8.6
Anesthésiques locaux : Effets indésirables
Alors que les anesthésiques locaux sont généralement sûrs et bien tolérés, ils peuvent occasionnellement causer des effets indésirables qui varient en…
Les anesthésiques locaux, ou LA, diffusent souvent dans la circulation systémique et affectent les organes qui dépendent du fonctionnement des canaux sodiques.
Le système nerveux central est généralement le plus touché, suivi du système cardiovasculaire.
L’ampleur des effets indésirables dépend de la concentration d’AL dans la circulation sanguine.
À de faibles concentrations systémiques, les AL induisent des étourdissements et des troubles auditifs et visuels. Ils engourdissent également la langue et laissent un goût métallique.
Lorsque la concentration sérique de l’AL atteint son maximum, les premiers symptômes non traités progressent pour provoquer des tremblements, des convulsions, un arrêt respiratoire, un collapsus vasculaire et même la mort.
De plus, certaines personnes sont allergiques aux AL et souffrent de dermatite allergique ou d’asthme. La plupart des réactions allergiques sont causées par le métabolisme des AL liés aux esters, qui produit l’allergène acide para-aminobenzoïque.
Une allergie aux AL liés à l’amide est rare, mais peut survenir en raison de la présence de conservateurs comme le méthylparabène.
View the full transcript and gain access to JoVE Core videos
Q1: What happens when local anesthetics enter the systemic circulation?
When local anesthetics diffuse into the bloodstream, they affect organs dependent on sodium channel function, particularly the central nervous system and cardiovascular system. The severity of adverse effects depends on the anesthetic concentration in the blood. Low concentrations cause dizziness, auditory and visual disturbances, and metallic taste, while higher concentrations trigger tremors, convulsions, respiratory arrest, and potentially death.
Q2: How do ester-linked and amide-linked local anesthetics differ in causing allergic reactions?
Most allergic reactions to local anesthetics stem from ester-linked agents, which metabolize to produce para-aminobenzoic acid, a known allergen. Amide-linked local anesthetics rarely cause allergies, though reactions can occur due to preservatives like methylparaben. Allergic symptoms range from dermatitis and asthma to severe anaphylaxis.
Q3: What are the early warning signs of local anesthetic toxicity?
Early signs of local anesthetic toxicity at low systemic concentrations include dizziness, auditory and visual disturbances, tongue numbness, and a metallic taste. These initial symptoms progress to tremors and convulsions as serum concentration increases. Recognizing these early manifestations is critical for preventing severe complications like respiratory arrest or vascular collapse.
Q4: What mechanisms contribute to neurotoxic effects of local anesthetics?
Local anesthetic neurotoxicity involves excessive or prolonged sodium channel blockade, disruption of neuronal cytoskeleton, neuronal membrane damage, disruption of axonal transport, and apoptosis. These mechanisms have been studied using cell culture, ex vivo, and in vivo models. Understanding these pathways helps predict and prevent neurotoxic complications during clinical application as spinal anesthesia or other regional techniques.
Q5: What are transient neurological symptoms and when do they occur?
Transient neurological symptoms, such as dysesthesia or transient pain syndrome, can occur when local anesthetics are administered spinally or epidurally. These symptoms cause mild to severe pain that sometimes exceeds the pain from surgical procedures. They represent a distinct adverse effect separate from systemic toxicity and require careful patient monitoring and management.
Q6: Can local anesthetics cause tissue damage, and under what conditions?
Local anesthetics can cause tissue necrosis if they inadvertently infiltrate blood vessels or are administered in excessive amounts. This represents a localized adverse effect distinct from systemic toxicity. Proper injection technique and dosing are essential to prevent this complication during clinical application as surface infiltration and conduction block anesthesia.
Q7: How do local anesthetic adverse effects progress with increasing blood concentration?
Local anesthetic toxicity follows a concentration-dependent progression. Low systemic concentrations produce sensory disturbances like dizziness and visual changes. As concentration increases, neuromuscular effects emerge including tremors and seizures. At peak concentrations, central nervous system depression, coma, cardiovascular collapse, and respiratory arrest can occur, potentially leading to fatal outcomes.