Local & systemic complications of LA

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Complications of local anesthesia:

Complications of local anesthesia SAJIDA SULTANA C.R.I

Anesthetic complication:

Anesthetic complication An “anesthetic complication” may be defined as any deviation from the normally expected pattern during or after the securing of regional analgesia.

CLASSIFICATION:

CLASSIFICATION

Primary or Secondary:

Primary or Secondary Primary complication is one that is caused and manifested at the time of anesthesia. Secondary complication is one that is manifested later, even though it may be caused at the time of insertion of the needle and injection of the solution.

Mild or severe:

Mild or severe A mild complication is one that exhibits a slight change from the normally expected pattern and reserve itself without any specific treatment. A severe complication manifests itself by a pronounced deviation from the normally expected pattern and requires a definite plan of treatment.

Transient or permanent:

Transient or permanent A transient complication is one that, although severe at the time of occurrence, leaves no residual effect. A permanent complication would, of course, leave a residual effect, even though mild in nature.

Classification:

Classification

Local complications:

Local complications Needle breakage Paresthesia Facial Nerve Paralysis Trismus Soft-tissue injury Hematoma Pain on injection Burning on injection Infection Edema Sloughing of tissues Post anaesthetic intraoral lesions

Systemic complications:

Systemic complications Adverse drug reactions Overdose Allergy Malignant hyperthermia

Local complications:

Local complications

Needle breakage:

Needle breakage

NEEDLE BREAKAGE:

NEEDLE BREAKAGE CAUSES: Primary cause – weakening of the dental needle by bending it before its insertion into the patient’s mouth. Sudden unexpected movement by the patient as the needle penetrates muscle or contacts periosteum. Smaller needles are more likely to break than larger needles. Needles that have previously been bent are weakened and more likely to break than unbent needles. Needles may prove to be defective in manufacture.

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PROBLEM: A Magill intubation forceps or hemostat can be used to grasp the visible proximal end of the needle fragment and remove it from the soft tissue.

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PREVENTION: Use larger gauge needles for techniques requiring penetration of significant depths of soft tissue. Use long needles for injections requiring penetration of significant (>18mm) depths of soft tissues. Do not insert a needle into tissues to its hub. Do not redirect a needle once it is inserted into tissues. Excessive lateral force on the needle is a factor in breakage. Withdraw the needle almost completely before redirecting it.

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MANAGEMENT: When a needle breaks, remain calm, do not panic, instruct patient not to move, if the fragment is visible, try to remove with a small hemostat or a Magill intubation forceps. If the needle is lost, do not proceed with an incision, refer to an oral surgeon for consultation not for removal. When the needle breaks, consideration should be given to its immediate removal under the following conditions: * The needle is superficial and easily located through radiological and clinical examination, removal by a competent dental surgeon is possible. * The needle is located in deeper tissues or hard to locate, it should be permitted to remain without an attempt at removal.

paresthesia:

paresthesia CAUSES: Trauma to any nerve. Injection of a LA solution contaminated by alcohol or sterilizing solution near a nerve produces irritation, resulting in edema and increased pressure leading to paresthesia. Trauma to the nerve sheath can be produced by the needle during injection. Injection of a needle into a foramen, as in the II division nerve block via the greater palatine foramen, also increases the likelihood of nerve injury. Hemorrhage into or around the neural sheath. Bleeding increases pressure on the nerve, leading to paresthesia.

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PROBLEM: Persistent anesthesia can lead to self-inflicted injury. Biting os thermal or chemical insult can occur. Sense of taste also may be impaired when the lingual nerve is involved.

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PREVENTION: Strict adherence to injection protocol and proper care and handling of dental cartridges.

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MANAGEMENT: Resolves within 8 weeks without treatment.

FACIAL NERVE PARALYSIS:

FACIAL NERVE PARALYSIS

Facial nerve paralysis:

Facial nerve paralysis CAUSES: Commonly caused by the introduction of local anesthesia into the capsule of the parotid gland, which is located at the posterior gland, which ramus, clothed by the medial pterygoid and masseter muscle.

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PROBLEM: Loss of motor function to the muscles of facial expression produced by deposition of local anaesthetia is normally transitory. Unilateral paralysis. Unable to voluntarily close one eye. Protective lid reflex of eye is abolished. Winking and blinking becomes impossible.

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PREVENTION: Adhere to protocol Needle tip in contact with bone.

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MANAGEMENT: Reassure the patient. An eye patch should be applied to the affected eye until muscle tone returns.

TRISMUS:

TRISMUS

trismus:

trismus CAUSES: Trauma to muscles or blood vessels in the infra temporal fossa. Local anesthesia solutions into which alcohol or cold sterilizing solutions have diffused, produce irritation of tissues potentially leading to trismus. Local anesthesia has slight mycotoxic properties leading to a rapidly progressive necrosis of the exposed muscle fibres. Hemorrhage. Low grade infection after injection. Multiple needle penetrations. Excessive volume of solution deposited into a restricted area produces distention of tissues which leads to trismus

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PROBLEM: Pain produced by hemorrhage leads to muscle spasm and limitation of movement. Chronic hyper mobility.

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PREVENTION: Use a sharp sterile disposable needle. Proper care and handle dental LA cartridges. Use aseptic technique. Practice atraumatic insertion and injection techniques. Avoid repeated injections and multiple injections. Use minimum effective volumes of LA.

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MANAGEMENT: Heat therapy, warm saline rinses, analgesics and muscle relaxants to manage the initial phase of muscle spasm. Initiate physiotherapy consisting of opening and closing of mouth as well as lateral excursions of the mandible for 5 minutes every 3 to 4 hours. Chewing gum.

Soft-tissue injury:

Soft-tissue injury

Soft-tissue injury:

Soft-tissue injury CAUSES: Primary cause – soft tissue anesthesia lasts longer than pulpal anesthesia.

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PROBLEM: Trauma can lead to swelling and significant pain when the anaethetic effects resolve.

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PREVENTION: LA of appropriate duration should be selected. Cotton rolls can be placed between the lips and teeth if they are still anaesthetized. Secure the roll with dental floss wrapped around the teeth. Warn the patient and guardian against eating, drinking hot fluids and biting on the lips and tongue to test for anesthesia. A self adherent warning sticker may be used in children.

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MANAGEMENT: Analgesics for pain. Antibiotics. Lukewarm saline rinse to aid in decreasing swelling. Petroleum jelly or other lubricant to cover a lip lesion and minimize irritation.

HEMATOMA:

HEMATOMA

hematoma:

hematoma CAUSES: Arterial or venous puncture after PSA or IANB. Blood effuses from vessels until extravascular exceed intravascular pressure or clotting occurs. IANB hematoma – visible intra orally. PSA hematoma – visible extra orally.

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PROBLEM: Bruise, trismus and pain. Swelling and discoloration subside within 7 to 14 days.

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PREVENTION: Knowledge of the normal anatomy involved in the proposed injection. Modify the injection technique as dictated by the patient’s anatomy. Use a short needle for the PSA nerve block to decrease the risk of hematoma. Minimize the number of needle penetration into tissue. Never use a needle as a probe in tissues.

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MANAGEMENT: Immediate: direct pressure should be applied to the site of bleeding for not less than 2 minutes. Subsequent: analgesics, ice Tincture of time is the most important element in managing a hematoma.

PAIN ON INJECTION:

PAIN ON INJECTION

Pain on injection:

Pain on injection CAUSES: Careless injection technique and callous attitude. Using a needle which is dull due to multiple injections. Rapid deposition. Needles with barbs.

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PROBLEM: Increases patient anxiety. Sudden unexpected movement. Increasing the risk of needle breakage.

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PREVENTION: Adhere to proper techniques of injection both anatomical and psychological. Use sharp needles. Use topical anaesthetic properly before injection. Use sterile local anaesthetic solutions. Inject local anaesthetic slowly. Be certain that the temperature of the solution is correct.

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MANAGEMENT: No management is necessary.

Burning of injection:

Burning of injection CAUSES: pH of the solution. Rapid injection. Contamination of cartridge. Solutions warmed to normal body temperature.

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PROBLEM: Tissue may be damages with subsequent development of other complications such as post anaesthetic trismus, edema or possible paresthesia.

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PREVENTION: Ideal rate of injecting : 1ml/min. Cartridge of anesthetic should be stored at room temperature in a container or in a container without alcohol or other sterilizing agents.

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MANAGEMENT: Formal treatment is not indicated. In few situations in which post injection discomfort, edema or paresthesia becomes evident, management of a specific person is indicated.

infection:

infection CAUSES: Contamination of a needle before administration of the anaesthetic. Improper technique in the handling of the LA equipment and improper tissue preparation for injection.

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PROBLEM: Low grade infection. Trismus.

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PREVENTION: Use sterile disposable needles. Properly care for needles and handle needles. Properly care for and handle dental cartridges. Properly prepare the tissues before penetration.

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MANAGEMENT: Immediate treatment used to manage trismus : Heat therapy, analgesic, muscle relaxant and physiotherapy. Prescribe 29 tablets of Penicillin V(250mg) 500mg immediately and 250mg x4 times a day. Erythromycin as a substitute.

EDEMA:

EDEMA

edema:

edema CAUSES: Trauma during injection. Infection. Allergy. Hemorrhage. Injection of irritating solutions. Hereditary angioedema.

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PROBLEM: Pain. Dysfunction. Angioneurotic edema.

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PREVENTION: Properly care for and handle the LA armamentarium. Use atraumatic injection techniques. Complete an adequate medical evaluation of the patient before drug administration.

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MANAGEMENT: Allergy induced edema: intra muscular and oral histamine blocker administration. Compromises breathing: Supine position, basic life support, epinephrine, histamine blocker, corticosteroid. Total airway obstruction: Cricothyrotomy.

Sloughing of tissues:

Sloughing of tissues CAUSES: Epithelial desquamation : Application of a topical anaesthetic to the gingival tissues for a prolonged period. Heightened sensitivity of the tissues to a LA. Reaction in an area where a topical has been applied. Sterile abscess: Secondary to prolonged ischemia . Develops on a hard palate.

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PROBLEM: Pain. Infection.

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PREVENTION: Topical anaesthetics : Allow the solution to contact mucous membrane for 1 to 2 mins. Nor ephinephrine : produces ischemia.

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MANAGEMENT: For pain , analgesics (aspirin and codeine). Topically applied ointment. (Orabase).

Post anaesthetic intraoral lesions:

Post anaesthetic intraoral lesions CAUSES: Recurrent aphthous stomatitis or Herpes simplex Trauma to tissues by a needle.

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PROBLEM: Acute sensitivity in ulcerated area. Risk of secondary infection is minimal.

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PREVENTION: Antiviral drugs.

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MANAGEMENT: Reassure the patient. Topical LA. Orabase without Kenalog. Tannic acid prep (Zilactin).

Systemic complications:

Systemic complications

Adverse drug reactions:

Adverse drug reactions CAUSES: TOXICITY CAUSED BY DIRECT EXTENSION OF THE USUAL PHARMACOLOGICAL EFFECTS BY DRUG 1. Side effects 2. Overdose 3. Local toxic effects TOXICITY CAUSED BY ALTERATION IN THE RECIPIENT OF THE DRUG 1. A disease process 2. Emotional disturbance 3. Genetic aberrations 4. Idiosyncrasy TOXICITY CAUSED BY ALLERGIC RESPONSES TO THE DRUG

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Overdose reactions are those clinical signs and symptoms that manifest as a result of an absolute or relative over-administration of a drug. Allergy is a hypertensive state acquired through exposure to a particular allergen, re-exposure to which brings about a heightened capacity to react. Idiosyncrasy , the third category of true adverse drug reactions, is a term used to describe a qualitatively abnormal, unexpected response to a drug, differing from its pharmacological actions and thus resembling hypersensitivity.

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Comparison of Allergy and Overdose Clinical response Allergy Overdose Dose Non-dose related Dose related S & S Similar, regardless of allergen Relate to pharmacology of drug administered Management Similar (epinephrine, histamine blockers) Different: specific for drug administered.

overdose:

overdose PREDISPOSING FACTORS: Patient factors: Age, weight, other drugs, sex, presence of disease, genetics, mental attitude and environment Drug factors: Vaso-activity, concentration, dose, route of administration, rate of injection, vascularity of injection site, presence of vasoconstrictors.

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CAUSES: Unusually slow biotransformation Slowly eliminated , unbiotransformed drug through the kidneys Large dose Unusually rapid absorption Inadvertent intravascular administration

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MANAGEMENT: Position Airway Breathing Circulation Definitive care

allergy:

allergy It is a hypersensitive state, acquired through exposure to a particular allergen, re-exposure to which produces a heightened capacity to react.

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GELL & COMB’S CLASSIFICATION OF ALLERGIC DISEASES I Anaphylactic II Cytotoxic III Immune complex IV Cell mediated/ Tuberculin-type response V Idiopathic

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Type Mechanism Principal Antibody/ Cell Time of reactions Clinical examples I Anaphylactic (immediate, homocytotropic , antigen-induced, antibody-mediated) IgE Seconds to minutes Anaphylaxis (drugs, insect venom, antisera ) Atrophic bronchial asthma Allergic rhinitis Urticaria Angioedema Hay fever

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Type Mechanism Principal Antibody/ Cell Time of reactions Clinical examples II Cytotoxic ( antimembrane ) IgG IgM (activate complement ) _ Transfusion reactions Goodpasture’s syndrome Autoimmune hemolysis Hemolytic anemia Certain drug reactions Membranous glomerulonephrosis

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Type Mechanism Principal Antibody/ Cell Time of reactions Clinical examples III Immune complex(serum sickness-like) IgG (form complexes with complement) 6 to 8 hours Serum sickness Lupus nephritis Occupational allergic alveolitis Acute viral hepatitis

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Type Mechanism Principal Antibody/ Cell Time of reactions Clinical examples IV Cell-mediated (delayed) or tuberculin-type response - 48 hours Allergic contact dermatitis Infectious granulomas (tuberculosis, mycoses) Tissue graft rejection Chronic hepatitis

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CAUSES: The primary cause of allergic reactions is a specific antigen-antibody reaction, where the patient has been previously sensitized to a particular drug or a chemical agent. SIGNS & SYMPTOMS: Skin rashes Uticaria Pruritis Edema Erythema Wheezing PREVENTION: Proper pre-anesthetic evaluation: Proper personal history , Interrogation into past dental history and drug history MANAGEMENT: Antihistamines – diphenhydramine (Benadryl) 20-50mg Epinephrine 0.5ml Administer O 2 , if necessary.

anaphylaxis:

anaphylaxis It is a life threatening or devastating allergic reaction of a drug SIGN & SYMPTOMS: Skin reactions Smooth muscles spasm Respiratory distress Cardiovascular collapse and loss of consiousness

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MANAGEMENT: Initial Therapy : 1. Stop Administration of the Antigen and Minimize [Inhaled Anaesthetics]. 2. Call for Help ; Stop Surgery. 3. Endotracheal Intubation and 100% O2. 4. Volume Expansion – Leg Elevation. 5. Adrenaline : 5-100 µg IV ; Closed Chest Cardiac Compressions. Secondary Therapy : 1. Histamine 1 Receptor Antagonists : Promethazine 50 mg IM. 2. Histamine 2 Receptor Antagonists : Ranitidine 50 mg IV. 3. Catecholamine Infusions. 4. Nebulization of Bronchodilators. 5. Corticosteroids : Hydrocortisone 5 mg/kg IV. 6. Airway Evaluation before Extubation.

idiosyncrasy:

idiosyncrasy Any reaction to a LA agent or any other drug that cannot be classified as allergic or toxic reaction is often called as idiosyncrasy PREVENTION: Pre-anesthetic evaluation Precautions to the patients from injuring Psychothreraphy Proper and adequate pre-medication MANAGEMENT: Supine position with legs slightly elevated Maintenance of airway Adequate O 2 supply Evaluate circulation Administer parenteral fluids*

Malignant hyperthermia:

Malignant hyperthermia Also known as hyperpyrexia. Malignant hyperthermia (MH; hyperpyrexia) is a pharmacogenic disorder in which a genetic variant in the individual alters that person’s response to certain drugs. Acute clinical manifestations of MH : tachycardia, tachypnea, unstable blood pressure, cyanosis, respiratory & metabolic acidosis, fever, muscle rigidity & death. Mortality: 63% - 73%

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