PrinciplesofAnesthesiology VMED5267 Localanesthesia

Dr.AndersondaCunha,D.V.M.,M.Sc. Adacunha@vetmed.lsu.edu Oce#3413

History
1stCocaine Thecompany(ParkeDavis,1885)promisedthatitscocaineproducts

wouldsupplytheplaceoffood,makethecowardbrave,thesilent eloquentand...renderthesuererinsensitivetopain.

WilliamHalstedrstbrachialplexusblock
in1885thetechniqueinvolvedsurgicalexposureoftheofBrachialPlexuswithdirect
applicationofcocaine

History
1884Dr.KollerforConjunctivalsac Dr.SigmundFreudberCoca 19011914Prohibition
Toxicityandaddictiveproperties

History

1905Procaine(Novocaine)
lessaddictiveandtoxiceects Prolongedonsetandlowpotency

1943Lidocaine
Shortperiodofonset

Mepivacaine
Slightlylesstoxic

Bupivacaine
4xaspotentaslidocaine

Localanesthe=chowdotheywork?
Groupofdrugsthatreversiblyblockthepropagationofaction potentialsalongnerveaxons Theprimaryactionisinterferencewithvoltagegatedsodium channels Theyslowtherateofdepolarizationsothatthresholdpotentialis notreached Theydonotaltertherestingtransmembranepotentialor thresholdpotential.

Mechanismofac=on
Donotalterrestingtransmembranepotential
(orthresholdpotential)

Slowdowntherateofdepolarization Thresholdpotentialisnotreached Impulsecannotbepropagated Conductionisblocked

Localanesthe=chowdotheywork?
Diusionintothenerve Sodiumchannelblockers Lipidsolubilitypotency Concentrationonsettimeandblockintensity pKathehigherthepKatheslowertheonsettime ProteinBindingdurationofaction

Reasonsforregionalandlocalanesthesia
Dorsalhornwindup Preemptiveanalgesia stressresponse MACsparing Avoiduseofsystemicanalgesics Postoperativeanalgesia

 OphthalmicProparacaine LaryngealLidocaine

Topicalaplica=on

TopicalPrilorcaine+Lidocaine(EMLA)

Onset
Lidocaine510min Mepivacaine510min Bupivacaine1520min Ropivacaine515min

Dura=on
12h 22.5h 2.56h 2.54h

SpeedofOnset
Localanestheticonset=
1 1 _______ = ______ Solubility pKa

UnchargednonionizedformareresponsibleforMbpermeability pKa
ifadrughaspKalowerthantissuepHtheonsetwillbeshorter ItpenetratesanddiusesaroundtheAdeltaberseasier producinggoodmotorblock

Dura=on
Potency

Lipidsolubility

Theorderoflocalanesthesiais:
Adelta>Aalpha>Abeta>Cbers

Factorsinuencinganesthe=cac=vity
Dose=ecacy,fasteronset,duration,toxicity
Volume=onset,density Concentration=onset,density 10mlof2%lidocaineepiduralproducesmoreintense

blockadethan20mlof1%lidocaine

Lidocaine
Localanesthesia Systemicanalgesia MACsparingeect Opioidsparingeectupto72Hours Antiarrhythmogenic Freeradicalsscavenging GImotility Antiinammatory Antiendotoxemia Decreasecellularapoptosisintheliverandkidneys

Adverseeects
Localsitereaction Centralnervoussystem Cardiovascularsystem Nerveinjury
Needleinduced Druginduced

Allergicreactionmethylparaben Methemoglobinemia

CNSToxicity
Largebloodvessels(epidural) CNStoxicitysymptomsusuallyoccurbefore

cardiovasculartoxicity

Seizureactivitybenzodiazepine+oxygen

CardiovascularToxicity
Directlyaectingthemyocardium,andthereforeinducingcardiac arrhythmias. Vasodilationhypotension Decreasedventricularcontractility,decreasedconductionof myocardium,lossofperipheralvasomotortonecardiacarrest Treatmentsmainlyfocusonsupportingcardiovascularfunction, includinguids,CPR,oxygen,untilthedrugismetabolized.

Toxicdosage
Lidocaine10to20mg/kg Bupivacaine2to3mg/kg
USEORLESSTHANTOXICDOSAGE

Catsaremoresensitivethandogs Birdsaremoresensitivethancats

Otheruses
Antiarrhythmicproperties Lidocaine Eectiveincontrolingmostventriculararrhythmias (VPC,Vtach)

Regionalanesthesia Legs
Epidural BrachialPlexusBlock Ringblock Pawblock

Useepiduralfor:
Caudalsurgery
Tailamputation Perianalsurgery Rearlimbsurgeries

Abdominalsurgery
Cesariansection

Urogenitalsurgery Thoracicsurgery(neuraxialanalgesia)

Epidural

AdaCunha

Muir & Hubbel, 2000.

AdaCunha

Donotuseepiduralif:
Absolute
Systemicorlocalinfection Bloodwithdraw Allergies(localanestheticsoropioids) Coagulopathies

Relative
Hemodynamicallyunstable Pelvicfracture

Epidural
Drugprotocol
Bupivacaine(5mg/ml)use0.2ml/kg Morphinepreservativefree0.1mg/kg Dependingonconcentrationofmorphinethetotalvolumeof

bupivacainewillchangetohave:

maximumTotalvolume
0.2ml/kg

Sterileprocedure
Clipping,scrub,surgicalgloves

Spinalneedle22G;1.5or2.5

Conrma=on
Lossofresistance
Airorsaline Hangingdrop Bubblecompression

Nerveirritation Radiography Analrelaxation Blood,CSF

Adverseeects
Hypotension Hypoventilation Pruritus Sedation

Complica=ons
Duralpuncturesubarachnoidinjection Venouspuncture Retentionofurine Infection Neurologicalsequelae

BrachialPlexusBlock

BrachialPlexusBlock

BrachialPlexusBlock

Avianbrachialplexus

BrachialPlexusBlock

BrachialPlexusBlock

BrachialPlexusBlock

BrachialPlexusBlock

BrachialPlexusBlock

Stop!
Bloodorairwithdraw

Nervender

 movie

Noblockeverfails, somejusthavetobesupplemented morethanothers

Anesthesiafordeclaw
Carpal pad Ulnar nerve Medial nerve

Dorsal branch

Radial nerve

Anesthesiafordeclaw

Facialblocks

AdaCunha
Muir & Hubbel, 2000.

Regionalanesthesia HEAD

Infraorbital

Muir & Hubbel, 2000.

Upperlipandnose

Upperlipandnose

Upperlipandnose

Lowerlipblock

Mentalnerveblock

Mandibularnerveblock

Mandibularnerveblock

Mandibularnerveblock

Mandibularnerveblock

Mandibularnerveblock
Cheekteeth,canine,

incisors,skinand mucosaofthechinand lowerlip.

Intercostalnerveblock

Intercostalnerveblock

Intercostalnerveblock

Intercostalnerveblock

Interpleuralregionalanesthesia

Interpleuralregionalanesthesia

Conclusion
Veryeective Littlesideeects Lowcost Relativelyeasy

Ques=ons???

Thank you!!!

Dr.SigmundFreudberCoca
...exhilarationandlastingeuphoria,whichinnoway

diersfromthenormaleuphoriaofthehealthy person...Youperceiveanincreaseofselfcontroland possessmorevitalityandcapacityforwork....Inother words,youaresimplynormal,anditissoonhardto believeyouareundertheinuenceofanydrug....Long intensivephysicalworkisperformedwithoutany fatigue...Thisresultisenjoyedwithoutanyofthe unpleasantaftereectsthatfollowexhilaration broughtaboutbyalcohol....Absolutelynocravingfor thefurtheruseofcocaineappearsaftertherst,or evenafterrepeatedtakingofthedrug...

Cm(minimumconcentra=on)
AnalogoustoMAC EachlocalanesthetichasitsuniqueCm
potencyofdrugs

FactorsdecreasingCm
Nervebersdiameter

Smallerbersrequirelessdrug

HigherpH Highfrequencyofstimulationofanerve Lessmyelin

Less[]forasubarachnoidinjection