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Progress in Medical World part 1

Progress in Medical World Anesthesiology (USE SCIENCE Drug) The second part of the second part RICHARD A. WIKLUND, M.D., And Stanley H. Rosenbaum, M.D. 

Local anesthetic Local anesthetic injection can be used for local or regional levels to cause matirasa during surgery. Regional injection of local anesthetic used for most pengeblokan nervous system and spinal (spine / subarachnoid) or pengeblokan epidural. Although the local anesthetic most widely used by the agents of drug users and have a good record for clinical safety, but has appeared several questions about the toxins contained therein.
Among the local anesthetics (lidocaine, mepivacine, and bupivacine) has replaced the ester (as procaine) because of its stability and the fact that local anesthetics do not cause allergic reactions. Because of the high fat solubility and height affinity for the protein binding site, then bupivacine have a longer duration of action than other local anesthetics. Nevertheless, the magnitude of the binding tendencies bupivacine with cardiac specific protein binding site after an accidental intravenous injection may cause profound myocardial depression which led to cessation of cardiac intractabel. By using a local anesthetic, like lidocaine, central nervous system will be affected due to the use of excessive dosage or intravenous injection is not accidental that occur at the level of blood pressure is low (8 or 10 g per millimeter) than the local anesthetic effect on cardiovascular toxic effects (20 g per millimeter). Toxic effects on the central nervous system caused by local anesthetics can be controlled with the use of intravenous benzodiazpin (midazolam or diazepam) or thiobarbiturate (thiopental) and protection of patient's airway and ventilation management. Toxic effects in the central nervous system and cardiovascular system occur at the same level bupivacine blood (3 to 5 g per millimeter). Awareness of extended and repeated use of epinephrine may not be able to restore cardiac function again. Report profound cardiovascular depression mainly associated with the use bupivacine higher concentration (0.75 percent). Consequently, this concentration is not recommended for routine use.
Ropivacine a local anesthetic with a duration of action similar to bupivacine. Property pharmacokineticnya also similar to bupivacine, although ropivacine have a lower fat solubility thus have a lower potential. Stereoisomerism not provided with ropivacine, but given the bupivacine. Isomer R (rectus) bupivacine exist in the sodium channel for long periods against the cardiotoxic effect. Isomer S (Sinister) bupivacine exist in the sodium channel for short periods. Therefore, it was concluded that the clinical pharmalogikal ropivacine have the same characteristics with bupivacine, but without cardiotoxic effects. The hypothesis is supported by a number of isolated rabbit heart studies showing that bupivacine have cardiodepressant and arrhythmogenic effects than lidocaine or ropivacine.
Lidocaine was used for spinal and epidural anesthesia for several decades due to the speed of onset and duration of action that can be predicted. Recent modifications in the technique of spinal anesthesia using preparations are believed to result in concentrations high local spinal lidocaine (5 percent lidocaine in a hyperbaric or more dense than the cerebrospinal fluid solution of dextrose). The concentration of local anesthetic solution to high spinal radicular cause temporary irritation, characterized by radicular pain that started 24 hours after spinal anesthesia and ending no later than two days. Hampl, et al. stated that temporary radicular irritation in more than a third of patients receiving lidocaine for spinal anesthesia. Transient radicular irritation does not occur when the powder is used as spinal anesthesia. In multiple studies conducted to compare isobaric or hyperbaric lidocaine spinal anesthesia with bupivacine for, Pollock, et al. stated that temporary radicular irritation in 13 percent of patients receiving lidocaine for hernia repair and in 16 percent of patients receiving lidocaine for arthroscopy, but none of them received bupivacine. The author argues that the position and manipulation operations give effect to local anesthesia. The same research results on radiculopathy caused the withdrawal of permission from the FDA for use microcatheter that uses 5 percent lidocaine for continuous spinal anesthesia. Not known for certain why the results of this research emerging now, after several decades of experience with the use of lidocaine for spinal anesthesia. In previous clinical studies, transient radicular irritation has not been associated with the use ropivacine for spinal anesthesia.  

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