l ocal a nesthetics by s. bohlooli, phd school of medicine, ardabil university of medical sciences
TRANSCRIPT
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LOCAL ANESTHETICSBy
S. Bohlooli, PhDSchool of Medicine, Ardabil University of Medical Sciences
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INTRODUCTION
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HISTORY
Cocaine, the first local anesthetic introduced into medical practice, was isolated by Niemann in 1860
Procaine was synthesized by Einhorn in 1905 Lidocaine, which is still a widely used local
anesthetic, was synthesized in 1943 by Löfgren.
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BASIC PHARMACOLOGY OF LOCAL ANESTHETICS
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CHEMISTRY: STRUCTURE ESTER
Cocaine Procaine (Novocain)
Tetracaine (Pontocaine) Benzocaine
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CHEMISTRY: STRUCTURE AMIDES
Lidocaine (Xylocaine) Mepivacaine
Bupivacaine; Levobupivacaine
Ropivacaine (Naropin)
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CHEMISTRY
Local anesthetics are weak bases the pKa of most local anesthetics is in the
range of 8.0–9.0 Cationic form is the most active form The uncharged form is important for rapid
penetration of biologic membranes
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PHARMACOKINETICS
Local anesthetics are usually administered by injection into dermis and soft tissues around nerves
Absorption and distribution are not as important
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ABSORPTION
Systemic absorption of injected local anesthetic depends on: Dosage Site of injection Drug-tissue binding Local tissue blood flow Use of vasoconstrictors (eg, epinephrine) Physicochemical properties of the drug
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DISTRIBUTION, METABOLISM AND EXCRETION
The amide local anesthetics are widely distributed after intravenous bolus administration
The local anesthetics are converted in the liver (amide type) or in plasma (ester type) to more water-soluble metabolites
Decreased hepatic elimination of local anesthetics would be anticipated in patients with reduced hepatic blood flow or hepatic diseases
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PHARMACODYNAMICS: MECHANISM OF ACTION
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PHARMACODYNAMICS
The function of sodium channels can be disrupted in several ways: batrachotoxin, aconitine, veratridine
bind to receptors within the channel and prevent inactivation
tetrodotoxin (TTX) and saxitoxin block sodium channels by binding to channel receptors
near the extracellular surface
Spinal neurons can be differentiated on the basis of tetrodotoxin effect into: TTX-sensitive TTX-resistant neurons
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PHARMACODYNAMICS
With increasing concentrations of a local anesthetic The threshold for excitation increases Impulse conduction slows The rate of rise of the action potential declines The action potential amplitude decreases The ability to generate an action potential is
completely abolished These effects result from binding of the local
anesthetic to more and more sodium channels
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EFFECT OF EXTRA CELLURAR IONS
Increase in extracellular calcium partially antagonizes the action of local anesthetics Owing to the calcium-induced increase in the
surface potential on the membrane. Increases in extracellular potassium enhancing the
effect of local anesthetics.: Depolarize the membrane potential and favor
the inactivated state.
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RELATIVE SIZE AND SUSCEPTIBILITY OF DIFFERENT TYPES OF NERVE FIBERS TO LOCAL ANESTHETICS
Fiber Type Function Diameter (m) Myelination Conduction Velocity (m/s)
Sensitivity to Block
Type A Alpha Proprioception, motor 12–20 Heavy 70–120 +
Beta Touch, pressure 5–12 Heavy 30–70 ++
Gamma Muscle spindles 3–6 Heavy 15–30 ++
Delta Pain, temperature 2–5 Heavy 5–25 +++
Type B Preganglionic autonomic
< 3 Light 3–15 ++++
Type C Dorsal root Pain 0.4–1.2 None 0.5–2.3 ++++
Sympathetic Postganglionic 0.3–1.3 None 0.7–2.3 ++++
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NERVE FIBERS DIFFER SIGNIFICANTLY IN THEIR SUSCEPTIBILITY
Effect of Fiber Diameter Effect of Firing Frequency Effect of Fiber Position in the Nerve Bundle Effects on Other Excitable Membranes
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CLINICAL PHARMACOLOGY OF LOCAL ANESTHETICS
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CLINICAL PHARMACOLOGY
Can provide highly effective analgesia in well-defined regions of the body
The usual routes of administration Topical application Injection in the vicinity of peripheral nerve
endings (perineural infiltration) Injection in the vicinity of major nerve trunks
(blocks) Injection into the epidural or subarachnoid
spaces surrounding the spinal cord Intravenous regional anesthesia (Bier block)
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Schematic diagram of the typical sites of injection of local anesthetics in and around the spinal canal
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THE CHOICE OF LOCAL ANESTHETIC
The choice of local anesthetic is usually based on the duration of action required Short-acting:
Procaine and chloroprocaine Intermediate duration :
lidocaine, mepivacaine, and prilocaine long-acting :
tetracaine, bupivacaine, levobupivacaine, and ropivacaine
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SOME TIPS
The onset of local anesthesia can be accelerated by the addition of sodium bicarbonate
Repeated injections of local anesthetics can result in loss of effectiveness
Pregnancy appears to increase susceptibility to local anesthetic toxicity
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TOXICITY
Central Nervous System Neurotoxicity
Lidociaine Cardiovascular System
Bupivacaine Hematologic Effects
Prilocaine: metabolite o-toluidine Allergic Reactions
The ester-type local anesthetics: p-aminobenzoic acid derivatives