LOCAL

ANESTHETICS

Dr Akasha Ambar Awan

PGR Plastic Surgery

(1st YEAR)
DEFINITION OF LOCAL
ANESTHESIA
 STRUCTURE
• Aromatic moiety
• Intermediate chain
• Amine amoiety
CLASSIFICATION OF LOCAL ANESTHETICS
Esters Am”i”des

Procaine (Novacaine) L”i”docaine

Chloroprocaine Bup”i”vacaine (Marcaine)

Tetracaine Pr”i”locaine

Cocaine Mep”i”vacaine,
Et”i”docaine
PHARMACOLOGY OF LOCAL
ANESTHETICS
 PHARMACOLOGY OF LOCAL
ANESTHETICS
Properties:
esters amides

Hydrolyzed by plasma Metabolized in liver

Pseudochilnesterase

Unstable in solution Stable in solution

Likely to cause allergenic Not allergic

reactions

*Vasodilating property (except cocaine)

 Maximum Dose Duration
Drug Onset (with Epinephrine) (with Epinephrine)

Lidocaine 10-20 min 4.5 mg/kg (7 mg/kg) 120 min (240 min)

Mepivacaine 10-20min 5 mg/kg (7 mg/kg) 180 min (300 min)

Bupivacaine 15-30min 2.5 mg/kg (3 mg/kg) 360-720 hours (8 h)

Procaine Rapid 8 mg/kg (10 mg/kg) 45 min (90 min)

Chloroprocaine Rapid 10 mg/kg (15 mg/kg) 30 min (90 min)

Etidocaine 10-20min 2.5 mg/kg (4 mg/kg) 360-720min (8 h)

Prilocaine 10-20min 5 mg/kg (7.5 mg/kg) 180-300min (360 min)

Tetracaine 20-30min 1.5 mg/kg (2.5 mg/kg) 300-600min (10 h)

 ORDER OF BLOCKADE
• The order of blockade:

Pain –> temperature – > postural, touch and

pressure and vibration – > motor fibres.

Tongue: bitter –> sweet –> sour –> salt

AN IDEAL LOCAL
ANESTHETIC
• Reversible action.
• Non-irritant.
• No allergic reaction.
• No systemic toxicity.
• Rapid onset of action.
• Sufficient duration of action.
• Potent.
• Stable in solutions.
• Not interfere with healing of tissue.
• Have a vasoconstrictor action or compatible with VC.
• Not expensive
ADDITION OF VASOCONSTRICTOR
(EPINEPHRINE)
• Why do we need to add???
▫ Clear field & hemostasis
▫ Prolonged action by limiting systemic drug
absorption
▫ Lower risk of toxicity/ and intravascular
injection
EPINEPHRINE WITH LOCAL
ANESTHETIC
• The dilution of vasoconstrictors referred to as a ratio i.e.,
1:50,000; 1:100,000; 1:200,000 etc,…
• A concentration of 1:1,000 means :
▫ 1 gram(1000 mg) of solute (drug) contained in 1000 ml (1 L) of
solution, therefore, 1:1,000 dilution contains 1000 mg in 1000 ml or
1.0 mg/ml of solution (1000 ug/ml)
• 1:1,000 is very concentrated (strong)
• much more dilute forms: for example, 1:50,000 > 1:100,000 > 1:200,000
• (1:100,000 = 0.01 mg/1 ml of solution)
• The maximum amount of 2% Lidocaine 1:100,000 epinephrine
that can be used is 300 mg which is 8.3 cartridges regardless of the
patient’s weight.
 CONTRAINDICATIONS OF LOCAL
ANESTHETICS WITH
VASOCONSTRICTOR
• Hypertension
• Coronary heart disease
• Arrythmias
• Already using MOA

• Epinephrne+local anesthetic solution should not used

in
proximity to end arteries
▫ (fingers,toes,penis,nose tip,ear lobules)
 SIDE EFFECTS
• Allergic effects
▫ Esters, epinephrine
• CNS toxicity
▫ At lower toxic dose, easily cross BBB
▫ initial excitatory effects on body & CVS
 ( tinnitus, light headedness, tremors,slurred speech, audiovisual
disturbance, metallic taste, numb lips and tongue)
▫ At more high doses: Grandmal seizures and later CNS
depression
• CVS toxicity
▫ Hypotension,arrythmias, myocardial depression
TYPES OF LOCAL
ANESTHESIA

• Topical anesthesia
• Local infilteration
• Peripheral nerve blocks
• Tumescent technique
TOPICAL/SURFACE ANESTHESIA

• Uses :
▫ Oral surgeries, nasal intubation, superficial surgical
procedure
• Advantages :
▫ technically easy
▫ minimal equipment
• Disadvantages :
▫ potential for large doses leading to toxicity
 COCAINE SUBSTITUTIONS

• lidocaine (Xylocaine) -oxymetazoline

(Afrin) combinations.
• tetracaine (pontocaine)-oxymetazoline
(Afrin) combinations.
• Tetracaine (pontocaine) (1%-2%).
• Lidocaine (Xylocaine) (2%-4%).
• benzocaine
TOPICAL ANESTHETIC SPRAY
 COMBINATION OF LOCAL
ANESTHETICS
Definition: eutectic mixture of local anesthetics
(EMLA) . ( lowest melting point)
 LOCAL INFILTERATION/FIELD
ANESTHESIA

• Uses:
▫ Suturing, minor superficial surgery, line placement, more
extensive surgery with sedation
• Advantages:
▫ minimal equipment, technically easy, rapid onset
• Disadvantages:
▫ potential for toxicity if large field
PERIPHERAL NERVE BLOCK

• Minor nerve block

• Major nerve block
▫ Plexus block
▫ i.v.block e.g. beir
block
 I.V BLOCK/BIER BLOCK

• Uses
▫ any surgical procedure on an extremity
• Advantages:
▫ technically simple, minimal equipment, rapid onset
• Disadvantages:
▫ duration limited by tolerance of tourniquet pain,
toxicity
 Minor nerve block
•Injecting local anesthetic near the
course of a named nerve
•Uses:
• Surgical procedures in the
distribution of the blocked nerve
•Advantages:
• relatively small dose of local
anesthetic to cover large area;
rapid onset
•Disadvantages:
• technical complexity,
neuropathy
 PLEXUS BLOCKAGE
• Injection of local anesthetic adjacent to a plexus,
e.g cervical, brachial or lumbar plexus
• Uses :
▫ surgical anesthesia or post-operative analgesia in
the
distribution of the plexus
• Advantages:
▫ large area of anesthesia with relatively large dose of
agent
• Disadvantages:
▫ technically complex, potential for toxicity
and neuropathy.
 TUMESCENT TECHNIQUE
• Large volumes of local anesthetic lidocaine (0.05%-1%) with
diluted EPI (1:500,000 to 1:1,000,000) for both anesthetic
and hemostatic effects.
• Safe technique,less toxicity levels, tissue plane for dissection
• For example, a mixture of 1000 mL of normal saline with 25 mL
of 2% lidocaine,I g/ml adrenaline will result in a concentration
of lidocaine upto .05%,adrenaline in 1:1000,000.
• maximum dose of lidocaine with epinephrine=7 mg/kg
during routine use. However, when used for tumescence
during liposuction, this ceiling is dramatically increased to
35 mg/kg (others report up to 55 mg/kg)
 Recipe for Tumescent Technique Anesthetic Solutions
for Body Liposuction

• (Lidocaine 0.05%, Epinephrine 1:1,000,000

Lidocaine: 500 mg (50 ml of 1% lidocaine

solution)
Epinephrine: 1 mg (1 ml of 1:1,000 solution of
epinephrine)
Sodium bicarbonate: 12.5 mEq (12.5 ml of an
8.4%
NaH2CO3 solution
Normal saline: 1000 ml of 0.9% NcC1 solution
 Typical Range of Volumes of Dilute Anesthetic Solutions
Used with the Tumescent Technique for Infiltration into
Various Areas

Abdomen, upper and lower (800 to 2000 ml)

Hip (flank, or love handle), each side (400 to 1000 ml)

Lateral thigh, each side (500 to 1200 ml)

Anterior thigh, each side (600 to 1200 ml)
Proximal medial thigh, each side (250 to 600 ml)

Knee (200 to 500 ml)

Male breast, each side (400 to 800 ml)

Submental chin (100 to 200 ml)
THANK YOU