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How to Use Local and Regional Anesthesia for Procedures of the Head and Perineum in the Horse

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How to Use Local and Regional Anesthesia for Procedures of the Head and Perineum in the Horse HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT How to Use Local and Regional Anesthesia for Procedures of the Head and Perineum in the Horse J. Brett Woodie, DVM Author’s address: Rood and Riddle Equine Hospital, PO Box 12070, Lexington, KY 40580–2070; e-mail: [email protected]. © 2013 AAEP. 1. Introduction cost.1 Peripheral nerve blocks and epidural anes- Combining local or regional anesthetic techniques thesia are typically performed with the use of a 2% with sedation will allow many diagnostic and surgi- lidocaine solution. The onset of action for periph- cal procedures to be safely performed in the horse. eral nerve blocks is typically 5 to 10 minutes. The Drugs used for local anesthesia are designed to pen- duration of action has been reported to be 1.5 to 3 hours, but clinical experience would suggest that the etrate peripheral nerves and interrupt nerve con- 1,2 duction resulting in reversible anesthesia for a duration of action is shorter. Repeated dosing or predictable period of time.1 It is important for the excessive amount of lidocaine can lead to toxicity. clinician to have a thorough understanding of the Total dosage should be kept less than 250 mL of 2% pertinent anatomy in order to be successful with lidocaine in a 500-kg horse. these techniques. Mepivacaine is very similar to lidocaine. It has a similar onset of action, but the duration of action is 1 2. Local Anesthetics longer. Mepivacaine has less vasodilatory activity compared with lidocaine, and mepivacaine is less The mechanism of action of local anesthetic drugs is effective as a topical anesthetic compared with to prevent transfer of nociceptive information by lidocaine. blocking sodium channels in excitable mem- 1,2 Bupivacaine is two to four times as potent as branes. Local anesthetics can be used topically, lidocaine and mepivacaine. It has a much slower injected over nerves (perineural anesthesia), intra- onset of action and a prolonged duration of action. synovial, regional infiltration, and injected into the The duration of action is reported to be greater than epidural space. Common local anesthetics used in 3 hours.1 equine practice are lidocaine hydrochloride, mepiva- caine hydrochloride, and bupivacaine hydrochloride. 3. Anesthesia of the Head Lidocaine is probably the commonly used because Dental procedures are one of the most common rea- of its potency, rapid onset of action, moderate dura- sons to use regional anesthesia of the head. Other tion of action, topical anesthetic properties, and indications include ophthalmic procedures, lacera- NOTES 464 2013 ր Vol. 59 ր AAEP PROCEEDINGS HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT tion repair, and repair of incisive bone fractures. eral side of the mandible and all of its dental struc- The maxillary, mandibular, alveolar, and mental tures are desensitized when the mandibular nerve is nerve blocks are the regional nerve blocks of the blocked at the level of the mandibular foramen. head.3 The horse should be sedated and properly The mandibular foramen is located by drawing an restrained before the nerve block is given. The imaginary line from the lateral canthus of the eye area over the injection site should be cleaned and ventrally and a second imaginary line that extends prepped. Clipping of the hair is not necessary. along and caudal to the occlusal surface of the man- dibular cheek teeth. The point at which these two Maxillary Nerve Block lines intersect is the mandibular foramen. A 6- to The maxillary nerve enters the infraorbital canal at 8-inch, 20- to 22-gauge spinal needle is used for the the pterygopalatine fossa and becomes the infraor- injection. The needle is inserted at the ventral bor- bital nerve.3 Anesthetizing the maxillary nerve at der of the ramus of the mandible and advanced the level of the pterygopalatine fossa will desensitize dorsally toward the mandibular foramen. A second the ipsilateral dental structures of the maxilla and spinal needle of the same length can be held against premaxilla, the paranasal sinuses, and the nasal the lateral surface of the mandible and used as a cavity. There are two techniques to perform this “depth guide” for the needle that was inserted on the block. The first method uses a 3.5-inch, 20- or 22- medial surface of the mandible. Fifteen to 20 mL of gauge spinal needle inserted perpendicular of the local anesthetic should be infused. Within 15 to 30 long axis of the head at the level of the caudal third minutes, structures innervated by the mandibular of the orbit. The needle should be just ventral to nerve should be desensitized. the zygomatic process and dorsal to the transverse facial vessels. The needle is advanced until bone is Mental Nerve Block contacted. The volume of local anesthetic to be in- The mandibular nerve travels through the mandib- jected is 15 to 20 mL. ular canal and emerges at the mental foramen as The second technique uses a 6-inch spinal needle the mental nerve.3 The mental nerve provides in- inserted just ventral to the most dorsal aspect of the nervation to the skin of the ipsilateral lip and chin. zygomatic process. The needle is directed rostrally Branches of the mandibular nerve that lie within and ventrally, aiming toward the rostral aspect of the mandibular canal provide innervation to the the contralateral facial crest. The needle should be mandibular canine, incisor, and cheek teeth. The advanced until bone is contacted. The volume of mental foramen is located on the lateral aspect of anesthetic to be injected is 15 to 20 mL. Within 15 the horizontal ramus of the mandible in the inter- minutes, structures innervated by the maxillary dental space. The foramen is beneath the tendon of nerve should be desensitized. the depressor labii inferioris muscle. This tendon must be elevated to palpate the foramen. To per- Infraorbital Nerve Block form this block, a 1.5-inch, 22-gauge needle is in- The infraorbital nerve can be desensitized as it serted through the skin, and the tendon of the emerges from the infraorbital canal or within the depressor labii inferioris muscle is then elevated. infraorbital canal.3 The effect is the same as The needle is advanced into the foramen and 5 to 10 achieved with the maxillary nerve block if local an- mL of local anesthetic is infused. Within 15 min- esthetic completely fills the infraorbital canal. The utes, structures innervated by the mental nerve skin of the ipsilateral lip, nostril, and face up to the should be desensitized. Infusing large volumes level of the infraorbital foramen are desensitized (Ͼ10 mL) of local anesthetic into the mandibular when the infraorbital nerve rostral to the infraor- canal is likely to desensitize the same structures as bital canal is blocked. The left infraorbital foramen in performing a mandibular nerve block. is located by placing the right thumb in the nasoin- cisive notch and the right middle finger on the ros- 4. Anesthesia of the Perineum tral aspect of the facial crest. The right index Caudal epidural anesthesia is a common technique finger should locate the foramen beneath the ventral used to desensitize the perineum and associated an- margin of the levator labii superioris halfway be- atomic structures. This technique has been used to tween and 1 to 3 cm caudal to an imaginary line facilitate many procedures, both medical and surgi- connecting the thumb and middle finger. cal. Examples include the following: to prevent or The infraorbital nerve is anesthetized by inserting stop rectal tenesmus, assist with obstetric manipu- a 22-gauge, 1.5-inch needle through the skin and lations, and assist with surgical procedures of the into the canal for a distance of 1 inch. The volume caudal reproductive tract.2 of local anesthetic to be infused is 5 to 10 mL. Within 15 minutes, structures innervated by Epidural Anesthesia the infraorbital nerve should be desensitized. Epidural anesthesia is achieved when the local an- esthetic solution is deposited between the dura ma- Mandibular Nerve Block ter and the periosteum of the spinal canal, which The mandibular nerve enters the mandibular canal blocks conduction in the caudal nerve roots.4 Cau- of the medial surface of the mandible.3 The ipsilat- dal epidural anesthesia implies that sensory inner- AAEP PROCEEDINGS ր Vol. 59 ր 2013 465 HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT vation is lost but motor control of the hind limbs is to 30 minutes and provide analgesia for 90 to 120 not affected. However, the tail should be tied over- minutes.4 Ataxia is a complication when local an- head to support the horse if ataxia develops. The esthetics are used. ␣ sacrocaudal or first intercaudal vertebral space is Epidural administration of 2-adrenergic agonists selected as the site for injection for epidural anes- such as xylazine will provide profound analgesia thesia.5 This location is found by grasping the tail without the complication of ataxia.6,7 The recom- and moving it up and down. The first articulation mended dose of xylazine is 0.17 mg/kg. The onset caudal to the sacrum is the first intercoccygeal of action is 10 to 30 minutes, and the duration of space. The site should be clipped and aseptically analgesia is 2.5 to 4 hours.5 The xylazine should be prepared. The epidural should be administered diluted in saline to a total volume of 6 to 10 mL. with the use of aseptic technique. There are vari- Epidural administration of detomidine (30–60 ␮g/ ous injection techniques and drug combinations that kg) provides analgesia lasting for 2 to 3 hours but can be used. The horse should be sedated and re- produces sedation and ataxia.5,6 The combination strained in stocks (if available) during administra- of lidocaine (0.22 mg/kg) and xylazine (0.17 mg/kg) tion of epidural anesthesia.
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