3. Recognition and Management of Systemic Anesthetic Complications and Vasoconstrictors Flashcards
(45 cards)
1
Q
Systemic Complications:
Principles
• No drug ever exerts a ____ action.
• No clinically useful drug is entirely devoid of ____.
• The potential toxicity of a drug rests in the hands of the ____
• Every drug exerts multiple actions
A
single
toxicity
user
2
Q
Adverse drug reactions = direct exntension of usual effects of the drug
- ____ effects
- ____
- Local ____ effects• ADR are not ____ reactions
A
side
overdose
toxic
allergic
3
Q
Overdose
• Clinical signs and symptoms that manifest as a result of an absolute or relative over-administration of a drug which produces elevated levels in the blood.
• Y axis = plasma cxn ○ 0-5 mg/ml > therapeutic effects of lidocaine (+ inotropy and anti-arrhythmic) • Lower levels of lido > minor neurologic > circumoral tongue \_\_\_\_, light headed, ringing in ears, muscle twitching and convulsions (10 mg/ml) > eventually coma, respiratory arrest and CV depression
A
numbness
4
Q
Overdose:
Predisposing Factors
Patient Factors • \_\_\_\_ • Weight • Other \_\_\_\_ • Physiologic status
Site Factors
• ____ of injection site
• Area of ____
Drug Factors • \_\_\_\_ • Dose • \_\_\_\_ of injection • Route of administration • Presence of \_\_\_\_
A
age
drugs
vascularity
absorption
concentration
rate
vasoconstrictor
5
Q
Overdose
• \_\_\_\_ individuals have a greater tendency to OD • \_\_\_\_ individuals have a great tendency to OD ○ Drugs ar ebased on mg/kg • Unhealthy people, poor metabolism > wille xperience toxic effects of lidocaine • Cxn = potency of drug • Doses larger than 5 mg/ml show an increase in OD • How fast is the lido injected; if it's injected quickly it'll be absorbed more quickly and will see more SE • RoA ○ IF lido is \_\_\_\_ > less likely to be toxic, if It were injected IV it will get to the BS quickly and exerting its effects • Vasoconstrictor ○ Epi to the lido; will keep it there longer § W/o Epi > absorbed into circulation andw ill casue \_\_\_\_ effects § Hardly ever done w/o: epi will hold the drug there, person will be anesthetized longer, and it doesn't get burned up as quickly; and also, from a surgical standpoint it wiill cause hemostasis § If a patient has CV problems w/ hypertension and refer to PCP > may come back and tell you to use no epi (won't use in these cases) § W/ epi casuing CV problems, but if don't use epi > will have bleeding, patient will be uncomfortable > will have endogenous produciton of epi (worse for the patient, epi will shoot out into their body and will cause a CV issue); better to have a small amount of epi • VoIS ○ Post max is more vascular ○ Inf Alv nerve block > can inject into inf alv artery or posterior superior alv atery > can inc the toxic effects of the drug • Area of absorption ○ How large, and how quickly into circulation
A
age
weight
subQ
toxic
6
Q
Adverse Drug Reactions:
Alteration of the drug by the recipient
- A disease process that alters the ____ of the drug
- Psychosocial disturbance
- ____ aberrations
- Idiosyncrasy = a response to a drug that cannot be ____ by a known pharmacological or biochemical mechanism.• Disease process that alters metbaolism
○ Liver disease
§ Drugs are metabolized in the lver; if have ESLD
• Example of a benzo causing combative effects and not sedative
○ Idiosyncratic reaction
A
metabolism
genetic
7
Q
Anesthetic Blood Levels:
Determining Factors
- Rate at which the drug is absorbed into the ____ system
- Rate of distribution of the agent from the ____ compartment to the tissues (more rapid in ____ individuals)
- Elimination of the drug through ____ and excretory pathways
- The rate of diffusion is governed by the ____, and a higher concentration increases ____ of onset• Rate absorbed more quickly > higher anesthetc blood elvels
• How quck is the distribtuion
○ If the durg is abosrbed into tissues . Less in the BS > happens more readily in healthy individuals
• If eliminated slowly, blood levels will be higher
A
cardiovascular vascular healthy metabolic concentration gradient rapidity
8
Q
Elevated Blood Levels:
Etiology
- Biotransformation of the drug is usually ____.
- The drug is too slowly eliminated from the body by the ____.
- Too high of a total dose is ____.
- Absorption from the injection site is unusually ____.
- Inadvertent ____ administration.• Doses > 5 mg/ml will see elevated blood levels
A
slow kidneys administered rapid intravascular
9
Q
Biotransformation:
Esters
- Plasma pseudocholinesterase causes hydrolysis to ____.
- 6 to 7 % may have atypical ____.• Ester and amids are metabolzied differently
• When PC transforms will transmforms into ____
○ 6-7% cannot metabolize this anesthetic
• ____ are what are mostly used
A
ABA
pseudocholinesterase
amides
10
Q
Biotransformation:
Amides
- Metabolized by hepatic ____ enzymes
- Use with caution in patients with ____ disease
A
microsomal
liver
11
Q
Elimination
- Renal dysfunction can delay the elimination of ____.
- A greater percentage of ____ are excreted in the urine unchanged compared to esters• Eters are ____ a lot more than the amides
A
local anesthetic
amides
metabolized
12
Q
Excessive Total Dose:
Factors effecting maximum recommended dosages
- ____
- Physical status
- ____
- Don’t want to give same amt of epi to soemwone with CV disease
- Elderly individuals > dec dosages; metbaolism isn’t as quick
- More frail individuals (children) > dec the recommended dosages
A
age
weight
13
Q
Adult Dosage Guidelines:
Maximum recommended dosages
LOOK AT THE TABLE
• KNOW lidocaine (2% w/ 1/1000 epi) > max dose is \_\_\_\_ mg (3.3 mg/lb) • 500 mg is base don healthy, normal individual • KNOW \_\_\_\_ > exact same as lido ○ (4% w/ 1/1000 epi) • \_\_\_\_ > used as a plain anesthetic ○ 3% mepic (higher cxn of local) w/o epi > mepiv can be absorbed quickly and can see toxic effects ○ Will often have to reinject (giving more durg, and the field is bloodier) • Lido most commoly used, and then articaine • Bupiv is a long-acting LA > useful to give to a patient wheny ou completed a procedure ○ After 6-8 carps of lido to get a set of wisdom teeth out, at the end > inject two blocks (marcay) of bupiv to anesthetize the manidble (long drive) ○ Several hours of relief until get to a pharmacy to get pain medication • Articaine/septicaine ○ Don't use for inf alv blocks > higher incidence of \_\_\_\_ and numbness ○ In canada and europe, it is most popular then lido ○ Can penetrate bone readily § In mandible, can inject around the area instead of blocking thew hole mandible □ Esp for \_\_\_\_, this will work well ○ When difficult time anesthetizing > will go to septicaine
A
500 articaine/septicaine mepivicaine paresthesia irrev pulpitis
14
Q
2% Lidocaine with 1/100,000 epinephrine:
Composition
- ____ - 36 mg
- ____ - 18 mcg (0.018 mg)
A
lidocaine
epinephrine
15
Q
Peak Blood Levels and Route of Administration
Intravenous: ____ time to peak level (min)
Topical: ____ time to peak level (min)
Intramuscular: ____ time to peak level (min)
Subcutaneous: ____ time to peak level (min)
• If epi into the BS (bc of the use with lido) > IV injection causing tachycardia and uneasy ○ Will pass \_\_\_\_ (a few minutes maybe) ○ Will think it's an \_\_\_\_ reaction, people are not acutlaly allergic to epi (rare to be allergic to anesthetics) § Can send to immunologist if there is a suspicision • With topical administration > like the esters > will be 5 mins
A
1 5 5-10 30-90 quickly allergic
16
Q
Diffusion of Local Anesthetics:
Concepts
- Some of the drug is absorbed by ____ tissues (i.e. muscle and fat).
- Some of the drug is diluted by ____ fluid.
- Some of the drug is removed by ____ and lymphatics from the injection site.
- Esters are ____.
- More ____ the patient > the more the drug is absorbed into the fat
- Esters hydrolyzed into PABA
A
non-neural interstitial capillaries hydrolyzed obese
17
Q
Cases where there is rapid absorption into the circulation:
- ____ delay absorption of injected local anesthetics into the CVS.
- ____ are absorbed into the CVS rapidly and are more likely to produce overdose.• Topical anesthetics are not used if they are amides bc more likely to produce an OD
○ Esp near a vascular bed
A
vasoconstrictors
topical amides
18
Q
Intravascular Injections:
Incidence of Positive Aspiration
Inferior alveolar: ____ % positive aspiration
Mental/incisive: ____ % positive aspiration
Posterior superior alveolar: ____ % positive aspiration
Anterior superior alveolar: ____ % positive aspiration
(Long) buccal: ____ % positive aspiration
• Always \_\_\_\_ before doing any injection! • Inf alv NB > lingual aspect of the mandible (in addition to a lingual nerve block) ○ More reliable in terms of anesthizing the patient • With septicaine > removing two incisors and don’t' want to give a block > esp if perio disease > \_\_\_\_ infiltration at the labial aspect as wellas the lignual aspect • Most aspiration bc of volume > posterior superior alv injections are more common
A
11.7
5.7
3.1
0.7
0.5
aspirate
septicaine
19
Q
Many local anesthetic overdose reactions occur as a result of the combination of inadvertent intravascular injection and too rapid a rate of injection, both of which are virtually 100% ____.
A
preventable
20
Q
Intravascular Injection: Prevention • Use an \_\_\_\_ syringe. • Use a needle no smaller than a \_\_\_\_. • Inject 1.8 ml in no less than \_\_\_\_ seconds.
* Gauage is \_\_\_\_ in terms of size > 19 gauge is much bigger in terms of diameter than a 30 guage * Use a needle no smaller than a 25 gauge needle * 19 gauge to flush out \_\_\_\_ * Patients can only sense how rapid the fluid is injected, cannot differentiate size of needle
A
aspirating 25 gauge 60 inverse TMJ
21
Q
Systemic Actions
- ____
- Analgesia
- ____ depression
- Vasodilation (except for cocaine)• Anticonvulsant > given in smaller doses will see them; larger doses you will see seizures, coma and resp/cardiac collapse
• Analgesic effect > will control pain
○ Used when the patient is asleep also [???]
○ Used for pain and hemostasis
• Cocaine is an anesthetic
○ It’s used for instance with ____ fractures > a lot of bleeding
A
anticonvulsant
myocardial
nasal
22
Q
Lidocaine blood levels
• Top normal blood levels ○ Anything less 4-5 in terms of CV system, will not have any effects below these levels • In terms of CNS > will give \_\_\_\_ effects • Vs toxic levels are go down the graph > CNS depression and seizures when at 7.5-10 mg/ml > coma • Cardiac actions > will see thera effects [???] ○ Once 5-10 mg/ml > alterations in EKG
A
anticonvulsant
23
Q
Toxicity
Initial symptoms include ____, muscle twitching, and convulsions. After the initial phase, ____, lethargy, and loss of consciousness is possible.
Cardiovascular depression may include ____.
____ secondary to respiratory depression can rapidly produce the most serious outcomes of cardiovascular collapse, brain damage, and death.
* Tremors and twitching before the seizures * Stop breathing > hypoxia > CV collapse and brain damage
A
tremors
respiratory depression
hypotension
hypoxia
24
Q
Minimal to Moderate Overdose Levels:
Signs
TAKE A LOOK!
A
ya
25
Mild Overdose:
(slow onset > ____ minutes after administration)
Treatment
____ patient
O2 nasal cannula
Monitor ____ signs
IV infusion: ____ 5 mg/min. midazolam 1mg/min.
Discharge with ____ or transfer for further evaluation
• Make sur ethey're getting O2 bc of hypoxia
• Diazepam/midazolam
○ ____ drugs > can break the seizure
○ Befor ethe seizure starts administer to prevent one
```
5
reassure
vital
diazepam
escort
anticonvulsant
```
26
Pre-convulsant:
Symptoms
```
____ of tongue and circumoral region
Warm, flushed feeling of skin
Pleasant ____ state
generalized light-headedness
____
Visual Disturbances (inability to focus)
____ disturbance (tinnitus) Drowsiness
Disorientation
```
numbness
dreamlike
dizziness
auditory
27
Pre-convulsant:
Signs
____ speech
Shivering
____ twitching
____ in muscle of face and distal extremities
slurred
muscular
tremor
28
Severe Overdose: (Rapid onset - within 1 minute)
Treatment
```
____
position to protect from self-injury
summon ____ assistance
basic life support
administer ____ (IM if IV is not possible)
treat hypotension:
-- ____
-- IV fluids
-- ____; i.e. phenylephrine
-- ephedrine
-- ____
```
• Trendelenburg position
○ ____ position
§ Oxygen to the brain quickly
○ Same with a patient with a syncopal episode
• Safest place to have a seizure is in a dental chair
• Anticonvulsant > diazepam (and midalazam)
○ Don't use diazepam bc very irritating to the veins, but now replaced by ____
```
trendelenburg
medical
anticonvulsant
positioning
vasopressor
methoxamine
```
head-down
midalazam
29
Blood levels of lidocaine and seizures:
Anti-convulsive: ____ blood levels
Pro-seizure signs and symptoms: ____ blood levels
Tonic-clonic seizures: ____ blood levels
0.5 to 4 ug/ml
4.5 to 7 ug/ml
> 7.5 ug/ml
30
Local Anesthetic without Vasoconstrictor:
Increased rate of ____ of the local anesthetic into the blood, which in turn carries it away from the injection site.
Higher ____ levels of the local anesthetic, with an increased risk of overdose reaction.
Decreased duration of ____ and decreased ____ of the local anesthetic because it diffuses away from the injection site more rapidly.
Increased ____ at the site of the administration due to increased profusion.
```
absorption
plasma
action
effectiveness
bleeding
```
31
Vasoconstrictors:
By constricting blood vessels, vasoconstrictors decrease ____(perfusion) to the site of the injection.
Absorption of the local anesthetic into the bloodstream is ____, thereby producing lower levels in the blood.
Lower blood levels of anesthetic decrease the risk ____ reaction.
Higher concentrations of local anesthetic agent remain in and around the nerve for longer periods, thereby increasing (in some cases significantly) the duration of ____ of most local anesthetics.
Vasoconstrictors decrease ____ at the site of their administration and are useful, therefore, when increased bleeding is anticipated (i.e. during a surgical procedure).
```
blood flow
slowed
overdose
action
bleeding
```
32
Vasoconstrictor (epinephrine 1:200,000) on peak LA
Mepivacaine
Dose: ____
W/o vasocon: ____
W/ vasocon: ____
Lidocaine
Dose: ____
W/o vasocon: ____
W/ vasocon: ____
Prilocaine
Dose: ____
W/o vasocon: ____
W/ vasocon: ____
Etidocaine
Dose: ____
W/o vasocon: ____
W/ vasocon: ____
```
500
4.7
3
400
4.3
3
```
```
400
2.8
2.6
300
1.4
1.3
```
33
V asoconstrictors Maximum Recommended Dosages: Heart Association Guidelines
```
Epinephrine
Concen:
Maximum recommended:
0.02 - ____ cartridges
0.01 - ____ cartridges
0.005 - ____ cartridges
```
Levonordefrin
Concen:
Maximum recommended:
0.05 - ____ cartridges
5
11
11
11
34
Vasoconstrictors
Maximum Recommended Dosages (mg):
Epinephrine
Healthy: ____
CV disease: ____
Concentrations: ____
Levarterenol
Healthy: ____
CV disease: ____
Concentration: ____
Levonordefrin
Healthy: ____
CV disease: ____
Concentration: ____
Phenylephrine
Healthy: ____
CV disease: ____
Concentration: ____
0. 20
0. 04
1: 50k, 1:100k, 1:200k
0. 34
0. 14
1: 30k
0. 5
0. 2
1: 20k
4. 00
1. 60
1: 2,500
35
in which vasoconstrictors should be avoided or used at minimum
Uncontrolled ____
____-sensitive asthma or true sulfite allergy
Patients who are undergoing general anesthesia with ____ agents
Patients receiving nonspecific ____, monoamine oxidase inhibitors, or tricyclic antidepressants
• Sulfite is a preservative found in the LA ____ with epi
○ Shouldn't get epinephrine, but RARE
• Halogenated - ____ (halofane not used anymore)
○ Not an issue anymore
• Can cause cardiac effects with tricyclic antidepressants
○ You want specific beta blockers vs ones that have alpha effects as well
```
hypethyroidism
sulfite
halogenated
beta blockers
cartridges
symptomimetic
```
36
Individuals with increased risk with epinephrine:
Patients with blood pressure in excess of ____ mm Hg systolic or 115 mm Hg diastolic
Patients with severe cardiovascular disease
Less than 6 months after ____
Less than 6 months after ____
Daily episodes of angina
pectoris or ____ (preinfarction) angina
Cardiac ____ despite appropriate therapy
Postcoronary artery bypass surgery, less then ____ months ago
____
• Cutoff is normally at 170-180 mmHg
○ Diastolic of 100
```
200
myocardial infarction
cerebrovascular accident
unstable
dysrhythmias
6
CHF
```
37
Vasopressor Overdose:
Clinical Manifestations
```
____
Restlessness
____ headache
____
Diaphoresis
____
Dizziness
____
Respiratory difficulty
____
```
```
fear, anxiety
throbbing
tremor
weakness
pallor
palpitations
```
38
Vasopressor Overdose:
Signs
Sharp elevation in ____ (____)
Elevated ____
Possible cardiac ____ (PVC, VT, Vfib)
```
• PVC are benign > anxious individual
○ Caffeine and nicotine can cause ____
• More severe > VT and Vfib
○ Shockable rhythms
○ When V tach > ominous, or Vfib
§ AED machine reads the rhythms and you don't have to do the shock yourself
```
```
blood pressure
systolic
heart rate
dysrhythmias
PVC
```
39
Management of an Epinephrine (vasopressor) Overdose:
____ dental procedure
P-position patient comfortably
A-B-C-assess and perform BLS, as needed,
```
D-Initiate ____ care;
Reassure patient
Monitor ____ signs
Summon medical assistance Administer ____
Permit recovery
Administer ____ (optional)
Permit recovery and discharge patient
```
• If giving NO with O2 > then swich the NO off and give 100% O2, or connect to O2 tank with a canula in their nose
• Vasodilators can be given to ____ the effect of epi
○ If high amount of epi, then high amount of lido > lido in toxic doses will cause vasodilatory effect
```
terminate
definitive
vital
O2
vasodilator
reverse
```
40
Allergies:
* Allergic reactions to ____ are extremely rare.
* Allergy to one type of amide does not preclude the use of other amides.
* Hypersensitivity to ____ is more frequent.
* Allergy with esters is usually due to breakdown product ____.
* ____ does occur with esters.
* Allergies to ____ cannot occur.
* Allergies to ____ in muti-dose vials.
* Allergies to sodium bisulfite/meta bisulfite in cartridges that contain ____.
• Can get bupivocaine if allergic to lidocaine
• Esters are not broken down by liver enzymes, but by PC into PABA and the breakdown is what some patients are allergic to
○ Cross-allergenicity does occur (unlike amide)
• Multi-dose vials have preservative that patients can have allergies to it, or within the cartridges (can still get epi however!)
```
amides
esters
PABA
cross-allergenicity
epinephrine
methylparaben
vasoconstrictor
```
41
Allergies:
Signs and Symptoms
Dermatologic
• ____
• Angioedema
```
Respiratory
• ____
• Wheezing
• ____
• Cyanosis
• ____
• Laryngeal edema
• Use of ____ Muscles
```
• Urticaria is the most likely derm reaction
• Angioedema > (right photo) > bilateral lower lip swelling
• ____ > a bad thing, and the patient may get epi in the ED
○ The vocal cords should not be that edematous, should see more of an airway
```
urticaria
dyspnea
flushing
diaphoresis
accessory
```
laryngedema
42
```
Anaphylaxis:
Signs and Symptoms
• ____ reactions
• Bronchospasm
• Respiratory ____
• Cardiovascular collapse
```
skin
| distress
43
Allergies:
Management
Immediate skin reaction
• IM/SC ____ or IM, then oral, antihistamine
Delayed skin reaction
• ____ blocker, i.e. Benadryl
Bronchospasm
• ____
• ____, i.e. albuterol • IM/SC epinephrine
• IM ____
```
epinephrine
oral histamine
oxygen
bronchodilators
antihistamine
```
44
Allergies:
Management
```
Laryngeal Edema
• IM/SQ ____
• Activate EMS
• Maintain ____
• IM/SQ corticosteroids
• ____ Airway
```
```
Generalized Anaphylaxis
• IM/SQ ____
• Activate EMS
• ____ Airway
• IM/SQ corticosteroids
```
epinephrine
airway
emergency
epinephrine
maintain
45
Methemoglobinemia:
* Metabolites of ____ and benzocaine can cause methemoglobinemia.
* Symptoms frequently do not occur for ____ hours after treatment.
* ____ without signs of respiratory distress may be apparent when methemoglobin levels reach 10 - 20%. ____ and headache have been described.
* At higher blood concentrations of methemoglobin dyspnea, ____, stupor, coma, and death are possible.
* Treatment is with IV ____ or IV/IM ____.
```
prilocaine
1-3
cyanosis
vomiting
dyspnea
methylene blue
vitamin C
```
