4/26/18 1 MICHELE (MIKE) BARLETTA, DVM, MS, PHD, DACVAA ASSISTANT PROFESSOR ANESTHESIOLOGY COLLEGE OF VETERINARY MEDICINE VETERINARY TEACHING HOSPITAL UNIVERSITY OF GEORGIA LOCAL ANESTHETICS OUTLINE • Terminology, nerve microanatomy, and fiber types • Mechanism of action and pharmacology • Mixtures of local anesthetics • Adjuvants • Potential adverse effects • Local techniques TERMINOLOGY • Topical or surface anesthesia • Topical application (e.g. EMLA, lidocaine patches) • Local or infiltration anesthesia • Injection in surgical field (e.g. injection or infusion catheters) • Regional or nerve (plexus) block anesthesia • Injection in vicinity of a peripheral nerve • Neuraxial anesthesia • Injection around spinal cord or in subarachnoid space • Intravenous regional anesthesia • IV Injection in extremities after exsanguination and placement of a tourniquet
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4/26/18 LOCAL ANESTHETICS...LOCAL ANESTHETICS OUTLINE • Terminology, nerve microanatomy, and fiber types • Mechanism of action and pharmacology • Mixtures of local anesthetics
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M I C H E L E ( M I K E ) B A R L E T T A , D V M , M S , P H D , D A C VA A A S S I S T A N T P R O F E S S O R A N E S T H E S I O L O G Y C O L L E G E O F V E T E R I N A R Y M E D I C I N E V E T E R I N A R Y T E A C H I N G H O S P I T A L U N I V E R S I T Y O F G E O R G I A
LOCAL ANESTHETICS
OUTLINE
• Terminology, nerve microanatomy, and fiber types
• Mechanism of action and pharmacology • Mixtures of local anesthetics • Adjuvants
• More ionized = slow onset • More lipid soluble = more potent (also longer onset and duration) • More protein bound = longer duration
MIXTURES OF LOCAL ANESTHETICS
• Few data available
• Decreased concentration of both drugs • Potential slower onset of the rapid one and shorter duration
of the long-lasting one
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EVIDENCE
• Galindo A, Witcher T. Mixtures of local anesthetics: bupivacaine-chloroprocaine. Anesth Analg. 1980 Sep;59(9):683-5
• rat sciatic nerve • 1 leg saline the other:
a. 0.5% bupivacaine b. 2% chloroprocaine (fast onset, short duration: 30-60 min) c. 50/50 mixture of 0.5% bupivacaine and 2% chloroprocaine
• Results • characteristics c = b • changing pH from 3.6 to 5.56 −> c = a
EVIDENCE
• Ribotsky BM1, Berkowitz KD, Montague JR. Local anesthetics. Is there an advantage to mixing solutions? J Am Podiatr Med Assoc. 1996 Oct;86(10):487-91
• 12 human subject, both feet • 1 foot saline the other:
a. 1% lidocaine b. 0.25% bupivacaine c. 50/50 mixture of 1% lidocaine and 0.25% bupivacaine
• Results • duration b > a = c • no advantages in mixing
EVIDENCE
• Cuvillon P et al. A comparison of the pharmacodynamics and pharmacokinetics of bupivacaine, ropivacaine (with epinephrine) and their equal volume mixtures with lidocaine used for femoral and sciatic nerve blocks: a double-blind randomized study. Anesth Analg. 2009 Feb;108(2):641-9
• 82 human patients • Sciatic and femoral blocks with:
a. 0.5% bupivacaine b. 50/50 mixture of 0.5% bupivacaine and 2% lidocaine c. 0.75% ropivacaine d. 50/50 mixture of 0.5% ropivacaine and 2% lidocaine
• Results • Lidocaine shortened the onset but decreased the duration
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ADJUVANTS
• Epinephrine (1:200,000 or 5μg/ml) • Add 0.1 ml of epinephrine 1:1,000 (1 mg/ml) to 20 ml of local
anesthetic • Vasoconstriction and decreases bleeding • Decreases systemic absorption • Lowers pH and increases onset of action
• Bicarbonate • Decreases onset and prolongs duration (ion trapping) • Decreases pain on injection • Lidocaine and mepivacaine −> add 1mEq NaHCO3/10ml • Bupivacaine and etidocaine −>NO, they precipitate
ADJUVANTS
• Opioids • Buprenorphine commonly used
• long duration • local anesthetic-like effect (block of Na+ channels)
• Studies in people but no in vet med • Sciatic nerve block and minor oral surgeries • What I do:
• buprenorphine 5-10 μg/kg + bupivacaine
• Alpha2-agonists • Dexmedetomidine used in rats and people (palatine n. block) • Decreases onset and increases duration • What I do:
• dexmedetomidine 0.5-1 μg/kg + bupivacaine
OUTLINE
• Terminology, nerve microanatomy, and fiber types
• Mechanism of action and pharmacology • Mixtures of local anesthetics • Adjuvants
• Potential adverse effects
• Local techniques
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TOXICITY
• Cardiovascular depression
• Respiratory arrest • Coma • Convulsions • Unconsciousness • Muscular twitching • Visual and auditory
disturbances • Lightheadedness • Numbness of the tongue
• Neurotoxicity – lidocaine
• Cardiovascular toxicity – Bupivacaine
• Methemoglobinemia (cats) – benzocaine, prilocaine, procaine, and
lidocaine (less often)
pla
sma
co
nc
en
tra
tion
TOXICITY
• Prevent • Calculate total dose
Recommended doses for blocks
Agent Dog Cat
Bupivacaine Up to 2 mg/kg Up to 1 mg/kg
Lidocaine Up to 6 mg/kg Up to 3 mg/kg
Mepivacaine Up to 6 mg/kg Up to 3 mg/kg
Lumb & Jones’ “Veterinary Anesthesia and Analgesia” 4th ed., Blackwell Publishing, 2007 p 994
TOXICITY
• Treatment depends on signs • IV fluids • Vasopressors/inotropes • Anticholinergics • CPR • Lipid emulsion 20%
• 4 ml/kg bolus, followed by 0.5 ml/kg/min for 10 minutes
• Methylene blue 1% (if methemoglobinemia) • 4 mg/kg in dogs and 1-2 mg/kg in cats
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OUTLINE
• Terminology, nerve microanatomy, and fiber types
• Mechanism of action and pharmacology • Mixtures of local anesthetics • Adjuvants
• Potential adverse effects
• Local techniques
INTERCOSTAL BLOCK
Lumb & Jones’ “Veterinary Anesthesia and Analgesia” fourth ed. P 568
BRACHIAL PLEXUS BLOCK
Lumb & Jones’ “Veterinary Anesthesia and Analgesia” fourth ed. P 572