Lidocaine with adrenaline

FIGURE 9 Resolution calculated by ChemStation software between 1-adrenaline and d-adrenaline 3.0 between d-adrenaline and lidocaine 0.09 (with permission from reference 10). 

An iatrogenic tension pneumothorax was the result of breast infiltration with lidocaine and adrenaline before an augmentation procedure (SEDA-20, 127). 

Lidocaine with epinephrine (adrenaline) has a similar acid pH, but it is impossible to do a peel with lidocaine. Acidity is therefore not the only important parameter. 

Sedation plus FNB with lidocaine without adrenaline (epinephrine)... 

This is the best technique for doing a full-face phenol peel. The patient and the doctor are at ease, under the benevolent protection of the anesthetist. Applying phenol to the whole face is completely painless and the patient does not experience or remember any stress or pain. Sedation and intravenous analgesia make up for the speed of sensory recovery after FNB with lidocaine without adrenaline. 

Before a fuU-face phenol peel, the patient is always put on a drip, electrocardiographic monitoring, pulse oximeter and blood pressure monitor. The doctor has everything he needs at his disposal in case of any allergic, vagal or other reactions. Although bupivacaine, ropivacaine or mepivacaine can be employed for FNB, these products should not be used for the reasons set out above, and anesthesia should consist of FNB with lidocaine without adrenaline and with deep sedation. 

Cardiovascular Cardiac arrest has been reported after nasal infiltration with lidocaine and adrenaline in a patient with a hypophysoma and a previously undiagnosed hypertrophic cardiomyopathy [26 ]. This emphasizes that absorbed adjuncts, such as adrenaline, can be hazardous and should be considered in the differential diagnosis if hemodynamic instability occurs after infiltration of a local anesthetic with adrenaline. 

Infiltration anaesthesia is applied fan-shaped, with as few needle punctures as possible, in close proximity of the wound or the skin area to be treated. An aspiration should always take place to avoid intravascular injection. Suitable alternatives are lidocaine (lignocaine) or prilocaine for injection 5-10 mg/ml, with or without adrenaline. When making an incision of an abscess it is sometimes difficult to use a local anaesthetic if there is a pronounced inflammatory reaction, since the effect of the anaesthetic is reduced due to an increased acidity level. While adrenaline reduces bleeding and delays dispersion of the anaesthetic, local anaesthetic/adrenaline combinations are contraindicated for local anaesthesia of digits, on the face or where the skin survival is at risk. 

Lidocaine (synonyme lignocaine) was introduced as the first amide in 1944 and is the most commonly used LA today. It has a rapid onset of action with intermediate duration and an intermediate toxicity. The maximum tolerated dose with infiltration or injection is 200 mg (500 mg when combined with adrenaline). Lidocaine is dealkylated in the liver to monoethylglycine xylidide and glycine xylidide which retain local anesthetic activity. It is available in a variety of preparations including creams, gels, patches and solutions, often in combination with adrenaline. 

Clinical use Because of its poor penetration of intact mucous membranes, procaine is largely ineffective for topical applications and has been mainly used in injection in combination with adrenaline, although in general it has been replaced by other LAs such as lidocaine. For infiltration anesthesia, 0.25 to 0.5 % solutions of procaine have been used in doses up to 600 mg. For peripheral nerve block, a common dose of 500 mg of procaine has been given as a 0.5 to 2.0 % solution. 

Clinical use Tetracaine is employed by ophthalmologists for surface anesthesia as a 0.5 % solution and by endoscopists for anesthesia of mucous membranes including airways as a 2.0 % solution. For topical anesthesia, a 4.0 % cream of tetracaine can also be used, which is, however, less effective than a lidocaine/prilocaine cream in preventing venipuncture-induced pain in children (van Kan et al., 1997). A combination of tetracaine with adrenaline and cocaine (TAC) is widely used for repair of... 

A 28 year-old woman with Kearns-Sayre Syndrome, previously exposed multiple times to lidocaine, underwent planned tooth extraction after injection of articaine 1.5 ml (60 mg) with adrenaline (0.009 mg) (168). Within 5 minutes she complained of a feeling of heat, fatigue, weakness, and a desire to sleep. She was unable to walk or stand and had frequent urination. At 20 hours after the injection she had diffuse weakness, reduced tendon and absent patellar reflexes, and sub-clonic Achilles tendon reflexes. She recovered fully 48 hours after the injection. 

LIDOCAINE BETA-BLOCKERS 1. Risk of bradycardia (occasionally severe), l BP and heart failure with intravenous lidocaine 2. Risk of lidocaine toxicity due to T plasma concentrations of lidocaine, particularly with propranolol and nadolol 3. t plasma concentrations of propranolol and possibly some other beta-blockers 1. Additive negative inotropic and chronotropic effects 2. Uncertain, but possibly a combination of beta-blocker-induced 1 hepatic blood flow (due to 1 cardiac output) and inhibition of metabolism of lidocaine 3. Attributed to inhibition of metabolism by lidocaine 1. Monitor PR, BP and ECG closely watch for development of heart failure when intravenous lidocaine is administered to patients on beta-blockers 2. Watch for lidocaine toxicity 3. Be aware. Regional anaesthetics should be used cautiously in patients with bradycardia. Beta-blockers could cause dangerous hypertension due to stimulation of alpha-receptors if adrenaline is used with local anaesthetic... 

The effect of a local anaesthetic is terminated by its removal from the site of application. Anything that delays its absorption into the circulation will prolong its local action and can reduce its systemic toxicity where large doses are used. Most local anaesthetics, with the exception of cocaine, cause vascular dilation. The addition of a vasoconstrictor such as adrenaline (epinephrine) reduces local blood flow, slows the rate of absorption of the local anaesthetic, and prolongs its effect the duration of action of lidocaine is doubled from one to two hours. Normally, the final concentration of adrenaline (epinephrine) should be 1 in 200 000, although dentists use up to 1 in 80 000. 

Intravenous. A double cuff is applied to the arm, inflated above arterial pressure after elevating the limb to drain the venous system, and the veins filled with local anaesthetic, e.g. 0.5-1% lidocaine without adrenaline (epinephrine). The arm is anaesthetised in 6-8 min, and the effect lasts for up to 40 min if the cuff remains inflated. The cuff must not be deflated for at least 20 minutes. The technique is useful in providing anaesthesia for the treatment of injuries speedily and conveniently, and many patients can leave hospital soon after the procedure. The technique must be meticulously conducted, for if the full dose of local anaesthetic is accidentally suddenly released into the general circulation severe toxicity and even cardiac arrest may result. Bupivacaine is no longer used for intravenous regional anaesthesia as cardiac arrest caused by it is particularly resistant to treatment. Patients should be fasted and someone skilled in resuscitation must be present. 

A 24-year-old man injured in a motorcycle accident was treated with viscous lidocaine and bacitracin zinc ointment for extensive abrasions on the extremities. Five minutes later, he developed symptoms of severe anaphylaxis and required adrenaline, antihistamines, intravenous fluids, and glucocorticoids. Two weeks later, only the prick test to bacitracin zinc ointment was positive. 

In 23 patients there was a significant dose-dependent reduction in blood pressure following submucosal infiltration of lidocaine plus adrenaline compared with saline plus adrenaline for orthognathic surgery (20). The study was randomized but small larger studies are needed to confirm effects that could easily have been due to multifactorial causes in patients undergoing general anesthesia. 

Comphcation rates increase with premedication at home, and pre-existing disease or risk factors, such as pregnancy, cardiovascular disease, and allergies. Articaine and lidocaine with epinephrine 1 200 000 were associated with a low incidence of comphcations (3.1 and 0%), whilst mepivacaine and articaine with adrenaline 1 100 000 caused the most frequent comphcations (7.2 and 6.1%) (SEDA-22,135). 

A 49-year-old man developed uvular deviation as a result of palatal muscle paralysis following intraoral mandibular block of the inferior alveolar nerve with 1.8 ml of 2% lidocaine with adrenaline 1 in 100 000 (96). A few minutes after injection he had swallowing difficulties and a foreign body sensation in his throat. There was paralysis of the velum palatinum, with deviation of the uvula towards the non-paralysed side opposite the point of anesthetic infiltration. This resolved after the anesthetic had worn off. 

Adverse ocular effects, such as ptosis, are on record (SEDA-15,118). Transient dizziness, diplopia, and partial blindness have been reported after the entry of lidocaine with adrenaline into the ophthalmic artery following mandibular block (97). A similar case after posterior alveolar block resulted in dizziness and diplopia for 3 hours when the patient stood up, possibly due to the entry of local anesthetic into the ophthalmic artery (SEDA-22,135). 

A 38-year-old woman nnderwent cystoscopy and nre-thral dilatation in the hthotomy position nnder contin-nons epidnral anesthesia at the L3-4 interspace with 3 ml of 1.5% lidocaine with adrenaline 1 200 000 as a test dose, followed by a total of 15 ml of 2% lidocaine with adrenahne 1 200 000 in incremental doses (133). The operation was nneventfnl, bnt 4 honrs later she developed severe bilateral bnttock and posterior leg pain, described as deep, aching, and excruciating, worse when immobile, and better when standing there were no other symptoms and ibnprofen gave immediate rehef. 

The cauda has a tenuous blood supply, and in this patient with pre-existing vascular disease, perioperative hypotension and the use of intrathecal adrenaline may have precipitated ischemia in an area with very poor reserve. To follow this with an accidental large dose of lidocaine, which is neurotoxic in animals when directly applied and theorized to cause interruption of nerve blood supply, would add insult to injury. The authors questioned the wisdom of performing continuous epidural anesthesia in such patients, when frequent neurological assessments cannot be performed. 

Prilocaine 3% + felypressin 0.03 lU/ml has been compared with Udocaine 2% + adrenaline 12.5 micrograms/ml in 300 women having large-loop excision of the cervical transformation zone (289). Those who received lidocaine had significantly less blood loss, but were more likely to have adverse effects, including shaking and feeling faint. 

Ventricular tachycardia, severe hypertension, and pulmonary edema developed in a 53-year-old woman soon after she had a skin flap infiltrated with 4 ml of 0.5% lidocaine and 0.0005% adrenaline (20 micrograms) (365). 

The presence of sodium metabisulfite as an antioxidant in commercial lidocaine with adrenaline significantly increased discomfort during injection (7). 

The activity of the local anesthetics is enhanced by increased extraneuronal pH and by coadministration of a vasoconstrictor (e.g. epinephrine (adrenaline)) or hyaluronidase. Sodium channel blockade is pH dependent, increasing when the pH is alkaline, and can be reduced in disease conditions associated with acid pH (e.g. inflammation). The addition of bicarbonate (e.g. to lidocaine) speeds up the onset and prolongs the duration of action. If bicarbonate is added to... 

Lidocaine (lignocaine) is an amide local anesthetic that is approved (2% solution, 20mg/ml) for use in horses. This agent is also used widely in humans and is available as 1% and 2% solutions also in combination with epinephrine (adrenaline) at a concentration of 1 in 200 000. 

Lidocaine is used in cardiovascular medicine for its antiarrhythmic properties (see Ch. 12). More recently, studies have looked at the i.v. administration of lidocaine to horses with colic (see Ch. 6). It appears that i.v. lidocaine (without epinephrine (adrenaline)) may have some desirable effects on jejunal distension and peritoneal fluid accumulation and is well-tolerated periop-eratively in horses with colic (Brianceau et al 2002). In addition, i.v. lidocaine reduced the halothane MAC significantly (Doherty Frazier 1998) in ponies. 

The posterior region of the scalp that concerns us is innervated by the occipital nerve of Arnold, which is easily blocked by an injection of 2% lidocaine with adrenaline (epinephrine). 

Gentle abrasion with sandpaper or intraepidermal erbium laser treatment help accelerate penetration of the ETCA solution considerably. When sandpaper abrasion is used, a topical anesthetic should be applied (a swab with 2% lidocaine with adrenaline (epinephrine)) after the abrasion, before applying the acid. With an erbium laser, a nerve block or ring block is necessary. 

Topical application of 2% lidocaine solution with adrenaline (epinephrine), poured directly onto sterile gauze... 

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