Local Anesthesia Pearls for Skin Surgery

Home , Eye drop

LOCAL ANESTHESIADuplicate PEARLS FORor SKIN SURGERY

Distribute Not KEN GROSS M.D. Do Potential Conflict of Interest

• Co-authored AAD Guidelines for the Use of Local Anesthesia in Office BasedDuplicate Dermatologic Surgery or

• June 2016 JAAD

Distribute Not Do 30 GAUGE 1” NEEDLES

• Fewer Needle Sticks of Patient Duplicate • Less Pain or • Smaller Total Volume

• “Reaches” More Nerve Blocks

Distribute Not Do 30 GAUGE 1” NEEDLES

• Fewer Needle Sticks Duplicate • Less Pain or • Smaller Total Volume

• “Reaches” More Nerve Blocks

• Flexible Needle – But The Tip MovesDistribute Like An 18 Wheeler Truck Not Do • Inject Sub-Dermally First

Duplicate or

Distribute Not Do • Inject Sub-Dermally First

• Then Do Dermal Injection Along Lines Of Planned Incision Duplicate or

Distribute Not Do • Inject Sub-Dermally First

• Then Do Dermal Injection Along Lines Of Planned Incision Duplicate • Allow Five Min For EPI Vasoconstriction To Take Effect (If Needed) or

Distribute Not Do • Inject Sub-Dermally First

• Then Do Dermal Injection Along Lines Of Planned Incision Duplicate • Allow Five Min For EPI Vasoconstriction To Take Effect (If Needed) or

• Inject Slowly

Distribute Not Do • Inject Sub-Dermally First

• Then Do Dermal Injection Along Lines Of Planned Incision Duplicate • Allow Five Min For EPI Vasoconstriction To Take Effect (If Needed) or

• Inject Slowly

• Warm Anesthesia Hurts Less Distribute Not Do • Inject Sub-Dermally First

• Then Do Dermal Injection Along Lines Of Planned Incision Duplicate • Allow Five Min For EPI Vasoconstriction To Take Effect (If Needed) or

• Inject Slowly

• Warm Anesthesia Hurts Less Distribute • 1:400,000 EPI Is All That’s Needed Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate or

Distribute Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or

Distribute Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or • EMLA, ELA-Max, Etc.

Distribute Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or • EMLA, ELA-Max, Etc.

• Iontophoresis

Distribute Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or • EMLA, ELA-Max, Etc.

• Iontophoresis

• Nitrous Oxide Distribute Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or • EMLA, ELA-Max, Etc.

• Iontophoresis

• Nitrous Oxide • Nerve Blocks Distribute Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or

• EMLA, ELA-Max, Etc.

• Iontophoresis

• Nitrous Oxide

• Nerve Blocks Distribute • Hypnosis Not Do ANESTHESIA ADJUNCTS

• Pre-Op Sedation With Sub-Lingual Halcion, Or Intra Nasal Versed Duplicate • Topical -Caines On Mucosal Areas & Eye drop Anesthesia Eye or • EMLA, ELA-Max, Etc.

• Iontophoresis

• Nitrous Oxide • Nerve Blocks Distribute • Hypnosis

• Vibratory DistractionNot Do Nitrous Is Safe And Effective Below 50% Concentration ,

Duplicate or

Distribute Not Do Nitrous Is Safe And Effective Below 50% Concentration , But Requires Much More Sophisticated Equipment Than Shown Here.

Duplicate or

Distribute Not Do Nitrous Is Safe And Effective Below 50% Concentration , But Requires Much More Sophisticated Equipment Than Shown Here.

Need “Fail Safe” O₂ Supply Duplicate or

Distribute Not Do Nitrous Is Safe And Effective Below 50% Concentration , But Requires Much More Sophisticated Equipment Than Shown Here.

Need “Fail Safe” O₂ Supply Need Scavenger System To Prevent Risk To You And StaffDuplicate or

Distribute Not Do Duplicate or Sub Lingual

Distribute Not Do For Mucosal Surfaces

Duplicate or

PHORE Distribute SOR Not Do Ester and Amide Anesthetics

• Esters: – Cocaine Duplicate

– Procaine (Novocain) or

– Chloroprocaine (Nesacaine)

– Tetracaine (Pontocaine) Distribute Not Do Ester and Amide Anesthetics

• Esters: • Amides: – Cocaine – LidocaineDuplicate(Xylocaine)

– Procaine (Novocain) – orMepivicaine (Carbocaine)

– Chloroprocaine (Nesacaine) – Prilocaine (Citanest)

– Tetracaine (Pontocaine) – Bupivicaine (Marcaine)

– Etidocaine (Duranest) Distribute – L-Bupivicaine (Chirocaine)

Not – Ropivicaine (Naropin) Do Neutralize Lidocaine Solutions (With Or Without EPI)

Duplicate or

Distribute Not Do The Maximum Dose Of 1.0% Lidocaine Or 0.50% Bupivicaine Is Equal To HALF Of The Patient’s Weight In Kilograms Duplicate or

Distribute Not Do The Maximum Dose Of 1.0% Lidocaine Or 0.50% Bupivicaine Is Equal To HALF Of The Patient’s Weight In Kilograms Duplicate Lidocaine: or • Maximum dose: 5 mg/kg

Distribute Not Do The Maximum Dose Of 1.0% Lidocaine Or 0.50% Bupivicaine Is Equal To HALF Of The Patient’s Weight In Kilograms Duplicate Lidocaine: or • Maximum dose: 5 mg/kg • Lidocaine 1.0% equals 10 mg/cc

• Toxicity Of LidocaineDistribute And Bupivicaine Are Additive Not Do Because The Toxicities Of Lidocaine And Bupivicaine Are Additive:

Duplicate or

Distribute Not Do Because The Toxicities Of Lidocaine And Bupivicaine Are Additive:

• You Can Give 35 ml Of 1% Lidocaine,Duplicate or

Distribute Not Do Because The Toxicities Of Lidocaine And Bupivicaine Are Additive:

• You Can Give 35 ml Of 1% Lidocaine,Duplicate Or or 35 ml Of 0.5% Bupivicaine,

Distribute Not Do Because The Toxicities Of Lidocaine And Bupivicaine Are Additive:

• You Can Give 35 ml Of 1% Lidocaine, Duplicate Or or 35 ml Of 0.5% Bupivicaine,

• BUT ONLY a Total of 35 ml (NOT 70 ml) Mixed Together Distribute Not Do • For Biopsies And Standard Excisions: Mix 1% Plain Lido + 0.5% Lido With EPI 1:200,000 +

9:1 NaHCO3 Duplicate This gives a final concentration orof 0.75 Lidocaine and 1:400,000 EPI

Distribute Not Do For Mohs I Use This Mix: 0.75% Bupivicaine (50%) 1% Plain Lidocaine (25%) 1% Lidocaine with 1:100,000 epi (25%)Duplicate This gives a final concentrationor of Epi of 1:400,000 Dr. Anne Truitt Uses In a 50cc Bottle of 1% Lidocaine with 1:100,000 epi

5cc’s NaHCO3 0.15cc 1% Clindamycin Re-injects BeforeDistribute Each Stage and Before Closure Not Do MAJOR PEARL • Introduction Of Air Into Vial Of Anesthesia Limits The Stability Of The Solution.Duplicate or

Distribute Not Do MAJOR PEARL • Introduction Of Air Into Vial Of Anesthesia Limits The Stability Of The Solution.Duplicate or • Do Not Inject Air Into The Bottle To Make It Easier To Draw Up Anesthesia Into The Syringe

• After A LongDistribute Weekend, A Mostly Empty Bottle Of Lidocaine May Not Be Effective Not Do Duplicate or

Distribute Not Do Duplicate or

Distribute Not Do Initial Tray Set up & Anesthesia

Duplicate or

Distribute Not Do Re-Injecting Anesthesia

Duplicate or

Distribute Not Do Marcaine Can’t Be Neutralized, It Precipitates

Duplicate or

Distribute Not Do Marcaine Can’t Be Neutralized, It Precipitates

Don’t Use 0.25% Duplicate or

Distribute Not Do • Use Of A 30 Gauge Needle Increases Costs Duplicate or

Distribute Not Do • Use Of A 30 Gauge Needle Increases Costs – A Larger Bore Needle Is Required To Draw Fluids Into The Syringe Duplicate or

Distribute Not Do • Use Of A 30 Gauge Needle Increases Costs – A Larger Bore Needle Is Required To Draw Fluids Into The Syringe Duplicate • 30 Gauge 1” Needles Best For Excisionsor

• But 30 Gauge ½” Needle Is Best For Biopsies

Distribute Not Do • Use Of A 30 Gauge Needle Increases Costs – A Larger Bore Needle Is Required To Draw Fluids Into The Syringe Duplicate • 30 Gauge 1” Needles Best For Excisionsor

• But 30 Gauge ½” Needle Is Best For Biopsies – Essential For Injections Of Triamcinolone Acetonide (Kenalog®) Distribute Not Do USE LOGICAL INJECTION TECHNIQUES • Start Injecting Proximally On Extremities, Fingers, Hands, Feet, And Penis Duplicate or

Distribute Not Do USE LOGICAL INJECTION TECHNIQUES • Start Injecting Proximally On Extremities, Fingers, Hands, Feet, And Penis Duplicate

• Start Injecting At The Periphery Of Theor Scalp And Work Inwards

Distribute Not Do USE LOGICAL INJECTION TECHNIQUES • Start Injecting Proximally On Extremities, Fingers, Hands, Feet, And Penis Duplicate

• Start Injecting At The Periphery Of Theor Scalp And Work Inwards

• Inject Around The Eyes With The Needle Pointed Away From The Eyeball And Best To Ask Patient To Keep Eyes Open Distribute Not Do USE LOGICAL INJECTION TECHNIQUES • Start Injecting Proximally On Extremities, Fingers, Hands, Feet, And Penis Duplicate

• Start Injecting At The Periphery Of Theor Scalp And Work Inwards

• Inject Around The Eyes With The Needle Pointed Away From The Eyeball And Best To Ask Patient To Keep Eyes Open Distribute • Hold One Or More Fingers On The Patient With The Syringe, Holding Hand,Not So The Hand Moves If Patient Moves Do PERI-OCULAR ANESTHESIA

• Use A Topical Eye-Drop First Duplicate or

Distribute Not Do PERI-OCULAR ANESTHESIA

• Use A Topical Eye-Drop First – It Makes The Patient Less “Squinchy” Duplicate or

Distribute Not Do PERI-OCULAR ANESTHESIA

• Use A Topical Eye-Drop First – It Makes The Patient Less “Squinchy” Duplicate or • Inject Away From The Eyeball If Possible

Distribute Not Do PERI-OCULAR ANESTHESIA

• Use A Topical Eye-Drop First – It Makes The Patient Less “Squinchy” Duplicate or • Inject Away From The Eyeball If Possible

• Inject From The Mucosal Surface Of The Lower Lid Sulcus

Distribute Not Do PERI-OCULAR ANESTHESIA

• Use A Topical Eye-Drop First – It Makes The Patient Less “Squinchy” Duplicate or • Inject Away From The Eyeball If Possible

• Inject From The Mucosal Surface Of The Lower Lid Sulcus – Toward The Cheek Distribute Not Do PERI-OCULAR ANESTHESIA

• Use A Topical Eye-Drop First – It Makes The Patient Less “Squinchy” Duplicate or • Inject Away From The Eyeball If Possible

• Inject From The Mucosal Surface Of The Lower Lid Sulcus – Toward The Cheek Distribute • Watch The Fluid Ahead Of Needle On Upper Lid Injections Not Do Finger Laying On Patient

Inject With Needle Pointed Away From Eyeball Duplicate or

Distribute

Vibratory Not Diverter Do Hibiclens Is Toxic To Eyes And Ears,

Use OCuSOFT® Prep for Peri-ocular Duplicate Use Hibiclens for Ear BUT Block Ear Canalor With Cotton & and Don’t Use in Ear Canal

Distribute Not Do • Forehead Anesthesia Can Be Difficult Duplicate or

Distribute Not Do • Forehead Anesthesia Can Be Difficult

• For Reasons That Are Not Clear, There SeemsDuplicate To Be A Persistent Superficial Sensitivity or

Distribute Not Do • Forehead Anesthesia Can Be Difficult

• For Reasons That Are Not Clear, There SeemsDuplicate To Be A Persistent Superficial Sensitivity or

• I Routinely Use Epinephrine 1:400,000 On Ears, Fingers, Toes, And Penis

Distribute Not Do