Anesthesia, Local

Definition
Purpose
Precautions
Description
Aftercare
Risks
Normal results

Definition

Anesthesia is used to make it possible for individuals to undergo surgery without pain. Local or regional anesthesia involves the injection or application of an anesthetic, or numbing, drug to a specific area of the body. This is in contrast to general anesthesia, which provides anesthesia to the entire body and brain.

Purpose

Local anesthetics are used to prevent patients from feeling pain during medical, surgical, or dental procedures. Over-the-counter local anesthetics are also available to provide temporary relief from pain, irritation, and itching caused by various conditions such as cold sores, canker sores, sore throats, sunburn, insect bites, poison ivy, and minor cuts and scratches.

Regional anesthesia blocks the sensation of pain over a large area of the body. For example, anesthesia is commonly injected into the spinal fluid (an epidural or spinal) to numb sensation in the lower body. Patients who are treated with regional anesthesia remain conscious, but lose feeling in a large part of their body.

Precautions

People who feel strongly that they do not want to be awake and alert during certain procedures may not be good candidates for local or regional anesthesia; however, other medications that have systemic effects may be given in addition to an anesthetic to relieve anxiety and help the patient relax.

Local anesthetics should be used only for the conditions for which they are intended. For example, a topical anesthetic meant to relieve sunburn pain should not be used on cold sores. Anyone who has had an unusual reaction to a local anesthetic in the past should check with a doctor before using any type of local anesthetic again. The doctor should also be told about any allergies to foods, dyes, preservatives, or other substances.

Older people may be more sensitive to the effects of local anesthetics, especially lidocaine. Children may also be especially sensitive to some local anesthetics; certain types should not be used at all on young children. People caring for these groups need to be aware that they are at increased risk of more severe side effects. Package directions should be followed carefully so that the recommended dosage is not exceeded. A doctor or pharmacist should be consulted about any concerns.

Regional anesthetics

Serious and possibly life-threatening side effects may occur when injectable or inhaled anesthetics are given to people who use street drugs. Doctors and nurses should inform patients about the dangers of mixing anesthetics with cocaine, marijuana, amphetamines, barbiturates, phencyclidine (also known as PCP or angel dust), heroin, or other street drugs. Some anesthetic drugs may interact with other medicines. When this happens, the effects of one or both of the drugs may change, or the risk of side effects may be greater. In select cases, a urinalysis can help identify drug use.

Patients who have a personal or family history of malignant hyperthermia after receiving a general anesthetic must also be cautious when receiving regional or local anesthetics. Malignant hyperthermia is a serious reaction that involves a fast or irregular heartbeat, high

KEY TERMS

Canker sore— A painful sore inside the mouth.

Cerebrospinal fluid— A clear fluid that fills the hollow cavity inside the brain and spinal cord. The cerebrospinal fluid has several functions, including providing a cushion for the brain against shock or impact, and removing waste products from the brain.

Cold sore— A small blister on the lips or face, caused by a virus. Also called a fever blister.

Epidural space— The space surrounding the spinal fluid sac.

Malignant hyperthermia— A type of reaction, probably with a genetic basis, that can occur during general anesthesia, in which the patient experiences a high fever, the muscles become rigid, and the heart rate and blood pressure fluctuate.

Subarachnoid space— The space surrounding the spinal cord that is filled with cerebrospinal fluid.

Topical— Not ingested; applied to the outside of the body, for example to the skin, eye, or mouth.

fever, breathing problems, and muscle spasms. All patients should be asked if they are aware of such a risk in their family before receiving any kind of anesthetic.

Although problems are rare, some side effects may occur when regional anesthetics are used during labor and delivery. Anesthetics can prolong labor and increase the risk of requiring a Caesarean section. Doctors should discuss the risks and benefits associated with epidural or spinal anesthesia with pregnant patients.

Regional anesthetics should be used only by an experienced anesthesiologist in a properly equipped environment with suitable resuscitative equipment. Although these anesthetics are generally safe when properly selected and administered, severe adverse reactions are still possible. If inadvertent subarachnoid injection occurs, the patient is likely to require resuscitation with oxygen and drug therapy. Careful positioning of the patient is essential to prevent leaking of cerebrospinal fluid.

Patients should not drive or operate machinery immediately following a procedure involving regional anesthesia because numbness or weakness may cause impairment. Doctors and nurses should also warn patients who have had local anesthesia, especially when combined with drugs to make patients sleep or to reduce pain, about operating any type of machinery.

Injectable local anesthetics

Until the anesthetic wears off, patients should be careful not to inadvertently injure the numbed area. If the anesthetic was used in the mouth, patients should not eat or chew gum until feeling returns.

Topical anesthetics

Unless advised by a doctor, topical anesthetics should not be used on or near any part of the body with large sores, broken or scraped skin, severe injury, or infection. They should also not be used on large areas of skin. Some topical anesthetics contain alcohol and should not be used near an open flame or while smoking.

Patients should be careful not to get topical anesthetics in the eyes, nose, or mouth. If a spray-type anesthetic is to be used on the face, it can be applied with a cotton swab or sterile gauze pad. After using a topical anesthetic on a child, the caregiver should make sure the child does not get the medicine in his or her mouth or eyes.

Topical anesthetics are intended for the temporary relief of pain and itching. They should not be used for more than a few days at a time. A doctor should be consulted if:

• discomfort continues for more than seven days;
• the problem gets worse;
• the treated area becomes infected; or
• new signs of irritation such as skin rash, burning, stinging, or swelling appear.

Dental anesthetics

Dental anesthetics should not be used if certain kinds of infections are present. Package directions should be checked or a dentist, pharmacist, or doctor should be consulted if there is any uncertainty. Dental anesthetics should be used only for temporary pain relief. Consult the dentist if problems such as toothache, mouth sores, or pain from dentures or braces continue or if signs of general illness such as fever, rash, or vomiting develop.

Patients should not eat or chew gum while the mouth is numb from a dental anesthetic to avoid accidentally biting the tongue or the inside of the mouth. In addition, the patient should not eat or drink for one hour after applying a dental anesthetic to the back of the mouth or throat because the medicine may interfere with swallowing and could cause choking. If normal feeling does not return to the mouth within a few hours after receiving a dental anesthetic, or if it is difficult to open the mouth, the dentist should be consulted.

Ophthalmic anesthetics

When anesthetics are used in the eye, it is important not to rub or wipe the eye until the effect of the anesthetic has worn off and feeling has returned. Rubbing the eye while it is numb could cause injury.

Description

Medical procedures and situations that regularly make use of local or regional anesthesia include the following:

• biopsies, in which skin or tissue samples are taken for diagnostic procedures;
• childbirth;
• scar repair;
• surgery on the face (including plastic surgery), skin, arms, hands, legs, and feet;
• eye surgery; and
• surgery involving the urinary tract or reproductive organs.

Surgery involving the chest or abdomen is usually performed under general anesthesia; however, laparoscopy and hernia repair may be performed under local or regional anesthesia.

Local and regional anesthesia have many advantages over general anesthesia. Most importantly, the risk of unusual and sometimes fatal reactions to general anesthesia is lessened. More minor, but significant, risks of general anesthesia include longer recovery time and the psychological discomfort of losing consciousness.

Regional anesthesia typically affects a larger area than local anesthesia. As a result, regional anesthesia is typically used for more involved or complicated procedures. The duration of action of an anesthetic depends on the type and amount of anesthetic administered.

Regional anesthetics are injected. Local anesthesia involves the injection into the skin or application to the skin surface of an anesthetic directly where pain will occur. Local anesthesia can be divided into four groups: injectable, topical, dental (non-injectable), and regional blockade injection.

Local and regional anesthesia work by altering the flow of sodium molecules into nerve cells (neurons) through the cell membrane. The exact mechanism is not understood, since the drug apparently does not bind to any receptor on the cell surface and does not seem to affect the release of chemicals that transmit nerve impulses (neurotransmitters) from the nerve cells. Experts believe that when the sodium molecules do not get into the neurons, nerve impulses are not generated and pain impulses are not transmitted to the brain.

Regional anesthesia

Types of regional anesthesia include:

• spinal anesthesia, which involves the injection of a small amount of local anesthetic into the cerebrospinal fluid surrounding the spinal cord, known as the subarachnoid space. A drop in blood pressure is a common but easily treated side effect;
• epidural anesthesia, which involves the injection of a large volume of local anesthetic into the space surrounding the spinal fluid sac, or epidural space, and not directly into the spinal fluid. Pain relief occurs more slowly, but is less likely to produce a drop in blood pressure. The block can be maintained for long periods, even for days if necessary; and
• nerve blockades, which involve the injection of an anesthetic into the area around a sensory or motor nerve that supplies a particular region of the body, preventing the nerve from carrying nerve impulses to and from the brain.

Local and regional anesthetics may be administered with other drugs to enhance their action. Examples include vasoconstrictors such as epinephrine (adrenaline) to decrease bleeding, or sodium bicarbonate to lower acidity, which may make a drug work faster. In addition, medications may be administered to help a patient remain calm and more comfortable or to make them sleepy.

Local anesthesia

INJECTABLE LOCAL ANESTHETICS. Injectable local anesthetics provide pain relief for some part of the body during surgery, dental procedures, or other medical procedures. They are given only by a trained health care professional in a doctor’s office or a hospital. Some commonly used injectable local anesthetics are lidocaine (Xylocaine), bupivacaine (Marcaine), and mepivacaine (Carbocaine).

TOPICAL ANESTHETICS. Topical anesthetics such as benzocaine, lidocaine (in smaller quantities or doses), dibucaine, and tetracaine relieve pain and itching by blocking the sensory nerve endings in the skin. They are the active ingredients in a variety of nonprescription products that are applied to the skin to relieve the discomfort of sunburn, insect bites or stings, poison ivy, and minor cuts, scratches, and burns. These products are sold as creams, ointments, sprays, lotions, and gels.

Topical dental anesthetics are intended for pain relief in the mouth or throat. They may be used to relieve throat pain, teething pain, painful canker sores, toothaches, or discomfort from dentures, braces, or bridgework. Some dental anesthetics are available only with a doctor’s prescription. Others may be purchased over the counter, including products such as Num-Zit, Orajel, Chloraseptic lozenges, and Xylocaine.

Ophthalmic anesthetics are designed for use in the eye. Lidocaine and tetracaine are used to numb the eye before certain eye examinations. Eye doctors may also use these medicines before measuring eye pressure or removing stitches or foreign objects from the eye. These drugs are to be given only by a trained health care professional.

The recommended dosage of a topical anesthetic depends on the type of local anesthetic and the purpose for which it is being used. When using a nonprescription local anesthetic, patients are advised to follow the directions on the package. Questions concerning how to use a product should be referred to a doctor, dentist, or pharmacist.

Aftercare

Most patients can return home immediately after a local anesthetic, but some patients might require limited observation. The degree of aftercare needed depends on where the anesthetic was given, how much was given, and other individual circumstances. Patients who have had their eyes numbed should wear a patch after surgery or treatment until full feeling in the eye area has returned. If the throat was anesthetized, the patient cannot drink until the gag reflex returns. If a major extremity was anesthetized, the patient may have to wait until function returns before being discharged. Some local anesthetics can cause cardiac arrhythmia and therefore require monitoring for a time with an EKG. Patients who have had regional anesthesia or larger amounts of local anesthesia usually recover in a post-anesthesia care unit before being discharged. There, medical personnel watch for immediate postoperative problems. These patients need to be driven home after discharge.

Risks

Side effects of regional or local anesthetics vary depending on the type of anesthetic used and the way it is administered. Any unusual symptoms following the use of an anesthetic requires the immediate attention of a doctor.

Paralysis after a regional anesthetic such as an epidural, spinal, or ganglionic blockade is extremely rare, but can occur. Paralysis reportedly occurs even less frequently than deaths due to general anesthesia.

There is also a small risk of developing a severe headache called a spinal headache following a spinal or epidural block. This headache is severe when the patient is upright, even when only elevated 30°, and is hardly felt when the patient lies down. It is treated by increasing fluids to help clear the anesthetic and enhance the flow of spinal fluid.

Finally, blood clots or an abscess can form at the site where an anesthetic is injected. Although these can usually be treated, antibiotic resistance is becoming increasingly common. Such infections must be regarded as potentially dangerous, particularly if they develop at the site of a spinal injection.

A physician should be notified immediately if any of the following symptoms occur:

• symptoms of an allergic reaction such as hives (urticaria), which are itchy swellings on the skin, or swelling in the mouth or throat;
• severe headache;
• blurred vision, double vision, or photophobia, which is sensitivity to light;
• dizziness or lightheadedness;
• drowsiness;
• confusion;
• an irregular, too slow, or rapid heartbeat;
• anxiety, excitement, nervousness, or restlessness;
• convulsions or seizures;
• feeling hot, cold, or numb anywhere other than the anesthetized area;
• ringing or buzzing in the ears;
• shivering or trembling;
• sweating;
• pale skin;
• breathing problems; or
• unusual weakness or tiredness.

Normal results

Local and regional anesthetics help to make many conditions and procedures more comfortable and tolerable with few or no side effects for patients.

Resources

BOOKS

Barash, P. G., B. F. Cullen, and R. K. Stoelting. Clinical Anesthesia, 5th ed. Philadelphia: Lippincott, Williams & Williams, 2005.

OTHER

“Anesthesia: A Look at Local, Regional and General Anesthesia.” Mayo Clinic.com. June 16, 2006. http://www.mayoclinic.com/health/anesthesia/SC00026 (February 6, 2008).

“Anesthesia.” Medline Plus. January 22, 2008. http://www.nlm.nih.gov/medlineplus/anesthesia.html (February 6, 2008).

Mercandetti, Michael, Adam J. Cohen, and Dedra Hern. “Anesthesia, Local with Sedation.” eMedicine.com. March 7, 2008. http://www.emedicine.com/plastic/topic112.htm (March 20, 2008).

Virtual Anaesthsia Textbook. December 5, 2004. http://www.virtual-anaesthesia-textbook.com/index.shtml (February 6, 2008).

ORGANIZATIONS

American Academy of Anesthesiologist Assistants, 2209 Dickens Road, Richmond, VA, 23230-2005, (804) 565-6353, (866) 328-5858, (804) 822-0090, http://www.anesthetist.org.

American Association of Nurse Anesthetists, 222 South Prospect Avenue, Park Ridge, IL, 60068-4001, (847) 692-7050, (847) 692-6968, [email protected], http://www.aana.com.

American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL, 60068-2573, (847) 825-5586, (847) 825-1692, [email protected], http://www.asahq.org.

Lisette Hilton

Sam Uretsky, Pharm.D.

Tish Davidson, A.M.