Complete prevention of blood loss with self-sealing haemostatic needles.

Bleeding is largely unavoidable following syringe needle puncture of biological tissues and, while inconvenient, this typically causes little or no harm in healthy individuals. However, there are certain circumstances where syringe injections can have more significant side effects, such as uncontrolled bleeding in those with haemophilia, coagulopathy, or the transmission of infectious diseases through contaminated blood. Herein, we present a haemostatic hypodermic needle able to prevent bleeding following tissue puncture. The surface of the needle is coated with partially crosslinked catechol-functionalized chitosan that undergoes a solid-to-gel phase transition in situ to seal punctured tissues. Testing the capabilities of these haemostatic needles, we report complete prevention of blood loss following intravenous and intramuscular injections in animal models, and 100% survival in haemophiliac mice following syringe puncture of the jugular vein. Such self-sealing haemostatic needles and adhesive coatings may therefore help to prevent complications associated with bleeding in more clinical settings.

A prospective, randomized controlled trial of conscious sedation using propofol combined with inhaled nitrous oxide for dental treatment.

PURPOSE: Adverse reactions during propofol sedation include a decrease in arterial blood pressure, propofol-induced pain on injection, and airway complications. The purpose of this study was to investigate whether combined use of intravenous propofol and inhaled nitrous oxide could decrease the hypotensive and other adverse effects of propofol. PATIENTS AND METHODS: We designed and implemented a prospective, randomized controlled trial. Patients undergoing dental procedures requiring intravenous sedation were randomly allocated to 2 groups: group P comprised those receiving sedation with propofol alone, and group N+P comprised those receiving sedation with 40% nitrous oxide inhalation and propofol. During the dental procedures, the sedation level was maintained at an Observer's Assessment of Alertness/Sedation scale score of 4 by adjusting propofol's target plasma concentration. Nitrous oxide inhalation was the predictor variable, whereas the hemodynamic changes, amount and concentration of propofol, and adverse events were the outcome variables. RESULTS: Eighty-eight patients were successfully analyzed without any complications. The total amount of propofol was significantly less in group N+P (249.8 ± 121.7 mg) than in group P (310.3 ± 122.4 mg) (P = .022), and the mean concentration of propofol was significantly less in group N+P (1.81 ± 0.34 µg/mL) than in group P (2.05 ± 0.44 µg/mL) (P = .006). The mean blood pressure reduction in group N+P (11.0 ± 8.0 mm Hg) was significantly smaller than that in group P (15.8 ± 10.2 mm Hg) (P = .034). Pain associated with the propofol injection and memory of the procedure were less in group N+P (P = .011 and P = .048, respectively). Nitrous oxide did not affect respiratory conditions or recovery characteristics. CONCLUSIONS: The results of this study suggest that nitrous oxide inhalation combined with propofol sedation attenuates the hypotensive effect and pain associated with propofol injections, along with potentiating the amnesic effect.

Pentoxifylline and tocopherol in the treatment of yearly zoledronic acid-related osteonecrosis of the jaw in a corticosteroid-induced osteoporosis.

Osteonecrosis of the jaw (ONJ) is a well-known side effect of bisphosphonate (BP) therapy. ONJ is specifically related to the intravenous form of BPs and is usually seen in combination with other risk factors, such as dental surgery, concurrent corticosteroids, chemotherapy, and tobacco use. The risk of developing ONJ in patients treated with oral BPs for osteoporosis is lower than that in patients with cancer but is still significant. Zoledronic acid is a third-generation nitrogen-containing BP. It was first used in the treatment of malignancy as a monthly infusion and then approved for the treatment of osteoporosis as a yearly infusion and is an attractive option that is more reliable than the oral form. ONJ related to the use of yearly zoledronic acid is rarely reported in the literature and is most likely underestimated. Pentoxifylline and tocopherol have been used in the treatment of osteoradionecrosis for many years, with observed lesion improvement. The authors present a case of ONJ development after 3 yearly zoledronic acid infusions for corticosteroid-induced osteoporosis. The patient was successfully managed using conservative treatment with pentoxifylline and tocopherol.

Oral mucosa produces cytokines and factors influencing osteoclast activity and endothelial cell proliferation, in patients with osteonecrosis of jaw after treatment with zoledronic acid.

OBJECTIVES: The intravenous injection of bisphosphonates, currently used as treatment for osteoporosis, bone Paget's disease, multiple myeloma, or bone metastases, can cause jaw bone necrosis especially in consequence of trauma. The present research aimed to clarify the mechanisms underlying bone necrosis, exploring involvement of the oral mucosa "in vivo." PATIENTS AND METHODS: Specimens of oral mucosa were removed from bisphosphonate-treated patients with or without jaw bone necrosis. In mucosa specimens, expression was evaluated of: cytokines involved in the inflammatory process, factors involved in osteoclast activity, i.e., receptor activator of nuclear factor kappa-B ligand (RANKL) and osteoprotegerin, a factor involved in cell proliferation, namely hydroxymethylglutaryl coenzyme A reductase, and a factor involved in angiogenesis, namely vascular endothelial growth factor (VEGF). RESULTS: Interleukin (IL)-6 and the RANK/osteoprotegerin ratio were significantly elevated in mucosa from patients with versus without jaw necrosis, whereas hydroxymethylglutaryl coenzyme A reductase and VEGF were significantly decreased. CONCLUSIONS: Our results suggest that mucosa, stimulated by bisphosphonate released from the bone, can contribute to the development of jaw necrosis, reducing VEGF, and producing IL-6 in consequence of hydroxymethylglutaryl coenzyme A reductase reduction. In turn, IL-6 stimulates osteoclast activity, as shown by the increased RANKL/osteoprotegerin ratio. CLINICAL RELEVANCE: The results of this study suggest the importance of evaluating during bisphosphonate treatment the production of IL-6, RANKL, osteoprotegerin, and VEGF, in order to monitor the jaw osteonecrosis onset. To avoid repeated mucosa excisions, the determination of these factors could be carried out in crevicular fluid.

Comparison of allergic reactions to pegasparaginase given intravenously versus intramuscularly.

BACKGROUND: Pegasparaginase (PEG) is important for treatment of Acute Lymphoblastic Leukemia (ALL). Despite conjugation to polyethylene glycol to reduce immunogenicity, allergic reactions still occur and may be severe. Traditionally, PEG is given via intramuscular (IM) injection but recent protocols have shown it can be safely given intravenously (IV), which may be preferred by patients. There is a potential concern that the IV route may result in more severe allergic reactions due to immediate exposure to reactive antibodies in the blood, which is delayed after IM administration. The purpose of our study is to compare the severity and incidence of allergic reactions with IV versus IM PEG. We are unaware of any prior studies examining this. PROCEDURE: We reviewed all patients with ALL diagnosed from 2005 to 2010 inclusive who received PEG and had an allergic reaction. Reactions were graded using both common toxicity criteria (CTC) 3.0 and 4.0. RESULTS: Allergic reactions were seen in 17 of 186 (9%) newly diagnosed patients receiving IM PEG and 4 of 11 (36%) receiving IV PEG; P = 0.019. The severity of reaction was not increased with IV versus IM. Allergic reactions occurred more frequently in high-risk patients (14 of 85; 16%) versus standard risk (7 of 112; 6%), P = 0.034. CONCLUSIONS: There appears to be an increased incidence of allergic reactions in patients who receive IV PEG compared with IM although the severity is similar. In addition high-risk patients appear to have more allergic reactions than standard risk.

Cyanoacrylate glue in the management of gastric varices.

Gastric varices (GV) are less common than esophageal varices, but their management represents a particular challenge. When bleeding occurs is usually severe, requiring immediate supportive intensive care and has a high mortality rate. The best management of GV is supposed to be with a multidisciplinary approach and close cooperation between gastroenterologists, interventional radiologists and the surgical team. Many studies in literature reported high success rates with intravariceal injection of cyanoacrylate in acute GV bleeding. This agent obliterates the variceal lumen by solidification within the vein and more than 80% primary obliteration rates are achieved. In comparison with other endoscopic techniques as variceal band ligation or sclerotherapy with ethanolamine oleate, alcohol and sodium tetradecyl sulphate, cyanoacrylate has shown to be more effective, with a decrease in complications and mortality rates. The cyanoacrylate has shown effective also in the secondary prophylaxis with an incidence of re-bleeding that ranges between 15% and 30%. Actually, there is no scientific evidence supporting the application of cyanoacrylate in primary prophylaxis of bleeding from GV. Significant procedural, septic and embolic complications have been reported with cyanoacrylate glue injection. In conclusion, the endoscopic treatment with cyanoacrylate of actively bleeding GV, as well as the prophylaxis of the re-bleeding, is a safe and effective procedure and should be considered as a first-line therapy, whenever available.

Bisphosphonate-related osteonecrosis of the jaws.

Bisphosphonates are a class of agents whose efficacy in treating and preventing the skeletal complications associated with osteoporosis and malignant bone metastases has been well established. Despite this benefit, osteonecrosis of the jaws is a significant complication in a subset of patients receiving these drugs. Based on a growing number of case reports and institutional reviews, bisphosphonate therapy may cause bone to become exposed and necrotic. Currently, this phenomenon is isolated to the jaw. This complication usually presents following simple dentoalveolar surgery. The pathogenesis for this complication appears to be related to the profound inhibition of osteoclast function and bone remodeling. This article serves to alert ists and dental specialists about the potential complication of jaw necrosis in patients receiving bisphosphonate therapy, and proposes a guideline for diagnosis, staging and management.

Phase 1A safety assessment of intravenous amitriptyline.

UNLABELLED: The antidepressant amitriptyline is used as an adjuvant in the treatment of chronic pain. Among its many actions, amitriptyline blocks Na+ channels and nerves in several animal and human models. As perioperative intravenous lidocaine has been suggested to decrease postoperative pain, amitriptyline, because of its longer half-life time, might be more useful than lidocaine. However, the use of intravenous amitriptyline is not approved by the US Food and Drug Administration. We therefore investigated the adverse effects of preoperative intravenous amitriptyline in a typical phase 1A trial. After obtaining written Food and Drug Administration and institutional review board approval, we obtained written consent for preoperative infusion of amitriptyline in an open-label, dose-escalating design (25, 50, and 100 mg, n=5 per group). Plasma levels of amitriptyline/nortriptyline were determined, and adverse effects were recorded in a predetermined symptom list. Infusion of 25 and 50 mg amitriptyline appears to be well tolerated; however, the study was terminated when 1 subject in the 100-mg group developed severe bradycardia. Intravenous infusion of amitriptyline (25 to 50 mg over 1 hour) did not create side effects beyond dry mouth and drowsiness, or dizziness, in 2 of our 10 otherwise healthy participants receiving the 25- to 50-mg dose. An appropriately powered future trial is necessary to determine a potential role of amitriptyline in decreasing postoperative pain. PERSPECTIVE: Amitriptyline potently blocks the persistently open Na+ channels, which are known to be instrumental in various pain states. As this occurs at very low plasma concentrations, a single preoperative intravenous infusion of amitriptyline could provide long-lasting pain relief and decrease the incidence of chronic pain.

Analgesic efficacy and safety of intravenous paracetamol (acetaminophen) administered as a 2 g starting dose following third molar surgery.

BACKGROUND: The recommended dose for intravenous (IV) paracetamol injection in adults is 1g, however pharmacokinetic and pharmacodynamic findings suggest that a better analgesia could be obtained with a 2 g starting dose. METHODS: A single-centre, randomised, double-blind, placebo-controlled, 3-parallel group study was performed to demonstrate the analgesic efficacy and safety of IV paracetamol 2 g. Following third molar surgery, patients reporting moderate to severe pain received a single 15-min infusion of either IV paracetamol 2 g, IV paracetamol 1g or placebo. Efficacy and safety were evaluated over 8 h. Laboratory tests were performed before and 48 h after drug administration. RESULTS: Two hundred and ninety seven patients (132 = IV paracetamol 2g; 132 = IV paracetamol 1g; 33 = placebo) were randomised and completed the study. The summed pain relief over 6h (TOTPAR6) was significantly superior with IV paracetamol 2 g as compared to IV paracetamol 1g and placebo (p < 0.0001). Pain relief scores of IV paracetamol 2g were significantly superior to IV paracetamol 1g and to placebo from T30' to T8h (p < 0.0001). Median duration of analgesia was significantly longer following IV paracetamol 2 g compared to IV paracetamol 1g and placebo (p < 0.0001). Adverse events occurred with the same frequency in the 3 treatment groups. No clinically significant changes from baseline were observed for vital signs or laboratory tests. CONCLUSION: The analgesic efficacy of a 2 g starting dose of IV paracetamol was superior over the recommended dose of 1g in terms of magnitude and duration of analgesic effect for postoperative pain following third molar surgery, with no significant difference between groups regarding safety.

Transient loss of power of accommodation in 1 eye following inferior alveolar nerve block: report of 2 cases.

Unintended intravascular injection from inferior alveolar nerve blocks can result in frustrating distant complications affecting such structures as the middle ear and eyes. Possible complications affecting the eyes include blurring of vision, diplopia, mydriasis, palpebral ptosis and amaurosis (temporary or permanent). In this article, we present a complication that has been reported only rarely. Two patients developed transient loss of power of accommodation of the eye resulting in blurred vision after routine inferior alveolar nerve blocks on the ipsilateral side. Clear vision returned within 10-15 minutes after completion of the blocks. The possible explanation for this phenomenon is accidental injection into the neurovascular bundle of local anesthetic agents, which were carried via the blood to the orbital region. This resulted in paralysis of a branch of cranial nerve III, the short ciliary nerves that innervate the ciliary muscle, which controls accommodation.

Comparative evaluation of propofol in nanoemulsion with solutol and soy lecithin for general anesthesia.

INTRODUCTION: The vehicle for propofol in 1 and 2% solutions is soybean oil emulsion 10%, which may cause pain on injection, instability of the solution and bacterial contamination. Formulations have been proposed aiming to change the vehicle and reduce these adverse reactions. OBJECTIVES: To compare the incidence of pain caused by the injection of propofol, with a hypothesis of reduction associated with nanoemulsion and the occurrence of local and systemic adverse effects with both formulations. METHOD: After approval by the CEP, patients undergoing gynecological procedures were included in this prospective study: control (n=25) and nanoemulsion (n=25) groups. Heart rate, noninvasive blood pressure and peripheral oxygen saturation were monitored. Demographics and physical condition were analyzed; surgical time and total volume used of propofol; local or systemic adverse effects; changes in variables monitored. A value of p<0.05 was considered significant. RESULTS: There was no difference between groups regarding demographic data, surgical times, total volume of propofol used, arm withdrawal, pain during injection and variables monitored. There was a statistically significant difference in pain intensity at the time of induction of anesthesia, with less pain intensity in the nanoemulsion group. CONCLUSIONS: Both lipid and nanoemulsion formulations of propofol elicited pain on intravenous injection; however, the nanoemulsion solution elicited a less intense pain. Lipid and nanoemulsion propofol formulations showed neither hemodynamic changes nor adverse effects of clinical relevance.

Efficacy of different fluids preload on propofol injection pain: A randomized, controlled, double-blinded study.

Injection pain of propofol remains a common clinical problem. Previous studies demonstrated that propofol injection pain was alleviated by applying nitroglycerin ointment to the skin of injection site, which inspires us to test whether venous vasodilation induced by fluid preload could alleviate the pain. Different types or volumes of fluid preload were compared. 200 ASA I-II adult patients were randomly assigned to five groups of 40 each. A 20 G cannula was established on the dorsum or wrist of the hand. When fluid preload given with Plasma-Lyte A 100 mL (P100 group), 250 mL (P250 group), 500 mL (P500 group), 0.9% saline 500 mL (N500 group) or Gelofusine 500 mL (G500 group) was completed within 30 min, respectively, Propofol (0.5 mg/kg, 1%) was injected at a rate of 0.5 mL/s. A blind investigator assessed the pain using a four-point scale. Incidence of pain in P100, P250, and P500 groups was 87.5%, 57.5% and 35%, respectively (P<0.05). The median pain intensity score was significantly lower in P500 group than that in P250 and P100 groups (P<0.05 and P<0.01, respectively). Comparison of the effect of different types of solution preload indicated that the highest incidence of pain was in N500 group (62.5%) (N500 vs. P500, P=0.014; N500 vs. G500, P=0.007). The median pain intensity score in N500 group was higher than that in P500 group (P<0.05) and G500 group (P<0.05). There was no significant difference between P500 and G500 groups. It is suggested that Plasma-Lyte A or Gelofusine preload with 500 mL before propofol injection is effective in alleviating propofol-induced pain.

Comparison of pain and efficacy of darbepoetin alfa and epoetin Beta pegol treatment in patients receiving peritoneal dialysis.

BACKGROUND: Sustained erythropoiesis-stimulating agents (ESAs) have recently been identified as the standard therapeutic agent for anemia in patients undergoing peritoneal dialysis (PD). However, few reports have compared pain between various types of sustained ESAs or between administration routes. Furthermore, the change ratio of the dose of sustained ESAs reportedly ranges from 0.8 to 1.3. In the present study, to compare darbepoetin alfa and epoetin beta pegol (a continuous erythropoietin receptor activator [CERA]), we examined the dolorific differences between administration routes and the effect on anemia by using a chjange ratio of 0.8 with darbepoetin alfa in patients with renal anemia undergoing PD. SUBJECTS AND METHOD: We randomly assigned 20 patients with stable hemoglobin levels undergoing PD to either a darbepoetin alfa therapy group or a CERA therapy group. Based on a previous report, the change ratio of the CERA group from CERA to darbepoetin alfa therapy was assumed to be 0.8, and therapy was crossed-over to darbepoetin alfa again 2 months later. The dolorific evaluation (pain measurement) used both a face scale and a visual analogue scale. We compared the agents as well as administration routes with respect to pain. We also measured variables related to anemia and iron metabolism. RESULTS: The change ratio of the CERA group at the start of the study was 0.821. On resumption of darbepoetin alfa therapy 2 months later, the doses of darbepoetin alfa increased. The darbepoetin alfa group showed a stronger tendency for pain, although the difference was not significant. In contrast, subcutaneous administration in the CERA group showed significant pain just after injection. The CERA group, however, showed a significant decrease in hemoglobin levels after 2 months of treatment (p=0.0489). No significant change was found in the hematocrit or the reticulocyte count. There were no significant differences in iron metabolism, as shown by serum iron levels and total iron-binding capacity, in either group. However, serum ferritin levels showed a tendency to decrease in the darbepoetin alfa group. CONCLUSION: No significant difference in pain was found between darbepoetin alfa and CERA therapies, but a significant difference in pain was noted between administration routes, just after injection, in the CERA group. The results also suggest that a change ratio of 0.8 from darbepoetin alfa to CERA is low for managing anemia.

Complications of intravenous therapy with steel needles and Teflon catheters. A comparative study.

Complications of intravenous therapy with steel needles and small-bore Teflon catheters were compared in a randomized study of 954 cannula insertions. Cannulas were inserted and cared for by an intravenous team following a standard protocol. There were no cases of cannula-related septicemia and only one case of local infection, a cellulitis in the group in which Teflon catheters were used. There was a low incidence of positive semiquantitative cannula cultures in both treatment groups (steel needles 1.5 percent, Teflon catheters 1.4 percent). The risk of phlebitis was significantly greater with Teflon catheters (18.8 percent with Teflon catheters, 8.8 percent with steel needles, adjusted odds ratio 1.87). Steel needles were significantly associated with infiltration (17.9 percent with Teflon catheters, 40.1 percent with steel needles, adjusted odds ratio 0.39). The over-all rate of complications was significantly greater for the group in which steel needles were used (53.8 versus 64.0 percent, adjusted odds ratio 0.72), principally due to the increased risk of infiltration with steel needles. Analysis of the per day risk of infiltration and phlebitis revealed that these relationships were present for each day the cannulas remained in place. We conclude (1) that steel needles and small-bore Teflon catheters can both be used with low risk of infection and (2) that Teflon catheters more frequently cause phlebitis, whereas steel needles infiltrate more readily.

Complement activation-related pseudoallergy caused by liposomes, micellar carriers of intravenous drugs, and radiocontrast agents.

There is growing awareness that numerous drug-induced immediate hypersensitivity reactions (HSRs) do not fit in Gell and Coombs' Type I category of drug allergies, characterized by the pivotal pathogenic role of allergen-specific IgE. Such non-IgE-mediated "pseudoallergic" reactions are primarily caused by (1) certain liposomal formulations of intravenous drugs and imaging agents, (2) infusion liquids containing micelle-forming amphiphilic lipids or synthetic block-copolymer emulsifiers, and (3) iodinated radiocontrast media with limited solubility in water. Common features of the latter "pseudoallergens" include the capacity to activate the complement (C) system; also, the symptoms they cause are often typical manifestations of excessive anaphylatoxin generation in blood. Hence, these reactions have been called "C activation-related pseudoallergy" (CARPA). The present review surveys the experimental and clinical evidence for the involvement of C activation in HSRs caused by pseudoallergens in the above, three categories. To fit CARPA within the classical scheme of HSRs, a subdivision of Type I allergy is proposed on the basis of the mechanism of mast cell (and basophil) activation. The new scheme distinguishes direct and receptor-mediated HSRs, with the latter category subdivided to true IgE-mediated allergy; anaphylatoxin-mediated CARPA; and IgE plus anaphylatoxin double-triggered reactions. Further issues addressed in the review include animal models, risk factors, laboratory predictive tests, and pharmacological prevention of CARPA.

Pulmonary microcrystalline cellulose deposition from intravenous injection of oral medication in a patient receiving parenteral nutrition.

A 50-year-old man who had been dependent on home parenteral nutrition (HPN) for 24 years presented with shortness of breath. A computed tomography scan of the lungs revealed a diffuse micronodular parenchymal infiltrate. On bronchoscopy, a crystalloid material was identified. This organic material was determined to be consistent with codeine. The patient had been injecting codeine into his intravenous catheter.

Two methods of administration of propofol for dental sedation.

Propofol was used for intravenous sedation in a group of 19 healthy fit young patients undergoing third molar extractions. We compared two ways of giving the drug, patient-controlled and operator-controlled, in a crossover trial. There were no differences between the two methods. The psychomotor functions returned to normal by 60 min, there was a high incidence of partial or complete amnesia and both methods were acceptable to 18/19 patients. There were only minimal changes in the respiratory function, and oxygen saturation remained normal. The only problem noted was mild pain on injection in 4 patients.

[Non-transfusional and non-intravenous drug addiction related transmission of hepatitis C virus]. / Modes de transmission non transfusionnelle et non par toxicomanie intra-veineuse du VHC.

PARENTERAL TRANSMISSION: Among subjects infected by the hepatitis C virus (HCV), about 40% have no history of blood transfusion or intravenous drug abuse. The highly variable presence of HCV in biological fluids other than blood would suggest that HVC transmission basically follows the parenteral route. Transmission of HCV via medical material contaminated by blood of an infected subject is a clinical reality: accidental needle prick, medical material (endoscope, physician-patient), tattooing, acupuncture, ear piercing, certain traditional practices, sharing toilet instruments (tooth brush, razor, fingernail shears). RARE SEXUAL TRANSMISSION: The prevalence of HCV infection is higher in people living with infected subjects, particularly spouses, than in the general population. However, transmission of HCV in this population probably follows a parenteral route (common risk factors, sharing toilet instruments) rather than by sexual transmission which plays a minor role except in sexually transmitted diseases with genital lesions. MOTHER-INFANT TRANSMISSION: Per- or post-partum transmission is possible though the risk is low, less than 5% of all infants are infected at the age of 1 year. The data are contradictory, but breast feeding would appear to play a role. Co-infection by the HIV virus, via high HCV viremia, clearly increases the risk of mother-infant transmission and perhaps also sexual transmission. NOSOCOMIAL TRANSMISSION: Nosocomial transmission is probably the most important factor in HCV transmission, but the risk remains to be quantified.

Evaluation of precautions adopted by dental surgeon using local anaesthesia.

There were 62 surgeons consisting of 38 (61.3%) males and 24 (38.7%) were females. Thirty-one (50%) were from private and state government owned clinics while the rest were from teaching hospitals. Thirty-three (53.2%) were dental house surgeons, senior dental house surgeons and dental officers, while 29 (46.8%) were within the rank of registrar and senior dental officer, senior registrar, principal dental officer and consultant. Six (9.7%) use aspirating syringe all the time. 11 (17.7%) use aspirating syringe occasionally and 45 (72.6%) use non aspirating syringe. All the surgeons wear facemasks and latex gloves. On the replacement of the needle guard after injection, 58 (93.5%) indicated that the needle is first inserted into the needle guard and then secure 4 while 4 (6.5%) pick-up the guard with their fingers, place it over the needle and secure the guard. Eight (12.9%) indicated that the maximum dose of 2% lignocaine with adrenaline 1:80,000 is 7 mg/kg body weight or less, 5 (8.1%) indicated 10 mg/kg body weight, while 49 (79.0%) did not complete this section. On the maximum number of 1.8 ml cartridges, all the surgeons indicated that the maximum is 12 or fewer cartridges. This study revealed that the risk of intravascular injection is high. Although of the most dental surgeons take necessary precautions to avoid complications arising from the use of local anaesthetics, there is a need for total compliance in view of fatal complications that may ensue. It also underscores the need for continuous dental education program to update practitioners.