Systemic Complications Systemic Complications Of Local AnesthesiaOf Local Anesthesia   

By :- Ahmed Amer Ibraheem

Under the supervision of Dr. Emad Hamoody Abdulla

Tikrit university

Collage of dentistry

ComplicationsComplications

ComplicationsComplications :- Any deviation from the :- Any deviation from the normally expectednormally expected pattern during or after pattern during or after securing localsecuring local analgesia  analgesia 

ClassificationsClassifications Primary or SecondaryPrimary or Secondary Mild or SeverMild or Sever Transient or PermanentTransient or Permanent Attributed to solution or needle insertion Attributed to solution or needle insertion

Complications from local Complications from local AnesthesiaAnesthesia

I. Complications associated to the I. Complications associated to the absorption of the solution used absorption of the solution used

II. Complications associated with needle II. Complications associated with needle insertion insertion

Complications associated with Complications associated with absorption of the anesthetic absorption of the anesthetic solutionsolution

1 Systemic reactions due to the local anesthetic 1 Systemic reactions due to the local anesthetic agent:agent:

1. Toxicity1. Toxicity 2. Allergy 2. Allergy 3. Anaphylactic reactions3. Anaphylactic reactions 4. Idiosyncrasy4. Idiosyncrasy 5. syncope and fainting5. syncope and fainting 6. pregnancy 6. pregnancy 7. Hypertension7. Hypertension

2. Local reactions:2. Local reactions: 11 ..Infections due to contaminated solutions Infections due to contaminated solutions 2. Local t issue irri tation  2. Local t issue irri tation 

Complications associated with Complications associated with needle insertionneedle insertion

( local complication )( local complication )1. Fainting and syncope1. Fainting and syncope2. Muscle trismus2. Muscle trismus3. Pain3. Pain4. Edema4. Edema5. Infection5. Infection6. Broken needles6. Broken needles7. Prolonged anesthesia7. Prolonged anesthesia8. Haematoma formation8. Haematoma formation9. Sloughing and ulceration9. Sloughing and ulceration10. Bizarre Neurological symptoms 10. Bizarre Neurological symptoms

Keep in mindKeep in mind

A: Airway » Clear » Adequate RespirationA: Airway » Clear » Adequate RespirationB: Bleeding » Stopped » Achieve inlet to B: Bleeding » Stopped » Achieve inlet to

vesselsvesselsC: Circulation » Fluids if neededC: Circulation » Fluids if neededD: Drugs to treat the present condition  D: Drugs to treat the present condition 

Keep in mindKeep in mind• • Call medical emergency serviceCall medical emergency service• • The patient position – Placed in horizontal position on his The patient position – Placed in horizontal position on his

back – Tilt the patient in a slightly head down position or back – Tilt the patient in a slightly head down position or – elevate the legs to help increase cerebral circulation– elevate the legs to help increase cerebral circulation

• • Adequate oxygenationAdequate oxygenation•• Check the patients cardiac and cardiovascular status•Check the patients cardiac and cardiovascular status• Start I.V. fluids (e.g. 5% dextrose in H2O)•Start I.V. fluids (e.g. 5% dextrose in H2O)• Drugs according to the condition•Drugs according to the condition• If complete circulatory standstill – IV injection of atropine – If complete circulatory standstill – IV injection of atropine –

Stimulation of the heart by introducing a needle directly Stimulation of the heart by introducing a needle directly into it – Intracardiac injection of epinephrine 0.1 ml of into it – Intracardiac injection of epinephrine 0.1 ml of 1.1000 solution  1.1000 solution 

Complications due to absorption of Complications due to absorption of the injected solutionthe injected solution

– Systemic complications Systemic complications 1. Toxicity1. Toxicity 2. Idiosyncrasy 2. Idiosyncrasy 3. Allergy 3. Allergy 4. Anaphylaxis 4. Anaphylaxis 5. syncope and fainting5. syncope and fainting 6. pregnancy 6. pregnancy 7. Hypertension7. Hypertension

DefinitionDefinition• • EtiologyEtiology• • Clinically (Signs & Symptoms)Clinically (Signs & Symptoms)• • PreventionPrevention• • Treatment Treatment

ToxicityToxicity Definition It refers to the symptoms Definition It refers to the symptoms

manifested as a result of over dosage or manifested as a result of over dosage or excessive administration of the solution excessive administration of the solution 

  EtiologyEtiology• • Large dose of drugLarge dose of drug• • Accidental intravenous injectionAccidental intravenous injection• • High concentration of a drugHigh concentration of a drug• • Unusually slow detoxification as a result of Unusually slow detoxification as a result of

severe liver diseasesevere liver disease• • Slow elimination as a result of kidney troubleSlow elimination as a result of kidney trouble• • Use of highly toxic drugs whose margin of safety Use of highly toxic drugs whose margin of safety

is narrowis narrow• • Injection of solution in highly vascular area Injection of solution in highly vascular area

without the addition of vasoconstrictor without the addition of vasoconstrictor substance  substance 

ClinicallyClinically

I. Early C.N.S. stimulation symptomsI. Early C.N.S. stimulation symptoms (1)Cerebral Cortex (2)Medulla(1)Cerebral Cortex (2)Medulla

1. Talkative 1. Lethargy1. Talkative 1. Lethargy 2. Restlessness 2. Sleepiness2. Restlessness 2. Sleepiness 3. Apprehensive 3. Unconscious3. Apprehensive 3. Unconscious 4. Excited4. Excited 5. Convulsive  5. Convulsive 

II. Late C.N.S. Depression symptomsII. Late C.N.S. Depression symptoms (3)Cerebral Cortex (4)Medulla(3)Cerebral Cortex (4)Medulla1. Increased blood 1. 1. Increased blood 1. Dropped blood Dropped blood pressure pressurepressure pressure

2. Increase pulse rate 2. Decreased pulse rate 2. Increase pulse rate 2. Decreased pulse rate

3. Increase respiratory rate 3. decrease heart rate3. Increase respiratory rate 3. decrease heart rate4 Nausea & vomiting 4. Respiratory 4 Nausea & vomiting 4. Respiratory depression depression 5. Unconsciousness5. Unconsciousness

N.B. Death usually occur due to respiratory N.B. Death usually occur due to respiratory depression and hypoxia and its depression and hypoxia and its subsequent effect on the cardiovascular subsequent effect on the cardiovascular system  system 

PreventionPrevention

1. Pre-analgesic evaluation of the patient1. Pre-analgesic evaluation of the patient2. Use the weakest possible concentration2. Use the weakest possible concentration3. Use vasoconstrictor whenever possible3. Use vasoconstrictor whenever possible4. Use of the least possible volume4. Use of the least possible volume5. Aspirate before injection5. Aspirate before injection6. Slow injection6. Slow injection7. Monitor the patient carefully after injection  7. Monitor the patient carefully after injection 

TreatmentTreatment

• • Mild StimulationMild Stimulation– – No treatment No treatment – – Stop further injectionStop further injection• • Moderate stimulationModerate stimulation• • Convulsions phaseConvulsions phase• • Depression phase Depression phase

TreatmentTreatment

• • Mild StimulationMild Stimulation• • Moderate stimulation Moderate stimulation – – IV injection of BarbituratesIV injection of Barbiturates • • 0.2% solution of sodium thiopental0.2% solution of sodium thiopental • • Secobarbital (Seconal) Secobarbital (Seconal) – – Oxygen inhalationOxygen inhalation• • Convulsions phaseConvulsions phase• • Depression phaseDepression phase

TreatmentTreatment• • Mild StimulationMild Stimulation• • Moderate stimulationModerate stimulation• • Convulsions phase Convulsions phase – – Anticonvulsent IV / IMAnticonvulsent IV / IM • • Coramine (150-450 mg. I.V.) Coramine (150-450 mg. I.V.) • • Metrazol (100 mg I.V.) (Midazolam or Diazepam)Metrazol (100 mg I.V.) (Midazolam or Diazepam) • • Wyamine (7.5 mg I.V. or 15 mg I.M.) or neosynephrineWyamine (7.5 mg I.V. or 15 mg I.M.) or neosynephrine – – Oxygen inhalationOxygen inhalation• • Depression  Depression 

TreatmentTreatment

• • Mild StimulationMild Stimulation• • Moderate stimulationModerate stimulation• • Convulsions phaseConvulsions phase• • Depression phaseDepression phase– – Artificial Respiration Artificial Respiration – – IV fluids IV fluids – – Sympathmemetic drugs Sympathmemetic drugs

Vasoconstrictor ToxicityVasoconstrictor Toxicity

DefinitionDefinition EtiologyEtiology Clinically Clinically – – PalpitationPalpitation – – TachycardiaTachycardia – – HypertensionHypertension – – HeadacheHeadache – – ApprehensionApprehension – – Restlessness Restlessness – – N.B. Difficult to differentiate from those of L.A. AgentN.B. Difficult to differentiate from those of L.A. Agent

• • Prevention and treatment Prevention and treatment

IdiosyncrasyIdiosyncrasy   

DefinitionDefinition• • Abnormal reaction to a drug or group of drugs Abnormal reaction to a drug or group of drugs

exhibited when only a small amount or a exhibited when only a small amount or a nontoxic dose of the drug has been usednontoxic dose of the drug has been used

• • This means that the susceptible patient reacts This means that the susceptible patient reacts adversely to a volume or concentration of the adversely to a volume or concentration of the drug that would not affect the typical patientdrug that would not affect the typical patient

• • Nontoxic – Non Allergic condition  Nontoxic – Non Allergic condition 

EtiologyEtiology

• • UnknownUnknown• • EnzymopathyEnzymopathy – – Congenital Congenital – – AcquiredAcquired• • Psychogenic Psychogenic

ClinicallyClinically

1. Pallor1. Pallor2. Tachycardia2. Tachycardia3. Hypotension3. Hypotension4. Decreased Heart rate4. Decreased Heart rate5. Collapse 5. Collapse

    PreventionPrevention 1. Do not use any drug, which the patient 1. Do not use any drug, which the patient

gives you a history of previous gives you a history of previous reactions to itreactions to it

2. Inject slowly and observe the patient 2. Inject slowly and observe the patient closely during injectionclosely during injection

    TreatmentTreatment• • The same as the depression stage of The same as the depression stage of

toxic overdose• Barbiturates are toxic overdose• Barbiturates are ineffective in the treatment or ineffective in the treatment or prevention of this condition prevention of this condition

Allergy and Anaphylaxis Allergy and Anaphylaxis

  DefinitionDefinition• • Allergy is a hypersensitive reaction that occurs Allergy is a hypersensitive reaction that occurs

through exposure to an antigen (Ag) such as a through exposure to an antigen (Ag) such as a drug ( as L.A. agent) which the pt. has been drug ( as L.A. agent) which the pt. has been previously exposed to it creating an Ag - Ab previously exposed to it creating an Ag - Ab reactionreaction

• • Anaphylaxis is a severe form of allergic reactions Anaphylaxis is a severe form of allergic reactions occurs suddenly & end fatally in which sudden occurs suddenly & end fatally in which sudden violent loss of vasomotor tonus violent loss of vasomotor tonus

ClinicallyClinically

AllergyAllergy1. Rashes1. Rashes2. Urticaria2. Urticaria3. Fever3. Fever4. Dermatitis4. Dermatitis5. Angioneurotic edema5. Angioneurotic edema6. Bronchial asthma6. Bronchial asthma7. Anaphylaxis( anaphylactic shock) 7. Anaphylaxis( anaphylactic shock)

Angioedema

Urticaria (hives)

Clinically AnaphylaxisClinically Anaphylaxis

1. Drop in B.P. (↓B.P.)1. Drop in B.P. (↓B.P.)2. Weak rapid pulse2. Weak rapid pulse3. Inadequate respiration (↓Respiratory rate)3. Inadequate respiration (↓Respiratory rate)4. Death 4. Death

ManagementManagement

1. Antihistaminic (benadryl 20 - 40 mg IV or 1. Antihistaminic (benadryl 20 - 40 mg IV or IM.)IM.)

2. Epinephrine 1:1000 concentration 0.3 mg 2. Epinephrine 1:1000 concentration 0.3 mg SC. or IM.SC. or IM.

3. Bronchodilator via inhaler3. Bronchodilator via inhaler4. Corticosteroid 100mg IV. hydrocortisone 4. Corticosteroid 100mg IV. hydrocortisone

hemisuccinate hemisuccinate

Fainting or SyncopeFainting or Syncope• • It is due to temporary cerebral ischemia as a It is due to temporary cerebral ischemia as a

result of dilation of the splanchnic B.V. & result of dilation of the splanchnic B.V. & reduced cardiac outputreduced cardiac output

• • Signs &symptoms: Signs &symptoms: 1. Pallor 1. Pallor 2. Cold 2. Cold 3. Sweaty3. Sweaty4. Dizzy 4. Dizzy 5. Nausea 5. Nausea 6. Loss of consciousness 6. Loss of consciousness

ManagementManagement• • Stop dental procedureStop dental procedure• • Place pt. in supine position with slight head down or Place pt. in supine position with slight head down or

elevate the legs ( to ↑ cerebral circulation)elevate the legs ( to ↑ cerebral circulation)oror • • Place the hands of the pt. behind his head and bend him Place the hands of the pt. behind his head and bend him

forward until his head is in between the knee( to produce forward until his head is in between the knee( to produce pressure on the splanchnic B.V. to replace the blood that pressure on the splanchnic B.V. to replace the blood that drained from the headdrained from the head

• • Reassure pt. Reassure pt. • • Aromatic spirit (ammonia) held under the nose of the pt. Aromatic spirit (ammonia) held under the nose of the pt.

for several breath  for several breath 

PregnancyPregnancy Anesthesia crosses the placenta and could be Anesthesia crosses the placenta and could be

toxic to the fetus, but is not a known toxic to the fetus, but is not a known teratogenteratogen No drug should be administered during No drug should be administered during

pregnancy especially the pregnancy especially the firstfirst trimester trimester If treatment is necessary, local anesthetics with If treatment is necessary, local anesthetics with

epinephrineepinephrine are considered relatively safe for are considered relatively safe for use during pregnancy; check with patient’s use during pregnancy; check with patient’s physicianphysician

Educate patients to the potential Educate patients to the potential risksrisks (document)(document)

HypertensionHypertension StressStress and and anxietyanxiety may may

raise the patient’s raise the patient’s

blood pressure (>160/100) blood pressure (>160/100) Thorough Thorough medicalmedical, , dentaldental and and patientpatient history history Norepinephrine and levonordefrin should not be used Norepinephrine and levonordefrin should not be used

because of because of alphaalpha11 stimulationstimulation

(2% Mepivacaine with 1:20,000 levonordefrin)(2% Mepivacaine with 1:20,000 levonordefrin) Up to Up to twotwo cartridges of 2% lidocaine with 1:100,000 cartridges of 2% lidocaine with 1:100,000

epinephrine is safeepinephrine is safe

Contraindication for Local Contraindication for Local Anesthetic with EpinephrineAnesthetic with Epinephrine

UncontrolledUncontrolled hypertension hypertension Myocardial infarction (within Myocardial infarction (within 66 months) months) Unstable Unstable anginaangina Coronary artery bypass Coronary artery bypass graftgraft (> 3 months (> 3 months))

ReferenceReference

www.elhawarydentalclinic.comwww.elhawarydentalclinic.com Complications of local anesthesiaComplications of local anesthesiaby by Umm Al-Umm Al- QuraQura

University Faculty of Dentistry University Faculty of Dentistry on on Feb Feb 25, 201225, 2012