Local anesthesia/anesthetics nerve block

Prilocaine, a local anesthetic (4% with 1 200,000 epinephrine in 1 to 8 mL dental cartridge), is indicated for local anesthesia by nerve block or infiltration in dental procedures. 

It is imjxjitant to note that topical anesthetics, while useful in laser resurfacing jjrocedures, should not be used prior to skin peels. Topical anesthetics can allow the peel solution to penetrate more greatly due to their ability to hydrate the skin. Local anesthesia, including nerve blocks, should be avoided, as it masks the ability to accurately read the skin. 

Local anesthetics are used for topical anesthesia, local infiltration, peripheral nerve block, paravertebral anesthesia, intravenous block also known as regional anesthesia, epidural block, and spinal i.e. subarachnoid blockade. The local anesthetics may be divided into two main groups, the esters and the amide-type agents. 

Mepivacaine hydrochloride [N-(2, 6-dimethylphenyl)-1-methyl 2-piperidinecarboxamide monohydrochloride] is an amino amide-type local anesthetic agent widely used to provide regional analgesia and anesthesia by local infiltration, peripheral nerve block, and epidural and caudal blocks. The pharmacological and toxicological profile of mepivacaine is quite similar to that of lidocaine, except that mepivacaine has a slightly longer duration of action and lacks the vasodilator activity of lidocaine. For this reason, it serves as an alternate choice for lidocaine when addition of epinephrine is not recommended in patients with hypertensive vascular disease. 

Local anesthetics are used to locally anesthetize a wide range of specific body parts or areas to allow painless surgery. Local anesthetics are most commonly used for dental procedures and repair of lacerations. They can also be used to provide neural blockade for larger, more painful procedures. Sites of LA application include localized injection, peripheral nerve blocks as well as central nerve blockade. The only safe agents which can be utilized for intravenous regional anesthesia (Bier block) are lidocaine and prilocaine. Other typical indications are outlined in Table 64.1. 

Lidocaine hydrochloride [73-78-9] (Xylocaine), is the most versatile local anesthetic agent because of its moderate potency and duration of action, rapid onset, topical activity, and low toxicity. Its main indications are for infiltration, peripheral nerve blocks, extradural anesthesia, and in spinal anesthesia where a duration of 30 to 60 min is desirable. Because of its vasodilator activity, addition of the vasoconstrictor, epinephrine, increases the duration of action of Hdocaine markedly. It is also available in ointment or aerosol preparations for a variety of topical appHcations. 

Local anesthesia involves the blockade of nerve conduction in order to stop sensation. Because local anesthetics act on all nerve fibers they may also temporarily create motor paralysis. The usefulness of local anesthetics is their ability to completely block axonal transduction, which is reversible and without any apparent lasting effects. 

Amide-type agents include articaine, lidocaine, bupivacaine, prilocaine, mepivacain and ropiva-caine. These are metabolized in the liver by microsomal enzymes with amidase activity. The amide group is preferred for parenteral and local use. If by accident rapidly administered intravascularly these agents, especially bupivacaine but also lidocaine, can produce serious and potentially lethal adverse effects including convulsions and cardiac arrest. They can more easily accumulate after multiple administrations. Intravenous lidocaine is sometimes used for regional anesthesia, for infiltration procedures, for the induction of nerve blockade and for epidural anesthesia. However, it is also used as an antiarrhythmic. Bupivacaine is a long-acting local anesthetic used for peripheral nerve blocks and epidural anesthesia. 

The first clinical uses of a local anesthetic agent occurred in 1884, when cocaine was employed as a topical agent for eye surgery and to produce a nerve block. These events inaugurated a new era, that of regional anesthesia. New applications were developed, including spinal, epidural, and caudal anesthesia. The search for a better local anesthetic led to chemical synthesis of a number of other compounds that have more selective local anesthetic properties and few systemic side effects. 

Lidocaine hydrochloride Xylocaine) is the most commonly used local anesthetic. It is well tolerated, and in addition to its use in infiltration and regional nerve blocks, it is commonly used for spinal and topical anesthesia and as an antiarrhythmic agent (see Chapter 16). Lidocaine has a more rapidly occurring, more intense, and more prolonged duration of action than does procaine. 

Dental or surgical procedures, childhirth Infiltration or Nerve Block Local anesthetic dosage varies with procedure, degree of anesthesia, vascularity, duration. Maximum dose 4.5 mg/kg. Do not repeat within 2 hr. 

Regional nerve block anesthesia— injection of a small amount of local anesthetic into the tissue immediately surrounding a nerve supplying the region to be anesthetized... 

Local anesthetics preferentially block small fibers because the distance over which such fibers can passively propagate an electrical impulse is shorter. During the onset of local anesthesia, when short sections of a nerve are blocked, the small-diameter fibers are the first to fail to conduct electrical impulses. For myelinated nerves, at least two and preferably three successive nodes of Ranvier must be blocked by the local anesthetic to halt impulse propagation. Therefore, myelinated nerves tend to become blocked before unmyelinated nerves of the same diameter. For this reason, the preganglionic fibers are blocked before the smaller unmyelinated C fibers involved in pain transmission. 

Pharmacological Profile. The profile of the ideal local anesthetic agent depends largely on the type and length of the surgical procedure for which it is applied. Procedures could include neuraxial (spinal and epidural) anesthesia, nerve and plexus blocks, or field blocks (local infiltration). In general, tine ideal agent should have a short onset of anesthesia and be useful for multiple indications such as infiltration, nerve blocks. 

Peripheral nerve block. The anesthetic is injected close to the nerve trunk so that transmission along the peripheral nerve is interrupted.61 This type of local anesthesia is common in dental procedures (restorations, tooth extractions, and so on) and can also be used to block other peripheral nerves to allow certain surgical procedures of the hand, foot, shoulder, and so forth. ii.56.65 xnjection near larger nerves (femoral, sciatic) or around a nerve plexus (brachial plexus)... 

Mechanism-specific adverse effects. Since local anesthetics block Na+ influx not only in sensory nerves but also in other excitable tissues (A and p.206), they are applied locally. Depression of excitatory processes in the heart, while undesired during local anesthesia, can be put to therapeutic use in cardiac arrhythmias (p.138). 

Peripheral nerve block anesthesia involves injecting the drug near the nerves close to the area to be anesthetized. Epidural anesthesia results when the local anesthetic is injected into the epidural space between a lumbar and sacral vertebra. Several drugs can safely produce useful levels of anesthesia for obstetrics as well as postoperative pain. Another method of utilizing local anesthetics is to inject solutions into subarachnoid spaces (e.g., the spaces between certain vertebrae). 

Lidocaine hydrochloride is a local anesthetic/vasopressor preparation. Lidocaine stabilizes neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action. Epinephrine stimulates both alpha and beta receptors within sympathetic nervous system relaxes smooth muscle of bronchi and iris and is an antagonist of histamine. They are indicated for production of local or regional anesthesia by infiltration techniques such as percutaneous injection, by peripheral nerve block techniques such as brachial plexus and intercostals, and by central neural techniques such as lumbar and caudal epidural blocks. 

Procaine (novocain), the first synthetic local anesthetic, is an amino ester (see Figure 14-1) with low potency, slow onset, and short duration of action. Its use now is confined to infiltration anesthesia and occasionally for diagnostic nerve blocks. Its hydrolysis in vivo produces para-aminobenzoic acid which inhibits the action of sulfonamides. Thus, large doses should not be administered to patients taking sulfonamide drugs. 

Tetracaine (pontocaine), a long-acting amino ester, is significantly more potent and has a longer duration of action than procaine. Tetracaine may exhibit increased systemic toxicity because it is more slowly metabolized than the other commonly used ester local anesthetics. It is widely used in spinal anesthesia when a drug of long duration is needed. Tetracaine also is incorporated into several topical anesthetic preparations. Tetracaine is rarely used in peripheral nerve blocks because of the large doses often necessary, its slow onset, and its potential for toxicity. 

Injection of a local anesthetic into or around individual peripheral nerves or nerve plexuses produces even greater areas of anesthesia than do the techniques described above. Blockade of mixed peripheral nerves and nerve plexuses also usually anesthetizes somatic motor nerves, producing skeletal muscle relaxation, which is essential for some surgical procedures. The areas of sensory and motor block usually start several centimeters distal to the site of injection. Brachial plexus blocks are particularly useful for procedures on the upper extremity and shoulder. Intercostal nerve blocks are effective for anesthesia and relaxation of the anterior abdominal wall. Cervical plexus block is appropriate for surgery of the neck. Sciatic and femoral nerve blocks are useful for surgery distal to the knee. Other useful nerve blocks prior to surgical procedures include blocks of individual nerves at the wrist and at the ankle, blocks of individual nerves such as the median or ulnar at the elbow, and blocks of sensory cranial nerves. 

Smaller-diameter nerve fibers are more sensitive to local anesthetics and are blocked more rapidly than those of larger size. As the local concentration of drug declines during recovery from local anesthesia, smaller fibers continue to be blocked and are the last to recover. The answer is (D). 

Local anesthetics are used to block pain conduction by nerves. They are used for infiltration anesthesia, local nerve blocks, spinal nerve blocks and epidural nerve blocks. The first local anesthetic was cocaine, which has largely been replaced by synthetic agents. 

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