Epinephrine with anesthesia

Isoflurane is a respiratory depressant (71). At concentrations which are associated with surgical levels of anesthesia, there is Htde or no depression of myocardial function. In experimental animals, isoflurane is the safest of the oral clinical agents (72). Cardiac output is maintained despite a decrease in stroke volume. This is usually because of an increase in heart rate. The decrease in blood pressure can be used to produce "deHberate hypotension" necessary for some intracranial procedures (73). This agent produces less sensitization of the human heart to epinephrine relative to the other inhaled anesthetics. Isoflurane potentiates the action of neuromuscular blockers and when used alone can produce sufficient muscle relaxation (74). Of all the inhaled agents currently in use, isoflurane is metabolized to the least extent (75). Unlike halothane, isoflurane does not appear to produce Hver injury and unlike methoxyflurane, isoflurane is not associated with renal toxicity. 

Morris LE, Noltensmeyer MH, White JM Jr. 1953. Epinephrine induced cardiac irregularities in the dog during anesthesia with trichloroethylene, cyclopropane, ethyl chloride and chloroform. Anesthesiology 14 153-158. 

The answer is d. (Hardman, p T36J The addition of a vasoconstrictor, such as epinephrine or phenylephrine, to certain short-acting, local anesthetics is a common practice in order to prevent the rapid systemic absorption of the local anesthetics, to prolong the local action, and to decrease the potential systemic reactions. Some local anesthetics cause vasodilation, which allows more compound to escape the tissue and enter the blood. Procaine is an ester-type local anesthetic with a short duration of action due to rather rapid biotransformation in the plasma by cholinesterases. The duration of action of the drug during infiltration anesthesia is greatly increased by the addition of epinephrine, which reduces the vasodilation caused by procaine. 

In an undated study, HCFC-141b was administered to male SpragueDawley rats at concentrations of 5,000, 10,000, or 20,000 ppm for 30 min (Eger, unpublished data). As exposure continued, bolus intravenous epinephrine, characterized as three times the dose that produced arrhythmias in the same rats anesthetized with halothane, was administered. The dose of epinephrine was defined as a maximum of 12 fig/kg. For this study, three or more premature ventricular contractions was considered an arrhythmic response (Table 4—5). Marked arrhythmias occurred at all concentrations. The author further compared the concentrations of halothane and HCFC-141b that produced arrhythmias with administration of various doses of exogenous epinephrine. The nominal chamber concentration for HCFC-141b did not differ from that of halothane. Furthermore, the arrhythmias were characterized as relatively mild and within acceptable limits for surgical anesthesia in humans. 

Procaine hydrochloride Novocain) is readily hydrolyzed by plasma cholinesterase, although hepatic metabolism also occurs. It is not effective topically but is employed for infiltration, nerve block, and spinal anesthesia. It has a relatively slow onset and short (1 hour) duration of action. All concentrations can be combined with epinephrine. It is available in dental cartridges with phenylephrine as the vasoconstrictor. 

Topical local anesthesia is often used for eye, ear, nose, and throat procedures. Satisfactory topical local anesthesia requires an agent capable of rapid penetration across the skin or mucosa, and with limited tendency to diffuse away from the site of application. Cocaine, because of its excellent penetration and local vasoconstrictor effects, has been used extensively for ear, nose and throat (ENT) procedures. Cocaine is somewhat irritating and is therefore less popular for ophthalmic procedures. Recent concern about its potential cardiotoxicity when combined with epinephrine has led most otolaryngology surgeons to switch to a combination containing lidocaine and epinephrine. Other drugs used for topical anesthesia include lidocaine-bupivacaine combinations, tetracaine, pramoxine, dibucaine, benzocaine, and dyclonine. 

Lidocaine Blockade of sodium channels Slows, then blocks action potential propagation Short-duration procedures epidural, spinal anesthesia Parenteral duration 30-60 min 2-6 h with epinephrine Toxicity CNS excitation... 

Epinephrine is not directly anesthetic either alone or in combination with cocaine for it does not increase the anesthetic effect when the circulation has previously been arrested. It also does not lower the threshold concentration in wheals, although the duration of the anesthesia is greater for a given concentration. 

This consists in the injection of the local anesthetic into or around the nerve trunk or in the area of its distribution, so as to block off sensory impulses from the operative field. Because fatal effects may arise from the absorption of the anesthetic, the smallest amount of the least-toxic agent that is effective should be employed, under conditions that minimize absorption. Procaine with the addition of epinephrine (1 100,000) is generally preferred. A well-planned technique is important. It is not necessary to flood the entire field of operation, as in the earliest methods, nor even to infiltrate the whole line of incision, as in infiltration anesthesia. It is now aimed at confining the anesthetic mainly to the nerves, by placing it where the nerves chiefly run or injecting it into the nerves themselves. 

Anesthesia of the lower extremities and abdomen may be induced by the introduction of anesthetic drugs into the subarachnoid space (Figure 23.6). The drug most often used for this purpose is bupivacaine. The latency period plus the duration of the maximal cephalad level for both plain and hyperbaric bupivacaine lasts from 10 to 60 min. A bupivacaine solution is made hyperbaric by the addition of 5 to 8% glucose. The distribution of bupivacaine in the cerebrospinal fluid (CSF) is affected by gravity and is therefore influenced by the patient s position. With a dose of 15 mg of plain 0.5% bupivacaine, a half-life of about 3 h is achieved. The addition of epinephrine to bupivacaine prolongs the duration of block. 

In experimental animals the effect of ephedrine administered intravenously is similar to that of epinephrine. The arterial pressure — systolic, diastolic, and mean pressure — rises and vagal slowing occurs. Compared with epinephrine, the pressor response to ephedrine occurs somewhat more slowly and lasts about ten times longer. Furthermore, it requires more ephedrine than epinephrine to obtain an equivalent pressor response. How much more depends on the species tested, type and degree of anesthesia, dose level, and individual variability of the test animal. It is, therefore, almost impossible to give a definite figure for the relative potency of ephedrine and epinephrine. It is commonly accepted that it requires about 250 times more ephedrine than epinephrine to achieve equipressor responses. 

Infiltration anesthesia The injection of local anesthetic directly into tissue without taking into consideration the course of cutaneous nerves duration can be extended with the addition of epinephrine (vasoconstrictor)... 

Iontophoresis of mepivacaine and lidocaine with epinephrine have been reported in human cadaver bladders and in clinical trials by Lugnani et al. [41], The study reported that the active electrode must be sited close to the geometric center of the bladder cavity in order to anesthesize the entire bladder. Siting the electrode close to the wall resulted in anesthesia of only that section of the bladder. 

Iontophoresis has been used to deliver local anesthetics in the field of dentistry. Gangarosa [45] reported the iontophoresis of a 2% solution of lidocaine, with epinephrine (1 100,000) for the local anesthesia for extraction of retained deciduous teeth. Iontophoresis has also been used to desensitize teeth [46]. 

The addition of epinephrine, a vasoconstrictor, to an injectable anesthetic prolongs the duration of anesthesia and decreases the rate of systemic absorption, thereby decreasing the risk of systemic toxicity. The duration of some anesthetics, such as bupivacaine, a long-acting anesthetic, cannot be significantly extended by adding epinephrine. Epinephrine also decreases local bleeding. Effective vasoconstriction is obtained with a concentration of 1 to 100,000 or even 1 to 200,000. The usual... 

Epinephrine or other vasoconstrictors have no significant effect on the duration of topical anesthesia and should never be combined with commercially available topical anesthetics. 

Figure 19-9 Subcutaneous injection of 1% lidocaine with epinephrine at base of papilloma provides adequate anesthesia for excision.

Some individual components of the injury experience have been studied separately in animal experiments. Pain, fear, hemorrhage, and tissue damage can all stimulate epinephrine production (Wl). Inhalational anesthesia stimulates the adrenal medulla but in deep anesthesia with intravenous barbiturates adrenomedullary secretion may be greatly diminished. 

Woldorf NM, Pastore PN. Extreme epinephrine sensitivity with a general anesthesia. Arch Otolaryngol 1972 96(3) 272-7. 

Hypersensitivity to amide-type local anesthetics, Adams-Stoke syndrome, supraventricular arrhythmias, Wolf-Parkinson-White syndrome. Spinal anesthesia contraindicated in septicemia. Caution Dosage should be reduced for elderly, debilitated, acutely ill safety in children has not been established. Severe renal/hepatic disease, hypovolemia, CHF, shock, heart block, marked hypoxia, severe respiratory depression, bradycardia, incomplete heart block. Anesthetic solutions containing epinephrine should be used with caution in peripheral or hypertensive vascular disease and during or following potent general anesthesia. Sulfite sensitivity or asthma for some local and topical anesthetic preparations. Tartrazine or aspirin sensitivity with some topical preparations. Anxiety, insomnia, apprehension, blurred vision, loss of hearing acuity, and nausea CNS depression, convulsion and respiratory depression... 

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