ABRAM CHAPTER 49 NOTES

Epidural infusions are used with caution in chest procedures because the analgesic may ascend along
the spinal cord and affect respiration. Intrapleural anesthesia involves the administration of
local anesthetic by a catheter between the parietal and visceral pleura. It provides sensory anesthesia
without affecting motor function to the intercostal muscles. This anesthesia allows more effective
coughing and deep breathing in conditions such as cholecystectomy, renal surgery, and rib fractures,
in which pain in the thoracic region would interfere with these exercises.

Epidural anesthesia involves injecting the anesthetic into the epidural space. It is used most
often in obstetrics during labor and delivery.

Clients receiving anticholinergic drugs must be monitored for dry mouth, difficulty swallowing,
constipation, urinary retention, tachycardia, pupil dilation and photophobia, cycloplegia and
blurring of vision, and heat intolerance caused by a decrease in sweating.

Nerve block local anesthesia involves injecting the anesthetic at some point along the nerve or
nerves that run to and from the region in which the loss of pain sensation or muscle paralysis is
desired. Several types of nerve blocks are possible. Epidural anesthesia is an injection of the
drug into the epidural space where the nerves emerge from the spinal cord.

Spinal anesthesia is a type of regional anesthesia, injected usually at the level of the second
lumbar vertebra, with a small gauge needle. It is inserted into the subarachnoid space and the
anesthesia is administered into the cerebrospinal fluid.

 The most common adverse effect from spinal anesthesia is a positional headache
followed by shivering. Nausea and vomiting are also common and can be caused by
hypotension.
 There is a lower incidence of pulmonary embolism (PE) and deep venous
thrombosis (DVT) with spinal anesthesia.
 There is a loss of feeling and movement in the lower extremities, lower abdomen, and
perineum.

CNS (central nervous system) symptoms (such as tinnitus and disorientation) are commonly
present before hemodynamic changes are evidenced when a patient has systemic toxicity.
Systemic toxicity in this case is from a local anesthetic being injected into a blood vessel.
(metallic taste in her mouth, hears a ringing in her ears, and appears confused)
ABRAM CHAPTER 49 NOTES

Local anesthetics decrease the permeability of the nerve cell membrane to ions, especially
sodium.

The local anesthetics are contraindicated with any of these conditions: history of allergy to any
one of these agents or to parabens to avoid hypersensitivity reactions; heart block, which could
be greatly exacerbated with systemic absorption; shock, which could alter the local delivery and
absorption of these drugs; and decreased plasma esterase, which could result in toxic levels of
the ester-type local anesthetics. It is not within your scope of practice to cancel the patient's
surgery. Notifying the surgeon is appropriate, as is telling the OR nurse. However, the most
important action is to notify the anesthesiologist.

A delayed hypersensitivity reaction to procaine hydrochloride can occur as late as 72 hours

after the initial injection.

LAST - local anesthetic systemic toxicity. When local anesthesia is given the first sensation lost
is temperature, followed by touch, proprioception, and then skeletal muscle tone. Initial
symptoms may include analgesia, circumoral numbness, metallic taste, tinnitus or auditory
changes, and agitation. LAST occurs when the local anesthetic is absorbed systemically,
resulting in extreme central nervous system (CNS) excitation followed by cardiovascular
excitation and cardiovascular collapse. LAST is not a hypersensitivity reaction or a result of
incomplete metabolism.

The nurse will have IV lipid emulsion available to give a client who develops severe
symptoms of LAST such as cardiac collapse. This drug has been found to assist the client.

Epinephrine can be mixed in certain situations with an injectable local anesthetic in order to
cause local vasoconstriction.

ELMA - Eutectic mixture of local anesthetics (ELMA) is a cream-based mixture of lidocaine and
prilocaine applied to intact skin. The cream is applied at an injection site with an occlusive
dressing at least 60 minutes before the vaccination or venipuncture.

Lidocaine is an amide local anesthetic and can become toxic in the tissues. Procaine,
chloroprocaine, tetracaine, and benzocaine are ester local anesthetics. The ester local
anesthetics are broken down immediately in the plasma by enzymes known as plasma
esterase’s. The amide local anesthetics are metabolized more slowly in the liver, and serum
levels of these drugs can increase and lead to toxicity. Applying lidocaine preparations to
severely traumatized mucosa (large skin abrasions, eczema, and burns) can increase its
ABRAM CHAPTER 49 NOTES

absorption, which in turn increases the risk of systemic toxicity. If lidocaine is administered into
a blood vessel, it can cause a life-threatening situation such as local anesthetic toxicity.

Lidocaine patches adverse effects include anxiety, tremors, and seizures.

Compressed gas can be used to administer lidocaine. It is needle–free, and it provides a rapid
loss of feeling to the skin.

A 2% lidocaine solution may be administered intravenously preceding administration of a painful

IV medication such as propofol (Diprivan) in the surgical arena.

Anesthetics are sprays, lotions, or creams used for pruritus (itching) and pain from wounds,
minor burns, prickly heat, chickenpox, insect bites, and sunburn. Pain relief drugs are lotions
and solutions that provide temporary pain relief, soothing emollients relieve itching and aid in
healing mild skin irritations, and antiseptics are germicidal agents.

Application of the 5% to -20% topical solution of benzocaine relieves hemorrhoid pain.

Sulfonamides and antihypertensive drugs may cause hypotension when procaine is

administered

Metabolic acidosis is associated with propofol infusion syndrome.

Patients who are allergic to soybean or soy products, or eggs or egg products, should not receive
propofol.