Tetracaine


Article Author:
Christopher Stringer


Article Editor:
Christopher Maani


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Savio John


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Sandeep Sekhon


Updated:
12/17/2018 6:59:22 PM

Indications

Tetracaine is an amino-ester class local anesthetic. It has been in use for a variety of purposes since the early 1930s, but its most common use today is as a topical ophthalmic anesthetic for short procedures on the surface of the eye, as well as the ears and nose. Spinal anesthesia is also another indication. The World Health Organization (WHO) lists tetracaine as an essential medicine and is relatively inexpensive in comparison to other local anesthetic agents.[1]

Mechanism of Action

Tetracaine functions primarily via blockade of intracellular sodium channels. The drug travels in non-ionized form across the lipid bilayer membrane and dissociates into its ionized form (cation/conjugate acid) which then acts on the alpha-subunit of the Na-channel. The drug functions as an allosteric inhibitor on the Na-channel when it is in the open-activated state; thus, the drug binds and activates faster when a Na/K channel for a particular nerve is in use. This blockade must occur at three successive nodes of Ranvier along an axon for nerve conduction to be impaired. During this process sodium influx is prevented, thereby stopping cellular depolarization and any potential action potential developing.[2][3]

Administration

Tetracaine has a pKa of 8.46 at room temperature (25C) which is moderate although the drug has a relatively quick onset of action, especially for intrathecal administration. Lipid solubility for tetracaine is high at a relative value of 80; thus, it is amongst the most potent of any local anesthetic. Its protein binding is moderate at 75% allowing a relative duration of action up to 200 minutes. The drug undergoes hydrolysis primarily via plasma cholinesterase (butyrylcholinesterase), produced in the liver, into an alcohol and para-aminobenzoic acid (PABA). There is also a small amount of metabolism by RBC cholinesterase. There is a minimal amount of tetracaine excreted unmetabolized in the urine. It has a pH of 4.5-6.5 in plain solution. It is commonly administered topically, subcutaneously, or via intrathecal injection.[4]

Adverse Effects

On a weight basis, it is recommended not to exceed 1.5-3mg/kg of actual patient weight for dosing. Toxicity of the drug is affected by the site of administration. Tetracaine undergoes absorption (from fastest to slowest) in the following order: IV > intercostal > caudal > epidural > brachial plexus > subcutaneous. Absorption speed may be mitigated by avoiding areas with high vascular supply nearby and/or by adding local vasoconstrictors to the solution (epinephrine or phenylephrine).[5] As alluded to earlier, metabolism occurs via plasma cholinesterase primarily produced from the liver, so dosing should cautious in patients with liver disease, neonates, and patients with atypical homozygous pseudocholinesterase deficiency.[6]

One of the primary concerns with tetracaine as with other local anesthetics is CNS toxicity. Toxicity may manifest initially as circumoral numbness, tinnitus, blurry vision, and dizziness. It may then present with hyperexcitability of the patient due to the blockade of CNS inhibitory pathways before progressing to depressive phenomena, seizures, and comatose state before hemodynamic collapse. Tetracaine does exhibit vasodilatory properties when given in toxic doses and exerts dose-dependent decreases on cardiac contractility. In addition to this, it may increase the duration of PR and QRS intervals progressing to sinus bradycardia then to asystole. Ventricular arrhythmia is a possibility but is more common with bupivacaine.[7]

Direct neural toxicity has been noted with chloroprocaine and lidocaine, although rare with tetracaine. These may manifest after neuraxial administration as cauda equina syndrome (lumbosacral radiculopathy, saddle anesthesia, loss of bowel/bladder tone). It may also manifest after neuraxial technique as transient neurologic symptoms (painful lumbosacral radiculopathy lasting up to 10 days); this may be particularly more common in patients undergoing surgery in the lithotomy position, who are or will be non-ambulatory for prolonged periods, and those who are obese. Some degree of risk may be mitigated by using lower doses of local anesthetic for neuraxial technique and by avoiding preservatives including sulfites and/or EDTA (which have been implicated for CES and TNS when used).[8]

Allergic reactions to tetracaine can occur. While allergy to local anesthetic is rare, it is more common with aminoesters than aminoamides.  This reaction is thought primarily to be due to para-aminobenzoic acid (PABA). In addition to this, care should be taken to review the drug label for any addition of preservatives, especially methylparaben which metabolizes to PABA.[9]

Contraindications

No absolute contraindications exist to the use of tetracaine aside from prior evidence of serious allergic response. Relative contraindication to use is previous administration of local anesthetic. Care should be taken to note when a patient has received such medications as in the case of postoperative pain relief when local anesthetic infiltrate has been used, concerning the duration of effect of different agents. Since the advent of liposomal bupivacaine, which may exercise its effect for up to 72 hours, it should be noted that concurrently administered local anesthetics may combine to precipitate toxic symptoms.[10]

Monitoring

The American Society of Anesthesiology, in addition to international standard conventions,  recommends continuous ECG and pulse oximetry, blood pressure monitoring intermittently with concomitant inspection of respiratory rate or ETCO2 during any regional or neuraxial anesthetic administration.[11]

Toxicity

The most feared complication of tetracaine toxicity is the progression to local anesthetic systemic toxicity (LAST) syndrome marked by all previously mentioned features of CNS and cardiovascular toxicity. The provider administering the medication must exercise prompt recognition of the progression of this syndrome.

Care should be taken to quickly secure the patient’s airway and breathing and support hemodynamics. It is important to note that hypoxia, hypercarbia, and acidosis can worsen cardiac contractility, exacerbate arrhythmia, and lower the seizure threshold. Controlled ventilation can attenuate hypoxia and hypercarbia mitigating such effects. Additionally, benzodiazepines may be prudent during the administration of high doses of tetracaine as they raise the seizure threshold and have the added benefit of anxiolysis during a nerve block or surgical procedure.

While there is no direct reversal agent or treatment for tetracaine toxicity, it is recommended to begin lipid rescue therapy immediately. Intravascular administration of concentrated lipid is theorized to act as a sump to freely circulating local anesthetic allowing for rapid clearance of the drug from systemic circulation. 20% lipid emulsion should be started at 1.5mL/kg immediately followed by infusion at 0.25mL/kg/min. The bolus dose may be repeated, and the infusion increased if the patient persists with hemodynamic compromise or arrhythmia.[12]

Enhancing Healthcare Team Outcomes

Tetracaine is rarely used today outside of topical application for short ENT and ophthalmologic procedures. It has been studied on rat models and found to additionally function via a dose-dependent inhibition of intracellular calcium release through ryanodine receptors. This pharmacology has not been studied in humans but may be of some interest as this mechanism is similar to that of dantrolene for use in treating malignant hyperthermia.[13]

For successful a successful outcome, the entire team including nurses, pharmacists, and other clinicians should work in a coordinated fashion to safely use tetracaine and monitor for side effects.


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Tetracaine - Questions

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Which local anesthetic has a low risk of toxicity in a patient with liver failure?



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Which of the following local anesthetics will exhibit the longest duration of action?



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Which of the following local anesthetics has the greatest potency?



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A healthy 22-year-old female presents to a small, rural hospital in early labor with her first child. On history, you note that the pregnancy has been uncomplicated, and she is at term. Her comprehensive physical exam is unremarkable. The patient is 150 cm tall and weighs 70kg. She has no prior medical or surgical history. She is only taking prenatal vitamins. An epidural catheter is placed after minimal blood return from the line and a negative test dose. Analgesia is started and maintained with a dilute solution of ropivacaine, fentanyl, and epinephrine. After 12 hours with the catheter in place and slow progress of labor, there is concern that the catheter has migrated, as the patient is now feeling numbness only in the legs. The anesthesia provider in house elects to test placement of the catheter by bolusing 10 mL of 1% lidocaine. After bolusing the lidocaine, the provider notes that the syringe used was actually 1% tetracaine. The patient is complaining of a metallic taste and ringing in her ears. She notes no change in the numbness of her legs over the next 15 minutes. What is the best course of action for this patient?



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An 84-year-old male undergoes right hip hemiarthroplasty with spinal anesthesia. The patient has a medical history significant for low back pain. His surgical history includes a previous, uncomplicated right hip hemiarthroplasty. The only medication he takes is celecoxib 400 mg daily as needed for arthritic hip pain. The procedure is estimated to last about 2 hours, and the anesthesia provider determines to use hyperbaric tetracaine. The procedure is completed uneventfully. On postoperative day one, the patient begins to complain of sharp, bilateral leg pain posteriorly. He has no neuromuscular deficits. Inspection of the surgical site shows a well-approximated, soft, minimally tender incision. Which of the following would have prevented the bilateral leg pain from occurring?



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Tetracaine - References

References

Ruetsch YA,Böni T,Borgeat A, From cocaine to ropivacaine: the history of local anesthetic drugs. Current topics in medicinal chemistry. 2001 Aug     [PubMed]
Lirk P,Picardi S,Hollmann MW, Local anaesthetics: 10 essentials. European journal of anaesthesiology. 2014 Nov     [PubMed]
Raymond SA,Steffensen SC,Gugino LD,Strichartz GR, The role of length of nerve exposed to local anesthetics in impulse blocking action. Anesthesia and analgesia. 1989 May     [PubMed]
Zhang J,Hadlock T,Gent A,Strichartz GR, Tetracaine-membrane interactions: effects of lipid composition and phase on drug partitioning, location, and ionization. Biophysical journal. 2007 Jun 1     [PubMed]
Emelife PI,Eng MR,Menard BL,Myers AS,Cornett EM,Urman RD,Kaye AD, Adjunct medications for peripheral and neuraxial anesthesia. Best practice & research. Clinical anaesthesiology. 2018 Jun     [PubMed]
Rico-Mora DA,Walton L,Navas-Blanco JR, Prolonged neuromuscular blockade in a middle-eastern female patient homozygous for atypical plasma cholinesterase. Saudi journal of anaesthesia. 2018 Oct-Dec     [PubMed]
Practical guide for the management of systemic toxicity caused by local anesthetics. Journal of anesthesia. 2018 Nov 11     [PubMed]
Neal JM,Kopp SL,Pasternak JJ,Lanier WL,Rathmell JP, Anatomy and Pathophysiology of Spinal Cord Injury Associated With Regional Anesthesia and Pain Medicine: 2015 Update. Regional anesthesia and pain medicine. 2015 Sep-Oct     [PubMed]
Bina B,Hersh EV,Hilario M,Alvarez K,McLaughlin B, True Allergy to Amide Local Anesthetics: A Review and Case Presentation. Anesthesia progress. 2018 Summer     [PubMed]
Balocco AL,Van Zundert PGE,Gan SS,Gan TJ,Hadzic A, Extended release bupivacaine formulations for postoperative analgesia: an update. Current opinion in anaesthesiology. 2018 Oct     [PubMed]
Gelb AW,Morriss WW,Johnson W,Merry AF,Abayadeera A,Belîi N,Brull SJ,Chibana A,Evans F,Goddia C,Haylock-Loor C,Khan F,Leal S,Lin N,Merchant R,Newton MW,Rowles JS,Sanusi A,Wilson I,Velazquez Berumen A, World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia. Anesthesia and analgesia. 2018 Jun     [PubMed]
Wolfe RC,Spillars A, Local Anesthetic Systemic Toxicity: Reviewing Updates From the American Society of Regional Anesthesia and Pain Medicine Practice Advisory. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2018 Dec     [PubMed]
Cobo R,Nikolaeva M,Alberola-Die A,Fernández-Ballester G,González-Ros JM,Ivorra I,Morales A, Mechanisms Underlying the Strong Inhibition of Muscle-Type Nicotinic Receptors by Tetracaine. Frontiers in molecular neuroscience. 2018     [PubMed]

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