LOCAL ANESTHESIA AND NERVE

BLOCKS IN LARGE ANIMALS

 Local anesthesia

 Definition: defined as the reversible loss of sensation in a limited area of body

without loss of consciousness by the use of a chemical agent.

 Also called local analgesia because local anesthesia blocks the pain
transmission.

 It produces desensitization and analgesia of skin surfaces(topical anesthesia),

tissues (infiltration and field blocks) and regional structures (conduction
anesthesia, intravenous regional anesthesia).
 Reasons for producing local anesthesia

 To provide effective preemptive and multimodal analgesia.

 To reduce the amount of inhalant or injectable drugs needed to

maintain anesthesia.

 To decrease the stress response to surgical trauma.

 To reduce the potential for the development of central sensitization.

 General considerations for local
anesthesia

1.Use of sterile solutions, equipments and techniques.

2.Avoid injection into inflamed area (if possible).

3.Use a small gauze of needle as practical.

4.Aspirate for blood before injecting.

5.Use lowest effective concentration of local anesthetic drug to

produce the desired effect.

6.Wait for onset of analgesia before proceeding.

 Desirable characters of local anesthesia
 Non-irritating to tissues.

 Reversible loss of sensation.

 Good penetrating qualities into body tissues.

 No structural damage to nerve or other tissues.

 Slow and gradual absorption.

 High potency so that low concentration can be used.

 No systemic adverse or side effect.

 Rapid but desirable duration of action (short or long).

 Should not cause hyperesthesia after recovery.

 Near neutrality pH.

 Should be sterilisable.
 Advantages and disadvantages
Advantages

 Suitable for performing surgery on standing animals

 Simple and requires no expensive or complicated equipments
 Performed by the surgeon himself so no need for anesthesiologist
 Low cost
 Low cardiovascular toxicity
 Minimal patient recovery time
 Used in conjunction with GA

Disadvantages

 Requires cooperative patient with or without significant restraint

 May require sedation
 Some local anesthetics are irritant or toxic to tissues
 Classification
A. On the basis of chemical structures;
classified into 3 groups.

1. Ester local anesthetics: Derived from benzoic acid.

Examples: Procaine, Chloroprocaine, benzocaine, amethocaine, cocaine etc.

2. Amide local anesthetics: Derived from aniline.

Example: Lignocaine, Bupivacaine, Mepivacaine, Etidocaine, and Ropivacaine.

3. Ether or Ketone local anesthetics

Examples: Pramoxine and dyclonine.

B. Based on potency and duration

i. Low potency and short duration
eg: procaine, chloroprocaine.

ii. Intemediate potency and medium duration

eg: Mepivacaine, prilocaine and Lidocaine.

iii. High potency and long duration

eg: Tetracaine, Bupivacaine and Etidocaine.
 Mechanism of action
• LAs block nerve conduction by inhibiting influx of Na+ ions through ion-
selective sodium channels in nerve membrane leading to impairment of the
generation of action potential.
• Thus, conduction of nerve impulses stoppage.
 Additives

1. Epinephrine
 Used as adjunct to local anesthesia.
 Vasoconstriction – decrease systemic absorption of the local
anesthetic agent- decrease the dose of local anesthetic required and
prolongs its duration of effect.
 Other vasocontrictors are: Phenylephrine or methoxamine.

2.Hyaluronidase:
 Used to improve the penetration and thereby shorten the onset of
action and increase the spread of block.
 Factors affecting activity and potency

 Lipid solubility

Increased drug lipid solubility tends to slow the rate of onset of action,
increase the duration of action, and increase potency.

 Protein binding

Increased plasma protein binding tends to be associated with increased

duration of action.
 Pharmacokinetics
Absorption
 Drugs with greater lipid solubility and protein binding will results lower systemic
absorption.

Metabolism
 Ester linked LA are metabolised in blood by non- specific plasma
pesudocholinesterage.
 Esterase present in liver, RBCs and synovial fluid also contribute to clearance of
these drug.
 Amide linked LA are almost exclusively metabolized in liver by microsomal
enzyme (cyp-450).

Excretion
 LA are poorly water soluble which limits the renal excretion of unchanged drug.
 Metabolites of
-- ester linked local anesthetics are excreted in urine.
-- amide linked local anesthetics are excreted in urine or bile.
Local anesthetics used in veterinary practices
Cocaine

 The original LA isolated from leaves of

coca.
 The only one that cause vasoconstriction.

Procaine
 Quick onset of action and short duration of effect (30-60 min).
 Epinephrine may be added to prolonged its duration of action.
 Systemic toxicity is minimal, but it occasionally causes allergic reaction
due to a hydrolysis metabolite (PABA).
 Used for infiltration and nerve blocks at concentration of 1-2%.
 IV procaine is a CNS stimulant in horses, due to CNS stimulant and
analgesic effect, illegally used in race horses.
 Also added to drug formulation to prolong duration of effect.
Example procaine penicillin.
Benzocaine

 Fast acting (approx. 30 sec) and short duration of effect (approx 30-60 min).

 Used exclusively for topical anesthesia.

 Also used as anesthetic for fish when added to water.

 Causes Methemoglobinemia in several species of animals so no longer in

clinical practice.
Chloroprocaine

 Similar to procaine with fast onset of action and short duration of

effect(30-60)min. • Available in concentration of 1% to 3%.

 Used for local infiltration blocks when a short duration effect is

required.

 Not widely used in veterinary medicine

Chloroprocaine
 Similar to procaine with fast onset of action and short duration of
effect(30-60)min.

 Available in concentration of 1% to 3%.

 Used for local infiltration blocks when a short duration effect is

required.

 Not widely used in veterinary medicine

Tetracaine
 Also known as amethocaine.

 Well absorbed by surfaces.

 Relatively toxic.

 Rarely used in veterinary medicine.

Lidocaine
 Most widely used in veterinary medicine due to
fast onset of action, moderate duration of effect
(1 hr ) and not decomposed by boiling, acids, or
alkali.

 Available as 0.5%, 1%, 1.5%, 2% and 4% solution.

 Antiarrhythmic effect.

 Used for infiltration anesthesia, peripheral nerve

block, epidural and intrathecal block and
intravenous regional anesthesia.

 When administered intravenously, reduces the

doses of inhalent anesthetics.

 Several non-anesthetic uses when administered

intravenously
 as antiarrhythmic drug  as analgesics
 as intestinal motility inhancer in case of ileus.
Mepivacaine

 Similar to lidocaine with a slightly longer duration of action (upto 2 hrs)

because of less intrinsic vasodilatory properties.

 Available at concentrations from 0.5% to 2%.

 Use in clinical practice similar to lidocaine except that it is not routinely

used for intravenous regional anesthesia or for obstetric procedures
because its metabolism is very slow in fetus and newborn.

 Not as effective topical anesthesia as lidocaine.

 Preferred agent for diagnostic peripheral nerve blocks in horse because of

its lower neurotoxicity compared with other local anesthetics.
Bupivacaine

 Highly lipophilic agent, about four times as potent as lidocaine, and

with slow onset of action (20-30) min and long duration of action (3-10)
hrs.

 Available in concentration of 0.125 % to 0.75%.

 Uses: infiltration, peripheral nerve block, epidural and intrathecal block.

 Not used for topical anesthesia and not recommended for intravenous
regional anesthesia due to CNS and cardio-toxicity potential.
Levobupivacaine

 Similar to bupivacaine in properties and clinical uses.

Ropivacaine

 Structurally related to mepivacaine and bupivacaine.

 Slightly less potent than bupivacaine.

 Available in concentrations of up to 1%.

Proparacaine

 Used to anesthesize the cornea of

eye.

 Rapid onset of action (within 1

minute) and lasts for about 15-30
minutes.

 Non-irritant and does not affect the

size of pupil.

 Available as 0.5% opthalmic solution.

 Prolonged use may produce

permanent corneal opacification
with accompanying visual loss.
Local anesthesia toxicity
Systemic

 CNS: Muscle twitching, Seizure, Coma and Death

 Cardiac toxicity: CV depression, Colapse

 Methemoglobinemia: Benzocaine and Prilocaine

Localized

 Allergic reaction: Wheel, Swelling, redness

COMMON METHODS OF PRODUCING LOCAL
ANESTHESIA
1. Surface (topical) anesthesia

2. Intrasynovial anesthesia

3. Infiltration anesthesia

4. Spinal anesthesia

5. Intravenous regional local anesthesia

6. Regional anesthesia
 Surface (Topical) anesthesia

 Refers to use of local anesthetics in solution, sprays as well as in

various creams and ointments on mucous membranes; drops into
the eye, sprays or brush in laryngeal area, infuse into nostrils,
urethra or rectum
 Intrasynovial anesthesia

 Used in joints, bursa and tendon sheaths.

 Useful for both diagnosis of lameness and for general pain relief.

 As these sites are prone to infection, used in sterility condition.

 Infiltration anesthesia

 Nerve endings are blocked at the actual

site of the operation.
 Field anesthesia
 Linear infiltration
 Inverted “L” or “7” block
 Ring block

 Uses
To minimize or prevent pain
To facilitate surgery
 Skin incision
 Surgical removal of superficial tumors
 Wound repair
• https://www.youtube.com/watch?
v=QXzIAkIe73E
 Spinal anesthesia
 Injection of local anesthetic around the spinal
cord.

 Lidocaine, bupivacaine or morphine used.

 All the segmental nerves ( sensory and motor)

nerves which pass through the anesthetic are
paralysed, although when opioid used, only
sensory nerves blocked.

Two types

1. Epidural or extradural anesthesia: local

anesthetic deposited into extradural space.

2. True spinal anesthesia: local anesthesia

deposited into subarachnoid space.
 Video epidural anesthesia
• https://www.youtube.com/watch?
v=1anGhzirQxE
 Nerve blocks

Nerve blocks of head

1. Cornual nerve block

• Indication: Dehorning, Disbudding,

Horn injury

• Anatomy: Branch of lacrimal

nerve(also called zygomaticotemporal),
which is a branch of opthalmic division
of trigeminal nerve is blocked.

• Injection site: Upper third of temporal

ridge about 2.5 cm below the base of
horn.
 dehorning
• https://www.youtube.com/watch?
v=bH9l4RB6r-4
 Cornual nerve block in goat:
Cornual branch of
Zygomaticotemporal and
infratrochlear nerves are are
blocked.
 Auriculopalpebral nerve block
• Indication: to prevent eyelid closure during examination of eyeball.

• Injection site: needle is inserted in front of the base of the ear at the end of
zygomatic arch and is introduced until its point lies at the dorsal border of the
arch.

• Caution: does not provide analgesia of the eye or eyelids.

• Nerve blocks in horse: less commonly used but mainly used general
anesthesia.
 Infraorbital and maxillary nerve block, Mental
and Mandibular nerve block
• Infraorbital nerve block: done at the exit of
infraorbital nerve from infraorbital foramen.

• Desensitize upper lip, nose and skin supplied

by nerve.

• Maxillary nerve block is achieved by

inserting needle into maxillary canal and
anesthetic deposited in canal.

• Desensitizes teeth as far as first molar,

maxillary sinus and skin upto medial canthus of
eye.

• Mental nerve block: done at the exit of

mental nerve from mental foramen.

• Desensitizes lower lip.

Mandibular Nerve Block

 Achieved by inserting needle in the

mandibular canal.

 Desensitizes lower incisors and

premolars.

Peterson Nerve Block Indication:

 Enucleation of eye ball and eyelid.

Technique: Notch formed by supraorbital

process cranially, zygomatic arch ventrally
and coronoid process of mandible
caudally.
 Retrobulbar nerve block
• https://www.youtube.com/watch?
v=n0NAGIdMnLA
Retrobulbar anesthesia

• Indication: Enucleation of eye ball.

• Technique:

Oriculopalpebral anesthesia is given. A

hypodermic needle is turned/curved at
appropriate angle 15-20 degree.
 Anesthesia of flank region

 Most commonly used in cattle .

 Rarely used in horses.

 Indications: GIT surgery(right/left flank)

eg: Rumenotomy, intestinal surgery,
cesarean section, urinary bladder
surgery etc.
 https://www.youtube.com/watch?
v=Id5EknlZnjM
 Linear infiltration

 Indication : Standing laprotomy, surgery such as C-section,

rumenotomy. Cecotomy, correction of GI displacement, intestinal
obstruction and volvulus.

• Anatomy and injection site: multiple subcutaneous injections of 0.5 –

1 ml of 2% lidocaine solution, 1-2 cm apart along the incision line.
 Inverted L or 7 block

 Indication : Standing laprotomy,

surgery such as C-section,
rumenotomy. Cecotomy,
correction of GI displacement,
intestinal obstruction and volvulus.

 Anatomy and injection site: this is

a nonspecific regional analgesic
technique in which all the nerves
entering surgical field are
desensitized.
 Proximal paravertebral nerve block
• Also called Farquharson, Hall or
Cambridge technique.

• Indication : Standing laprotomy, surgery

such as C-section, Rumenotomy. Cecotomy,
correction of GI displacement, intestinal
obstruction and volvulus.

Anatomy and injection site: Dorsal aspect

of transverse processs of the last thoracic
(T13) and First and second lumbar (L1 and
L2) vertebrae is the site for needle
placement.

• The dorsal and ventral nerve roots of the

last thoracic and first and second lumbar
spinal nerves emerge from the
intervertebral foramina are desensitized.
 Distal paravertebral nerve block

• Also called Magda, Cakala or Cornell

technique.

• Indication : Standing laprotomy,

surgery such as C-section,
Rumenotomy. Cecotomy, correction
of GI displacement, intestinal
obstruction and volvulus.

• Anatomy and injection site: The

dorsal and ventral rami of spinal
nerves T13, L1 and L2 are desensitized
at the distal ends of L1, L2 and L4.
 Intravenous regional Analgesia of limb

• Also called Biers block.

https://www.youtube.com/watch?
v=DY24WTwlw30

• Indication: amputation of digits, removal

of interdigital hyperplastic lesions, treatment
of infections of foot.

• Anatomy and injection site: injecting local

analgesic into any accessible superficial vein
in the extremity isolated from the general
circulation by a tourniquet, an elastic
bandage or an inflatable cuff.

• The limb distal to site of application of the

Front limbs
 Dorsal metacarpal vein

 Planter metacarpal vein

 Radial metacarpal vein planter vein

Rear limbs
 Cranial branch of lateral saphenous
vein

 Lateral
Teat/udder anesthesia/analgesia

Ring block: repair of teat laceration, teat

fistula.

Teat cistern infusion: removal of teat

polyps, teat spider
 Intra-testicular anesthesia/analgesia

• Indication: surgical castration in cattle.

• 8-10 ml local anesthetic is injected into each testicle.

• In horse, local anesthetic can be injected in conjuction with general

anesthesia.

Internal pudendal nerve block

• Indication: surgical examination of penis.

• Site: ischio-rectal fossa.

 Regional anesthesia of Nerve blocks in
Limbs
 Used in for diagnosis of lameness.

 Nerve blocks carried out from bottom

to top.

 Sequences of blocks up to knee/hock

 Digital palmar/plantar nerve

block

 Abaxial nerve block

 Low four point nerve block

 High four point nerve block

In fore limb, Proximal to
carpus

 Median

 Ulnar

 Musculocutaneous

In hind limb, Proximal

to tarsus

 Tibial

 Saphenous

 Superficial peroneal

 Deep peroneal
 Palmar / Plantar Digital Nerve Block
• Blocks palmar/plantar third of
• Volume: foot and sole
– 1 – 2 cc – Navicular bone
• Needle: – Navicular bursa
– Digital cushion
– 25 gauge, ¾ inch
– Distal aspect of DDFT
• Technique: – Sole, bars, heels, frog
– Palpate the lateral and – (occasionally) coffin joint
the medial palmar/plantar digital
neurovascular bundle.
– Place needle axial to
the collateral cartilage, as low in
the foot as possible.
– Can perform with the
limb held up or with the horse
standing on the limb.
 Abaxial Nerve Block
• Volume:
– 1 – 2 cc
• Needle:
– 25 gauge, ¾ inch
• Technique:
– Palpate the lateral and medial
palmar/plantar digital neurovascular bundle on
the abaxial aspect of the sesamoid bones.
– Insert needle along length of the
nerve.
– Nerve is at the palmar/plantar
aspect of the bundle

• Blocks everything below the level of the

fetlock
– Foot
– Coffin joint
– Pastern Joint
– Distal DDFT
– Distal Extensor Tendons
 Low Four Point Nerve Block

• This block is specific for the forelimbs

• Volume & Needle:

– 2 – 3cc
– 1 inch, 22 gauge

• Technique:
– Lateral & medial palmar nerves (2)
– Lateral & medial palmar
metacarpal nerves (2)
– Lateral & medial palmar nerves
• Between the DDFT and
suspensory ligament, halfway up the length of
the cannon bone
• Avoid the flexor tendon
sheath
– Lateral & medial palmar metacarpal
• Distal to the ‘button’ of the
 HIGH FOUR POINT NERVE BLOCK

• Performed when low four point

nerve block fails.

• 3-5 ml local anesthetic deposited

using 25G 5/8’ needle, is inserted
through the fascia near the nerve
at dorsal border of deep digital
flexor tendon.

• Used to examine the lameness.

References

1. Veterinary Anesthesia and Analgesia, the 5th edition of Lumb and Jones.

2. Hand book of Veterinary anesthesia, 5th edition by William W. Muir, III, John A.E.
Hubbell, Richard M. Bednarski and Phillip Lerche.

3. Anesthesia and Analgesia for Veterinary Technicians, 4th edition by John A. Thomas
and Phillip Lerche.

4. Essentials of Veterinary Pharmacology and Therapeutics by Harpal Singh Sandhu

and Satyavan Rampal.

5. A hand book on Veterinary Local Anesthesia by Syed Sajjad Hussain.