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Miscellaneous Actions
Neuromuscular Blockade
Many local anesthetics have been demonstrated to block neuromuscular transmission in
humans. This is a result of the inhibition of sodium diffusion through a blockade of sodium
channels in the cell membrane additive to that produced by both depolarizing (eg,
succinylcholine) and nondepolarizing (eg, atracurium, vecuronium) muscle relaxants; this
may lead to abnormally prolonged periods of muscle paralysis. Such actions are unlikely to
occur in the dental outpatient.
Drug Interactions
In general, CNS depressants (eg, opioids, antianxiety drugs, phenothiazines, barbiturates),
when administered in conjunction with local anesthetics, lead to potentiation of the CNS-
depressant actions of the local anesthetic. The conjoint use of local anesthetics and drugs that
share a common metabolic pathway can produce adverse reactions. Both ester local
anesthetics and the depolarizing muscle relaxant succinylcholine require plasma
pseudocholinesterase for hydrolysis. Prolonged apnea may result from concomitant use of
these drugs. Drugs that induce the production of hepatic microsomal enzymes (eg,
barbiturates) may alter the rate at which amide local anesthetics are metabolized. Increased
hepatic microsomal enzyme induction increases the rate of metabolism of the local
anesthetic. Specific drugdrug interactions related to the administration of local anesthetics
are reviewed in Chapter 10.
Malignant Hyperthermia
Malignant hyperthermia (MH; hyperpyrexia) is a pharmacogenic disorder in which a genetic
variant in an individual alters that person's response to certain drugs. Acute clinical
manifestations of MH include tachycardia, tachypnea, unstable blood pressure, cyanosis,
respiratory and metabolic acidosis, fever (as high as 42 C [108 F] or more), muscle rigidity,
and death. Mortality ranges from 63% to 73%. Many commonly used anesthetic drugs can
trigger MH in certain individuals. Until recently, the amide local anesthetics were thought to
be capable of provoking MH and were considered to be absolutely contraindicated in MH-
susceptible patients. 68 The Malignant Hyperthermia Association of the United States
(MHAUS), after evaluating recent clinical research, concluded that in fact no documented
cases in the medical or dental literature (over the past 30 years) support the concept
of amide anesthetics triggering malignant hyperthermia. 69