DOCSLIB.ORG

Compounded Topical Anesthetics in Orthodontics

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Compounded Topical Anesthetics in Orthodontics OVERVIEW Compounded Topical Anesthetics in Orthodontics NEAL D. KRAVITZ, DMD, MS JOHN W. GRAHAM, DDS, MD JONATHAN L. NICOZISIS, DMD, MS JAY GILL, PharmD (Editor’s Note: In this regular column, JCO pro- present, compounded topical anesthetics are in vides an overview of a clinical topic of interest to “regulation limbo”—neither regulated nor un- orthodontists. Contributions and suggestions for regulated by the U.S. Food and Drug Administra- future subjects are welcome.) tion (FDA).6 In 2007, a comprehensive review of com- pounded topical anesthetics in the Journal of the ompounded topical anesthetics are commonly American Dental Association examined clinical Cused in orthodontics as an alternative to local trials, case reports, descriptive articles, FDA regu- infiltration for soft-tissue laser surgery,1,2 place- lations, clinical implications, and legitimate risks ment of temporary anchorage devices,3,4 and trans- associated with their uncontrolled application.7 mucosal alveolar micro-osteoperforation.5 Ques- This article will serve as a follow-up for orthodon- tions remain, however, regarding the consistency tists, providing current information on the creation of their formulation and the safety of their use. At and packaging of compounded topical anesthetics. Dr. Kravitz Dr. Graham Dr. Nicozisis Dr. Gill Dr. Kravitz is a Contributing Editor of the Journal of Clinical Orthodontics; an adjunct faculty member, Department of Orthodontics, Washington Hospital Center, Washington, DC; and in the private practice of orthodontics at 25055 Riding Plaza, Suite 110, South Riding, VA 20152; e-mail: [email protected]. Dr. Graham is a Contributing Editor of the Journal of Clinical Orthodontics; an Adjunct Associate Professor, Department of Orthodontics, Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco, and the Department of Orthodontics, University of Rochester School of Medicine and Dentistry, Rochester, NY; and in the private practice of orthodontics in Salt Lake City. Dr. Nicozisis is in the private practice of orthodontics in Princeton, NJ. Dr. Gill is a compounding pharmacist and owner, The Compounding Center, Leesburg, VA. VOLUME XLIX NUMBER 6 © 2015 JCO, Inc. 307 OVERVIEW TABLE 1 POPULAR COMPOUNDED TOPICAL ANESTHETICS Brand Name* Active Ingredients TAC 20% Alternate 20% lidocaine, 4% tetracaine, 2% phenylephrine Profound 10% lidocaine, 10% prilocaine, 4% tetracaine Profound PET/DēpBlu 10% lidocaine, 10% prilocaine, 4% tetracaine, 2% phenylephrine Baddest Topical in Town 3% lidocaine, 12.5% prilocaine, 12.5% tetracaine, 3% phenylephrine Best Topical Ever 12.5% lidocaine, 3% prilocaine, 12.5% tetracaine, 3% phenylephrine *Any compounding pharmacy can create any formulation with a prescription. Compounded Preparations The confusion between compounded phar- maceuticals and manufactured drugs is likely due Simply put, a compounded preparation is a to two factors: the emergence of large, multicenter custom-made pharmaceutical. Compounding is the compounding pharmacies that produce hundreds process by which the pharmacist or doctor com- of custom-made medical, dental, and veterinary bines, mixes, or alters pharmaceutical ingredients medications, and the brand names assigned to in accordance with a prescription.8 Compounds are compounded pharmaceuticals. in common usage as intravenous or parenteral Section 503A states that a pharmacy cannot medications, anti-inflammatories, antibiotics, compound an “inordinate” amount of a preparation soaps, troches, rinses, and topicals. At the most before receiving a prescription.6 “Inordinate” is not basic level, when you dilute the Listerine bottle at defined, but state inspectors generally look to your brushing station with tap water, you are prac- match historical use patterns with the amount of ticing a form of compounding. premade preparations on the pharmacy’s shelf. For Compounding is not the same as drug manu- example, if a pharmacy can show that it typically facturing. A compounded preparation is created receives six orders a month for a specific pharma- for the unique needs of an individual patient. Al- ceutical, it would be allowed to premake the com- though the separate components of a compounded pound in anticipation of those orders. If an inspec- preparation are commonly manufactured under tor saw a 30-gallon drum of the premade FDA approval, it is their alteration and combina- preparation, however, it would be a violation of the tion that make the end product unregulated. Under pharmacy’s 503A status. Where “inordinate” prep- section 503A of the Food and Drug Administration aration actually becomes an end run around drug- Modernization Act of 1997, any drug products that manufacturing regulations is a gray area of phar- are compounded on a customized basis are exempt macy law. from the FDA’s approval requirements.9 In addition, a compounded pharmaceutical On the other hand, drug manufacturing is is sometimes given an attractive brand name that defined as the production, preparation, propaga- can diminish the product’s individualization and tion, processing, and packaging of a pharmaceuti- perceived risks. The brand name becomes a form cal for general use.10 Manufactured drugs are of marketing, inappropriately tying the compound- regulated under the Federal Food, Drug, and Cos- ed formulation to a particular pharmacy. Popular metic Act. For example, benzocaine gel is a pop- brand names of intraoral mucosal compound top- ular FDA-approved topical anesthetic sold over ical anesthetics include TAC Alternate, Profound, the counter under brand names such as Anbesol, DēpBlu, Baddest Topical in Town, and Best Topi- HurriCaine, Orajel, and Orabase. cal Ever. 308 JCO/JUNE 2015 Kravitz, Graham, Nicozisis, and Gill Popular Compounded Anesthetics caine, and 3% lidocaine) and a vasoactive agent in Orthodontics (3% phenylephrine). BTT was introduced by Dr. Nicozisis for use with Propel transmucosal alveo- Regardless of brand name, mucosal com- lar micro-osteoperforation.5 The high concentra- pound topical anesthetics are relatively similar. tion of tetracaine provides strong, penetrating an- Each contains a combination of high-dose anes- esthesia. Another popular topical compound, the thetics, including both ester-type (tetracaine) and Best Topical Ever, uses similar active ingredients, amide-type (lidocaine and prilocaine), to provide but reverses the concentration of lidocaine and profound numbness, as well as other inactive in- prilocaine (12.5% lidocaine, 12.5% tetracaine, and gredients for structure and taste. Some formula- 3% prilocaine). tions also contain vasoconstrictors such as phen- It should be noted that dermal compounded ylephrine—though it is debatable what this agent topical anesthetics made for extraoral use should truly contributes. Orthodontists should be familiar not be applied intraorally. Although the active in- with a few of the most popular mucosal com- gredients may be similar to those of a mucosal pounded topical anesthetics (Table 1): compounded topical anesthetic used inside the TAC 20% Alternate, or TAC Alternate, contains mouth, the carrier ingredient is different. two anesthetic agents (20% lidocaine and 4% tetra caine) and one vasoactive agent (2% phenyl- ephrine). The original TAC, composed of tetra- What to Look for in caine, epinephrine (adrenaline), and cocaine, was a Compounding Pharmacy once commonly used in hospital emergency de- Any compounding pharmacy can create the partments as a dermal topical anesthetic to provide formulations listed above at the request of a li- pain relief and vasoconstriction prior to suturing. censed prescriber. When choosing a compounding TAC Alternate is somewhat of a misnomer, since pharmacy, it is important to ensure that it meets the formulation does not contain cocaine. Its active the following criteria: ingredients are identical to those of LET (lido- caine, epinephrine, and tetracaine), another popu- • Is licensed and in good standing with its state lar dermal compounded topical anesthetic.7 pharmacy board. Profound is a topical anesthetic gel compounded • Is accredited by the Pharmacy Compounding from three anesthetic agents (10% lidocaine, 10% Accreditation Board. prilocaine, and 4% tetracaine). Its equal concentra- • Purchases ingredients from FDA-registered tion of lidocaine and prilocaine is similar to that suppliers. of two FDA-approved topical anesthetics: EMLA • Documents the Certificate of Analysis on its cream (2.5% lidocaine and 2.5% prilocaine), ingredients. which provides dermal anesthesia prior to veni- • Strictly follows U.S. Phamacopeia (USP)- puncture, and Oraqix (2.5% lidocaine and 2.5% National Formulary guidelines. prilocaine), which is inserted into the gingival Orthodontists should familiarize themselves sulcus before root planing. Dr. Graham has intro- with chapters 795 and 797 of the USP Compound- duced Profound PET (for “phenylephrine thick”),11 ing Compendium8 (www.usp.org). Chapter 795 or Profpet, which adds a vasoactive agent (2% provides guidance on the preparation of nonsterile phenylephrine) and methylcellulose for greater compounded formulations, including definitions viscosity. DēpBlu, another popular compounded of terms and criteria for compounding each drug. anesthetic, was developed by Dr. Jason Cope and Chapter 797 lists procedures and requirements for has the same active ingredients as those of Pro- compounding sterile preparations. It also describes found PET. how to prevent harm to patients from contamina- Baddest Topical in Town (BTT), is composed of
Load more

Recommended publications
  • Evaluation of Liposomal Delivery System for Topical Anesthesia
    THERAPEUTICS FOR THE CLINICIAN Evaluation of Liposomal Delivery System for Topical Anesthesia Mohamed L. Elsaie, MD, MBA; Leslie S. Baumann, MD Local anesthesia is an integral aspect of cutane- infiltrative anesthetics, now can be accomplished ous surgery. Its effects provide a reversible loss safely and comfortably with the use of topi- of sensation in a limited area of skin, allowing cal anesthetics.1 Topical anesthetics originated in dermatologists to perform diagnostic and thera- South America; native Peruvians noted perioral peutic procedures safely, with minimal discomfort numbness when chewing the leaf of the cocoa plant and risk to the patient. Moreover, the skin acts (Erythroxylon coca). The active alkaloid, cocaine, was as a major target as well as principle barrier for isolated by Niemann in 1860 and applied to con- topical/transdermal (TT) drug delivery. The stra- junctival mucosa for topical anesthesia by Koller in tum corneum (SC) plays a crucial role in barrier 1884. The development of similar benzoic acid esters function for TT drug delivery. Despite the major continued until 1943 when Loefgren synthesized lido- research and development efforts in TT systems caine hydrochloride, the first amide anesthetic.2 and their implementation for use of topical anes- We review the administration of local anes- thetics, low SC permeability limits the useful- thetics, specifically the liposomal delivery system ness of topical delivery, which has led to other for topical anesthesia, based on a review of the delivery system developments, including vesicu- literature and clinical experience. lar systems such as liposomes, niosomes, and proniosomes, with effectiveness relying on their Anatomy physiochemical properties.
    [Show full text]
  • Prolonged Duration Topical Corneal Anesthesia with the Cationic Lidocaine Derivative QX-314
    https://doi.org/10.1167/tvst.8.5.28 Article Prolonged Duration Topical Corneal Anesthesia With the Cationic Lidocaine Derivative QX-314 Alan G. Woodruff1,2, Claudia M. Santamaria1, Manisha Mehta1,2, Grant L. Pemberton1, Kathleen Cullion1,2,4, and Daniel S. Kohane1,2,3 1 Kohane Lab for Biomaterials and Drug Delivery, Department of Anesthesia, Perioperative and Pain Medicine, Division of Critical Care, Boston Children’s Hospital, Boston, MA, USA 2 Harvard Medical School, Boston, MA, USA 3 David H. Koch Institute, Massachusetts Institute of Technology, Cambridge, MA, USA 4 Department of Medicine, Division of Medicine Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA Correspondence: Daniel S. Kohane, Purpose: Topical corneal local anesthetics are short acting and may impair corneal Laboratory for Biomaterials and healing. In this study we compared corneal anesthesia and toxicity of topically applied Drug Delivery, Department of Anes- N-ethyl lidocaine (QX-314) versus the conventional local anesthetic, proparacaine thesia, Division of Critical Care (PPC). Medicine, Boston Children’s Hospi- tal, Harvard Medical School, 61 Methods: Various concentrations of QX-314 and 15 mM (0.5%) PPC were topically Binney Street, Room 361, Boston, applied to rat corneas. Corneal anesthesia was assessed with a Cochet-Bonnet MA 02115, USA. e-mail: Daniel. esthesiometer at predetermined time points. PC12 cells were exposed to the same [email protected] solutions to assess cytotoxicity. Repeated topical corneal administration in rats was then used to assess for histologic evidence of toxicity. Finally, we created uniform Received: 6 May 2019 corneal epithelial defects in rats and assessed the effect of repeated administration of Accepted: 15 August 2019 these compounds on the defect healing rate.
    [Show full text]
  • Safety Alert: Risks Associated with Ophthalmic Anesthetics
    WRHA Pharmacy Program Health Sciences Centre MS-189 820 Sherbrook St. Winnipeg, Manitoba R3A 1R9 CANADA TEL: 204-787-7183 Fax: 204-787-3195 FAX: 204-787-3195 Safety Alert: Risks associated with Ophthalmic Anesthetics The self-administration of ophthalmic anesthetics by patients for the relief of eye pain should be avoided and they should not be given to patients to take home for pain relief. Vision threatening complications of topical anesthetic abuse are common. There is no indication for the use of ophthalmic anesthetics except for diagnostic and short term therapeutic purposes (the removal of a foreign body or ocular surgery) and therefore, these products should only be used under a physician’s supervision. Eye trauma resulting in a corneal abrasion (epithelial injury) is a common complaint in the Emergency department (1). A superficial corneal injury can cause intense pain causing a patient to seek medical help or immediate relief from available over the counter remedies. In Canada, only two topical ophthalmic anesthetic drugs are available commercially as single entities, proparacaine (proxymetacaine) and tetracaine (available in bottle and minim forms). Benoxinate (oxybuprocaine) is only available in combination with fluorescein (3). Lidocaine is also used in ophthalmic surgical procedures however, it is not available in the Canadian market as an ophthalmic preparation. Topical ophthalmic anesthetics function by blocking nerve conduction when applied to the cornea and conjunctiva. The ocular surface is innervated by the multiple branches of the trigeminal nerve. The cornea is supplied by the long and short ciliary nerves, the nasociliary nerve and the lacrimal nerve (4). Topical anesthetics reduce sodium permeability preventing generation and conduction of nerve impulses, increasing excitation threshold, and slowing the nerve impulse propagation.
    [Show full text]
  • Midazolam Injection, USP
    Midazolam Injection, USP Rx only PHARMACY BULK PACKAGE – NOT FOR DIRECT INFUSION WARNING ADULTS AND PEDIATRICS: Intravenous midazolam has been associated with respiratory depression and respiratory arrest, especially when used for sedation in noncritical care settings. In some cases, where this was not recognized promptly and treated effectively, death or hypoxic encephalopathy has resulted. Intravenous midazolam should be used only in hospital or ambulatory care settings, including physicians’ and dental offices, that provide for continuous monitoring of respiratory and cardiac function, i.e., pulse oximetry. Immediate availability of resuscitative drugs and age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and personnel trained in their use and skilled in airway management should be assured (see WARNINGS). For deeply sedated pediatric patients, a dedicated individual, other than the practitioner performing the procedure, should monitor the patient throughout the procedures. The initial intravenous dose for sedation in adult patients may be as little as 1 mg, but should not exceed 2.5 mg in a normal healthy adult. Lower doses are necessary for older (over 60 years) or debilitated patients and in patients receiving concomitant narcotics or other central nervous system (CNS) depressants. The initial dose and all subsequent doses should always be titrated slowly; administer over at least 2 minutes and 1 allow an additional 2 or more minutes to fully evaluate the sedative effect. The dilution of the 5 mg/mL formulation is recommended to facilitate slower injection. Doses of sedative medications in pediatric patients must be calculated on a mg/kg basis, and initial doses and all subsequent doses should always be titrated slowly.
    [Show full text]
  • Lidocaine Hcl) Solution
    451424/Issued: September 2014 ® 2% Xylocaine Viscous (lidocaine HCl) Solution A Topical Anesthetic for the Mucous Membranes of the Mouth and Pharynx. WARNING: Life-threatening and fatal events in infants and young children Postmarketing cases of seizures, cardiopulmonary arrest, and death in patients under the age of 3 years have been reported with use of Xylocaine 2% Viscous Solution when it was not administered in strict adherence to the dosing and administration recommendations. In the setting of teething pain, Xylocaine 2% Viscous Solution should generally not be used. For other conditions, the use of the product in patients less than 3 years of age should be limited to those situations where safer alternatives are not available or have been tried but failed. To decrease the risk of serious adverse events with use of Xylocaine 2% Viscous Solution, instruct caregivers to strictly adhere to the prescribed dose and frequency of administration and store the prescription bottle safely out of reach of children. DESCRIPTION: Xylocaine (lidocaine HCl) 2% Viscous Solution contains a local anesthetic agent and is administered topically. Xylocaine 2% Viscous Solution contains lidocaine HCl, which is chemically designated as acetamide, 2-(diethylamino)-N-(2,6-dimethylphenyl)-, monohydrochloride and has the following structural formula: 1 Reference ID: 3633341 The molecular formula of lidocaine is C14H22N2O. The molecular weight is 234.34. COMPOSITION OF SOLUTION: Each mL contains 20 mg of lidocaine HCl, flavoring, saccharin sodium, methylparaben, propylparaben and sodium carboxymethylcellulose in purified water. The pH is adjusted to 6.0 to 7.0 with sodium hydroxide. CLINICAL PHARMACOLOGY Mechanism of Action Lidocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes required for the initiation and conduction of impulses, thereby effecting local anesthetic action.
    [Show full text]
  • Preoperative Evaluation, Premedication, and Induction of Anesthesia ELIZABETH A
    Preoperative Evaluation, Premedication, and Induction of Anesthesia ELIZABETH A. GHAZAL, MARISSA G. VADI, LINDA J. MASON, 4 AND CHARLES J. COTÉ Preparation of Children for Anesthesia Rectal Induction Fasting Full Stomach and Rapid-Sequence Induction Piercings Special Problems Primary and Secondary Smoking The Fearful Child Psychological Preparation of Children for Surgery Autism History of Present Illness Anemia Past/Other Medical History Upper Respiratory Tract Infection Laboratory Data Obesity Pregnancy Testing Obstructive Sleep Apnea Syndrome Premedication and Induction Principles Asymptomatic Cardiac Murmurs General Principles Fever Medications Postanesthesia Apnea in Former Preterm Infants Induction of Anesthesia Hyperalimentation Preparation for Induction Diabetes Inhalation Induction Bronchopulmonary Dysplasia Intravenous Induction Seizure Disorder Intramuscular Induction Sickle Cell Disease Preparation of Children for Anesthesia clear fluids from the stomach is approximately15 minutes (Fig. 4.1); as a result, 98% of clear fluids exit the stomach in children FASTING by 1 hour. Clear liquids include water, fruit juices without pulp, Infants and children are fasted before sedation and anesthesia to carbonated beverages, clear tea, and black coffee. Although fasting minimize the risk of pulmonary aspiration of gastric contents. In for 2 hours after clear fluids ensures nearly complete emptying a fasted child, only the basal secretions of gastric juice should be of the residual volume, extending the fasting interval to 3 hours present
    [Show full text]
  • Anesthesiology Primer for SIU Medical Students
    An Anesthesiology Primer for SIU medical students Part 1. What do anesthesiologists do? Part 2. Preoperative evaluation - Airway Exam - ASA physical status - NPO guidelines - Medication review Part 3. Anesthetic drugs - Sedatives/Induction agents - Volatile anesthetics - Opioids - Muscle relaxants - Local anesthetics Part 4. Airway management - Airway support - Mask ventilation - Laryngeal mask airway - Endotracheal intubation/Endotracheal tubes Part 5. Regional anesthesia - Subarachnoid blocks - Epidural blocks - Peripheral nerve blocks - Compartment blocks Part 6. Intraoperative care - Monitoring equipment - Fluid management Part 7. Anesthesia complications - Postoperative nausea and vomiting - Dental injury - Aspiration - Nerve injury - Malignant hyperthermia Part 1. What do anesthesiologists do? Anesthesiologists are experts in perioperative medicine. On a simplistic level, we put patients to sleep and wake them up. But really we are in charge of the patient’s entire operative experience, including preoperative assessment and medical optimization, intraoperative management of medical problems, and postoperative care including pain management. The field of anesthesiology is closely aligned with critical care medicine. Knowledge of cardiopulmonary support is key to a successful anesthetic. In addition, we function as the patient’s primary care provider during surgery and must be able to manage both common and rare medical issues that may emerge. Anesthesiologists provide services throughout the hospital. In addition to operating room procedures, we also provide patient assessment and management of procedural care for labor and delivery, radiology, gastroenterology, and ECT. Because of our expertise in airway management, we may be consulted emergently by the ED or ICU for endotracheal intubation in a patient with a difficult airway, or for other procedures such as vascular access, pain blocks, or epidural blood patches.
    [Show full text]
  • Topical Anesthesia for Endoscopic Office-Based Procedures of The
    Topical Anesthesia for Endoscopic Office-based Procedures of the Upper Aerodigestive Tract *David J. Wellenstein, †Raymond A.B. van der Wal, *Henrieke W. Schutte, *Jimmie Honings, *Frank J.A. van den Hoogen, *Henri A.M. Marres, *Robert P. Takes, and *Guido B. van den Broek, *yNijmegen, The Netherlands Summary: Objective. Over the last two decades, an increase in office-based procedures under topical anesthesia in laryngology and head and neck oncology has occurred. Adequate anesthesia in the nasal cavity, pharynx, and larynx is essential for successful performance of these procedures. Our goal is to provide an objective summary on the avail- able local anesthetics, methods of application, local secondary effects, efficacy, and complications. Material and Methods. A descriptive review of literature on topical anesthesia for office-based procedures in laryn- gology and head and neck oncology was performed. Results. Lidocaine is the most applied and investigated topical anesthetic. Topical anesthesia results in decreased sen- sory function without impairing motor function of the pharynx and larynx. For the nasal cavity, cotton pledgets soaked in anesthetic spray and decongestant, or anesthetic gel, are effective. For the pharynx, anesthetic spray is the most frequently used and effective method. For the larynx, applying local anesthesia through a catheter through the working channel of the endoscope or anesthetic injection through the cricothyroid membrane is effective. Studies com- paring the most effective application methods for each anatomical site are lacking. Complications of topical lidocaine administration are rare. Conclusions. By properly applying topical anesthesia to the upper aerodigestive tract, several surgical procedures in laryngology and head and neck oncology can be performed in the outpatient clinic under topical anesthesia instead of the operating room under general anesthesia.
    [Show full text]
  • EMLA CREAM (Lidocaine 2.5% and Prilocaine 2.5%)
    EMLA CREAM (lidocaine 2.5% and Prilocaine 2.5%) DESCRIPTION EMLA Cream (lidocaine 2.5% and prilocaine 2.5%) is an emulsion in which the oil phase is a eutectic mixture of lidocaine and prilocaine in a ratio of 1:1 by weight. This eutectic mixture has a melting point below room temperature and therefore both local anesthetics exist as a liquid oil rather than as crystals. It is packaged in 5 gram and 30 gram tubes. Lidocaine is chemically designated as acetamide, 2-(diethylamino)-N-(2,6-dimethylphenyl), has an octanol: water partition ratio of 43 at pH 7.4, and has the following structure: Prilocaine is chemically designated as propanamide, N-(2-methylphenyl)-2-(propylamino), has an octanol: water partition ratio of 25 at pH 7.4, and has the following structure: Each gram of EMLA Cream contains lidocaine 25 mg, prilocaine 25 mg, polyoxyethylene fatty acid esters (as emulsifiers), carboxypolymethylene (as a thickening agent), sodium hydroxide to adjust to a pH approximating 9, and purified water to 1 gram. EMLA Cream contains no preservative, however it passes the USP antimicrobial effectiveness test due to the pH. The specific gravity of EMLA Cream is 1.00. CLINICAL PHARMACOLOGY Mechanism of Action: EMLA Cream (lidocaine 2.5% and prilocaine 2.5%), applied to intact skin under occlusive dressing, provides dermal analgesia by the release of lidocaine and prilocaine from the cream into the epidermal and dermal layers of the skin and by the accumulation of lidocaine and prilocaine in the vicinity of dermal pain receptors and nerve endings. Lidocaine and prilocaine are amide-type local anesthetic agents.
    [Show full text]
  • 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.
    [Show full text]
  • Topical Lidocaine-Prilocaine Cream (Emla) Versus Mepivacaine Infiltration for Reducing Pain During Repair of Mediolateral Episio
    AL-AZHAR ASSIUT MEDICAL JOURNAL AAMJ ,VOL 13 , NO 4 , OCTOPER 2015 SUPPL-2 TOPICAL LIDOCAINE-PRILOCAINE CREAM (EMLA) VERSUS MEPIVACAINE INFILTRATION FOR REDUCING PAIN DURING REPAIR OF MEDIOLATERAL EPISIOTOMY AFTER SPONTANEOUS VAGINAL DELIVERY Hossam M Abdelnaby and Ahmed Mahmoud Abdou Obstetrics & Gynecology Department, Faculty of Medicine, Zagazig University ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Objective: to compare the efficacy of lidocaine-prilocaine cream (EMLA cream) versus ordinary local infiltration anesthetic mepivacaine in pain relief during repair of mediolateral episiotomy. Patients and methods: This study was conducted during the period from 1 January 2015 to 31 July 2015 in Zagazig University Maternity Hospital, Egypt. It comprised 82 vaginally laboring women. They were randomly allocated into 2 groups; group a (mepivacaine 1% infiltration just before performing the episiotomy) and group B (lidocaine-prilocaine cream applied as a thick layer to perineum approximately one hour before the predictable time of childbirth). Primary outcome measure was pain scores during repair of episiotomy after childbirth. Secondary outcome measures were the need for additional intra-operative anesthetic or post-operative analgesia and patient satisfaction. Results: There was a statistically significant more pain score during the suture of episiotomy in mepivacaine
    [Show full text]
  • ASGE Guidelines
    Sedation and anesthesia in GI endoscopy This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using MEDLINE and PubMed databases through May 2008 that related to the topic of "sedation and anesthesia for gastrointestinal endoscopy" by using the key word(s) "sedation," "anesthesia," "propofol," "gastrointestinal endoscopy," "endoscopy," "endoscopic procedures," and "procedures." The search was supplemented by accessing the "related articles" feature of PubMed, with articles identified on MEDLINE and PubMed as the references. Pertinent studies published in English were reviewed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment.
    [Show full text]