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How to Minimize the Pain of Local Anesthetic Administration

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How to Minimize the Pain of Local Anesthetic Administration Roberto A. Martinez, MD; Ashlee Hurff, MD; Katharine C. DeGeorge, How to minimize the pain of MD, MS; Brent R. DeGeorge Jr, MD, PhD Department of Plastic local anesthetic administration Surgery, University of Virginia, Charlottesville (Drs. Martinez and Expertise in the delivery of effective local analgesia is DeGeorge Jr); Department of Family Medicine, critical to the success of in-office procedures. Here’s how University of Virginia, Charlottesville (Drs. Hurff to optimize patient outcomes and satisfaction. and DeGeorge) [email protected] The authors reported no potential conflict of interest n-office procedures are increasingly emphasized as a way relevant to this article. PRACTICE to reduce referrals, avoid treatment delay, and increase RECOMMENDATIONS practice revenue. Local analgesia is administered before ❯ Add epinephrine and I many in-office procedures such as biopsies, toenail removal, sodium bicarbonate and laceration repair. Skin procedures are performed most buffer to local anesthetic commonly; nearly three-quarters (74%) of family physicians solution to reduce pain and 1 procedural blood loss. A (FPs) provided these services in 2018. Administration of local anesthetic is often the most feared and uncomfortable step in ❯ Use such techniques as the entire process.2 counter-stimulation, a perpendicular angle of Knowledge of strategies to reduce pain associated with injection, a subcutaneous anesthetic administration can make a huge difference in the depth of injection, and a slow patient experience. This article explores evidence-based tech- rate of injection to minimize niques for administering a local anesthetic with minimal pa- patient discomfort. A tient discomfort. Strength of recommendation (SOR) 4 factors influence the pain A Good-quality patient-oriented evidence of local anesthetic administration B Inconsistent or limited-quality Pain is perceived during the administration of local anesthetic patient-oriented evidence because of the insertion of the needle and the increased pres- C Consensus, usual practice, opinion, disease-oriented sure from the injection of fluid. The needle causes sharp, prick- evidence, case series ing “first pain” via large diameter, myelinated A-delta fibers, and the fluid induces unmyelinated C-fiber activation via tis- sue distention resulting in dull, diffuse “second pain.” Four factors influence the experience of pain during ad- ministration of local anesthetic: the pharmacologic properties of the anesthetic itself, the equipment used, the environment, and the injection technique. Optimizing all 4 factors limits pa- tient discomfort. Pharmacologic agents: Lidocaine is often the agent of choice Local anesthetics differ in maximal dosing, onset of action, and duration of effect( TABLE3). Given its ubiquity in clinics and hospitals, 1% lidocaine is often the agent of choice. Onset 172 THE JOURNAL OF FAMILY PRACTICE | MAY 2020 | VOL 69, NO 4 TABLE Characteristics of local anesthetics3 Local anesthetic Onset (min) Duration (min) Duration with Maximum dose Maximum dose epinephrine (min) (mg/kg) with epinephrine (mg/kg) INJECTABLE LOCAL ANESTHETICS Bupivacaine 2-10 120-240 240-480 2.5 3 Chloroprocaine 5-6 30-60 N/A 11 14 Etidocaine 3-5 200 240-360 4.5 6.5 Lidocaine < 1 30-120 60-400 4.5 7 Mepivacaine 3-20 30-120 60-400 6 7 Prilocaine 5-6 30-120 60-400 7 10 Procaine 5 15-90 30-180 10 14 Tetracaine 7 120-240 240-480 2 2 TOPICAL LOCAL ANESTHETICS EMLA < 60 60-120 N/A LMX-4 < 2 30-45 N/A N/A, not applicable. Adapted with permission from: Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol. 2016;74:1201-1219. of effect occurs within minutes and lasts up the maximum allowable volume of local an- to 2 hours. Alternative agents, such as bupi- esthetics in milliliters: vacaine or ropivacaine, may be considered to prolong the anesthetic effect; however, (maximum allowable dose in mg/kg) × limited evidence exists to support their use (weight in kg) × (1 divided by the concentra- in office-based procedures. Additionally, tion of anesthetic). bupivacaine and ropivacaine may be associ- ated with greater pain on injection and para- For delivery of lidocaine with epinephrine sthesias lasting longer than the duration of in a 50-lb (22.7-kg) child, the calculation pain control.4-6 In practice, maximal dosing would be (7 mg/kg) × (22.7 kg) × (1 divided by is most important in the pediatric popula- 10 mg/mL) = 15.9 mL. tion, given the smaller size of the patients and their increased susceptibility to toxicity. The advantages ❚ Calculating the maximum recom- (and misconceptions) of epinephrine mended dose. To calculate the maximum The advantage of adding epinephrine is that recommended dose of local anesthetic, it prolongs the effect of the anesthesia and you need to know the concentration of the it decreases bleeding. Epinephrine is com- anesthetic, the maximum allowable dose monly available as a premixed solution with (mg/kg), and the weight of the patient.7,8 The lidocaine or bupivacaine at a concentration of concentration of the local anesthetic is con- 1:100,000 and is generally differentiated from verted from percentage to weight per unit “plain” local anesthetic by a red label and cap. volume (eg, 1% = 10 mg/mL; 0.5% = 5 mg/ Although maximum vasoconstriction may mL). Multiply the patient's weight (kg) by occur as long as 30 minutes after injection,10 the maximum dose of local anesthetic (mg/ adequate vasoconstriction is achieved in 7 to kg) and divide by the concentration of the lo- 10 minutes for excision of skin lesions.11 cal anesthetic (mg/mL) to get the maximum ❚ Traditional teaching recommends recommended dose in milliliters. Walsh et al9 against using epinephrine in the “fingers, described a simplified formula to calculate toes, penis, ears, or nose” because of poten- MDEDGE.COM/FAMILYMEDICINE VOL 69, NO 4 | MAY 2020 | THE JOURNAL OF FAMILY PRACTICE 173 tial arterial spasm, ischemia, and gangrene tion.22 This may be done in a variety of ways distal to the injection site.12 These concerns depending on available in-office equip- were based on experiences with procaine ment. Water baths, incubators, fluid warm- and cocaine mixed with epinephrine. Studies ers, heating pads, or specific syringe warmers suffered from multiple confounders, includ- may be used. Multiple studies have shown ing tourniquets and nonstandardized epi- improvement in patient satisfaction with nephrine concentrations.13-15 warming.23 Moreover, warming and buffering No association of distal ischemia with solution provide a synergistic effect on pain epinephrine use was identified in a recent reduction.23 Cochrane Review or in another multicenter prospective study.16,17 Phentolamine, a non- selective alpha-adrenergic receptor antago- Equipment: nist and vasodilator, can be administered to Size matters reverse vasoconstriction following inadver- ❚ Smaller diameter needles. Reducing the tent administration of high-dose epinephrine outer diameter of the needle used for injec- (1:1000) via anaphylaxis autoinjector kits. tion improves pain by reducing activation Dosing of phentolamine is 1 mL of 1 mg/ of nociceptors.24-26 Reduced inner diameter mL solution delivered subcutaneously to the restricts injection speed, which further re- affected area; reversal decreases the duration duces pain.25 We recommend 27- to 30-gauge Add epinephrine of vasoconstriction from 320 minutes to ap- needles for subcutaneous injection and 25- to the anesthetic proximately 85 minutes.18 As always, when to 27-gauge needles for intra-articular or ten- solution applying literature to clinical practice, one don sheath injections. to prolong must keep in mind the risks and benefits of ❚ Appropriate syringe size. Filling a sy- anesthesia any intervention. As such, in patients with ringe to capacity results in maximal deploy- and decrease pre-existing vascular disease, vaso-occlusive ment of the plunger. This requires greater bleeding. or vasospastic disease, or compromised per- handspan, which can lead to fatigue and fusion due to trauma, one must weigh the loss of control during injection.26,27 Using a benefits of the hemostatic effect against po- syringe filled to approximately half its capac- tential ischemia of already susceptible tis- ity results in improved dexterity. We recom- sues. In such instances, omitting epinephrine mend 10-mL syringes with 5 mL to 6 mL of from the solution is reasonable. local anesthetic for small procedures and 20-mL syringes filled with 10 mL to 12 mL for The benefits of sodium bicarbonate larger procedures. The acidity of the solution contributes to the ❚ Topical local anesthetics may be used level of pain associated with administration either as an adjunct to decrease pain dur- of local anesthesia. Previously opened con- ing injection or as the primary anesthetic.28 tainers become more acidic.19 Addition of A variety of agents are available for clinical 8.4% sodium bicarbonate, at a ratio of 1 mL use, including eutectic mixture of local an- per 10 mL of 1% lidocaine with 1:100,000 epi- esthetics (EMLA), lidocaine-epinephrine- nephrine, neutralizes the pH to 7.4.19 A Co- tetracaine (LET), lidocaine, benzocaine, and chrane Review showed that correction of pH tetracaine. FPs should be familiar with their to physiologic levels results in a significant different pharmacokinetic profiles. reduction in pain.20 EMLA is a mixture of 25 mg/mL of li- This solution can be easily prepared, as docaine and 25 mg/mL of prilocaine. It is standard
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