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Local Anesthesia: Achmad Assegaf, DR., SP - An
Local Anesthesia: Achmad Assegaf, DR., SP - An
Anesthesia
General
I.V I.M Inhalation
Local
Topical Infiltration Field Block Nerve Block Spinal Epidural Intra Venous
COMBINATION
REGIONAL ANESTHESIA : Impulse less/not reach to CNS Segmental blockade T5 L1 Block sympathetic system
Cortisol N / less Catecholamine N / less
Subarachnoid
Local/Regional Anesthesia Partial sensation loss Conscious
Epidural Nerve Ending Medulla Spinalis
ADVANTAGES :
Simple, Cheap Non explosive
No pollution
Post op care relative easy Conscious aspiration risk (-) Blood loss Autonomic & endocrine response
DISADVANTAGES :
needed Fear that the effect of drug vanished the surgery not finished Side effect so severe death
2. Amide Compound
Xylocaine / Lidocaine Prilocaine / Citanest Bupivacaine / Marcaine Etidocaine / Duranest Ropivacaine Levo Bupivacaine
Agent
Cocaine Procaine
Max:Single dose
150 Mg 500 Mg EPI 600 Mg + EPI 1012 Mg/Kg
Potency
Low
Chloro procaine
Infiltration 1% Epidural 2% Plexus block 2% Topical 0,5-1% Infiltr 0,1-0,2% Epidrl 0,4-0,5% Spinal 1%
Rapid 45-60
600 Mg EPI Interme diate 650 Mg + EPI 10-15 Mg/Kg 100 Mg 2 Mg/Kg High
Tetracaine
Slow 180-300
Agent
Xylocaine
Max:Single dose
Potency
Prilocaine
175 Mg EPI Interme diate 250 Mg + EPI 3-4 Mg/Kg 175 Mg EPI 250 Mg + EPI 3 4 Mg/Kg 300 Mg EPI 400 Mg + EPI 4-5 Mg/Kg High
Bupivacaine
Infilt 0,25-0,5% N.blok 0,5-0,75% Spinal 0,5% Infiltr 0,5% N.blok 0,5-1% Epidrl 1-1,5%
Etidocaine
High
(-)
p Ka
P Ka as pH at which its ionized and non ionized are in complete equilibrium L.A. with pKa closer to tissue pH more rapid onset p Ka lidocaine = 7,7 Bupivacaine = 8,3
Influence
potency and duration of action Degree of vascular absorption is related to blood flow through the area All local anesthetic vasodilation except Cocaine
2.
3.
CVS
CV collaps
Local irritation
Neural damage
Miscellanous Allergy Met.Hb.emia Addiction
Chloroprocaine
Systemic toxicity
L.A. agent are relatively free of side effect, if :
1. 2.
In appropriate dosage toxic excessive dose In appropriate anatomical location toxic reaction following :
Systemic toxicity
CNS is more susceptible than CVS Adverse effect involving CVS tend to be
CNS toxicity
CNS is more susceptible to the systemic actions of L.A. than CVS
Tinnitus Light headedness Confusion Circumoral numbness Drowsiness unconscious Twitching & tremors muscles of face & distal extremities convulsion Respiratory arrest
pH
convulsive threshold
CVS toxicity
Cardiac
- Ventricular fibrillation
bupivacaine
decrease in SV
CO
Neurological Blockade
Peripheral :
- Spinal - Epidural
Spinal Anesthesia
L.A Subarachnoid space
analgesic level
Indication
Abdominal surgery esp. lower abdomen Hernia Inguinalis
Contraindication
Absolute :
- refusal of the patients - local infection - coagulopathy Relative : - Sepsis - Neurological disease - Technical problems - Hypovolemia
Advantages
Conscious Relaxation (+)
Disadvantages
Hypotension
Durante & post op nausea & vomiting Post op headache Disturb respiration high level Urinary retention
Technique
Lateral / sitting position
Level of injection : iliac crest L R L4-5 Needle is advanced until duramater is pierced CSF flow back The higher the dose the greater the height of block Lower abdominal surgery T 8-10 1,8 2 cc Higher abdominal surgery T 4-5 2 2,5 cc
Management
Fluid : 0,5 1 L
Post injection :
- Hypotension fluids ephedrine 5 10 mg i.v - High risk patients early ephedrine drips If necessary : - diazepam / midazolam - Hypnotic - N2O/O2 - Light G.A
needle less PSH G.N 25 3,5% ; 27 1% ; 29 < 1% Th/ : Laid flat 24 hrs Analgesic agent Autolog epidural blood patch
Epidural Analgesia
Thoracal, lumbar, caudal
Indication / contraindication = spinal
Anatomy
Duramater is begine from foramen magnum
and end at S2 level Posterior to the dura lies lig. Flavum Diameter 0,5 cm at L2 Content of epidural space : - fat - vascular vessel - lymph vessel - areolar tissue - spinal nerve roots
- Loss of resistance - Hanging drop Dose : 1 1.5 ml / segment Injection begin with 3 ml of test dose consist of lidocaine 2 % + adrenaline 1 : 200.000
Complication
Penetrate duramater
Post
Spinal advantages
Less time to perform eq. technique
easier Less doses More rapid onset Better quality sensory & motor block
Epidural advantages
Segmental block No PS Hypotension is not abrupt Less motoric block Can be used for post op. pain catheter
Epidural disadvantages
More difficult Larger doses Systemic reaction Total spinal if not in proper place
Caudal Block
Disadvantages
Difficult to reach