Professional Documents
Culture Documents
Sona Pradhan
July 3, 2009
2009
Local Anesthetic
A local anesthetic is an agent that
interrupts pain impulses in a specific
region of the body without a loss of
patient consciousness. Normally, the
process is completely reversible--the
agent does not produce any residual
effect on the nerve fiber.
History
The first local anesthetic was Cocaine which
was isolated from coca leaves by Albert
Niemann in Germany in the 1860s. The very
first clinical use of Cocaine was in 1884 by
Sigmund Freud who used it to wean a patient
from morphine addiction. It was Freud and
his colleague Karl Kollar who first noticed its
anesthetic effect. Kollar first introduced it to
clinical ophthalmology as a topical ocular
anesthetic. Also in 1884, Dr. William Stewart
Halsted was the first to describe the injection
of cocaine into a sensory nerve trunk to
create surgical anesthesia.
Chemistry
All local anesthetics are weak bases,
classified as tertiary amines.
Esters:
These include cocaine, procaine,
tetracaine, and chloroprocaine.
They are hydrolyzed in plasma by
pseudo-cholinesterase. One of the
by-products of metabolism is
paraaminobenzoic acid, the common
cause of allergic reactions seen with
these agents
Amides:
These include lidocaine, mepivicaine,
prilocaine, bupivacaine, and
etidocaine.
They are metabolized in the liver to
inactive agents. True allergic
reactions are rare (especially with
lidocaine)
Mechanism of Action
Local anesthetics work to block nerve
conduction by reducing the influx of sodium
ions into the nerve cytoplasm.
Sodium ions cannot flow into the neuron,
thus the potassium ions cannot flow out,
thereby inhibiting the depolarization of the
nerve.
If this process can be inhibited for just a
few Nodes of Ranvier along the way, then
nerve impulses generated downstream
from the blocked nodes cannot propagate
to the ganglion.
Mechanism of action
local anesthetics bind directly to the
intracellular voltage-dependent
sodium channels
Block primarily open and inactive
sodium channels, at specific sites
within the channel
Mechanism of action
1) slow rate of depolarization
2) reduce height of action potential
Effect of pH
charged (cationic) form binds to
receptor site uncharged form
penetrates membrane ,efficacy of
drug can be changed by altering
extracellular or intracellular pH
Effect of lipophilicity
ANESTHETIC POTENCY
Lipid solubility appears to be the primary
determinant of intrinsic anesthetic potency.
Chemical compounds which are highly
lipophilic tend to penetrate the nerve
membrane more easily, such that less
molecules are required for conduction
blockade resulting in enhanced potency.
more lipophilic agents are more potent
as local anesthetics
Effect of protein binding - increased
binding increases duration of action
Effect of diffusibility - increased
diffusibility = decreased time of
onset
Effect of vasodilator activity - greater
vasodilator activity = decreased
potency and decreased duration of
action
FIBER SIZE AND FUNCTION
α: (dia 12-20um; cond vel 70-120m/s)
largest, afferent to and efferent from
muscles and joints. Actions: motor
function, proprioception, reflex activity.
β: (dia 5-12um; 30-70m/s) large as A-
alpha, afferent to and efferent from
muscles and joints. Actions: motor
proprioception, touch, pressure, touch and
pressure.
γ: (dia 3-6um; 15-30m/s) muscle spindle
tone.
δ: (dia 2-5um; 12-30m/s) thinnest, pain
and temperature. Signal tissue damage.
B fibers: (dia – 2-5um) Myelinated
preganglionic autonomic. Innervate
vascular smooth muscle. Though
myelinated, they are more readily
blocked by LA than C fibers.
C fibers: (dia 0.4-1.2 um)
Nonmyelinated, very small nerves.
Smallest nerve fibers, slow
transmission. Transmit dull pain and
temperature, post-ganglionic
autonomic.
* Both A-d and C fibers transmit pain
and are blocked by the same
concentration of LA.
Susceptibility to block by local
anesthetics of types of nerve fibers
In
general, small nerve fibers are
more susceptible than large fibers;
however,
– the type of fiber
– degree of myelination
– fiber length and
– frequency- dependence are also
important in determining susceptibility
Order of sensory function block
1. pain
2. cold
3. warmth
4. touch
5. deep pressure
6. motor