Professional Documents
Culture Documents
Per H. Rosenberg
Department of Anaesthesiology and
Intensive Care Medicine
Helsinki University Hospital
Helsinki, Finland
T
he recommendations regarding maximum local anaesthetic does not play any greater role in
doses of local anaesthetics presented in influencing its absorption. Ropivacaine has been
physicians’ pharmaceutical reference found to produce less vasodilatation than other
books or in anaesthesiology text books are commonly used amide-linked local anaesthetics 4,
not evidence based. As a matter of fact, most or even vasoconstriction, but whether this has any
of the recommendations are published by the clinically beneficial consequences remains open. As
manufacturer and are often very conservative. an example, plasma concentrations of ropivacaine
Usually, the recommendation of a maximum in epidural anaesthesia are similar to those
dose is expressed as the total amount of the local measured after a similar dose of bupivacaine 5, 6.
anaesthetic, e.g. 200 mg for lidocaine in an adult.
The site of administration, size and age of the Adrenaline
patient, concomitant diseases and medications Adrenaline slows the absorption of local anaesthetic
are not taken into account. This controversy has and prolongs the anaesthetic action and increases
been pointed out several times, and most strongly the duration of the block. A suitable adrenaline
by Daniel C. Moore and co-workers 1 and by Bruce concentration is 5 µg/ml which reduces the peak
Scott 2. They questioned the validity of maximum plasma concentration of the local anaesthetic,
dose recommendations because of the completely depending on the local anaesthetic, by 30–60 %.
ignored consideration of the various factors known Higher adrenaline concentrations are commonly
or suspected, to affect absorption, metabolism and used in dentistry, but if one aims primarily at
elimination of the drug. reducing the uptake of the local anaesthetic into
blood, as low adrenaline concentration as 1.7 µg/
Drug-related factors ml (1 : 600,000) has been shown to be effective with
lidocaine 8.
Influence of site injection
The vascularity and the binding of the local Patient-related factors
anaesthetic to the tissues will influence the rate of
absorption into the circulating blood. Absorption Age
from richly vascularized regions such as the Deterioration in morphology and nerve
pleura, the bronchial mucosa, and the scalp occurs conduction by aging may increase the sensitivity
rapidly 3. to local anaesthetic block 8. In addition, because of
reduced clearance, the doses of local anaesthetics
Intrinsic vasoactivity of the local anaesthetics need to be reduced in adults, age-dependently
The vasoactive potency of the clinically used between 10–20 % 9.
amide-linked local anaesthetics varies. The effect is In the newborn less than 4 months old, the low
dose-dependent and as a rule, high concentrations plasma concentrations of α1-acid glycoprotein
cause dilatation and low concentrations cause (AAG), the local anaesthetic-binding acute phase
constriction. The intrinsic vasoactivity of the protein, is related to an enhanced risk of toxicity.