Idiosyncrasy

Genetically determined abnormal reactivity

to a drug.
Resembles hypersensitivity, neither allergic
nor overdose rxn
Eg: CNS depression drug histamine causes
stimulation or excitation in some
individuals
Specific management of idiosyncratic rxns
is difficult bcoz of unpredictable nature of
response.

Treatment
Symptomatic includes positioning,
airway , breathing , circulation and
definitive care.

Lignocaine overdose
Defined as those clinical signs and
symptoms that result from an overly
high blood level of a drug in various
target organs and tissues

Patient factors
Age : young and old high risk of overdose
Weight : greater the body wt. , the larger
the dose that can be tolerated before
overdose rxn occur
Other medications :
Sex :
Presence of disease : liver and renal dz
risk of overdose
Genetics :
Mental attitude and environment :

Drug factors :
Vasoactivity :
Concentration : greater concn -overdose

Dose :

route of administration
Rate of injection :
Route of injection :
Vascularity of injection site
Presence of vasoconstrictors

Cause :
Biotransformation of lignocaine is
unusually slow
The unbiotransformed drug is too
slowly eliminated from the body
through the kidneys
Too large a total dose is administered
Absorption from the injection site is
unusually rapid
Intravascular administration

Biotransformation and
elimation :

Biotransformed in liver by hepatic

microsomal enzyme
History of liver dz (ASA 2 or 3)- use
judiciously (use minmum effective vol)
Renal dysfunction : blood level of active
lignocaine

Excessive total overdose

In excess - overdose
Maximum recommended dose (MRD)
of lignocaine

Drug

Formulatio MRD(mg Mg/lb

n
)

Mg/k
g

lignocaine

Plain
With
epinephrine

4.4*
7.0*

300*
500*

2.0
3.3

* manufacture recommendation : prescribing

information,dental,westborough,mass,1990,astra pharmaceutical product

Patient age and physical status should

also be considered

Rapid absorption into circulation

use LA with Vasoconstrictor
topical LA high concentration than
parenteral formulations
Lignocaine rapidly absorbed Increased risk of overdose so limit
area of application and use in small
amounts

Intravascular injection
Both IV and IA injection produce
overdose
Nerve block
Positive aspiration
rate

Inferior alveolar

11.7

Mental or incisive

5.7

Posterior superior
alveolar

3.1

Anterior superior
alveolar

0.7

Long buccal

0.5

Reverse carotid flow

Rapid intra arterial administration of LA retrograde blood
flow due to hig pressure produced by the rate of injection

prevention
Use aspirating syringe
When risk of aspiration high no
smaller than 25G needle
Aspirate in at least 2 planes initial
aspiration
rotate syringe
about 45
Slowly inject LA : ideal rate 1ml/min
Divided doses

Factors adding to increase risk of LA

overdose in younger patients
Treatment plan where all 4 quadrants are
treated with LA in one visit
LA solution administered is a plain solution
Full cartidges (1.8ml) administered with each
injection
LA administered to all 4 quadrants at one time
Exceeding maxm dosage based on pts body
wt ( smaller dosage minimize but do not
gurantee overdose will not be seen; larger
dose increase but does not guarantee
overdose will not happen)