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BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE

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         BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
            BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

     BUPIVACAIN HYDROCLORIDE INFLUENCE
   WITH OR WITHOUT EPINEPHRINE VASE IN THE
  BLOOD PRESSURE IN NORMOTENSES PATIENTS –
        CLINICAL COMPARATIVE STUDY *

 INFLUÊNCIA DO CLORIDRATO DE BUPIVACAINA
COM E SEM VASO CONSTRITOR SOBRE A PRESSÃO
   ARTERIAL EM PACIENTES NORMOTENSOS –
       ESTUDO CLÍNICO COMPARATIVO




                                      Marcos Vinicius TAMURA CAMPOS **
                                                       Clóvis MARZOLA ***
                                           João Lopes TOLEDO-FILHO ***
                                                Gustavo Lopes TOLEDO ***
                                           Marcos Maurício CAPELARI ***
                                          Cláudio Maldonado PASTORI ***
                                       Daniel Luiz Gaertner ZORZETTO ***




______________________________________________
* Based on a monograph submitted to the Postgraduate Programs in Buco Maxillofacial Surgery and
          Traummatology, São Paulo Association of Dental Surgeons (APCD)-Bauru-São Paulo
          State, in partial fulfillment of the requirements for a Specialist degree, 1994.
** Specialist in Buco Maxillo Facial Surgery and Traummatology. Author of the monograph.
*** Titular Professor of Anatomy of the São Paulo University. Supervisor of the monograph.
*** Professors of Buco Maxillo Facial Surgery and Traummatology Postgraduate Programs, Base
          Hospital of São Paulo, São Paulo Association of Dental Surgeons (APCD)-Bauru-São
          Paulo State.
                                                                                    851
        BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
           BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

                                    SUMMARY

              A study performed on 38 patients in 51 procedures, with 25 females
and 13 males. We used the local anesthetic Neocain 0.5% which comes to the
Bupivacain hydrochloride with or without epinephrine, to assess its influence on
blood pressure.

                                     RESUMO

               Estudo realizado com 38 pacientes, em 51 procedimentos, sendo 25 do
gênero feminino e 13 do masculino. Foi utilizado o anestésico local Neocain 0,5%
que vem a ser o cloridrato de Bupivacaina, com e sem epinefrina, para a verificação
da sua influência sobre a pressão arterial.

Uniterms: Anesthesia; Anesthetic; Neocain; Bupivacain hydrochloride; Blood
       pressure.

Unitermos: Anestesia; Anestésico; Neocain; Cloridrato de Bupivacaina; Pressão
       arterial.

                                INTRODUCTION

               Since the early discovery of anesthesia by dentist Horace Wells, and
later the local anesthetic by Carl Koller, who is improving and seeking more
effective and safer drugs in order to be a pain of the biggest fears of man
(MARZOLA, 2008).
               Because an increasing number of patients with disorders related to
blood pressure, sought to establish this work using local anesthesia of long duration,
in the case of Bupivacaina hydrochloride. This survey was planned by the need for a
longer period of anesthesia in cases of delayed surgeries, and in case of hypertensive
patients.
               The Bupivacaine hydrochloride is presented as a valuable resource for
surgeries where one expects a major trauma, and its main advantage lies in its
prolonged anesthetic action. It is a salt of amide anesthetic that resulted from the
structural modification of the molecule of mepivacaine. The coefficient of
participation oil / water Bupivacaine is 27.5, determining the potency of the
anesthetic (Table 1). It is approximately four times more potent than lidocaine,
prilocaine and mepivacaine, presenting the highest percentage of protein binding,
come to determine the duration of anesthesia. Its dissociation constant (pKa) defines
the pH at which the ionized and non-ionized forms of an anesthetic are in
equilibrium, determining the onset of the anesthetic, which in this case is about 3-4
times greater than lidocaine. The maximum dose recommended by the FDA (Food
and Drug Administration - USA) is 90 mg, equivalent to 10 tubes of 05%
bupivacaine (RANALI; VOLPATO, 1990).
               Bupivacaine is a local agent for the effective blockade of peripheral
nerves, is endowed with an element of high intrinsic anesthetic potency and low-
power and seizures at therapeutic doses, and has not developed any significant
cardiotoxic effect (SOUZA et al., 1989).
               Adrenaline also could be a chemical transmitter, released by
stimulation of sympathetic fibers according to research (Elliot, 1904). Among the
                                                                                            852
         BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
            BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

various effects of adrenaline in adrenergic nerve stimulation, one can highlight the
circulatory effects that will affect blood pressure, heart and vessels (ROSA, 1989).
The adrenaline causes a very large increase in pressure when injected into a vein.
Initially hypertension occurs primarily by peripheral vasoconstriction, tachycardia,
always in proportion to the injected dose. In a second phase occurs a bradycardia
and a third stage is the normalization of blood pressure.
                Adrenaline in the heart exerts a powerful stimulating action,
promoting tachycardia than enhanced myocardial contraction and an increase in
systolic performance. In pulmonary and cerebral vessels by having a small number of
vasomotor nerves suffer very little vasoconstrictor action, tending to dilate passively
by the displacement of the mass and blood in coronary vessels produces
vasodilatation (ROSA, 1989).
                In local anesthetics is the combination of adrenaline in order to
prolong the anesthetic effect due to vasoconstriction, thereby promoting greater
contact time with the anesthetic nerve tissue. With this you can reduce the volume of
administered solution reducing the risk of poisoning.
                It should also be used in routine daily use of syringes with retro
aspiration not to accidentally inject the anesthetic agent within a vessel. Through
studies it was found that the lethal dose of adrenaline is about 10 mg although the
volume and concentration administered a local anesthetic to be small in patients with
angina in the chest, where you can quickly trigger an angina pain, for the aggravation
of coronary insufficiency subject to increased cardiac work. Still depending on the
amount administered can be observed cardiac toxicity, vascular. toxic effects are
nervous anxiety, feelings of fear, trembling and others. The toxic effects are acute
attacks of vascular hypertension, cerebral and pulmonary. In the heart tissue
tachycardia and palpitations are occurring frequently (Table 1).
                Given all that was sought in this work to present a collaboration to
offer more safety to our patients in all dental procedures. Mainly engaged and get
ready in their offices to detect all these problems with regard to blood pressure.
Many professionals do not have the equipment necessary to evaluate these problems.

Table 1 – Physico-chemical and Pharmacological properties some Local Anesthetics *.


                                Physico-chemical                    Pharmacological

                             PKA     Coefficient   Connection     Latency    Relative   Length
                            (250C)    Partition     Proteic                   Power


            Prilocaine        7,9        0,9           55 x         Fast         2      Moderate

            Lidocaíne         7,9        2,9           64 x         Fast         2      Moderate

          Mepivacaine         7,6        0,8           78 x         Fast         2      Moderate

          Bupivacaine         8,1        27,5          96 x      Moderate        8       Long



* Compared with the standard of procaine is equal to 1.
Fonte: RANALI, J.; VOLPATO, M. C. Anestésico local de longa duração – Revisão sobre sua
         Farmacologia e uso clínico em Odontologia. Rev. brasil. Odont., v. 47, n. 6, p. 36-40,
         nov.,/dez., 1990.
                                                                                    853
        BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
           BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

                           LITERATURE REVIEW

                The responses of blood pressure in 10 normal patients were studied
and it was concluded that differences in blood pressure in both the mean systolic and
diastolic pressures, between the procedures were insignificant (SHIP, 1960).
                Were observed variations in systolic and diastolic pressure before and
during anesthesia and is attributed more too psychological factors (SCHIFINO,
1960).
                Cardiovascular responses in normotensive and hypertensive patients
were studied, and used the 2% lidocaine, with and without epinephrine. The
responses of hypertensive patients differed from those of normotensive more
quantitatively, being shown the influence of psychological factors (VERNALE,
1957).
                Regarding the use of epinephrine in patients with cardiovascular
disease, based on literature review, some authors argue that one must know the
quantity used method of injection, stressing that there is considerable disparity
between dental and medical dosages epinephrine (HOLROYD et al., 1960).
                The pioneering use of bupivacaine in oral surgery has been awarded to
some authors who concluded that the analgesia of the soft tissues is significantly high
and that the postoperative pain only appeared two hours after the time mepivacaine
compared with bupivacaine (FELDMAN; NORDENRAM, 1966).
                Bupivacaine was also used in 49 patients for surgical removal of
impacted third molars, concluding that promotes a deep anesthesia, and that installs
quickly and remained in long-term, and easily penetrate into the tissues of the mouth
structure (PRICCO; WIS, 1977).
                Studies also showed that the vasoconstrictor contained in the
anesthetic has no effect on blood pressure elevation (TUCCI et al., 1977).
                Ten (10) patients with retained third molars were submitted to loco
regional anesthesia by 0.5% bupivacaine with epinephrine 1:200,000, for the removal
of these teeth. Was obtained a postoperative analgesia for up to nine hours after the
completion of surgery and did not present any problem worthy of record (SOUZA;
VIEIRA, 1984).
                Because bupivacaine hydrochloride 0.5% with and without
vasoconstrictor anesthetic of a long and valuable assistance extended to, we tried to
study its relationship with blood pressure in the Dental Clinic. Especially in view of
the scarcity of works on the subject and thereby seeking to add a few more
information about this anesthetic salt.

                       MATERIAL AND METHODS
               This study treated 38 patients aged over 14 years, of both genders,
with good health with normal blood pressure. These patients underwent various
procedures, from multiple extractions of subgengival scaling, being treated at the
outpatient clinic at the health post of Pioneer Village in the City of Toledo in
Parana. Were carried out 51 visits varied, not subject to a certain type in order to
arrive at the conclusions more comprehensive, because with this, in some cases, the
same patient was evaluated in different situations.
               For this work was taken as the norm NEW HEART ASSOCIATION
(1955), setting a ceiling of normal blood pressure for adults, 140 mm Hg (systolic)
and 90 mm Hg (diastolic).
                                                                                      854
          BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
             BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

               Blood pressure was always observed on the right arm using a
sphygmomanometer and stethoscope (BECTON DICKINSON) of domestic
manufacture, and by the same professional, always observing the recommended
method (ROMEIRO, 1954).
               All patients were anesthetized with bupivacaine hydrochloride, and 27
calls were used to bupivacaine with epinephrine and 24 calls, we used bupivacaine
without epinephrine.
               In patients who underwent interventions in the jaw, were anesthetized
by infiltrating and terminal anesthesia, the mandible were performed regional
anesthesia to the inferior alveolar nerve, lingual and buccal (MARZOLA, 2008).
We used a (01) 1.8 ml plastic tube to the maxilla and two (02) tubes to the mandible.
               A blood pressure check was made on the day on which the patients
were scheduled was checked their blood pressure, knowing that today he would not
be met, to avoid that occur with changes in AP by psychic factor. On the day of
service was found to PA before anesthesia during the procedure and after its
completion. The interval between one measurement and another was more or less 20
minutes, and we noted in a statement.
               Bupivacaine hydrochloride used in the survey had a 0.5%
concentration with and without epinephrine 1:200,000, which was acquired directly
from the manufacturer *.
               Among the 51 appointments made, 16 patients were males and 35
females.




___________________________________________
* Neocain 0,5% - Cristália Laboratories.

                                           RESULTS
              The results with regard to blood pressure in patients treated with
bupivacaine without vasoconstrictor and outside the office were analyzed and
evaluated. This evaluation was performed the day before surgery, in the office
before anesthesia, during treatment about 20 minutes after anesthesia, and after
finishing the procedure, about 40 minutes after anesthesia, showed the following
(Tables 2 and 3).
                                                                                                  855
          BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
             BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

Table 2 - Patients treated with bupivacaine without vasoconstrictor.




              CASES              01*              02*              03*              04*

                 1             140/90           140/90           150/90           140/90

                 2             100/70           120/70           120/80           120/80

                 3             110/70           110/60           110/70           110/70

                 4             110/80           120/60           120/65           110/70

                 5             110/70           110/60           110/60           110/60

                 6             100/70           130/80           130/90           130/90

                 7             130/70           150/90           150/100          145/90

                 8             120/80           140/80           130/75           130/75

                 9             120/70           130/50           115/45           110/40

                10             110/80           130/80           125/70           110/60

                11             120/80           125/75           120/75           115/75

                12             100/70           120/60           120/60           130/70

                13             120/80           120/80           110/80           110/80

                14             140/80           120/80           125/80           120/80

                15             110/70           110/65           120/65           120/65

                16             100/60           120/70           120/80           120/90

                17             100/60           110/80           110/80           110/80

                18             110/80           100/60           110/75           110/80

                19             160/90           170/90           190/100          180/95

                20             110/60           120/60           120/70           120/75

                21             110/60           100/60           110/70           110/70

                22             120/80           150/90           130/90           140/90

                23             100/60            90/60            90/60            90/60

                24             110/70           100/60           100/60           100/60




* 01 – Arterial blood pressure outside the Office the day before surgery.
* 02 – Arterial blood pressure in the Office before anesthesia.
* 03 – Arterial blood pressure during the treatment about 20 minutes after anesthesia.
* 04 – Arterial blood pressure after finishing the procedure about 40 minutes after anesthesia.
                                                                                                  856
          BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
             BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

Table 3 - Patients treated with bupivacaine with vasoconstrictor.




              CASES              01*              02*               03*            04*

                 1             110/80           120/80           120/80           110/70
                 2             110/70           110/60           100/50           110/60
                 3             140/80           170/90           160/90           160/90
                 4             120/80           110/70           110/70           110/70
                 5             120/70           110/50           110/50           110/50
                 6             100/80           100/70           100/70           100/70
                 7             100/70           120/70           120/60           120/60
                 8             120/80           150/85           130/80           120/75
                 9             120/80           130/80           130/80           130/80
                 10            110/60           140/80           140/80           140/80
                 11            110/70           140/85           130/85           130/80
                 12            120/80           120/80           120/80           120/80
                 13            110/70           110/50           110/50           110/50
                 14            120/70           130/50           120/40           120/40
                 15            120/60           120/60           110/60           110/60
                 16            130/100          130/90          140/100          150/110
                 17            110/80           110/60           110/60           110/60
                 18            110/70           120/60           120/70           120/65
                 19            100/60           110/70           110/60           110/60
                 20            120/80           120/80           120/80           120/85
                 21            120/70           110/70           100/60           110/70
                 22            120/80           130/90           120/80           120/80
                 23            110/70           125/75           120/80           120/80
                 24            120/70           120/80           120/70           120/70
                 25            110/70           160/100         170/100          180/100
                 26            100/60           105/75           115/75           110/70
                 27            120/80           120/75           120/75           120/75




* 01 – Arterial blood pressure outside the Office the day before surgery.
* 02 – Arterial blood pressure in the Office before anesthesia.
* 03 – Arterial blood pressure during the treatment about 20 minutes after anesthesia.
* 04 – Arterial blood pressure after finishing the procedure about 40 minutes after anesthesia.
                                                                                     857
         BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
            BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

                                    DISCUSION

                By necessity, in many cases the anesthesia of long duration and with a
view to the bupivacaine hydrochloride provides a time of anesthesia according to the
literature in 5-9 hours, researched in this paper the relationship of this salt with or
without epinephrine, relating him with blood pressure.
                A total of 51 outpatient visits was observed in only six (06) cases
(11.85%) had elevated blood pressure, two (02) patients anesthetized with
bupivacaine hydrochloride with epinephrine and four (04) with bupivacaine
hydrochloride without epinephrine.
                In twelve (12) procedures (23.5%) showed a drop in blood pressure,
and six (06) were anesthetized with bupivacaine with epinephrine, and six (06)
without epinephrine. Yet, in thirty-three (33) cases corresponding to 64.7%,
observed no change in blood pressure (Table 4).
                Changes in blood pressure occur due to psychological factors for
autogenous and adrenaline, not to that injected during anesthesia (MARTINEZ
GARZA, 1953; VERNALE, 1957; VIANA, 1957; TUCCI, 1965; KAIND;
KOHN, 1971; TUCCI et al., 1977; KALIL, 1983; BENNETT, 1984; TUCCI et
al., 1986/1987; ANTONIAZZI, 1989; BUFFINGTON, 1989; NANCARROW et
al., 1989; STOLF; RANALI, 1990; JOHNSON; LOFSTROM, 1991; PERUSSE
et al., 1992 and MARZOLA, 2008). In this study we observed this finding in some
patients because the blood pressure returned to normalcy after the end of the
procedure, considering that the anesthetic salt does not cause blood pressure changes.
                With respect to anesthesia time reported by the patients was observed
that was approximately seven (07) hours.
                Among the most varied ages of the patients treated, between 14-72
years, was not observed any reaction on the blood pressure, or some other incident.
                The most significant property anesthetic bupivacaine hydrochloride
because of its high protein binding is undoubtedly its long duration. This is to
provide a calmer patient, calm, relaxed and, moreover very cooperative. This
behavioral state of the patient reverts to a greater security by the professional. This,
since it can track where all your patients this way, monitoring them, regardless of the
type of procedure he will perform (MILAN; GIOVANNITTI, 1984; BUCKLEY et
al., 1985; SOUZA et al., 1991; COVINO, 1986; STOLF; RANALI, 1990;
MCLEAN et al., 1993 and MARZOLA, 2008).

Table 4 – Number and percentage of patients in relation to blood pressure and bupivacaine
        hydrochloride with or without epinephrine.

          Arterial Blood      Total Number          Patients           Patients
            Pressure           of Patients      anesthetized with    anesthetized
                                                  epinephrine          without
                                                                     epinephrine
         Remained the same      33 (64,7%)         19 (70,4%)         14 (58,5%)
                PA
           Increased the        6 (11,85%)          2 (7,4%)          4 (16,7%)
                PA
             Lowered            12 (23,5%)         6 (22,2%)          6 (24,8%)
                PA
                                                                                     858
         BUPIVACAIN HYDROCLORIDE INFLUENCE WITH OR WITHOUT EPINEPHRINE VASE IN THE
            BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

                                  CONCLUSIONS

               Based on these results we can conclude that:
               1. The 0.5% bupivacaine hydrochloride with or without epinephrine is
an anesthetic that observed when some measurements, showed no change that would
contra-indicated.
               2. The 0.5% bupivacaine hydrochloride to be a long lasting anesthetic
should be used primarily for operations that require long periods of anesthesia.
               3. There were no changes in blood pressure that could contraindicate
the bupivacaine hydrochloride with or without epinephrine.
               4. 33 (64.7%) patients maintained the same blood pressure checked.
               5. 6 (11.85%) patients had a blood pressure increase.
               6. In 12 (23.5%) patients had a low blood pressure.
               7. In anesthetized patients with and without vasoconstrictor 19 (70.45)
maintained BP and without pot, 14 (58.5%) maintained PA.
               8. In 2 (7.4%) patients anesthetized with vasoconstrictor BP increased,
and 6 (22.2%) patients had a low BP.
               9. 4 (16.7%) patients anesthetized without vasoconstrictor BP
increased, and six (24.8%) patients had a low BP.

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* According ABNT norms.
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           BLOOD PRESSURE IN NORMOTENSES PATIENTS – CLINICAL COMPARATIVE STUDY

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