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LOCAL ANESTHESIA

LOCAL ANESTHESIA
DEFINATION

Local Anesthesia has been defined as
loss of sensation in circumscribed
area of the body caused by a
depression of excitation in nerve
endings or an inhibition of the
conduction process in peripheral
nerves.

METHODS OF INDUCTION




Mechanical trauma
Low temperature
Anoxia
Chemical irritants
Neurolytic agents

Alcohol, Phenol

Chemical agents

Local Anesthesia

The interior of the nerve is negative relative to the exterior. .ELECTROPHYSIOLOGY OF NERVE CONDUCTION • • • A nerve possesses a resting negative electrical potential of – 70 Mv produced by difference of concentration of ions on either side of the membrane.

The electrical potential within the nerve becomes slightly less negative. • An electrical potential of +40 mV occurs on the interior of the nerve cell. • Firing threshold • Decrease of Trans membrane potential to -15 mv (from -70 to -55mv) is required. . • Na ions influx causes depolarization to -50 to -60m v.SEQUENCE OF EVENTS(EXITATION) • Deploarization • An initial phase of slow deploarization.

. • Caused by inactivation of increased permeability to Na.• REPOLARIZATION: • The electrical potential becomes more ---ve inside the nerve cell. • Original resting potential of -70mv is achieved.

 The surface charge (repulsion) theory • LA acts by binding to the nerve membrane and changes the electrical potential at membrane surface. .  The calcium displacement theory • LA causes displacement of calcium from some membrane site that controlled permeability to sodium.SITE OF ACTION OF LOCAL ANESTHETICS The nerve membrane is the site at which local anesthetics exert their pharmacological action.

. • LA acts by binding to specific receptors on the Na channel. • Specific Receptor site for LA agents exists in the Na channel either on its external or internal surface.The membrane expansion theory • LA molecules diffuse to hydrophobic regions of excitable membranes. permeability to Na ions is decreased and nerve conduction is interrupted. producing a general disturbance of the membrane structure which in turns prevents Na impermeability. • LA binds to the receptors.  Specific receptor theory.

MODE OF ACTION OF LOCAL ANESTHETICS Local anesthetics interfere with excitation process in nerve membrane in one or more of the following ways. • Altering the basic resting potential of the nerve membrane • Altering the threshold potential(firing level) • Decreasing the rate of depolarization • Prolonging the rate of repolarization .

Binding of the local anesthetics molecules to this receptor site.MECHANISM OF ACTION OF LOCAL ANESTHETIC • • • • • • • • By producing a conduction block by decreasing the permeability of the ionic channels to Na+ ions :Displacement of calcium ions from the sodium channel receptor site. . Lack of development of action potential. Blockade of the sodium channel Decrease in sodium conductance Depression of the the rate of electrical depolarization Failure to achieve the threshold potential level. Conduction blockade.

• Acidification of tissue or LA decreases LA properties.ROLE OF PH IN LOCAL ANESTHETIC ACTIVITY Normal Ph 7.ph 5.• • • • Slower onset of anesthesia • Prolongs its effectiveness. • Burning sensation on inj .4 LA without a vasoconstrictor .the buffering capacity of the tissue fluids rapidly returns the Ph to normal 7.5 LA with a vasoconstrictor .PH 5 to 6 • When injected into a tissue .3 due to antioxidant to inhibit oxidation of vasopressor.4.Ph 3. • Inflamed tissue (acidic) .

DURATION . • Recovery starts when Intraneural LA starts diffusing outside. • The degree of protein binding of local anesthetic molecule is responsible for the duration of anesthetic activity . • Vasodilator activity . • Mantle \ proximally innervated regions –early recovery • core bundles \ distal region –later.ONSET.RECOVERY FROM LA • LA with greater lipid solubility produces rapid onset of action.

CLASSIFICATION OF LOCAL ANESTHETICS • ESTERS ESTERS OF BENZOIC ACID Butacaine Cocaine benzocaine Tetracaine Piperocaine ESTERS OF PARAAMINOBENZOIC ACID Chloroprocaine Procaine Propoxycaine .

 AMIDES Lignocaine Articaine Bupivacaine Mepivacaine Prilocaine .

• AMIDES • The primary site of biotransformation is liver. • Procaine hydrolysis to Peraaminobenzoic acid (PABA). . • Patients with low hepatic blood flow (Hypotension. • Contraindication  Liver dysfunction  Heart failure .METABOLISM OF LA • ESTERS • Hydrolysis in the plasma by the enzyme pseudo cholinesterase.ccf ) or poor liver function (Cirrhosis) are unable to biotransforme amides at normal rate .increase toxicity.

EXCRETION   The kidneys are primary excretory organ for both the local anesthetic and its metabolites . . A percentage of a given dose of local anesthetic is excreted unchanged in the urine.

VASOCONSTRICTORS .

EFFECTS OF VASOCONSTRICTORS • • Vasoconstriction decreases blood flow (perfusion) to the site of administration. Decrease absorption of the LA into cvs • Lower anesthetic blood levels. • • Increases duration of action as increased amounts of LA remain in and around the nerve for longer periods Decreases bleeding -Vasoconstrition . • Minimum risk of LA toxicity.

and dopamine are the naturally occurring catecholamines of the sympathetic nervous system. . nor epinephrine. Felypressin is a synthetic analogue of vasopressin (antidiuretic hormone).CHEMICAL STRUCTURE    Epinephrine. Isoproterenol and levonordefrin are synthetic catecholamines.

000 concentration=0. . 1:100.01mg/ ml of vasoconstrictor.DILUTION OF VASOCONSTRICTORS   A concentration of 1:1000 means that there is 1 gram (1000 mg) of solute (drug) contained in 1000 ml of solution.

Levonordefrine. .CLASSIFICATION OF VASOCONSTRICTORS      Epinephrine (adrenaline) Nor epinephrine. Octapressin. phenyl ephrine.

The shelf life of LA • With adrenaline • Without adrenaline -18 months -36 months. .PHARMACOLOGY OF ADRENALINE    Acidic solutions are relatively stable if protected from air. Sodium bisulfite is added to delay its deterioration.

B effects predominate. . Activation of A receptor causes • Contraction of smooth muscles in blood vessels (vasoconstriction .MODE OF ACTION EPINEPHRINE    Epinephrine acts directly on both alpha and Beta-adrenergic receptors.Haemostasis)  Activation of B receptor causes • Relaxation of smooth muscles in blood vessels (vasodilatation – Reactive Hyperemia –Post Op bleeding after 6 hrs) • Cardiac stimulation.

SYSTEMIC ACTIONS OF EPINEPHRINE        Increased Increased Increased Increased Increased Increased Increased • • • systolic and diastolic pressures cardiac output stroke volume heart rate strength of contraction myocardial oxygen consumption incidence of dysrhythmias Ventricular tachycardia premature ventricular contractions. .

pallor throbbing headache systolic (>300 mm Hg) diastolic (>200mm Hg) Because of the rapid inactivation of epinephrine. cardiac dysrhythmias. • •  anxiety. tremor. cerebral hemorrhage. weakness.. dizziness. . the stimulatory phase of the overdose (toxic) reaction usually is brief. tension. restlessness.OVERDOSE & SIDE EFFECTS  CNS stimulation • • •   Palpitation.

O4 mg per appointment in cardiovascular patients.SAFE DOSE     Maximal epinephrine doses be limited to 0. Max epinephrine dose be limited to 0. Blood Pressure and heart rate. are minimally affected at these dosages. It is currently thought that the cardiovascular effects of conventional epinephrine doses are of little practical concern. even in patients with heart disease. .2 mg per appointment. however.

• Both systolic and diastolic pressures are increased -alpha receptor stimulation causing peripheral vasoconstriction  The extravascular injection of norepinephrine into tissues produces necrosis and sloughing.NOR EPINEPHRINE   The actions of nor epinephrine are almost exclusively on alpha receptors (90%) Blood pressure. • Sterile palatal abscess .

isoflurane. . diabetes and sulfite sensitivity) • GA (drug interaction)  MAO inhibitors.   SELECTION OF A VASOCONSTRICTOR Length of procedure Length of procedure • Plain 2% lig -10 min –hard/pulp • 2% lig+ vasocont -60min –hard/pulp Hemostasis requirement Medical states (contraindications) • Cardiovascular disease (ASA III and IV) • Thyroid dysfunction. or enflurane-Ven Dys • Felypression  Minimum cardiovascular stimulatory  Recommended drug for ASA III & IV cardiovascular risk patients.  Halothane. tricyclic antidepressants and phenothiazines.

LOCAL ANESTHETIC AGENTS .

LA DRUGS AVAILABLE      2% 4% 0.5% 3% 4% Lignocaine Articaine Bupivacaine MEPIVACAINE Prilocaine .

DURATION OF ACTION    Individual response to drug Accuracy in deposition of the local anesthetic Status of the tissues at the site of drug deposition • • •  Inflamation. infection vascularity pH Type of injection administered • • • supraperiosteal infiltration nerve block .

000 180-300 .DURATION OF CLINICAL ANESTHESIA 2% Lig Duration of Analgesia(min) pulpal .soft tissue 5-10 60-120 2% Lig 60 with 1:100.

MAX RECOMMENDED DOSAGE Lignocaine mg/kg No Vaso 4.6 MRD (mg) 300 500 .4 With Vaso 6.

8 ml CARTRIDGE) 2% Lig mg/ml 20mg x1.CALCULATION OF LA ( 1.8ml=mg/cartridge 36mg .

TOPICAL ANESTHETICS     Benzocaine Cocaine Hcl Lignocaine Tetracaine Hcl .

Do not contain vasoconstrictors. mepivacaine. Higher concentration • facilitates diffusion of the drug through the mucous membrane • Rapid higher blood levels achieved as compare to inj • increases the risk of toxicity Many LA are ineffective topically • articaine. . prilocaine and procaine.TOPICAL ANESTHETICS      Topical anesthesia are effective only on surface tissues (2 to 3 mm) The required concentration of topical LA is greater than LA administered by inj.

FACTORS IN SELECTION OF LA      Length of time pain control is necessary Potential need for post treatment pain control Possibility of self-mutilation in the postoperative period Requirement for hemostasis Presence of any contraindications to LA. .

• Patients on dialysis • 3 % mepivacaine or 4 % prilocaine is recommended. 0. • younger children who might accidentally bite or chew their lips or tongue.5% bupivacaine (for 8 to 12 hours of soft-tissue anesthesia) For patients in whom postoperative anesthesia is a potential hazard. shorterduration anesthetics should be considered.FACTORS IN SELECTION OF LA   When postoperative pain is considered likely. .

The ARMAMENTARIUM .

SYRINGS AVAILABLE  Non disposable syringes • Breech-loading metallic / plastic. cartridge type  aspirating (positive aspiration 10% to 15%)  self aspirating • Pressure syringe for periodontal ligament injection • Jet injector (“needle less” syringe)    Disposable syringes “Safety” syringes Computer controlled local anesthetic delivery systems .

the greater the diameter of the lumen. • 27 gauge ( yellow ) – most commonly used long needle • 30 gauge ( blue ) – most commonly used short needle • 25 gauge ( red ) – When risk of positive aspiration –Nerve Block • 30.gauge needles are more likely to break than 25-gauge needles.and 27.NEEDLE GAUGE   Stainless steel needles .recommended Gauge • Gauge is diameter of lumen of the needle: • Smaller the number . . • 25-. and 30-gauge needles are recommended.27-.

and maxillary nerve blocks . sharp containers .20 mm • Long needle .32 mm A long needle – When penetration of significant thicknesses of soft tissue required • Inferior alveolar block • Gow-Gates tech • Akinosi • Infra orbital.NEEDLE LENGTH       Length • Short needle . Short needles -20 mm -Thin soft tissue • Infiltration Needles should not be inserted into tissues to their hubs Recapping is a accomplished using the “scoop” technique Disposed in :• contaminated containers .

CARTRIDGE CONTENTS       Drug • LA agent A vasoconstrictor (vasopressor) drug.Thymol.. Preservative • Na meta bisulphite is added. • Na meta bisulphite +oxygen ---Na Bisulphate Bacteriostatic/ Fungicidal Agent • Methylparaben 0. Reducing Agent (antioxidant) • To avoid oxidation of adrenaline on exposure to sunlight –(Brown color soln). Vehicle • Ringers soln (isotonic) . • It prevents oxidation of vasopressor by consuming oxygen.1% (1mg/ml) .

CARTRIDGE PRECATUIONS  Autoclaved/ boiled • Local anesthetic drug is stable • Other components of the cartridges are destroyed e.g vasopressor . cartridge seals • Discomfort & nerve damage  Storage • In their original container • At room temperature • Avoid direct sunlight   Don’t Reuse Cartridges color .

ANATOMICAL CONSIDERATIONS .

BASIC INJECTION TECHNIQUES .

Near terminal nerve endings • Sub mucous injection • Supra periosteal injection • Sub periosteal injection • Intra osseous injection • Intra septal injection • Intra Ligamentary Injection Regional or Block anesthesia • LA deposited close to a main nerve trunk • Posterior superior alveolar • inferior alveolar • nasopalatine .TYPES OF LOCAL ANESTHESIA    Topical or surface Infiltration anesthesia . .

Onset 2 min Duration 10 min Ester . • Ointment :.10 mg / spray.200mg • Aerosol :.Lidocaine Allergic reactions to esters > greater than amide Lignocaine topical anesthetics • Max Recommended Doze . Amides .Benzocaine .TOPICAL ANESTHETICS  Topical anesthetic • • •     Applied by applicator stick –For 1 minute.50 mg / ml .

Position the patient Position of Dr Dry tissue .BASIC INJECTION TECHNIQUE • • • • • • Use a sterilized sharp needle. Check the flow of local anesthetic solution Determine whether to warm the anesthetic cartridges or syringe.

BASIC INJECTION TECHNIQUE







Apply topical anesthehtic
Communication with the patient
Make the tissue taut.
Keep the syringe out of sight
Insert the needle into the mucosa
Aspirate
Slowly deposit the LA -Observe the patient after the injection
--

PATIENT POSITION

Supine Position
• Head and heart parallel to the floor
• Feet slightly elevated

Upright position
• Causes Cerebral ischemia
• Blood pressure in cerebral arteries is
decreased by 2 mm Hg for each inch
above the level of the heart.

ADMINISTRATOR POSITION



Upper quadrants-LT - 10 o'clock
Upper quadrant RT - 8 o'clock
Posture upright
Mirror /Fingers to retract cheek

.   NEEDLE INSERTION & ASPIRATION Make the tissue taut. Bevel of the needle towards bone Inferior alveolar nerve block • Average depth of needle insertion 20-25 mm  Aspiration • The thumb ring pulled back gently ( 1-2 mm ) • Sign of blood in cart +ve aspiration. • Remove and reinsert needle.

DEPOSITE THE SOLUTION

Slowly inject.
1 ml of local anesthetic solution in
60 seconds.
1.8 ml cartridge requires approx 2
min but usually 60 sec
Recap by ‘scoop’ technique
• slide the needle tip into the cap without
touching the cap

OBSERVE THE PATIENT

observe the patient closely
Patients should never be left
unattended after inj.
Most adverse drug reactions, with in
5 min of inj

TECHNIQUES
OF
MAXILLARY
ANESTHESIA

6 to 1 ml over 20 seconds. Insert the needle into the height of the muco buccal fold over the target tooth.SUPRAPERIOSTEAL INJECTION  Indication. Hold the syringe parallel with the long axis of the tooth -bevel faces bone. . pulling the tissue taut. Advance the needle until its bevel is at or above the apical region of the tooth Deposit 0.topical anesthetic Lift the lip.-Procedures TECHNIQUE confined to small       circumscribed area 25 or 27-gauge .

6 ml in > 30 sec.45 to 0. . • Slowly inj 0.pain full Technique • Topical anesthesia –Maintain pressure • bevel faces bone./ right angle to bone • Advance the needle at the apical region of the tooth mid way between gingival margin & mid palate.  Avoid inj close to greater palatine foramen • Soft palate numbness / swallowing difficult • Palatal inj not beyond 2nd molar.ANESTHESIA OF PALATAL TISSUES   Tight adherent mucoperiosteum.

Intra septal & crestal injection Intra osseous injection Posterior superior alveolar nerve block • For all Molars Middle superior alveolar nerve block • For pre molars.MAXILLARY INJ TECHNIQUES BUCCAL        Supra periosteal (infiltration) Periodontal ligament inj. mesio buccal root of 1st molar) Anterior superior alveolar (infraorbital) nerve block • For Anterior teeth/Premolars/soft tissues .

MAXILLARY INJ TECHNIQUES PALATAL     Greater palatine nerve block • For teeth distal to canine Nasopalatine nerve block • For canine to canine bilaterally Anterior middle superior alveolar nerve block • For Anterior teeth Palatal anterior superior alveolar nerve block • For Anterior teeth .

1st molars (except mesio buccal root) • Buccal periostium and bone Technique difficult :no bony landmarks during Inj Target area • PSA nerve-posterior. 2nd .POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK    Areas anesthetized • max 3rd. • superior. and medial to the posterior border of the maxilla  Risk of hematoma .

TECHNIQUES OF MANDIBULAR ANESTHESIA .

BLOCKS        Inferior alveolar Incisive Gow – Gates Vazirani – Akinosi Mental Buccal Infiltration • Not effective / increased density of buccal cortical bone .

Lingual soft tissues   Positive Aspiration 10% to 15% Failure rate 15% to 20% . Ant 2/3rd tongue.INFERIOR ALVEOLAR NERVE BLOCK  Nerves anesthetized • Inf Alv. Incisive. Mental  Area anesthetized • Mand teeth. Lingual. Floor.

3/4th distance on the line from finger • It is 6 to 10 mm above occlusal plane .INFERIOR ALVEOLAR NERVE BLOCK -TECHNIQUE     25 g/ long / barrel towards bone Rt IANB – 8 o clock.Lt IANB – 10 o Clock Wide mouth opening Landmarks • Coronoid notch • Pterygomandibular raphe • Occlusal plane  Height/Antero posterior site of INJ • Place index / thumb in coronoid notch • An imaginary line from finger tip to pterygomandibular raphe • Needle insertion point.

deposit 0.5 ml in 60 sec For lingual nerve • With draw needle & at half way.1 ml  Labial numbness / lingual sulcus .INFERIOR ALVEOLAR NERVE BLOCK -TECHNIQUE  Penetration depth • Bone contact • Penetration up to 20-25 mm Bone contacted too soon – Tip anterior  Bone not contacted – Tip posterior      Withdraw needle – 1 mm Aspirate Deposit 1.

BUCCAL NERVE BLOCK  Buccal nerve • Ant branch of V3 • Sensory innervation to buccal soft tissues adj to molars • Not anesthetized in IANB  Insertion – Mucous membrane distal and buccal to last molar • Depth 1 to 2 mm  Deposit • 0.3 ml in 10 sec .

Mylohoid. Indications • Routine tech.GOW – GATES TECHNIQUE    Nerves Anesthetized • Inf Al.8 ml in 60 sec • Slow onset 5 min (thick nerve) . Auriculo temp. unsuccessful Inf Al block Technique • Wide mouth opening  condyle anteriorly positioned  comes close to mand nerve trunk • Target area – lateral side of condylar neck • Needle insertion  Distal to max 2nd molar at the height of mesoi palatal cusp  Parallel to a line connecting corner of mouth and intertragic notch  Depth 25 mm / Bone is contacted • Aspirate & deposit 1. Mental . Buccal. Ling. Incisive.

reflect soft tissue laterally Needle insertion • Bevel away from bone • Syringe parallel to max occlusal plane • Insert at height of mucogingival junction adjacent to max 3 rd molar • Depth 25 mm .8 ml in 60 sec . Mid of Pterygo mand space • Aspirate & Deposit 1. long .VAZIRANI – AKINOSI TECH (CLOSED MOUTH BLOCK)     Indications • Limited mouth opening • Inability to visualize landmark for IANB Nerves/Area anesthetized • Same as IANB Technique • 25 g. target Area – soft tissue on medial side of ramus • Finger/thumb on coronoid notch.

.MENTAL NERVE BLOCK   Terminal branch of IAN Sensory innervation – • Buccal soft tissues anterior to foramen • Lower lip. chin    Area of insertion – Mucobuccal fold until apices of ist & 2nd premolar Deposit 5 to 6 mm Deposit 0.6 ml.

INCISIVE NERVE BLOCK     Terminal branch of IAN Anesthetizes:. incisors & soft tissues In bilateral procedures:In Bilateral procedures • bilateral incisive nerve block for anesthetizing premolar to premolar area • Incisive nerve block on one side and IAN block on other side.Premolars. canine. .

SUPPLEMENTAL INJ TECHNIQUES   As a sole technique To supplement failed or partially successful traditional Inj Tech • Periodontal ligament injection • Intraosseous injection • Intra septal injection • Intra pulpal injection .

5 sec pressure–1/8 th of car.Duration 4555min Single tooth procedure Disadvantages • No numbness .Fails in long rooted teeth .within 30 sec.Pain full .tooth extrusion . one inj for each root    Rapid on set.INTRA LIGAMENTARY INJECTION • Technique • 27 gauge Needle –Gingival sulcus . Cartridge breakage .

pulp • By diffusion through marrow.PERIODONTAL LIGAMENT INJECTION  Area anesthetized • Bone. soft tissue. . quadrants If soft tissue anesthesia not required – children If block is contraindicated – haemophilics When rapid onset of action required. not period ligAvu  Indications • • • • • If pulpal anesthesia of one tooth required Anesthesia in two lower.

along interpoximal area Single rooted – mesial or distal side Multiple rooted – Both on mesial and distal sides • Deposit 0. primary teeth • Difficult needle placement • Breakage of glass needle – 2/3rd empty. tissue sloughing. extrusion  Technique • • • Long axis of tooth. • Effectiveness    Significant resistance Adjacent soft tissue ischemia Duration – 5 to 55 min for pulpal anesth . Disadvantages • Contra indicated in local infection. • Post injection discomfort.2ml in 20 sec. focal tissue damage.

45 angle to long axis over interdental papilla Contact with bone .INTRA SEPTAL INJECTION     Useful in providing osseous and soft tissue anesthesia For periodontal curettage/surgical flap elevation.

INTRAL PULPAL INJECTION      Absence of inadequate anesthesia from other technique Fit needle snugly into canals Resistance during solution delivery Separate injection for multiple canals Immediate action .

COMPLICATION OF LOCAL ANESTHESIA   Local complications Systemic complications .

LOCAL COMPLICATION          Needle breakage Persistent anesthesia or paresthesia Facial nerve paralysis Trismus Soft tissue injury.Lip Biting Burning on injection Infection – Leads to trismus Sloughing of tissues Post anesthetic intral oral lesions .

NEEDLE BREAKAGE     Fine needle for block.use 25 gauge Needle bending & redirection Needle insertion up to hub Sudden patient movement .

rare Haematoma leading to nerve compression Neurotoxic effect of LA eg 4% prilocaine . sterilizing soln Trauma to nerve .PARESTHESIA     LA Contamination by alcohol .

FACIAL NEVER PARALYSIS   Inj in deep lobe of parotid gland In infra orbital nerve block – Injury to terminal branches – Muscle droop .

mycotoxic effect of LA Heat therapy . low grade infection.TRISMUS  Injection in • medial ptrygoid muscle • infra termporal fossa   Hamorrhage . Muscle relaxant . . NSAID . physiotherapy antibiotics if not improved in 48 hrs.

HAEMATOMA    Injury / prick to a vessel Haematoma formation untill hydrostatic pressure difference Swelling – intra oral in IAN block • Extra oral in PSAN block  Causes trismus/Pain .

BURNING SENSATION     Reduced PH of soln Rapid injection of LA Contamination of soln Warmer soln .

TISSUE SLOUGHING EPTHELIAL DESQUAMATION / STERILE ABSCESS     Topical anesthetics Secondary to prolong ischemia (epinephrine) Seen in palatal tissue Symptomatic treatment – recovery 7-10 days .

POST ANESTHETIC INTRA ORAL LESIONS   Recurrent apthous stomatitis (Apthous ulcers) Herpes simplex .

SYSTEMIC COMPLICATION   Unwanted effects due to LA agent Unwanted effects not due to LA agent .

headache . muscular twitching . vomitting sweating . convulsion  Depression of medulla • Resp centre – resp depression • Vasomotor centre depression – BP falls . nausea . loss of consciousness • Cardio vascular system (intra vascular inj)  Heart • Cardiac depression – Cardiac arrest  Vascular bed • Peripheral vasodilatation – BP Falls . visual disturbances . confusion .UNWANTED EFFECTS DUE TO LA AGENT  In normal individuals (Type A reaction) • CNS  Stimulation of cerebral cortex • Apprehension. excitability .

 In abnormal individuals • Drug Allergy (Hypersensitivity) • Idio syncrasy Unexpected response of drug differing from its pharmacological action  Fever. uriticaria . anaphylaxis  Photo sensitivity  . angioodema . dermatitis .

UNWANTED EFFECTS NOT DUE TO LA    Psychomotor Drug Interaction Vaso pressor effects • Local effects  Vaso constriction (initial) • Pallor • Local cyanosis  Later – Reactive Hyperemia • Increased risk of post op bleeding • General effects (inj in vein/raping absorption)  Tachycardia (palpation)  Apprehension  BP increased • Metabolic effects  Increased blood glucose level  Decrease K levels .