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Description: Choice of Local Anesthetic for Cardiac Compromised Patients, Congestive Heart Failure, Ischemic Heart Disease, Cardiac Arrhythmias, Stress Reduction Protocol, Endogenous Epinephrine, Local Anesthetic and Vasoconstrictors, Bupivacaine, Cardiotoxicity of Local Anesthetics, Ropivacaine in Dentistry, Chloroprocaine, Weavercaine, Cardiac stability.
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September 21, 2013
October 25, 2013
November 15, 2013
October 12, 2013
Choice of Local Anesthetic for Cardiac Compromised Patients
Dr. Scott Brown Dr. Matt Pingel
General Practice Residency The Ohio State University College of Dentistry and University Medical Center April 2004
Medical Histories of Concern
Hypertension Congestive Heart Failure Ischemic Heart Disease Cardiac Arrhythmias The list goes on....
Impacts 58 million Americans Essential Hypertension affects 95% of patients; etiology unknown Secondary Hypertension causes 5% of cases and the underlying cause is known HTN causes arterial damage, renal damage, MI, CVA, CHF and blindness
Congestive Heart Failure
Affects 2 million Americans Cause in 75% is Hypertension Other causes include pulmonary HTN, congenital heart disease, severe anemia, thyrotoxicosis and rheumatic fever May cause failure of right, left, or both ventricles
Ischemic Heart Disease
Causes include atherosclerosis, embolism, coronary ostial stenosis, coronary artery spasm, and congential abnormalities. Decreased perfusion of myocardium may lead to myocardial infarction and sudden cardiac death.
Definition: variation in normal rhythm of heartbeat. Disturbances in rhythm, rate, or conduction are present. Primary causes: primary cardiovascular disease, pulmonary disorders, systemic diseases, drugrelated side effects, electrolyte imbalances
Minimize stress, anxiety Patient may need treated in a monitored, hospital setting. Otherwise, monitor vitals at each appointment. Consult physician Judicious use of local with epinephrine
Most references suggest a limit of 0.04 mg of epi.
Stress Reduction Protocol
Minimize stress with use of oral or IV sedation Some patients may require general anesthesia Profound local anesthesia minimizes production and release of endogenous epinephrine
Adrenal Medulla produces between 0.007 mg/min and 0.014 mg/min in a patient at rest. Venous plasma concentration of epinephrine is approximately doubled by the intraoral injection of a single cartridge of 2% lidocaine with 1:100,000 epi. Capable of producing 0.28 mg/min in times of stress A 1.8ml cartridge of 2% lidocaine with 1 to 100,000 epinephrine contains 0.018 mgs.
Local Anesthetic and Vasoconstrictors
2% Lidocaine with 1:100,000 epinephrine widely used in dentistry Epinephrine needed because lidocaine alone causes vasodilation Lidocaine without epinephrine is not reliable in achieving pulpal anesthesia after maxillary infiltration Maximum recommended dose of epinephrine in patient's with compromised cardiac status is 40 micrograms (0.04 mg)
To vasoconstrict or not?
Concerned about intravascular injections of local anesthetic with vasoconstrictor; Blood pressure spikes Drug interactions are another cause for concern- propanolol, reserpine, and guanethidine Local anesthetic with vasoconstrictor can still be safely used in most patients. However, can't exceed 40 micrograms-- implications for surgical procedures
Full Mouth Extraction
Quickly exceed 40 micrograms of epinephrine; complicates choice of local anesthetic in patients with compromised cardiac status Alternatives to 2% lidocaine with 1 to 100,000 epi:
0.5% bupivacaine with 1 to 200,000 epi, Tetracaine Mepivacaine Prilocaine Etidocaine Chloroprocaine Ropivacaine.
Amide type local anesthetic Could use 8ml's prior to reaching 40 micrograms of epinephrine Prolonged duration of action; Beneficial in surgical procedures since it provides 5 to 8 hours of postoperative analgesia
Sold as a racemic mixture of the R and S enatiomers The R (+) isomer is highly cardiotoxic due to its affinity for voltage gated sodium channels Causes negative ionotropy Depresses the myocardium
Cardiotoxicity of Local Anesthetics
Direct correlation exists between cardiac toxicity, lipid solubility, and nerve blocking potentcy Hyerkalemia exacerbates the cardiotoxicity of local anesthetics. Bupivacaine and etidocaine are highly lipophilic Mepivacaine has been reported to decrease peripheral vascular resistance and cause increases in cardiac output
Rank Order of Local Anesthetic Cardiotoxicity (lowest to highest)
Prilocaine Lidocaine Mepivacaine Ropivacaine Bupivacaine Etidocaine Tetracaine
Amide type local anesthetic Produced as a single S stereoisomer Used for epidural anesthesia Binds three times less firmly to sodium channels than bupivacaine and unbinds 4 times as slowly. Is 2-3 times less lipid soluble than bupivacaine Smaller direct ionotropic effect when compared to bupivacaine
Ropivacaine in Dentistry
Limited research available Similar duration and onset to bupivacaine Does not require epinephrine?
Ropivacaine in dentistry
Study by Ernberg and Kopp concluded that ropivacaine can be useful for mandibular nerve block but not for maxillary infiltration. Study by Kennedy, Reader, Beck,et al suggest that the addition of epinephrine to ropivacaine results in a 75% success rate of maxillary pulpal anesthesia. Ernberg and Kopp reported a 20 to 60% success rate of pulpal anesthesia after maxillary infiltration. Rate of success was dosage and concentration dependent.
Similar to Procaine Ester type LA Rapid onset MSD- 11mg/kg, 800mg max. Extremely short half-life May cause depression of myocardium, hypotension, bradycardia, ventricular arrhythmias.
Metabolized by plasma cholinesterase Low cardiotoxicity Most commonly used in epidural anesthesia
1:1 mixture of 0.5% ropivacaine and 3% chloroprocaine Used for surgical procedures in cardiac compromised patients Mouth anesthetized in quadrants
Case Presentation #1
51 y/o caucasian with rampant caries, chronic generalized periodontal disease. H/O CHF, CAD, statis post cabbage, NIDDM, hypothyroidism, GERD, bipolar, obesity, hypertriglyeridemia. Allergy to PCN. 19 meds include digoxin, amiodarone, furosemide and lasix. TX- FME in OR GENERAL ANESTHESIA LA used: 10ml of 3% Cholorprocaine and 10 ml of 0.5% Ropivacaine.
Case #1 Radiographs
Cardiac stability during GA Case #1
Case Presentation #2
52 y/o caucasian male with rampant decay, multiple abscesses, severe generalized pediodontitis requiring FME prior to coronary bypass graft. H/O CAD, CHF, ejection fraction of 20%, HTN, chronic restrictive lung disease, hypertriglyceridemia. FME in OR with MAC with 11 ml of 3% Cholorprocaine and 11 ml of 0.5% Ropivacaine.
Case Presentation #2
Pt. was mildly uncooperative BP elevation more pronounced during maxillary than mandibular extractions. PDL's given to enhance anesthesia Abscess inhibited profound anesthesia
Case #2 Panorex
Cardiac stability during MAC Case #2
Recommendations on "Weavercaine"
Useful for cardiac compromised patients. Anesthesia not always as profound as you'd like--particularly problematic in the maxilla Treat in quadrants to avoid infusing a large bolus of anesthetic Anesthetize ONLY immediately in advance of starting treatment in an area to avoid loss of anesthesia.
Local Anesthesia of the Oral Cavity, Jastak, Yagiela, and Donaldson. 1995 Dental Management Of The Medically Compromised Patient, Little and Falace. Fourth Edition 1993 Pharmacology and Therapeutics for Dentistry. Yagiela, Neidle, and Dowd. Fourth Edition. 1998 Heavner J, Cardiac Toxicity of Local Anesthetics in the Intact Isolated Heart Model: A review. Regional Anesthesia and Pain Medicine, 2002;27:545-555. Kennedy M, Reader A, Beck M, et al: An evaluation of the anesthetic efficacy of .5% ropivicaine, .5% ropivicaine with 1 to 200,000 epinephrine, and .5% bupivicaine with 1 to 200,000 epinephrine in human maxillary local anesthetic infliltration. Oral Surg Oral Med Oral Pathol 91:406, 2001 Ernberg M, Kopp S: Ropivicaine for Dental Anesthesia: A DoseFinding Study. JOral Maxillofac Surg 60:1004-1010, 2002 http://www.emedicine.com/ent/topic20.htm http://depts.washington.edu/anesth/regional/ropivicainetext/html