Complications of local anesthesia

Complications Of Local Anesthesia

ELHAWARY


In the name of Allah, Most Gracious,
Most Merciful
‫ﺑ م ﷲ ر ن رﺣ م‬
ِ ‫ِﺳْ ِ ا ِ اﻟ ﱠﺣْﻣ ِ اﻟ ﱠ ِﻳ‬

‫َﺎ َ ﱡ َﺎ اﻟﱠﺎ ُ ِﱠﺎ ﺧﻠﻘْ َﺎ ُﻢ‬
‫ﯾ أﯾﮭ ﻨ س إﻧ ََ ﻨ ﻛ‬
O mankind! We created you from
a single (pair) of a male and a

COMPLICATIONS‫ﻠْﻨ‬OF‫ﻣﱢﻦ ذَﻛَﺮٍ وَأُﻧﺜَﻰ‬
ْ‫ َ َﻌ َﺎ ُﻢ‬LOCAL
‫وﺟ َ ﻛ‬
female, and made you into
nations and tribes, that ye may
‫ﺷﻌ ﺎ وﻗﺒ ﺋﻞ ﻟﺘﻌ َﻓ ِن‬
‫ُ ُﻮﺑ ً َ َ َﺎ ِ َ ِ َ َﺎر ُﻮا إ ﱠ‬
know each other (not that ye may
ANESTHESIA‫أَﻛْﺮَﻣَﻜُﻢْ ﻋِﻨﺪَ اﻟﻠﱠ‬
despise (each other). Verily the
‫ﮫ أ ﻘ ﻛ ِن‬
‫ِ َﺗْ َﺎ ُﻢْ إ ﱠ‬
most honoured of you in the sight
‫ﻠﮫ ﻋﻠ ﻢ ﺧﺒ ﺮ‬
ٌ ‫اﻟﱠ َ َِﯿ ٌ َ ِﯿ‬
of Allah is (he who is) the most
righteous of you. And Allah has
full knowledge and is well
acquainted (with all things).
Dr. Hesham El-Hawary
[13 : ‫]اﻟﺤﺠﺮات‬
Al Hujurât 13 Lecturer OMFS
Faculty of Oral & Dental Medicine
Cairo University

ELHAWARY


Complications Of
Local Anesthesia
Dr. Hesham El-Hawary
Ass. Professor
Oral and Maxillofacial Surgery

ELHAWARY


Complications
Any deviation from the normally expected
pattern during or after securing local
analgesia

ELHAWARY


Complications
Any deviation from the normally expected
pattern during or after securing local
analgesia

Classifications
 Primary or Secondary
 Mild or Sever
 Transient or Permanent
 Attributed to solution or needle insertion

ELHAWARY


Complications from local Anesthesia

I. Complications associated to the
absorption of the solution used

II. Complications associated with
needle insertion

ELHAWARY


Complications associated with absorption of
the anesthetic solution
1. Systemic drug reactions due to the local anesthetic
agent:
1. Toxicity
2. Allergy
3. Anaphylactic reactions
4. Idiosyncrasy

2. Local reactions:
1. Infections due to contaminated solutions
2. Local tissue irritation

ELHAWARY


Complications associated with needle
insertion
1. Fainting and syncope
2. Muscle trismus
3. Pain
4. Edema
5. Infection
6. Broken needles
7. Prolonged anesthesia
8. Haematoma formation
9. Sloughing and ulceration
10. Bizarre Neurological symptoms
ELHAWARY


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

ELHAWARY


Keep in mind
• Call medical emergency service
• The patient position
– 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
• Check the patient's cardiac and cardiovascular status
• Start I.V. fluids (e.g. 5% dextrose in H2O)
• Drugs according to the condition
• If complete circulatory standstill
– IV 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
ELHAWARY


Complications due to absorption
of the injected solution
Systemic complications
1. Toxicity
2. Idiosyncrasy
3. Allergy
4. Anaphylaxis

ELHAWARY


• Definition
• Etiology
• Clinically (Signs & Symptoms)
• Prevention
• Treatment

ELHAWARY


Toxicity

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Definition

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

ELHAWARY


Etiology
• Large dose of drug
• Accidental intravenous 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

ELHAWARY


Clinically
I. Early C.N.S. stimulation symptoms

1)Cerebral Cortex 2)Medulla
1. Talkative 1. Lethargy
2. Restlessness 2. Sleepiness
3. Apprehensive 3. Unconscious
4. Excited
5. Convulsive

ELHAWARY


Clinically
II. Late C.N.S. Depression symptoms

3)Cerebral Cortex 4)Medulla
1. Increased blood 1. Dropped blood pressure
pressure
2. Decreased pulse rate
2. Increase pulse rate
3. Decreased heart rate
3. Increase respiratory
4. Respiratory depression
rate
5. unconsciousness
4. Nausea & vomiting
ELHAWARY


N.B.
Death usually occur due to
respiratory depression and
hypoxia and its subsequent
effect on the cardiovascular
system

ELHAWARY


Prevention

1. Pre-analgesic evaluation of the patient
2. Use the weakest possible concentration
3. Use vasoconstrictor whenever possible
4. Use of the least possible volume
5. Aspirate before injection
6. Slow injection
7. Monitor the patient carefully after injection

ELHAWARY


Treatment
• Mild Stimulation
– No treatment
– Stop further injection
• Moderate stimulation
• Convulsions phase
• Depression phase

ELHAWARY


Treatment
– IV injection of Barbiturates
• 0.2% solution of sodium thiopental
• Secobarbital (Seconal)
– Oxygen inhalation

ELHAWARY


Treatment
– 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

ELHAWARY


Treatment
– Artificial Respiration
– IV fluids
– Sympathmemetic drugs

ELHAWARY


Vasoconstrictor Toxicity

ELHAWARY


• Definition
• Etiology
• Clinically
– Palpitation
– Tachycardia
– Hypertension
– Headache
– Apprehension
– Restlessness
– N.B. Difficult to differentiate from those of L.A. Agent
• Prevention and treatment

ELHAWARY


Idiosyncrasy

ELHAWARY


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

ELHAWARY


Etiology

• Unknown
• Enzymopathy
– Congenital
– Acquired
• Psychogenic

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Clinically

1. Pallor
2. Tachycardia
3. Hypotension
4. Decreased Heart rate
5. Collapse

ELHAWARY


Prevention
1. Do not use any drug, which the patient gives you a
history of previous reactions to it
2. Inject slowly and observe the patient closely during
injection

ELHAWARY


Prevention
1. Do not use any drug, which the patient gives you a
history of previous reactions to it
2. Inject slowly and observe the patient closely during
injection

Treatment
• The same as the depression stage of toxic overdose
• Barbiturates are ineffective in the treatment or
prevention of this condition

ELHAWARY


Allergy and Anaphylaxis

ELHAWARY


Definition
• Allergy is a hypersensitive reaction
that occurs through exposure to an
antigen (Ag) such as a drug ( as L.A.
agent) which the pt. has been
previously exposed to it creating an
Ag - Ab reaction
• Anaphylaxis is a severe form of
allergic reactions occurs suddenly &
end fatally in which sudden violent loss
of vasomotor tonus

ELHAWARY


Clinically
Allergy
1. Rashes
2. Urticaria
3. Fever
4. Dermatitis
5. Angioneurotic edema
6. Bronchial asthma
7. Anaphylaxis( anaphylactic shock)

ELHAWARY


Clinically

Anaphylaxis
1. Drop in B.P. (↓B.P.)
2. Weak rapid pulse
3. Inadequate respiration (↓Respiratory rate)
4. Death

ELHAWARY


Management
1. Antihistaminic
(benadryl 20 - 40 mg IV or IM.)
2. Epinephrine 1:1000 concentration
0.3 mg SC. or IM.
3. Bronchodilator
via inhaler
4. Corticosteroid
100mg IV. hydrocortisone hemisuccinate

ELHAWARY


Complications due to absorption
of the injected solution

Local Reactions
1. Infection
2. Tissue irritation

ELHAWARY


Infection
Infection from contaminated L.A. solutions 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

ELHAWARY


Complications associated with
needle insertion

ELHAWARY


Fainting or Syncope
• It is due to temporary cerebral ischemia as a result
of dilation of the splanchnic B.V. & reduced cardiac
output
• Signs &symptoms:
1. Pallor
2. Cold
3. Sweaty
4. Dizzy
5. Nausea
6. Loss of consciousness

ELHAWARY


 Management:
• Stop dental procedure
• Place pt. in supine position with slight head down
or elevate the legs ( to ↑ cerebral circulation)
or
• Place the hands of the pt. 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
• Reassure pt.
• Aromatic spirit (ammonia) held under the nose of
the pt. for several breath

ELHAWARY


Muscle Trismus
• Inability to open the mouth normally
• Etiology:
– Injecting into muscles or ligaments
– Needle borne infection
– Contaminated irritating solutions
– Haematoma formation in the muscle
• Prevention:

ELHAWARY


 Management:
Depends upon the cause

– If it is due to trauma it necessitates slight muscle
exercise and drug therapy to relieve pain if present
– If due to infection this needs antibiotics

1. Heat therapy
2. Warm saline rinses
3. Analgesics
4. Muscle relaxant

ELHAWARY


Pain
• Etiology:
– Injection into a muscle or ligament, parotid gland, T.M.J.
– Using a non-isotonic solution
– Very cold solutions
– Contaminated solutions
– Too rapid injection resulting in tissue distention
– Numerous needle punctures
• Prevention
 Management:
1. Assure the pt.
2. Analgesics
ELHAWARY


Edema
• It is usually a symptom
• Etiology:
– Trauma
– Infection
– Allergy
– Hemorrhage

• Treatment and prevention depends upon the cause

ELHAWARY


Infections
• Etiology:
– Contaminated Non-sterile needles or solutions
– Carrying surface bacteria from non-sterile mucous
membrane into the deeper structures with the tip of the
needle are the causative factors
– Injection into infected area
• Prevention
 Management:
– Antibiotics
– Antinflammatory drugs

ELHAWARY


Broken needles
• Do not use old or dull needles
• Do not use short needles 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
• Do not use a needle of a too fine gauge

ELHAWARY


• 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
tissues

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


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

ELHAWARY


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
 Management:
1. Assure the pt.
2. It takes some time to disappear

ELHAWARY


Haematoma and Ecchymosis
• The effusion of blood into the tissues as a result of
punctured B.V. leading to haematoma formation
• Common sites: maxillary tuberosity region
 Management:
1. No attempt should be made to aspirate the contents
of the haematoma
2. It will absorb with time (7 – 14) days
3. Ice packs may be applied initially to act as analgesic
& a vasoconstrictor to reduce size of haematoma

ELHAWARY


Sloughing and Ulceration
• Traumatic ulcers
– Appear 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. lead to sloughing & ulceration
 Management:
Usually resolves within a few days or one week without any
intervention

ELHAWARY


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

ELHAWARY

‫‪Complications Of Local Anesthesia‬‬

‫ﺑ ﻢ ﷲ ﺮ ﻦ ﺮﺣ ﻢ‬
‫ِﺴْ ِ ا ِ اﻟ ﱠﺣْﻤ ِ اﻟ ﱠ ِﯿ ِ‬

‫ﯾ أﯾﮭ ﻨ س إﻧ ﺧﻠ ﻨ ﻛ ﻣ ذﻛﺮ‬
‫َﺎ َﱡ َﺎ اﻟ ﱠﺎ ُ ِ ﱠﺎ ََﻘْ َﺎ ُﻢ ﱢﻦ َ َ ٍ‬
‫وﺟﻌ ﻨ ﻛ ﺷﻌ ﺎ وﻗﺒ ﺋﻞ‬
‫َُﻧ َﻰ َ َ َﻠْ َﺎ ُﻢْ ُ ُﻮﺑً َ َ َﺎ ِ َ‬ ‫وأ ﺜ‬
‫ِ َ َﺎ َ ُﻮا ِ ﱠ َﻛْ َ َ ُﻢْ ِﻨ َ اﻟﱠ ِ َﺗْ َﺎﻛﻢْ‬
‫ﻟﺘﻌ رﻓ إن أ ﺮﻣﻜ ﻋ ﺪ ﻠﮫ أ ﻘ ُ‬
‫إن ﻠﮫ ﻋﻠ ﻢ ﺧﺒ ﺮ‬
‫ِ ﱠ اﻟﱠ َ َِﯿ ٌ َ ِﯿ ٌ‬
‫]اﻟﺤﺠﺮات : 31[‬
‫‪ELHAWARY‬‬


Thank You
Hesham El-Hawary
www.elhawarydentalclinic.com

ELHAWARY

Complications of local anesthesia

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