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Ovid: Atlas of Primary Care Procedures

Editors: Zuber, Thomas J.; Mayeaux, E. J. Title: Atlas of Primary Care Procedures, 1st Edition Copyright ©2004 Lippincott Williams & Wilkins > Table of Contents > Dermatology > 9 – Local Anesthesia Administration 9 Local Anesthesia Administration The techniques for minimizing discomfort during local anesthetic administration are often overlooked in modern clinical practice. Most minor or office operations are performed after injection of local anesthesia. Proper administration technique can reduce patient discomfort, improve patient satisfaction with the service, and improve the procedure’s outcome. The two main classes of injectable local anesthetics are the amides and the esters. The amides are more widely used and include lidocaine (Xylocaine) and bupivacaine (Marcaine). The esters, represented by procaine (Novocain), have a slower onset of action than the amides, and a higher rate of allergic reactions. Individuals with an allergy to one class of anesthetics generally can receive the other class safely. Administration of the esters is limited to individuals with a prior allergic reaction to amide anesthetics. Many patients claim allergy to “caine” drugs, but they actually have experienced a vagal response or other systemic response to receiving an injection. If the exact nature of the prior reaction cannot be ascertained, administration of diphenhydramine hydrochloride (Benadryl) can provide sufficient anesthesia for small surgical procedures. Between 1 and 2 mL of diphenhydramine (25 mg/mL) solution is diluted with 1 to 4 mL of normal saline for intradermal (not subdermal) injection. Epinephrine in the local anesthetic solution prolongs the duration of the anesthetic and reduces bleeding by producing local vasoconstriction. The use of epinephrine also permits use of larger volumes of anesthetic. An average-sized adult (70 kg) can safely receive up to 28 mL (4 mg/kg) of 1% lidocaine and up to 49 mL (7 mg/kg) of 1% lidocaine with epinephrine. Historically, physicians have been taught to avoid administering solutions with epinephrine to body sites served by single arteries, such as “fingers, toes, penis, and the end of the nose.” The safety of administering epinephrine to the tip of the nose or to the digits has been documented in some reports, but limiting the use of epinephrine in these sites is prudent in the current medicolegal climate. Local anesthetics can be injected intradermally or subdermally. Intradermal administration produces a visible wheal in the skin, and the onset of action of the anesthetic is almost immediate. Intradermal injection of a large volume of solution P.72
can stretch pain sensors in the skin, aiding in the anesthetic effect. This volume effect is believed to explain the benefit of normal saline injections into trigger points. Intradermal injection is especially useful for shave excisions, because the anesthetic solution effectively thickens the dermis, elevates the lesion, and prevents inadvertent penetration beneath the dermis. Subdermal injections take effect more slowly but generally produce much less discomfort for the patient. Some physicians recommend initial administration of an anesthetic into a subdermal (less painful) location and then withdrawing the needle tip for intradermal injection. The initial subdermal administration often reduces the discomfort of the intradermal injection. RECOMMENDATIONS TO REDUCE THE DISCOMFORT OF LOCAL ANESTHESIA

  • Stretch the skin using the nondominant hand during administration.
  • Encourage the patient to talk as a distraction and for monitoring for vagal responses.
  • Talk to the patient during administration; silence increases patient discomfort.
  • Use the smallest gauge needle possible (preferably 30 gauge).
  • Consider spraying aerosol refrigerant onto the skin before needle insertion.
  • Consider vibrating nearby skin or patting distant sites to distract during administration.
  • Administer anesthetic at room temperature (i.e., nonchilled solutions).
  • Insert the needle through enlarged pores, scar, or hair follicles (i.e., less sensitive sites).
  • Pause after the needle penetrates the skin to allow for patient recovery and relaxation.
  • Inject a small amount of anesthetic and pause, allowing the anesthetic to take effect.
  • Empower the patient by temporarily stopping the injection when burning is detected.
  • Inject anesthetics slowly.
  • Begin the injection subdermally, and then withdraw the needle tip for intradermal injection.
  • Consider addition of bicarbonate to buffer the acidity of the anesthetic.
  • Permit adequate time for the anesthetic to take effect before initiating a surgical procedure.

PROCEDURE Stretch the skin with the nondominant hand before insertion of the needle into the skin. Patients dread having the needle inserted; the discomfort is reduced if the pain sensors in the skin are stretched.

(1) Reduce the patient’s discomfort by stretching the skin with your nondominant hand before insertion of the needle.

PITFALL: Replace the needle used for drawing the anesthetic from the stock bottle with a smaller (30-gauge) needle before injection into the patient. P.74
The syringe is held in the dominant hand in the position ready to inject (Figure 2A). The thumb should be near (but not on) the plunger. after the needle is inserted into skin, some physicians prefer to withdraw the plunger to ensure that the needle tip is not in an intravascular location. The thumb can be slipped under the back edge of the plunger and pulled back (Figure 2B), looking for blood to enter the syringe to ensure that the needle tip is not in a blood vessel. The thumb then slips onto the plunger for gentle injection. However, it is very unlikely that a short, 30-gauge needle tip will enter a significant vessel, and many physicians prefer to inject without withdrawing, because pulling back on the plunger moves the needle tip and causes discomfort for the patient.

(2) To ensure that the needle is not inserted into a blood vessel, hold the syringe with your dominant hand, placing the thumb near the plunger; insert the needle; and pull the plunger back with your thumb, checking for the presence of blood.

PITFALL: Avoid movement of the needle after it enters the skin. Many physicians hold the syringe like a pencil for needle insertion. After insertion, they stop stretching the skin with the nondominant hand and grab the syringe, shift the dominant hand back onto the plunger, and pull back on the plunger to check for vascular entry of the needle tip. They then shift the hands again and move the dominant hand into a position for injection. All of these shifts cause movement of the needle tip in the skin and increase the discomfort for the patient substantially. Insert the needle with the hand in a position ready to inject. Insert the needle into skin at a 15- or 30-degree angle. The depth of the needle tip is more difficult to control at a 90-degree angle of entry.

(3) The needle should be inserted into the skin at a 15- or 30-degree angle.

When injecting laceration sites for repair, insert the needle into the wound edge, rather than intact skin. Insertion of a needle into a wound edge produces less discomfort.

(4) When injecting laceration sites for repair, insert the needle into the wound edge rather than intact skin.

Pause after the needle enters the skin. Try to make the patient laugh. Patients fear the needle entry; after they realize that the discomfort was less than anticipated, patients often relax. Maintain skin stretch with the nondominant hand for the injection.

(5) Pausing after the needle enters the skin allows the patient to relax, reducing anxiety and discomfort.

PITFALL: Plunging in anesthetic immediately after needle entry causes continued discomfort and anxiety. Most vagal or syncopal episodes are related to the catecholamine storm produced by the patient’s anxiety. Pausing after needle insertion and slow administration allow patients to relax, reducing their catecholamine production, and reducing complications. P.76
Intradermal injection creates a wheal in the skin.

(6) A wheal is created in the skin during intradermal injection.

Administer the local anesthetic for a shave excision below the center of the lesion to be removed (Figure 7A). The anesthetic fluid effectively increases the depth of the dermis, reducing chances for subdermal penetration at shave excision. The fluid also floats the lesion upward, facilitating removal by shave technique (Figure 7B).

(7) For a shave excision, local anesthetic should be administered below the center of the lesion to be removed.

CODING INFORMATION The work of local anesthesia administration generally is included in the codes for most office surgical procedures and cannot be billed as a separate procedure. The anesthesia codes (00100–01999) in the Current Procedural Terminology (CPT®) book generally reflect general, regional, or supplementation of local anesthesia by an anesthesiologist. The anesthesia codes generally are not billed for office procedures. INSTRUMENT AND MATERIALS ORDERING A suggested anesthesia tray that can be used for this procedure is listed in Appendix G. BIBLIOGRAPHY Avina R. Office management of trauma: primary care local and regional anesthesia in the management of trauma. Clin Fam Pract 2000;2:533–550. Baker JD, Blackmon BB. Local anesthesia. Clin Plast Surg 1985;12:25–31. Brown JS. Minor surgery: a text and atlas, 3rd ed. London: Chapman & Hall Medical, 1997. deJong RH. Toxic effects of local anesthetics. JAMA 1978;239:1166–1168. Dinehart SM. Topical, local, and regional anesthesia. In: Wheeland RG, ed. Cutaneous surgery. Philadelphia: WB Saunders, 1994:102–112. Grekin RC. Local anesthesia in dermatologic surgery. J Am Acad Dermatol 1988;19:599–614. Kelly AM, Cohen M, Richards D. Minimizing the pain of local infiltration anesthesia for wounds by injection into the wound edges. J Emerg Med 1994;12:593–595. Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med 1998;31:36–40. Smith DW, Peterson MR, DeBerard SC. Local anesthesia. Postgrad Med 1999;106:57–66. Stegman SJ, Tromovitch TA, Glogau RG. Basics of dermatologic surgery. Chicago: Year Book Medical Publishers, 1982:23–31. Swanson NA. Atlas of cutaneous surgery. Boston: Little, Brown, 1987:156–162. Winton GB. Anesthesia for dermatologic surgery. J Dermatol Surg Oncol 1988;14:41–54. Yagiela JA. Oral-facial emergencies: anesthesia and pain management. Emerg Med Clin North Am 2000;18:449–470. Zuber TJ, DeWitt DE. The fusiform excision. Am Fam Physician 1994;49:371–376. Zuber TJ. Administration of local anesthesia. AAFP manuals and videotapes of skin surgery techniques. Kansas City: American Academy of Family Physicians, 1999.

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