids, Sympathomemetic

drugs) Barbiturates are ineffective in the treatment or

prevention of this condition

ALLERGY AND ANAPHYLAXIS

Definition

Allergy is a hypersensitivity reaction that occurs through exposure to an antigen (Ag) such as a drug (as L.A agent) which the patient has been previously exposed to it creating an Ag-Ab reaction

Anaphylaxis is a severe form of allergic reaction occurs suddenly and end fatally in which sudden violent loss of vasomotor tonus

Clinically

Allergy

1. Rashes2. Urticaria3. Fever4. Dermatitis5. Angioneurotic edema6. Bronchial asthma7. Anaphylaxis (Anaphylactic shock)

Clinically

Anaphylaxis

1. Drop in B.P2. Weak rapid pulse3. Inadequate respiration (RR)4. Death

Management

Epinephrine -- 1:1000 concentration -- 0.3 mg SC or IM Bronchodilator -- Via inhaler

Antihistaminic -- Benedryl 20-40 mg IV or IM Corticosteroids -- 100 mg IV hydrocortisone hemisuccinate

COMPLICATIONS OF LOCAL ANESTHESIAPART III

Dr. Rahaf Al-Habbab BDS. MsD. DABOMSDiplomat of the American Boards of Oral and Maxillofacial Surgery2013

COMPLICATIONS DUE TO ABSORPTION OF THE INJECTED SOLUTION

Local reaction1. Infection 2. Tissue Irritation

Infection

Infection from contaminated L.A solution 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

COMPLICATIONS ASSOCIATED WITH NEEDLE INSERTION

Fainting or Syncope

Due to temporary cerebral ischemia as a result of the

splanchnic B.V and reduced cardiac output

Signs and Symptoms:1. Pallor2. Cold3. Sweaty4. Dizzy5. Nausea6. Loss of consciousness

Fainting or Syncope

Management:

1. Stop dental procedure2. Place patient in supine position with slight head down tilt or

elevate the legs (to increase cerebral circulation)Or

3. Place the hands of the patient 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

4. Reassure patient5. Aromatic spirit (ammonia) held under the nose of the patient

for several breath.

Muscle Trismus

Inability to normally open the mouth

Etiology:1. Injecting into muscles or ligaments2. Needle borne infection3. Contaminated/Irritating solutions4. Hematoma formation in the muscle

Muscle Trismus

Management:Depends on the cause

If its due to Trauma it necessitates slight muscle exercise and drug therapy to relieve pain if present

If due to Infection then it needs antibiotics.

1. Heat therapy2. Warm saline rinses3. Analgesics4. Muscle relaxant

Pain

Etiology:1. Injection into a muscle or ligament, parotid gland, TMJ2. Using a non-isotonic solution3. Very cold solution4. Contaminated solution5. Too rapid injection resulting in tissue distention6. Numerous needle punctures

Management:7. Assure the patient8. analgesics

Edema

It is usually a symptomEtiology:1. Trauma2. Infection3. Allergy4. Hemorrhage

Management:Depends on the cause

Infection

Etiology:1. Contaminated Non-sterile needles or solution2. Carrying surface bacteria from non-sterile mucous

membrane into the deeper structures with the tip of the needle are the causative factors

3. Injection into infected area

Management: Antibiotics Anti-Inflamatory drugs

Broken Needle

Do not use a needle of a too fine gauge

Do not use old or dull needle

Do not use short neeldle 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

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 tissue

Needles should not be sterilized by flaming because the tamper of their alloy will be destroyed and they break easily

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

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

Prolonged Anesthesia

Management:

Assure the patient It takes some time to disappear (8-12 weeks) Examine and map the patient Follow up and re-evaluate.

Hematoma and Ecchymosis

The effusion of blood into the tissues as a result of punctured B.V leading to hematoma formation

Common sites: Maxillary tuberosity region

Management: No attempt should be made to aspirate the contents of hematoma It will absorb with time usually within 7-14 days Ice packs may be applied initially to act as analgesic and a

vasoconstrictor to reduce size of hematoma Antibiotics can be prescribed in cases of large hematoma to

prevent secondary infection

Sloughing and Ulceration

Traumatic Ulcers: Appears 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 leading to sloughing and ulceration (epithelial desquamation)

Management: Usually resolves within a few days or one week without

any intervention.

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

THANK YOU