How to minimize the pain of local anesthetic administration

,; ,; ,; ,

Applied Evidence

How to minimize the pain of local anesthetic administration

J Fam Pract. 2020 May;69(4):172-178

PDF Download

References

1. American Academy of Family Physicians. Family Medicine Facts. 2018. www.aafp.org/about/the-aafp/family-medicine-specialty/facts/table-12(rev).html. Accessed April 27, 2020.

2. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132:675-684.

3. 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.

4. Vinycomb TI, Sahhar LJ. Comparison of local anesthetics for digital nerve blocks: a systematic review. J Hand Surg Am. 2014;39:744-751.e5.

5. Valvano MN, Leffler S. Comparison of bupivacaine and lidocaine/bupivacaine for local anesthesia/digital nerve block. Ann Emerg Med. 1996;27:490-492.

6. Spivey WH, McNamara RM, MacKenzie RS, et al. A clinical comparison of lidocaine and bupivacaine. Ann Emerg Med. 1987;16:752-757.

7. Neal JM, Mulroy MF, Weinberg GL, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity. Reg Anesth Pain Med. 2012;37:16-18.

8. Neal JM, Bernards CM, Butterworth JF, et al. ASRA practice advisory on local anesthetic systemic toxicity. Reg Anesth Pain Med. 2010;35:152-161.

9. Walsh K, Arya R. A simple formula for quick and accurate calculation of maximum allowable volume of local anaesthetic agents. Br J Dermatol. 2015;172:825-826.

10. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay between epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg. 2013;131:811-814.

11. Hult J, Sheikh R, Nguyen CD, et al. A waiting time of 7 min is sufficient to reduce bleeding in oculoplastic surgery following the administration of epinephrine together with local anaesthesia. Acta Ophthalmol. 2018;96:499-502.

12. McKee DE, Lalonde DH, Thoma A, et al. Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet. Hand (NY). 2015;10:613-615.

13. Krunic AL, Wang LC, Soltani K, et al. Digital anesthesia with epinephrine: an old myth revisited. J Am Acad Dermatol. 2004;51:755-759.

14. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg. 2007;119:260-266.

15. Lalonde DH, Lalonde JF. Discussion. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010;126:2035-2036.

16. Prabhakar H, Rath S, Kalaivani M, et al. Adrenaline with lidocaine for digital nerve blocks. Cochrane Database Syst Rev. 2015;(3):CD010645.

17. Lalonde D, Bell M, Benoit P, et al. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30:1061-1067.

18. Nodwell T, Lalonde D. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective, randomized, blinded study: the Dalhousie Project experimental phase. Can J Plast Surg. 2003;11:187-190.

19. Frank SG, Lalonde DH. How acidic is the lidocaine we are injecting, and how much bicarbonate should we add? Can J Plast Surg. 2012;20:71-73.

20. Cepeda MS, Tzortzopoulou A, Thackrey M, et al. Cochrane Review: adjusting the pH of lidocaine for reducing pain on injection. Evidence-Based Child Heal. 2012;7:149-215.

21. Barros MFFH, da Rocha Luz Júnior A, Roncaglio B, et al. Evaluation of surgical treatment of carpal tunnel syndrome using local anesthesia. Rev Bras Ortop. 2016;51:36-39.

22. Hogan M-E, vanderVaart S, Perampaladas K, et al. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med. 2011;58:86-98.e1.

23. Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med. 1998;16:353-356.

24. Arendt-Nielsen L, Egekvist H, Bjerring P. Pain following controlled cutaneous insertion of needles with different diameters. Somatosens Mot Res. 2006;23:37-43.

25. Edlich RF, Smith JF, Mayer NE, et al. Performance of disposable needle syringe systems for local anesthesia. J Emerg Med. 1987;5:83-90.

26. Reed KL, Malamed SF, Fonner AM. Local anesthesia Part 2: technical considerations. Anesth Prog. 2012;59:127-137.

27. Elliott TG. Tips for a better local anaesthetic. Australas J Dermatol. 1998;39:50-51.

28. Kumar M, Chawla R, Goyal M. Topical anesthesia. J Anaesthesiol Clin Pharmacol. 2015;31:450.

29. Polishchuk D, Gehrmann R, Tan V. Skin sterility after application of ethyl chloride spray. J Bone Joint Surg Am. 2012;94:118-120.

30. Franko OI, Stern PJ. Use and effectiveness of ethyl chloride for hand injections. J Hand Surg Am. 2017;42:175-181.e1.

31. Fossum K, Love SL, April MD. Topical ethyl chloride to reduce pain associated with venous catheterization: a randomized crossover trial. Am J Emerg Med. 2016;34:845-850.

32. Görgülü T, Torun M, Güler R, et al. Fast and painless skin tag excision with ethyl chloride. Aesthetic Plast Surg. 2015;39:644-645.

33. Azar FM, Lake JE, Grace SP, et al. Ethyl chloride improves antiseptic effect of betadine skin preparation for office procedures. J Surg Orthop Adv. 2012;21:84-87.

34. Oliveira NCAC, Santos JLF, Linhares MBM. Audiovisual distraction for pain relief in paediatric inpatients: a crossover study. Eur J Pain. 2017;21:178-187.

35. Pillai Riddell RR, Racine NM, Gennis HG, et al. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2015;(12):CD006275.

36. Attar RH, Baghdadi ZD. Comparative efficacy of active and passive distraction during restorative treatment in children using an iPad versus audiovisual eyeglasses: a randomised controlled trial. Eur Arch Paediatr Dent. 2015;16:1-8.

37. Uman LS, Birnie KA, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013;(10):CD005179.

38. Ahmad Z, Chawla R, Jaffe W. A novel distraction technique to facilitate daycase paediatric surgery under local anaesthesia. J Plast Reconstr Aesthetic Surg. 2012;65:e21-e22.

39. Hartling L, Newton AS, Liang Y, et al. Music to reduce pain and distress in the pediatric emergency department. JAMA Pediatr. 2013;167:826.

40. Varelmann D, Pancaro C, Cappiello EC, et al. Nocebo-induced hyperalgesia during local anesthetic injection. Anesth Analg. 2010;110:868-870.

41. Nelson TW. Accidental intravascular injection of local anesthetic? Anesthesiology. 2008;109:1143-1144.

42. Taghavi Zenouz A, Ebrahimi H, Mahdipour M, et al. The incidence of intravascular needle entrance during inferior alveolar nerve block injection. J Dent Res Dent Clin Dent Prospects. 2008;2:38-41.

43. Taddio A, Ilersich AL, Ipp M, et al; HELPinKIDS Team. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: systematic review of randomized controlled trials and quasi-randomized controlled trials. Clin Ther. 2009;31:S48-S76.

44. Aminabadi NA, Farahani RMZ, Balayi Gajan E. The efficacy of distraction and counterstimulation in the reduction of pain reaction to intraoral injection by pediatric patients. J Contemp Dent Pract. 2008;9:33-40.

45. Martires KJ, Malbasa CL, Bordeaux JS. A randomized controlled crossover trial: lidocaine injected at a 90-degree angle causes less pain than lidocaine injected at a 45-degree angle. J Am Acad Dermatol. 2011;65:1231-1233.

46. Zilinsky I, Bar-Meir E, Zaslansky R, et al. Ten commandments for minimal pain during administration of local anesthetics. J Drugs Dermatol. 2005;4:212-216.

47. Bartfield JM, Sokaris SJ, Raccio-Robak N. Local anesthesia for lacerations: pain of infiltration inside vs outside the wound. Acad Emerg Med. 1998;5:100-104.

48. Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med. 1998;31:36-40.

49. Kattan AE, Al-Shomer F, Al-Jerian A, et al. Pain on administration of non-alkalinised lidocaine for carpal tunnel decompression: a comparison between the Gale and the “advancing wheal” techniques. J Plast Surg Hand Surg. 2016;50:10-14.

50. Tangen LF, Lundbom JS, Skarsvåg TI, et al. The influence of injection speed on pain during injection of local anaesthetic. J Plast Surg Hand Surg. 2016;50:7-9.

51. McGlone R, Bodenham A. Reducing the pain of intradermal lignocaine injection by pH buffering. Arch Emerg Med. 1990;7:65-68.

52. Lalonde D, Wong A. Local anesthetics. Plast Reconstr Surg. 2014;134(4 Suppl 2):40S-49S.

53. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248-263.

54. Williams JG, Lalonde DH. Randomized comparison of the single-injection volar subcutaneous block and the two-injection dorsal block for digital anesthesia. Plast Reconstr Surg. 2006;118:1195-1200.

55. Thomson CJ, Lalonde DH. Randomized double-blind comparison of duration of anesthesia among three commonly used agents in digital nerve block. Plast Reconstr Surg. 2006;118:429-432.

The advantages (and misconceptions) of epinephrine

The advantage of adding epinephrine is that it prolongs the effect of the anesthesia and it decreases bleeding. Epinephrine is commonly available as a premixed solution with lidocaine or bupivacaine at a concentration of 1:100,000 and is generally differentiated from “plain” local anesthetic by a red label and cap. Although maximum vasoconstriction may occur as long as 30 minutes after injection,¹⁰ adequate vasoconstriction is achieved in 7 to 10 minutes for excision of skin lesions.¹¹

Traditional teaching recommends against using epinephrine in the “fingers, toes, penis, ears, or nose” because of potential arterial spasm, ischemia, and gangrene distal to the injection site.¹²These concerns were based on experiences with procaine and cocaine mixed with epinephrine. Studies suffered from multiple confounders, including tourniquets and nonstandardized epinephrine concentrations.^13-15

Add epinephrine to the anesthetic solution to prolong anesthesia and decrease bleeding.

No association of distal ischemia with epinephrine use was identified in a recent Cochrane Review or in another multicenter prospective study.^16,17 Phentolamine, a non-selective alpha-adrenergic receptor antagonist and vasodilator, can be administered to reverse vasoconstriction following inadvertent administration of high-dose epinephrine (1:1000) via anaphylaxis autoinjector kits.

Dosing of phentolamine is 1 mL of 1 mg/mL solution delivered subcutaneously to the affected area; reversal decreases the duration of vasoconstriction from 320 minutes to approximately 85 minutes.¹⁸ As always, when applying literature to clinical practice, one must keep in mind the risks and benefits of any intervention. As such, in patients with pre-existing vascular disease, vaso-occlusive or vasospastic disease, or compromised perfusion due to trauma, one must weigh the benefits of the hemostatic effect against potential ischemia of already susceptible tissues. In such instances, omitting epinephrine from the solution is reasonable.

The benefits of sodium bicarbonate

The acidity of the solution contributes to the level of pain associated with administration of local anesthesia. Previously opened containers become more acidic.¹⁹Addition of 8.4% sodium bicarbonate, at a ratio of 1 mL per 10 mL of 1% lidocaine with 1:100,000 epinephrine, neutralizes the pH to 7.4.¹⁹ A Cochrane Review showed that correction of pH to physiologic levels results in a significant reduction in pain.²⁰

Continue to: This solution can be...