Local Anesthetic Systemic
Complications and Treatment
Adverse Drug Reactions
1) Side effects
2) Overdose reactions
3) Local toxic effects (most common)
4) Allergic reactions
Toxicity caused by alteration in
the recipient of the drug
1) Disease process
2) Emotional disturbances
3) Genetic aberrations
4) Idiosyncrasy
Signs and Symptoms – Toxic Reaction
to Local Anesthesia
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Talkativeness
Slurred speech
Dizziness
Nausea
Depression
Euphoria
Excitement
Convulsions
Overdose Reactions
Clinical signs and symptoms that
develop as a result of an
over-administration of a drug
Overdose Contributing Factors
• Age
• Weight
• Other medications
• Presence of disease
• Genetics
• Mental wellbeing
Drug Factors
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Vasoactivity
Concentration
Dose
Route of administration
Rate of injection
Vascularity of the injection site
Presence of vasoconstrictors
Mild Overdose Reaction
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Slow onset
Reassure patient
Administer oxygen
Monitor vital signs
Allow patient to recover as long as
necessary
Slower Onset of Overdose
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Reassure patient
Administer oxygen
Monitor vital signs
Administer anticonvulsant
Call 911
After reaction, have patient examined by a
physician
• Do not let patient leave alone
Severe Overdose Reaction
• Rapid onset (within one minute)
• Remove syringe (if in the process of an injection)
• Protect patient for trauma if convulsions are
present
• Call 911
• Basic life support
• Administer anticonvulsant
• Allow patient to recover
• Do not let patient leave alone
Epinephrine Overdose
Very rare for patient to experience an
epinephrine overdose
Signs and Symptoms of Epinephrine
Overdose
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Fear, anxiety
Tenseness
Restlessness
Throbbing headache
Tremor
Perspiration
Weakness
Dizziness
Pallor
Respiratory difficulty
Palpitations
Management of Epinephrine Overdose
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Terminate dental procedure
Sit patient upright in the dental chair
Reassure patient
Monitor blood pressure
Administer oxygen
Allergic Reactions to Local
Anesthetic Agents
• Hypersensitive state as a result of
exposure to an allergen
• Re-exposure can heighten the initial
reaction
Clinical Manifestations of an Allergy
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Fever
Angioedema
Urticaria
Dermatitis
Depression of blood-forming organs
Photosensitivity
Anaphylaxis
Angioedema
Urticaria (hives)
Allergy
• Incidents of allergy are low
• Often allergic reaction is to one of the
ingredients within the cartridge, not the
local anesthesia itself
How to Prevent An Allergic
Reaction
• Take a thorough medical history
• Dialogue the medical history with the
patient
Common Questions to Ask
the Patient
• Allergic to any medications?
• Have you ever had a reaction to local
anesthesia?
• If yes, describe what happened
• Was treatment given? If so, what?
Allergic Responses to local
anesthetic
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Dermatitis (hives)
Bronchospasm
Systemic anaphylaxis
Hypersensitivity to esters
(atypical pseudo cholinesterase, PABA)
Latex Allergy
• The cartridge opening into which the needle
is inserted is aluminum with a very thin
diaphragm of latex in the middle
• Though patients with a latex allergy are at
an increased risk, there are no known cases
or reports of an allergic response from the
latex on a local anesthetic cartridge
Asthma Patient
• Thorough medical and dental history
• Avoid use of anesthesia that contain
epinephrine or levonordefrin because of
sulfites (may cause wheezing)
• Asthma patient that is steroid dependant
may develop brochospasms
• Establish rapport and calm environment
Renal Disease
Common diseases associated with renal
failure are diabetes mellitus,
hypertension, or systemic lupus
erythematosus (SLE)
Kidneys are compromised
Drugs Metabolized by the Liver
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Lidocaine (Xylocaine)
Prilocaine (Citanest)
Mepivacaine (Carbocaine, Polocaine)
Bupivacaine (Marcaine)
• Appear to be safe for use on patients with liver
disease when used in appropriate amounts
Pregnancy
• Anesthesia crosses the placenta and could be toxic
to the fetus, but is not a known teratogen
• No drug should be administered during pregnancy
especially the first trimester
• If treatment is necessary, local anesthetics with
epinephrine are considered relatively safe for use
during pregnancy; check with patient’s physician
• Educate patients to the potential risks (document)
FDA Category of Prescription Drugs
Drug
Category
Use During
Pregnancy
Risk
Lidocaine
B
Yes
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Prilocaine
B
Yes
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Mepivacaine
C
Use with cautionConsult physician
Fetal
bradycardia
Bupivacaine
C
Use with cautionConsult physician
Fetal
bradycardia
Hypertension
• Stress and anxiety may raise the patient’s blood
pressure (>160/100)
• Thorough medical, dental and patient history
• Norepinephrine and levonordefrin should not be
used because of alpha1 stimulation
(2% Mepivacaine with 1:20,000 levonordefrin)
• Up to two cartridges of 2% lidocaine with
1:100,000 epinephrine is safe
Contraindication for Local Anesthetic
with Epinephrine
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Uncontrolled hypertension
Myocardial infarction (within 6 months)
Unstable angina
Coronary artery bypass graft (> 3 months)
Quiz
1. Local anesthetics and vasoconstrictors do cross the
placenta in pregnant women; local anesthetics and
vasoconstrictors are known teratogens (cause birth
defects).
a. The first part of the statement is true, the second
part is true.
b. The first part of the statement is true, the
second part is false.
c. The first part of the statement is false, the second
part is false.
d. The first part of the statement is false, the second
part is true.
2. What should you do when using local anesthesia on a patient with
controlled hypertension?
a. Take the BP before the injection and use Mepivacaine only
b. Take the BP before the injection and use an anesthetic without a
vasoconstrictor
c. Take the BP before the injection and use anesthetic with a
vasoconstrictor judiciously
d. Local anesthetics should not be used on patients with hypertension
3. Since local anesthetics are excreted through the
kidneys, what is true concerning giving local
anesthesia to a patient with renal dysfunction?
a. Consult patient’s physician
b. Potential for overdose
c. Use anesthetics in minimal doses
d. All of the above
4. What is the most common reason for allergies to
local anesthetic solutions?
a. Asthma
b. The anesthetic solution itself
c. The other added ingredients to the solution
d. The vasoconstrictor
5. To prevent an overdose, what should the
maximum safe doses of anesthetic be based on?
a. The patient’s age
b. The patient’s weight
c. The patient’s physical status
d. The patient’s health
e. All of the above