MODALITAS

1. Nerve Stimulator

• Commonly used method for localizing nerves before the injection of local
anesthetic
• Electrical nerve stimulation in regional anesthesia is a method of using a low-
intensity (up to 5 mA) and short-duration (0.05-1 ms) electrical stimulus (at 1-
2 Hz repetition rate) to obtain a defined response (muscle twitch or
sensation) to locate a peripheral nerve or nerve plexus with an (insulated)
needle
• The goal is to inject a certain amount of local anesthetic in close proximity to
the nerve to block nerve conduction and provide a sensory and motor block
for surgery and/or, eventually, analgesia for pain management.
• The use of nerve stimulation can also help to avoid an intraneural
intrafascicular injection and, consequently, nerve injury
 Anatomy femoral nerve
• The femoral nerve is formed within the psoas major muscle by
the posterior divisions of L2 to L4, emerges from the lateral
border of that muscle, and descends in the groove between the
psoas and iliacus muscles
• It enters the thigh lateral to the femoral artery and divides into
anterior and posterior branches distal to the inguinal ligament
• The femoral nerve supplies the anterior compartment muscles of
the thigh (quadriceps, sartorius) and skin of the anterior thigh
from the inguinal ligament to the knee
• Below the knee, it supplies sensation to the medial side of the
leg, extending to the big toe in the distribution of the saphenous
nerve
 CLINICAL PHARMACOLOGY
• Clinically, the order of loss of nerve function is as follows: (1) pain, (2) temperature, (3) touch,
(4) proprioception, and (5) skeletal muscle tone

• Systemic absorption of local anesthetics produces effects on the cardiovascular and central
nervous systems (CNS). At blood concentrations achieved with normal therapeutic doses,
changes in cardiac conduction, excitability, refractoriness, contractility, and peripheral
vascular resistance are minimal

• In addition, myocardial contractility is depressed and peripheral vasodilation occurs, leading

to decreased cardiac output and arterial blood pressure

• Following systemic absorption, local anesthetics can produce central nervous system
stimulation, depression, or both

• Apparent central stimulation is manifested as restlessness, tremors and shivering progressing

to convulsions, followed by depression and coma progressing ultimately to respiratory arrest
 Mechanisms of Action
• Na channels are membrane-bound proteins that are composed of one large α subunit,
through which Na ions pass, and one or two smaller β subunits
• Voltage-gated Na channels exist in (at least) three states—resting (nonconducting), open
(conducting), and inactivated (nonconducting)
• Local anesthetics bind a specific region of the α subunit and inhibit voltage-gated Na channels, preventing channel
activation and inhibiting the Na influx associated with membrane depolarization – does not alter the resting
membrane potential.

• As a consequence, impulse conduction slows, the rate of rise and the magnitude of the action potential decrease, and
the threshold for excitation and impulse conduction increases progressively.

• At high enough local anesthetic concentrations and with a sufficient fraction of local anesthetic-bound Na channels,
an action potential can no longer be generated and impulse propagation is abolished.

• Local anesthetic binding to open or inactivated channels, or both, is facilitated by depolarization. The fraction of Na
channels that have bound a local anesthetic increases with frequent depolarization (eg, during trains of impulses)

• This phenomenon is termed use-dependent block

• Put another way, local anesthetic inhibition is both voltage and frequency dependent, and is greater when nerve
fibers are firing rapidly than with infrequent depolarizations

• Clinically, the order of loss of nerve function is as follows: (1) pain, (2) temperature, (3) touch, (4) proprioception, and
(5) skeletal muscle tone
 Pharmacokinetics
• Pharmacokinetic studies on the plasma profile of MARCAINE
after direct intravenous injection suggest a three-compartment
open model. The first compartment is represented by the
rapid intravascular distribution of the drug. The second
compartment represents the equilibration of the drug
throughout the highly perfused organs such as the brain,
myocardium, lungs, kidneys, and liver. The third compartment
represents an equilibration of the drug with poorly perfused
tissues, such as muscle and fat. The elimination of drug from
tissue distribution depends largely upon the ability of binding
sites in the circulation to carry it to the liver where it is
metabolized.
• may last 2 or 3 times longer than lidocaine
and mepivacaine for dental use, in many
patients up to 7 hours. The duration of
anesthetic effect is prolonged by the addition
of epinephrine 1:200,000.
•
Adverse Reactions
Central Nervous System Reactions
– : These are characterized by excitation and/or depression. Restlessness, anxiety, dizziness, tinnitus, blurred vision, or
tremors may occur, possibly proceeding to convulsions. However, excitement may be transient or absent, with
depression being the first manifestation of an adverse reaction. This may quickly be followed by drowsiness merging
into unconsciousness and respiratory arrest. Other central nervous system effects may be nausea, vomiting, chills,
and constriction of the pupils.
• Cardiovascular System Reactions: High doses or unintentional intravascular injection may lead to high
plasma levels and related depression of the myocardium, decreased cardiac output, heartblock,
hypotension, bradycardia, ventricular arrhythmias, including ventricular tachycardia and ventricular
fibrillation, and cardiac arrest.
• Allergic: Allergic-type reactions are rare and may occur as a result of sensitivity to the local anesthetic or to
other formulation ingredients, such as the antimicrobial preservative methylparaben contained in multiple-
dose vials or sulfites in epinephrine-containing solutions. These reactions are characterized by signs such
as urticaria, pruritus, erythema, angioneurotic edema (including laryngeal edema), tachycardia, sneezing,
nausea, vomiting, dizziness, syncope, excessive sweating, elevated temperature, and possibly,
anaphylactoid-like symptomatology (including severe hypotension). Cross sensitivity among members of
the amide-type local anesthetic group has been reported. The usefulness of screening for sensitivity has
not been definitely established.
• Neurologic: Neurologic effects following epidural or caudal anesthesia may include spinal block of varying
magnitude (including high or total spinal block); hypotension secondary to spinal block; urinary retention;
fecal and urinary incontinence; loss of perineal sensation and sexual function; persistent anesthesia,
paresthesia, weakness, paralysis of the lower extremities and loss of sphincter control all of which may
have slow, incomplete, or no recovery; headache; backache; septic meningitis; meningismus; slowing of
labor; increased incidence of forceps delivery; and cranial nerve palsies due to traction on nerves from loss
of cerebrospinal fluid. Neurologic effects following other procedures or routes of administration may
include persistent anesthesia, paresthesia, weakness, paralysis, all of which may have slow, incomplete, or
no recovery
 STRUCTURE ACTIVITY
RELATIONSHIPS

• Local anesthetics consist of a lipophilic group (usu- ally an

aromatic benzene ring) separated from a hydrophilic group
(usually a tertiary amine) by an intermediate chain that includes
an ester or amide linkage.
• Local anesthetics are weak bases that usually carry a positive
charge at the ter- tiary amine group at physiological pH.
• The nature of the intermediate chain is the basis of the classifi-
cation of local anesthetics as either esters or amides
• Physicochemical properties of local anesthetics depend on the
substitutions in the aro- matic ring, the type of linkage in the
intermediate chain, and the alkyl groups attached to the amine
nitrogen.
• The patients requiring emergency or urgent lower limb amputation due to poor
circulation usually present with cellulitis, sepsis, multi-organ dysfunction, and
comorbid conditions

– Neuraxial blocks are precluded because of coagulopathy, systemic infection, and hemodynamic
instability
– General anesthesia can be catastrophic due to profound hypotension and myocardial depression
at induction. These patients almost always required mechanical ventilation postoperatively for
tachypnea and respiratory compensation.
• Neuraxial anesthesia (spinal and epidural) may lead to hypotension due to
sympathetic blockade and deteriorate the already compromised cardiovascular
function that will be difficult to reverse.

• Use of peripheral nerve blocks for below knee amputation (BKA) have advantage of
cardiovascular stability and pain relief intra- and postoperatively
• Local and regional anesthesia and analgesia
techniques depend on a group of drugs—local
anesthetics—that transiently inhibit sensory,
motor, or autonomic nerve function, or a
combination of these functions, when the
drugs are injected or applied near neural
tissue.
• Bupivacaine & Adrenaline Injection 0.25% w/v,
1 in 200,000. Each 10ml of this solution
contains 25mg of anhydrous bupivacaine
hydrochloride and 50 micrograms of
adrenaline.
• Teknik anestesi PNB dipilih sebagai salah satu usaha dari dokter anestesi untuk menjaga stabilitas
dari hemodinamik terutama hipotensi dan meningkatkan mobilisasi postoperatif

• Teknik ini dapat dilakukan dengan Ultrasond Guided Regional Anesthesia (UGRA), Peripheral Nerve
Stimulator (PNS) dan digabung seperti pada kasus ini  menurunkan risiko terjadinya Local
Anesthetic Systemic Toxicity (LAST)

• Kelebihan dari PNB adalah kualitas analgesia setara dengan epidural dengan efek samping lebih
ringan dan superior dari opioid, menurunkan risiko instabilitas hemodinamik dan retensi urin, dan
mempertahankan kekuatan kaki kontralateral sehingga dapat membantu rehabiltasi postoperatif

• Kekurangan dari PNB adalah kerusakan dari saraf, post block paresthesia, LAST dan hematoma
retroperitoneal

• Pada pasien ini perlu diberikan MIDAZOLAM dikarenakan pasien gelisah. Ini merupakan kekurangan
dari PNB, dimana suara mesin saat operasi dan guncangan dapat membuat pasien merasa gelisah
dan terganggu