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2.2: Local Anesthesia

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Medicines used as local anesthetics cause revisable absence of pain sensation, although other senses are often affected as well. Also when it is used on specific nerve pathways, paralysis also can be achieved.

Lidocaine, Bupivacaine and Ropivacaine

B: Lidocaine: Maximum 4.5mg/kg without vasoconstrictors (adrenaline) or 7mg/kg with vasoconstrictors

OR

D: Levobupivacaine: Infusions in 100ml or 200ml bags of levobupivacaine 625 µg/ml (0.0625%) 1.25 mg/ ml (0.125%)

OR

C: Hyperbaric Bupivacaine: bupivacaine hydrochloride 5mg/ ml (0.5%) with 80 mg/ ml glucose (specific gravity of 1.026). The addition of glucose produces a hyperbaric solution relative to cerebrospinal fluid.

Medicines for Local Anaesthetics Overdose

S: Lipid Emulsion (intralipid 20% or 30% solution) for severe local anaesthetic toxicity with cardiovascular or neurological impairment

Dose: 1.5 mL/kg over 1min, then continuous infusion 0.25 mL/kg/min. Repeat bolus 1–2 times for persistent cardiovascular collapse. Double infusion rate to 0.5 mL/kg/min if BP remains low. Continue infusion for at least 10 minutes after cardiovascular stability attained. Recommended upper limit:

approximately 10 mL/kg lipid emulsion over the first 30 minutes.

Adjuvants To Anesthetics

Medical Gases

B: Medical gases (Air and Oxygen)

OR

C: Nitrous Oxide

Pressos

Ephedrine: Used frequently for hypotension in obstetric anesthesia as it may maintain uterine/placental blood flow more efficiently than some other sympathomimetic it should be reserved for this indication.

B: Ephedrine Dose: IV, 3–5 mg as a single dose and then further boluses as required to a maximum of 30 mg. OR

S: Phenylephrine: IV, 50–100 µg as a single dose and then infuse at 60–180 µg/minute. Administer intravenously after dilution to at least 1 mg/ ml 10 ml.

OR

S: Metaraminol 0.5–5mg followed by infusion of 15–100mg in 500mls of normal saline or 5% Dextrose injection adjusting rate to maintain desired blood pressure. Administer intravenously after dilution to at least 1 mg/ ml 10 ml

Pressors by Infusion: Noradrenaline, Adrenaline; Dopamine, Dobutamine

A: Adrenaline 1–2µg/kg, nebulised to reduce symptoms associated with acute upper airway obstruction, post–intubation swelling and infectious croup

OR

S: Noradrenaline 0.05–0.1µg/kg/min infusion

OR

D: Dobutamine: in Critical Care practice a combination of noradrenaline and dobutamine is often preferred to adrenaline alone, giving greater control over rate and pressure.

Medicines For Treatment Of Malignant Hyperthermia

S: Dantrolene Sodium Treatment of acute MH will also require rapid access to ice–cold normal saline 2 l, calcium chloride 10%, sodium bicarbonate 8.4%, glucose 20%, amiodarone 300 mg and a beta–blocker.

Dose: 2.5–10mg/kg, to be reconstituted with water, each vial contains mannitol 3g. Continue repeated administration until cardiac and respiratory symptoms stabilize.

Others:

A: Magnesium sulphate: for prevention and control of seizure caused by pre– eclampsia or eclampsia, Severe Tetanus. It is valued as an adjunctive agent during anesthesia.

S: Dexmedetomidine: is a potent and highly selective α2–adrenoreceptor agonist utilized for continuous infusion for sedation/analgesia in the intensive care unit (ICU). Dexmedetomidine has demonstrated to be an efficacious and safe anaesthetic adjuvant Dose: Hydrochloride Injection, 1µg/kg

S: Clonidine: (hydrochloride injection 500µg/ml) used as an adjuvant in regional anesthesia with proved effect of prolonging the duration of the analgesic effect of local anaesthetics. Use in General anesthesia as in use of Dexmedetomidine. Dose: 2µg/kg

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