1. Local anaesthesia
Duaa Migdadi

2. Clinical Uses of Local Anaesthetics1.
Topical Anaesthesia 2.
Infiltration Anaesthesia 3.
Peripheral Nerve Blockade 4.
Intravenous regional anaesthesia (IVRA) 5.
Spinal Anaesthesia 6.
Extradural Anaesthesia

3. 1: Topical Anaesthesia LA may be applied to the skin, the eye, the ear, the nose and the mouth as well as other mucous membranes. Most useful and effective: Lidocaine and prilocaine .
  : Infiltration Anaesthesia provide anaesthesia for minor surgical procedures (like incision , hydrocele and herniorrhaphy )
commonly used Amide LA are (Lidocaine , prilocaine , mepivacaine and Bupivacaine).
The site of action is at unmyelinated nerve endings and onset is almost immediate , this blocks the sensory nerve endings (no action on the motor function) .

4. 3: Intravenous regional anaesthesia (IVRA)
IVRA (BIER s Block) analgesia for minor surgical procedures. The local anaesthetic agent is injected into a vein of a limb that has been previously exsanguinated and occluded by a tourniquet. The site of action is probably the unmyelinated nerve fibres, Prilocaine and Ldocaine are commonly used. Bupivacaine and etidocaine should never be used for IVRA! They are significantly protein bound and once the tourniquet is released there is a risk of cardiotoxicity. Several deaths have been reported during IVRA with bupivacaine.
: the action or process of draining or losing blood

6. 4: Peripheral Nerve Blockade :
Regional anesthetic procedures that inhibit conduction in fibers of the peripheral nervous system. It can be divided into:
Minor nerve blocks involve the blocking of single nerve entities such as the inferior alveolar nerve, mental nerve, ulnar or radial nerve
Major nerve blocks involve the blocking of deeper nerves or trunks with a wide dermatomal distribution (e.g. brachial plexus blockade).
The commonly used LA agents are: Lidocaine, prilocaine, mepivacaine, and bupivacaine.

7. 5: Extradural Anaesthesia: LA agent injected in the epidural space between the dura mater and the Ligamentum Flavum. which usually acts on nerve roots and produces multiple paravertbral blocks usually used mainly isobaric Bupivacaine 0.5% or lidocaine (2.0%)
6.: Spinal Anaesthesia
injction directly into the cerebrospinal fluid (subarachnoid space) produces spinal anaesthesia.
*injction directly into the subarachnoid space (CSF btw L2-L3 or L3-L4)
*The primary site of action is the nerve roots in cauda equina and due to this
injection the lower limb and pelvis get paralyzed and anesthetized
*This technique is usually used for operation on lower limb , pelvis and abdomen
commonly used : mainly hyperbaric Bupivacaine 0.5% or lidocaine (5%)

9. Lidocaine
Lidocaine, the first amino amide-type local anestheticand and it is the most common local anesthetics that uses nowadays.
Lipo-philic, widely distributed into the body
it has rapid onset of action (in IV injection …within 3-5 min )
The half-life of lidocaine is 90 min to 120 min in most patients.
(This may be prolonged in patients with hepatic impairment because It metabolizes in the liver (p450 system))
Protein binding 60-80%
It is completely eliminated by the kidney after about 9 hr

10. Lidocaine
Lidocaine use in anesthesia can be explained by the fact that it alters depolarization in neurons, by blocking the fast voltage gated sodium (Na+) channels in the cell membrane. With sufficient blockade, the membrane of the presynaptic neuron will not depolarize and so fail to transmit an action potential, leading to its anesthetic effects. Careful titration allows for a high degree of selectivity in the blockage of sensory neurons, whereas higher concentrations will also affect other modalities of neuron signalling.

11. Lidocaine is a local anesthetic and antiarrhythmic drug.
Action:
ON CNS : Blocks conduction around a nerve
-Initially causes drowsiness &lethargy
-Higher doses cause excitation followed by depression
On CVS: Blood vessels : vasodilation in the injected area
Lidocaine is a local anesthetic and antiarrhythmic drug.

12. Lidocaine 1. local anesthesia : * Spinal & epidural anesthesia
Longer-acting substances such as bupivacaine are sometimes given preference for Lidocaine
Epidural :ideal for obstetric anesthesia
* preinduction: -Blunt the stress response to intubation –(eg. prior to laryngoscopy)
* to blunt the pain of propofol - 2ml of 1% lidocaine in 18 ml of propofol
* in dental procedures & minor surgery
* Lidocaine is used topically to relieve itching, burning and pain from skin inflammations

13. LIDOCAINE 2.antiarrythmic drug:
it is used intravenously for the treatment of ventricular arrhythmias if amiodarone is not available or contraindicated.
*Lidocaine should be given for this indication after defibrillation, CPR, and vasopressors have been initiated

14. Lidocaine
Lidocaine Solutions 0.5, 1, 1.5 and 2% contain lidocaine hydrochloride 5, 10, 15 and 20 mg/mL, respectively. Solutions with epinephrine contain (1:100,000) or 0 (1:200,000) epinephrine.
Lidocaine mixed with a small amount of epinephrine is available to allow larger doses for numbing, and to make the numbing effect last longer *pH of plain solution-6.5 while pH of vasoconstrictor containing solution
Duration of action :
Spinal:1-1.5 without Epi
Epidural:2hr without Epi /3hr with Epi
IV injection:15-30 min
IV regional anesthesia :tourniquet time
Periphral nerve block:1hr without Epi /3hr with Epi

15. lidocaine Contraindications:
* Heart block, second or third degree (without pacemaker)
* Serious adverse drug reaction to lidocaine or amide local anesthetics
*Concurrent treatment with quinidine, flecainide ,disopyramide , procainamide (class I antiarrhythmic agents)
*they inhibit of the cytochrome P450 enzyme and can lead to increased blood levels of lidocaine

16. Toxicity from Local Anaesthetic Drugs
when excessive blood levels occur. usually due to:
Accidental rapid intravenous injection.
Rapid absorption, such as from a very vascular site ie mucous membranes. Intercostal nerve blocks will give a higher blood level than subcutaneous infiltration, whereas plexus blocks are associated with the slowest rates of absorption and therefore give the lowest blood levels.
Absolute overdose if the dose used is excessive.
It involves the CNS and CVS.
In general (CNS) is more sensitive to LA than the CVS.
Therefore CNS manifestations tend to occur earlier. Brain excitatory effects occur before the depressant effects

17. Signs and Symptoms of LA Toxicity
CNS signs & symptoms
Early or mild toxicity: light-headedness, dizziness, tinnitus, circumoral numbness, confusion and drowsiness.
Severe toxicity: tonic-clonic convulsion leading to progressive loss of consciousness, coma, respiratory depression, and respiratory arrest.
CVS signs & symptoms
Early or mild toxicity:
if LA with Adrenaline tachycardia with Hypertension
If no Adrenaline : bradycardia with hypotension
Severe toxicity: Usually about times the convulsant dose needs to be injected before CV collapse occurs.
Collapse is due to the depressant effect of the LA acting directly on the myocardium (e.g. Bupivacaine)
Severe and intractable arrhythmias can occur with accidental iv injection.

18. Essential Precautions and Treatment
Prevention: Monitor ECG,O2 saturation , Always have adequate resuscitation equipment and drugs available before starting to inject
Treatment: stop the injection and assess the patient.
Call for help while treating the patient
Treatment is based on the A B C D of Basic Life Support
Ensure an adequate airway,
give O2 in over facemask .
Ventilate the patient if there is inadequate spontaneous respiration .
Intubation : if the patient is unconscious and unable to maintain an airway.
Administering a 20% lipid emulsion infusion (lipid rescue therapy) is a valuable asset

19. Treatment of circulatory failure
with I.V fluids and vasopressors: Ephedrin
: If not available or not effective in correcting the hypotension ….Adrenaline
Treat arrhythmias. Start CPR ( chest compressions) if cardiac arrest occurs.
Treat Convulsions with anticonvulsant drugs (Diazepam mg/kg , Thiopentone 1-4 mg/kg

20. Thank you