Complications Of Local Anesthesia 2nd part.pptx

Complications Of Local Anesthesia in maxillary nerve blocks

1. Complications O f Maxillary Nerve Blocks

2. Paresthesia Hematoma Facial Nerve Palsy Diplopia Pressure Necrosis Contents

3. PARASTHESIA It is defined as persistent anesthesia, (anesthesia well beyond the expected duration ) . HYPERESTHESIA (increased s ensitivity to noxious stimuli) D YSESTHESIA (painful sensation occuring to non noxious stimuli), I n both of these cases, patient experience PAIN & NUMBNESS. CAUSE - Trauma to any nerve. Haemorrhage into or around the neural sheath. Injection of a LA solution contaminated by alcohol or sterilizing solution. Trauma to the nerve sheath.

4. Problem: May lead to self inflicted injury Biting or thermal or chemical insult can occur without a patient awareness . Prevention - Strict adherence to injection protocol & proper care & handling of dental cartridges.

5. Management - Reassure the patient, speak to the p a t ient personally, & explain it is not uncommon after LA admin i stration . D etermine the degree & extent of the paresthesia. Follow up in every 2 months . Dental treatment may continue, but avoid readminstration LA into the region of the previously traumatized nerve.

6. Pogrel et al. in 2000 conducted a study where patients with paraesthesia secondary to local anaesthetic use underwent surgical exploration of their affected sites. All cases showed that there was no evidence of damage to the affected nerve caused by the anaesthetic needle shank. Mechanical trauma alone appears to be an unlikely cause and nerve damage itself has been hypothesised to be caused by neurotoxicity of the local anaesthetic in combination with a minor trauma created by the needle. pogrel , m.a. , thamby , s. permanent nerve damage involvement . jada 2000; 131 (7): 901-907

7. HEMATOMA The effusion of blood into extravascular spaces can, result from inadvertently nicking a blood vessel during the injection of local anesthesia. Injecting the LA solution into the pterygoid plexus. Tissue density surrounding the injured vessel is a determining factor.

8. Pathophysiology: An V enous puncture ( In pterygopalatine venous plexes ) after PSA block, the tissue surrounding these vessels more readily accommodate significant volume of blood, due to lack of valvular mechanism in veins. This occur un til extravascular pressure is e qual or exceeds intravascular pressure or till the blood clot is formed. Hematoma after PSA are visible Extra Orally.

9. PROBLEM- A hematoma rarely produces significant problems, aside from the resulting bruise, which may or may not be visible extraorally. Swelling & discoloration subsides within 7- 14 days both with or without treatment . Possible complication includes trismus & pain .

10. PREVENTION Knowledge of the normal anatomy The depth of penetration for PSA may be decreased in a patient with smaller facial characteristics . Use shorter needle for PSA. Minimize the no. of needle penetration into tissue Never use a needle as a probe in tissue.

11. MANAGEMENT Immediate- Direct pressure should be applied tothe site of bleeding. PSA usually produces largest & unappealing hematoma. Digital pressure can be applied in the soft tissues in the mucobuccal fold as far distally as can be tolerated by the patient. Apply pressure in a medial & superior direction . Ice pack should be applied initially as it causes vasoconstriction and acts as an Analgesic. And later Hot application should be applied.(after 24hrs)

12. SUBSEQUENT- Patient should be discharged once the bleeding stops, advise the patient about possible soreness and limitation of movement. For soreness, take an analgesic . Do not apply heat for the next 4- 6hrs, heat produces VASODILATION thereby increasing the size of hematoma. Heat may be applied beginning of the next day, that w ill increase the rate at which blood elements are resorbed.

13. FACIAL NERVE PARALYSIS CAUSE- P aralysis of some of the terminal branches of the 7 th cranial nerve, when infra orbital nerve block is injected or when maxillary canine are infilterated . This may occur when anesthetic is introduced into the deep lobe of the parotid gland, through which terminal portions of the facial nerve extend.

14. PROBLEM- Loss of motor functions to the muscles of facial expression, there is usually minimal or no sensory loss. Inability to close the eyelid. Drooping of lip on the affected side. Winking and blinking becomes impossible. MANAGEMENT- Reassure the patient- situation is transitory Contact lenses must be removed until muscle movement returns Eye patch should be applied, periodically lubricate the eyes .

15. OCCULAR COMPLICATIONS Diffusion of the anesthetic drug through myofascial spaces or bony openings. Sved et  al. reported a high incidence of diplopia (35.6%) after second division trigeminal blocks (V2) via the greater palatine canal approach. They assumed that the anesthetic solution diffuses through the inferior orbital fissure to affect the extraocular muscles. Alamanos et al. belived that an intra-arterial route of the anesthetic solution could cause systemic symptoms, skin and mucosal blanching, sensory deficits, vision loss, and parasympathetic denervation .

16. Inadvertent intraarterial injection of the local anesthetic. Although felt by some authors to be highly improbable—as arteries have muscular walls that respond to stimulation by going into spasm—it has been theorized that the combination of an intra-arterial injection and an anatomic variation of the internal maxillary and middle meningeal arteries may direct the anesthetic solution to the ophthalmic artery and from there to the central retinal artery. The vasoconstrictor could then interrupt the blood supply to the retina, resulting in visual phenomena or blindness, depending on the duration and the degree of vasoconstriction.

17. Management of Ocular Complications: Each case involving an ocular complication should be evaluated individually. It is recommended that consultation with an ophthalmologist be obtained whenever there is uncertainty as to the cause. The data reviewed by Alamanos et al.64 showed that diplopia always have a transient character and that 75% of the cases resolve within 6 hours. Therefore in conditions such as convergent strabismus or binocular diplopia, at least until the anesthetic effect resolves, a “wait and observe” approach is recommended; supportive measures, such as patient reassurance and patching of the affected eye, should be undertaken.

18. Tissue necrosis Prolonged irritation or ischemia of gingival soft tissues may lead to a number of unpleasant complications, including epithelial desquamation and sterile abscess Causes: Epithelial Desquamation Application of a topical anesthetic to the gingival tissues for a prolonged period Heightened sensitivity of the tissues to either topical or injectable local anesthetic Sterile Abscess Secondary to prolonged ischemia resulting from the use of a local anesthetic with a vasoconstrictor (usually norepinephrine) Usually develops on the hard palate Pain, at times severe, may be a consequence of epithelial desquamation or a sterile abscess. It is remotely possible that infection may develop in these areas

19. Use topical anesthetics as recommended. Allow the solution to contact the mucous membranes for 1 to 2 minutes to maximize its effectiveness and minimize toxicity. When one is using vasoconstrictors for hemostasis, do not use overly concentrated solutions. Norepinephrine 1:30,000 is the agent most likely to produce ischemia of sufficient duration to cause tissue damage and a sterile abscess. The palatal tissues are likely the only place in the oral cavity where this phenomenon is likely to arise MANAGEMENT: Usually no formal management is necessary for epithelial desquamation or sterile abscess. Be certain to reassure the patient of this fact. Management may be symptomatic. For pain, analgesics, such as aspirin or another nonsteroidal anti-inflammatory drug and a topically applied ointment (triamcinolone ointment), IS recommended to minimize irritation to the area. Epithelial desquamation resolves within a few days; the course of a sterile abscess may run 7 to 10 days. Antibiotics are only necessary if the lesion is secondarily infected. Surgical management is only necessary if the ulcer does not heal 

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