Regional/ neuraxial block Cough suppression Attenuate ICP/BP raise during laryngoscopy Attenuate reflex bronchospasm that may occur with airway instrumentation Suppress ventricular dysrhythmias

cocaine ↓ reuptake of NE → leads to ↑ concentrations of NE restlessness, tremors, seizures & euphoria tachycardia/MI

Local Anesthetics - the drugs Flashcards by I M

Its metabolite interferes with efficacy of sulfonamide antibiotics

Procaine

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what LAs have significant 1^st pass effect by the lungs

Bupivicaine

Lidoicaine

Prilocaine

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Chloroprocaine duration after infiltration

30 min to 1 hr

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LAs that come as pure enantiometrs

Ropivacaine

Levobupivacaine

*advantage = less toxic, easier to resuscitate in case of toxicity

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What is the dose of Lidocaine for epidural placement?

It depends on the level of blockade required and the density of blockade required. If you want profound motor blockade at T4 for example and the epidural is placed at the L2-3 interspace that is about 10 segments. Say this person is average size – I would give 1.5ml per segments I wanted blocked – so I would give 15cc of 2% lidocaine. 15cc X 20mg/cc = 300mg of lidocaine. I would need to make sure that this amount did not exceed the maximum dose allowed which is 5mg/kg for plain lidocaine. If the patient was 70kg that is 350mg – so 15cc is O.K. If I wanted to give more I might add epi which would increase my maximum dose to 7mg/kg or 490mg.

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Chloroprocaine Max Dose

12 mg/kg

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Lidocaine uses?

Regional/ neuraxial block
Cough suppression
Attenuate ICP/BP raise during laryngoscopy
Attenuate reflex bronchospasm that may occur with airway instrumentation
Suppress ventricular dysrhythmias

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Tetracaine Max Dose

3 mg/kg

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Cocaine toxicity sxs

cocaine ↓ reuptake of NE → leads to ↑ concentrations of NE

restlessness, tremors, seizures & euphoria
tachycardia/MI

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LAs that come in racemic mixtures

Bupivacaine

Mepivacaine

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Arrange LAs in the order of non-ionization %

cocaine, lidocaine, mepivacaine, chloroprocaine, prilocaine, ropivacaine, tetracaine, procaine

Procaine 3%

Chloroprocaine 5%

Tetracaine 7%

Cocaine 7%

Bupivacaine/Levobupivacaine 17%

Ropivacaine 17%

Lidocaine 24%

Prilocaine 24 %

Mepivacaine 39%

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Bupivacaine E½t

3.5 hrs

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LA great for differential nerve block (sensory>motor)

great for OB

Bupivacaine

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when do you redose lidocaine (epidural)?

lidocaine lasts about 1.5-2 hours etc

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Ropivacaine max spinal dose

15-20

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Bupivacaine DOA after spinal

1.5 to 3.5 hr

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List max doses of LAs

Bupivacaine, cocaine, tetracaine, ropivacaine, etidocaine, lidocaine, mepivacaine, choroprocaine

Bupivacaine 2.5 mg/kg

Cocaine 3 mg/kg

Tetracaine 3 mg/kg

Ropivacaine 3 mg/kg (3.5 w epi)

Etidocaine 4 mg/kg

Lidocaine 4 mg/kg (7 w epi)

Mepivacaine 4 mg/kg (7 w epi)

Chloroprocaine 12 mg/kg

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Prilocaine duration after infiltration

1 -2 hrs

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Mepivacaine duration after infiltration

1.5 - 3 hr

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LAs with pKa in the ≈ 8s

Bupivacaine/Levobupivacaine 8.1

Ropivacaine 8.1

Cocaine 8.5

Tetracaine 8.5

Chloroprocaine 8.7

Procaine 8.9

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which has more CNS toxicity poptential

lidocaine or mepivacaine

mepivacaine

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Does lidocaine have an active metabolite?

YES.

2 Monoethylglycinexylidide (80% activity)

(Mono-ethyl-glycine-xylidide)

xylidide (10% activity)

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Bupivacaine (Levobupivacaine)

duration after infiltration

4-8 hrs

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LAs with pKa in the ≈7s

Mepivacaine 7.6

Etidocaine 7.7

Lidocaine 7.9

Prilocaine 7.9

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Shortest DOA for epidural

Chloroprocaine

Ropivacaine duration after infiltration

4-8 hrs

LA toxicity s/s?

**CNS** circumoral numbness, tinnitus, vision changes, dizzy, slurred speech, restless, muscle twitching (especially in the face), seizures (which cause CNS depression, apnea, hypotension) **CV** hypotension, myocardial depression, AV block Note: bupivacaine is most CV toxic

Lidocaine max spinal dose

30-100 mg

Bupivacaine pros and cons?

**Pro** highly protein bound * low incidence of neuro complications with spinal * longer DOA (good for post-op pain and labor) Also, A alpha, beta, and gamma fibers are not completely blocked, so sensory is blocked and motor is not completely blocked. **Con** TOXICITY! very cardio toxic; pressure is still felt, that can freak people out

metabolism of prilocaine.

Rapid metabolism TOXIC metabolite ortho-toluidine Must be avoided in OB due to metabolite Big doses will convert hgb to methemoglobin (treated with methylene blue)

Bupivacaine solution concentration

Spinal 0.5 - 0.75% Epidural 0.0625 - 0.5% Peripheral nerve block 0.25 - 0.5%

LAs that cannot be give epidurally

Procaine Tetracaine

Lidocaine onset and DOA w/ epidural

onset 5-15 min DOA 90-130 min

what LAs are highly lipid soluble

Bupivicaine Etidocaine Tetracaine BET

Lidocaine Max Dose

4 mg/kg 7 mg/kg with epi

Chloroprocaine onset and DOA w/ epidural

onset 5-15 min DOA 30-90 min

most cardiotoxic LA

Bupivacaine

LAs that cannot be given in aperipheral block

Tetracaine

Lidocaine solution concentrations topical regional IV PNB Spinal Epidural

topical 4% regional IV 0.25-0.5% PNB 1-2 % Spinal 1.5 - 5% Epidural 1.5 - 2%

Mepivacaine onset and DOA w/ epidural

onset 2-15 min DOA 1 - 3 hrs

Mepivacaine Max Dose

4 mg/kg 7 mg/kg with epi

What is chloroprocaine used for?

OB epidurals it has an ultra rapid serum hydrolysis (metabolism) which reduces toxicity risk to mom and baby

LAs that can be given IV

Lidocaine Prilocaine

How is cocaine metabolized?

Liver, plasma esterases, and about 10-12% eliminated by kidney careful with renal disease NOT PAVA like the other esters

Long DOA for an ester

Tetracaine 1.5 - 3.5hrs

Mepivacaine max spinal dose

40-80 mg

Bupivicaine max spinal dose

15-20 mg

pt cannot have epi what LA is best alternative

Mepivacaine it doesn't vasodilate like lidocaine so can be used when avoiding epi

Bupivacaine Max Dose

2.5 mg/kg

Cocaine Max Dose

3 mg/kg

Which LAs have slow, moderate, and fast onsets?

Slow: procaine, tetracaine (esters) Intermediate: bupivacaine Fast: chloroprocaine, lidocaine, etidocaine, mepivacaine

Etidocaine Max Dose

4 mg/kg

LA not effective topically

Mepivacaine

Tetracaine max spinal dose

5-20 mg

Ropivacaine Max Dose

3 mg/kg 3.5 mg/kg with epi

Procaine duration after infiltration

45 min - 1 hr

Why is lidocaine avoided in spinals?

Linked to caudal equina syndrome Epidural ok to use

LAs that are still questionable for a spinal block

Chloroprocaine Lidocaine Mepivacaine Prilocaine

Procaine max spinal dose

100-200 mg

Bupivacaine onset and DOA w/ epidural

onset 15-20 min DOA 3 - 6 hrs

LAs used topically

tetracaine Lidocaine

S (or levo) enantiomer of bupivacaine

Ropivacaine less cardio-toxic

Local Anesthetics - the drugs Flashcards

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