Contraindications and Complications for Local Anesthetics
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| Medical Problem: Documented L.A. allergy. | All L.A's of that type (esters or amides):
Absolute:
L.A. of other type (amide, esters)
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| Medical Problem: Malignant Hyperthermia | Amides:
Relative:
Use amides judiciously
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| Medical Problem: Atypical Pseudocholinesterase | Esters:
Relative:
Amides
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| Medical Problem: Significant Liver Dysfunction | Amides:
Relative:
Use amides judiciously
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| Medical Problem: Renal Dysfunction | Esters and Amides:
Relative:
Amides or esters, but use judiciously
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| Medical Problem: Methemoglobinemia | Prilocaine and Benzocaine:
Relative:
Any other Anesthetics
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| Medical Problem: Patient taking Acetaminophens (long term basis may cause Methemoglobinemia) : | Prilocaine and Benzocaine:
Relative:
Any other anesthetics
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| Medical Problem: Patient taking Cimetadine (Tagamet, Zantac) on a regular basis | Amides:
Relative:
Reduce dosage by one half. Drug reduced liver's capacity to metabolize amide anesthetics.
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| Medical Problem: Significant Cardiovascular Disease | High Vasoconstrictor concentrations of local anesthetics:
Relative:
3% Mepicacaine
4% Prilocaine Plain
4% Prilocaine w/ 1:200,000 epi
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| Medical Problem:Clinical Hyperthyroidism | High vasocontrictor concentrations:
Relative:
3% Mepicacaine
4% Prilocaine Plain
4% Prilocaine w/ 1:200,000 epi
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| Medical Problem:Hypothyroidism | All L.A.:
Relative:
Normal dosages could produce overdose since metabolism is significantly diminished
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| Medical Problem: Antianxiety drugs Benzodiazepines Ex. Vallium | All L.A. :
Relative:
Minimize dosages of all anesthetics
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| Complication: Fainting | Form of shock-sometimes due to seeing the needle.
Low BP, pallor, coolness of skin, perspiration, light-headedness, nausea:
Lower chair so legs are elevated, have ammonia ampule handy:
Keep pt. as calm as possible, keep needle out of view
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| Complication: Muscle Trismus | Trauma to muscle during needle insertion. Hemorrhage. Multiple needle penetrations:
Muscle soreness. Limited movement of mandible:
Heat therapy 20 min/hr. Analgesics-Ibuprofen. Gum chewing: Watch landmarks. Good technique. Limit # of injections in area
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| Complication: Pain (hyperesthesia) : | Poor technique, rapid depositions, needle w/ barbs:
Pain:
Reassure pt:
Topical. Change needle every 3-4 injections
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| Complication: Infection | Unsterile instruments:
Low grade inflammation resulting in trismus:
Penicillin or erythromycin:
Aseptic Technique
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| Complication: Broken Needle | Sudden, unexpected movement:
Instruct pt. to not move. Keep hand in pt.s mouth. Remove w. cotton pliers, if lost refer to oral surgeon:
Do not force against resistance. Know landmarks. Do not insert needle past sight.
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| Complication: Hematoma | Torn blood vessel:
Swelling, discoloration, soreness:
Direct pressure for 10 min, Ice pack, Heat 4-6 hrs (20 min/hr):
Good Technique, occur w/ proper technique
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| Complication: Parethesia | Trauma to nerve, contaminated solutions, hemorrhage:
Persistent anesthesia for hours, days or long term:
Examine, reassure pt., refer to oral surgeon after 1 yr:
Technique, # of injections in one area, do not store carps by cleaning solutions
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| Complication: Facial Nerve Paralysis : | Injecting into parotid gland capsule:
Loss of motor function, dehydration of cornea:
Reassure pt., anesthesia to wear off, manually close eyes:
Technique, contact bone prior to injection
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| Complication: Post Anesthetic Intraoral Lesions | Trauma to oral tissues:
Recurrent apthous stomatitis:
Tx. symptoms:
No prevention, more suseptable than others
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| Complication: Burning | Rapid injection, ph low, warm solution, contaminated:
Trismus, edema paresthesia:
no tx given:
Inject slowly, La w. vaso has lower pH, no contaminated solution
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| Complication: Toxicity | Inadvertent IV injection. Slow biotransformation and elimination:
High BP, pulse, respiration, pt. becomes apprehensive,depression, low BP, pulse, respiration, convulsion, unconsciousness:
Discontinue tx, maintain airway:
through patient evaluation
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| Complication: Allergic Reaction | antigen-antibody reaction:
rash, urticaria:
Antihistamines:
Thorough medical history
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| Complication: Anaphylatic Allergic Reaction | severe form of allergy:
sudden onset rash, wheezing:
prompt action, administer epi, 911:
thorough medical history
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| Complication: Idiosyncrasy (any reaction that cannot be classified as toxic or allergic) | genetic aberration, specific drug that induces bizarre clinical manifestation:
impossible to outline in advanced:
basic life support:
do not expose pt. to anything w/ past reaction
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| Complication: Contamination | rare:
local tissue irritation:
none:
double check for debris, inject slowly, buy from reliable maker
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| Complication: Sloughing of Tissue | Topical anesthetic for prolonged time:
epithelial desquamation:
reassure pt:
use properly, use low concentrations
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| Complication: Edema | trauma during injection, infection or allergy:
pain, dysfunction, compromised airway:
decrease swelling soon, analgesics or antihistamine:
good technique, aseptic technique, thorough medical history
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| Complication: Lip/Soft Tissue Injury | biting one self while anesthetized:
trauma, pain, swelling:
analgesics for pain, salkine rinses, lubricated:
warn pt. good communication, short acting anesthetic
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| Blood Pressure Classification: Normal | 120/80
Tx modifications usually not needed, routine management, recheck in six months
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| Blood Pressure Classification: Prehypertension | 120-139 or 80-89
Routine tx ok
discuss guidelines w/ pt.
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| Blood Pressure Classification: Stage I Hypertension | 140-159 or 90-99
Routine tx ok
consider sedation for complex dental or surgical procedures; refer for medical consult
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| Blood Pressure Classification: Stage II Hypertension | 160-100 (95)
Restrict Vasocontrictor Use
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| 160-179 or 100-109 | Routine tx ok, restrict vasoconstrictor use
consider sedation for complex dental or surgical procedures; refer for medical consult
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| 180-209 or 110-119 | No dental tx with out medical consultation
refer for prompt medical consult/ medical tx
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| 210-120 | no dental tx
refer for emergency medical tx
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| ASA Classifications: I: Normal Healthy Individual | Tx modifications usually not needed
No abnormalities found, tolerant of stress
Normal BP 120-80
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| ASA Classifications: II: Pt. w/ mild to mod. systemic disease | well-controlled epilepsy, asthma, non-insulin-dependent diabetes, and thyroid disorders
otherwise healthy pt. will allergies or extreme dental fears
prehypertension, adult w/ BP of 120-139/80-89
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| ASA Classifications: III: Pt w. severe systemic disease that limits activity but is not incapacitating | stable angina pectoris 6 months past MI
exercise induced asthma, COPD, well controlled insulin dependent diabeties
Stage I hypertension: adult BP 140-159/90-99
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| ASA Classifications: IV: pt w/ severe systemic disease that limits activity and is a constant threat to life | Myocardial infarction or CVA within the last 6 months
uncontrolled epilepsy, diabetes, COPS with o2
stage 2 hypertension, BP 160-100
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| ASA Classifications V: Moribund pt. not expected to survive 24 hrs w. or w/o an operation | Terminal cancer
end-stage renal disease, hepatic disease and infectious disease
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| Relative Contraindication: Pt. taking Tricyclic antidepressants (Triavil, Elavil, Norpramin, Tofranil, Aventyl, Vivetil, etc) | Increases the effects of epi. Levonordefrin should be avoided completely. Both may cause acute hypertension and cardiac dysrhythmia.
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| Relative Contraindication: Patient taking Phenothaiazides (Tindal, Thorazine, Trilafon, Vesprin, Mellaril, etc.) | Increases risk of hypertension resulting in rebound bradycardia potential cardiac arrest
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| Relative Contraindication: Patient taking Non selective beta blockers (indural, Corgard, etc) | increased hypertension resulting in rebound bradycardia potential cardiac arrest
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| Relative Contraindication: Cocaine abusers | may lead to myocardial infarction
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| Relative Contraindication: Glaucoma | causes increased ocular pressure
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| Relative Contraindication: Controlled Diabetes Especially Type I | Vasoconstrictors directly opposes effect of insulin, possible changes in blood levels of glucose
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| Relative Contraindication: Controlled Hypertheyroidism | Vasocontrictors effect increased
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| Relative Contraindication: Controlled high blood pressure | Very controversial, risks associated with vasoconstrictors, increase in blood pressure.
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