Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Options for painless local anesthesia H. Spencer Holmes MD To cite this article: H. Spencer Holmes MD (1991) Options for painless local anesthesia, Postgraduate Medicine, 89:3, 71-72, DOI: 10.1080/00325481.1991.11700843 To link to this article: http://dx.doi.org/10.1080/00325481.1991.11700843
Published online: 17 May 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Monash University Library]
Date: 03 July 2016, At: 03:10
--@
CME credit article
Options for painless local anesthesia
H. Spencer Holmes, MD
Downloaded by [Monash University Library] at 03:10 03 July 2016
Preview Fear of the needle is a real issue with some patients and may be an obstacle to inducing anesthesia before minor surgical procedures are performed. Adults may express this fear verbally or, out of embarrassment, even avoid coming to the physician's office. Children may become intensely anxious and hysterical. In this article, Or Holmes describes the use of alternative procedures and agents for reducing the pain of inducing anesthesia and thus reducing patients' anxiety.
The pain of the needlestick and the longer, more intense pain on infiltration of local anesthetic can be avoided by modifYing usual procedures and substituting inherently painless anesthetic compounds for lidocaine (Xylocaine) hydrochloride or similar preparations. 1 Instead of feeling a sharp, stinging sensation, patients experience at most the sensation of cool water on the skin. Table 1 summarizes how to prepare the alternative anesthetic agents I use in my dermatology practice. Although I am aware that most patients can tolerate the pain of injection, I prefer to use one or more of these alternative agents for all of my patients.
Ice An ice cube or, better yet, a "syringe ice push-up" (figure 1) is an effective topical anesthetic for reducing or eliminating needlestick pain. Rubbing the skin firmly for 10 seconds offers about 2 seconds of anesthesia. Refrigerant sprays have a similar effect, bur some patients find them to be rather uncomfortable. Also, I find that refrigerant sprays harden the
skin and make penetration by the needle more difficult. Ice is readily available, does not harden the skin, and is a familiar substance to the frightened patient.
Needles I no longer use anything except 30-gauge needles for injecting local anesthetic. Their sharpness allows easy penetration of even thick surfaces such as the palm and sole, and in other areas some patients do not feel the needlestick even without prior use of ice.
Bacteriostatic saline solution One of the most readily available and inexpensive local anesthetics is bacteriostatic saline solution (Bacteriostatic Sodium Chloride Injection) with benzyl alcohol. This preparation produces 2 to 5 minutes of anesthesia with no pain on infiltration. Use of benzyl alcohol as a local anesthetic was first reported in 1918,2 and it is still listed as a local anesthetic under the aromatic alcohol classification.' However, it is used in injectable saline solution
VOL 89/NO 3/FEBRUARY 15, 1991/POSTGRADUATE MEDICINE • PAINLESS LOCAL ANESTHESIA
mainly because of its bacteriostatic properties. 4 Saline solution without benzyl alcohol does not produce anesthesia, which proves that the anesthetic effect is not due to a physical mechanism. 1 Injection of bacteriostatic saline solution with benzyl alcohol produces adequate anesthesia for the removal of small lesions, such as tags, warts, and moles. Anesthesia is instantaneous if a tense wheal is produced, bur because the effect is brief, the surgical procedure should be performed immediately. When injected beneath warts, the preparation not only produces anesthesia but also separates the wart from underlying structures, including nerves, which should not be frozen. The preparation also provides anesthesia when hemostasis (eg, by electrocautery, application of Monsel's solution) is needed following a surgical procedure. Occasionally a patient comments that the site of mole removal is somewhat painful as it "wakes up." Adding a small amount of epinephrine to bacteriostatic saline solution with benzyl alcohol lengthens the duration of anesthesia to about continued
Figure 1. "Syringe ice push-up" used as topical anesthetic.
71
Injection of bacteriostatic saline solution with benzyl alcohol provides adequate anesthesia for the removal of small lesions, such as tags, warts, and moles.
Downloaded by [Monash University Library] at 03:10 03 July 2016
Table 1. Preparation of alternative local anesthetic agents "Syringe ice push-up" Fill3-cc syringe with water and seal with covered needle or plastic cap. Freeze. Before use, cut off needle end of syringe with small hacksaw.
Bacteriostatic saline solution (Bacteriostatic Sodium Chloride Injection) Comes ready to use. Must contain benzyl alcohol.
Bacteriostatic saline solution with epinephrine Add 0.3 ml of 1:1 ,000 epinephrine to 30-cc vial of bacteriostatic saline solution to make dilution of 1:100,000.
Alkalinized lidocaine Add 5 ml of 7.5% sodium bicarbonate solution to 50 ml of 1% lidocaine (Xylocaine) hydrochloride. If solution is cloudy, a trace amount of calcium is probably present and solution should be discarded.*
Lidocaine and bacteriostatic saline solution Add 3 ml of plain lidocaine or lidocaine with epinephrine to 27 ml of bacteriostatic saline solution. This makes a 1: 10 solution.
by plain lidocaine or lidocaine with epinephrine. The procedure is painless if the lidocaine is not forced beyond the area containing the saline solution.
Conclusion
Offering all patients local anesth.esia that is as painless as possible should be an important part of modem medical practice. Use of ice to eliminate needlestick pain, a 30-gauge needle, and alternative anesth.etic agents makes the process less threatening and more tolerable. PCN
-@
Earn credit on this article.
"I have noted no problems with precipitate when using LyphoMed's 50-cc vials of 7.5% sodium bicarbonate solution.
70 minutes and does not increase the pain on infiltration. 1
Modified lidocaine Almost all patients find the injection of lidocaine unpleasant. Alkalinizing lidocaine by adding small amounts of sodium bicarbonate solution to plain lidocaine or to lidocaine with epinephrine has become popular in the last few years. Duration of anesthesia with plain lidocaine is about 25 minutes; with lidocaine with H. Spencer Holmes, MD Or Holmes is in the department of dermatology, Park Nicollet Medical Center, Minneapolis. His major interest is local anesthesia.
72
epinephrine it is more than 100 minutes. Reduction or absence of pain on infiltration has been attributed to elevation of the pH.6 Some of my patients detect slight pain even when a freshly made solution is used; however, alkalinized lidocaine is always better tolerated than plain lidocaine or lidocaine with epinephrine. Pain on infiltration can also be reduced by injecting lidocaine diluted with bacteriostatic saline solution. This preparation produces about 20 minutes of anesthesia. A two-step procedure consists of injecting bacteriostatic saline solution with benzyl alcohol, followed
See CME Quiz.
Address for correspondence: H. Spencer Holmes, MD, Department of Dermatology, Park Nicollet Medical Center, 5000 W 39th St, Minneapolis, MN 55416.
References I. Holrnes HS. Painless anesrhesia. Dialogues Dermarol (Audiocasserre) 1990;26(5) 2. Macht 01. A pharmacological and rherapeuric srudy of benzyl alcohol as a local anesrheric. J Pharmacal Exp Ther 1918;11:263-79 3. Cutting WC. Handbook of pharmacology: rhe acrions and uses of drugs. Easr Norwalk, CT: Appleton & Lange, 1972:514 4. Harvey SC. Antiseptics and disinfecranrs; fungicides; ectoparasiricides. In: Gilman A, Goodman LS, Rail Tw, er a!, eds. Goodman and Gilman's rhe pharmacological basis of rherapeurics. 7rh ed. New York: Macmillan, 1985:962 5. Grekin RC, Auletta MJ. Local anesrhesia in dermarologic surgery. JAm Acad Dermarol1988; 19(4):599-614 6. Stewart JH, Cole GW, Klein JA Neutralized lidocaine wirh epinephrine for local anesrhesia. J DermatolSurgOncol1989;15(0cr 10):1081-3
PAINLESS LOCAL ANESTHESIA • VOL 89/NO 3/FEBRUARY 15, 1991/POSTGRADUATE MEDICINE
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Options for painless local anesthesia H. Spencer Holmes MD To cite this article: H. Spencer Holmes MD (1991) Options for painless local anesthesia, Postgraduate Medicine, 89:3, 71-72, DOI: 10.1080/00325481.1991.11700843 To link to this article: http://dx.doi.org/10.1080/00325481.1991.11700843
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Monash University Library]
Date: 03 July 2016, At: 03:10
--@
CME credit article
Options for painless local anesthesia
H. Spencer Holmes, MD
Downloaded by [Monash University Library] at 03:10 03 July 2016
Preview Fear of the needle is a real issue with some patients and may be an obstacle to inducing anesthesia before minor surgical procedures are performed. Adults may express this fear verbally or, out of embarrassment, even avoid coming to the physician's office. Children may become intensely anxious and hysterical. In this article, Or Holmes describes the use of alternative procedures and agents for reducing the pain of inducing anesthesia and thus reducing patients' anxiety.
The pain of the needlestick and the longer, more intense pain on infiltration of local anesthetic can be avoided by modifYing usual procedures and substituting inherently painless anesthetic compounds for lidocaine (Xylocaine) hydrochloride or similar preparations. 1 Instead of feeling a sharp, stinging sensation, patients experience at most the sensation of cool water on the skin. Table 1 summarizes how to prepare the alternative anesthetic agents I use in my dermatology practice. Although I am aware that most patients can tolerate the pain of injection, I prefer to use one or more of these alternative agents for all of my patients.
Ice An ice cube or, better yet, a "syringe ice push-up" (figure 1) is an effective topical anesthetic for reducing or eliminating needlestick pain. Rubbing the skin firmly for 10 seconds offers about 2 seconds of anesthesia. Refrigerant sprays have a similar effect, bur some patients find them to be rather uncomfortable. Also, I find that refrigerant sprays harden the
skin and make penetration by the needle more difficult. Ice is readily available, does not harden the skin, and is a familiar substance to the frightened patient.
Needles I no longer use anything except 30-gauge needles for injecting local anesthetic. Their sharpness allows easy penetration of even thick surfaces such as the palm and sole, and in other areas some patients do not feel the needlestick even without prior use of ice.
Bacteriostatic saline solution One of the most readily available and inexpensive local anesthetics is bacteriostatic saline solution (Bacteriostatic Sodium Chloride Injection) with benzyl alcohol. This preparation produces 2 to 5 minutes of anesthesia with no pain on infiltration. Use of benzyl alcohol as a local anesthetic was first reported in 1918,2 and it is still listed as a local anesthetic under the aromatic alcohol classification.' However, it is used in injectable saline solution
VOL 89/NO 3/FEBRUARY 15, 1991/POSTGRADUATE MEDICINE • PAINLESS LOCAL ANESTHESIA
mainly because of its bacteriostatic properties. 4 Saline solution without benzyl alcohol does not produce anesthesia, which proves that the anesthetic effect is not due to a physical mechanism. 1 Injection of bacteriostatic saline solution with benzyl alcohol produces adequate anesthesia for the removal of small lesions, such as tags, warts, and moles. Anesthesia is instantaneous if a tense wheal is produced, bur because the effect is brief, the surgical procedure should be performed immediately. When injected beneath warts, the preparation not only produces anesthesia but also separates the wart from underlying structures, including nerves, which should not be frozen. The preparation also provides anesthesia when hemostasis (eg, by electrocautery, application of Monsel's solution) is needed following a surgical procedure. Occasionally a patient comments that the site of mole removal is somewhat painful as it "wakes up." Adding a small amount of epinephrine to bacteriostatic saline solution with benzyl alcohol lengthens the duration of anesthesia to about continued
Figure 1. "Syringe ice push-up" used as topical anesthetic.
71
Injection of bacteriostatic saline solution with benzyl alcohol provides adequate anesthesia for the removal of small lesions, such as tags, warts, and moles.
Downloaded by [Monash University Library] at 03:10 03 July 2016
Table 1. Preparation of alternative local anesthetic agents "Syringe ice push-up" Fill3-cc syringe with water and seal with covered needle or plastic cap. Freeze. Before use, cut off needle end of syringe with small hacksaw.
Bacteriostatic saline solution (Bacteriostatic Sodium Chloride Injection) Comes ready to use. Must contain benzyl alcohol.
Bacteriostatic saline solution with epinephrine Add 0.3 ml of 1:1 ,000 epinephrine to 30-cc vial of bacteriostatic saline solution to make dilution of 1:100,000.
Alkalinized lidocaine Add 5 ml of 7.5% sodium bicarbonate solution to 50 ml of 1% lidocaine (Xylocaine) hydrochloride. If solution is cloudy, a trace amount of calcium is probably present and solution should be discarded.*
Lidocaine and bacteriostatic saline solution Add 3 ml of plain lidocaine or lidocaine with epinephrine to 27 ml of bacteriostatic saline solution. This makes a 1: 10 solution.
by plain lidocaine or lidocaine with epinephrine. The procedure is painless if the lidocaine is not forced beyond the area containing the saline solution.
Conclusion
Offering all patients local anesth.esia that is as painless as possible should be an important part of modem medical practice. Use of ice to eliminate needlestick pain, a 30-gauge needle, and alternative anesth.etic agents makes the process less threatening and more tolerable. PCN
-@
Earn credit on this article.
"I have noted no problems with precipitate when using LyphoMed's 50-cc vials of 7.5% sodium bicarbonate solution.
70 minutes and does not increase the pain on infiltration. 1
Modified lidocaine Almost all patients find the injection of lidocaine unpleasant. Alkalinizing lidocaine by adding small amounts of sodium bicarbonate solution to plain lidocaine or to lidocaine with epinephrine has become popular in the last few years. Duration of anesthesia with plain lidocaine is about 25 minutes; with lidocaine with H. Spencer Holmes, MD Or Holmes is in the department of dermatology, Park Nicollet Medical Center, Minneapolis. His major interest is local anesthesia.
72
epinephrine it is more than 100 minutes. Reduction or absence of pain on infiltration has been attributed to elevation of the pH.6 Some of my patients detect slight pain even when a freshly made solution is used; however, alkalinized lidocaine is always better tolerated than plain lidocaine or lidocaine with epinephrine. Pain on infiltration can also be reduced by injecting lidocaine diluted with bacteriostatic saline solution. This preparation produces about 20 minutes of anesthesia. A two-step procedure consists of injecting bacteriostatic saline solution with benzyl alcohol, followed
See CME Quiz.
Address for correspondence: H. Spencer Holmes, MD, Department of Dermatology, Park Nicollet Medical Center, 5000 W 39th St, Minneapolis, MN 55416.
References I. Holrnes HS. Painless anesrhesia. Dialogues Dermarol (Audiocasserre) 1990;26(5) 2. Macht 01. A pharmacological and rherapeuric srudy of benzyl alcohol as a local anesrheric. J Pharmacal Exp Ther 1918;11:263-79 3. Cutting WC. Handbook of pharmacology: rhe acrions and uses of drugs. Easr Norwalk, CT: Appleton & Lange, 1972:514 4. Harvey SC. Antiseptics and disinfecranrs; fungicides; ectoparasiricides. In: Gilman A, Goodman LS, Rail Tw, er a!, eds. Goodman and Gilman's rhe pharmacological basis of rherapeurics. 7rh ed. New York: Macmillan, 1985:962 5. Grekin RC, Auletta MJ. Local anesrhesia in dermarologic surgery. JAm Acad Dermarol1988; 19(4):599-614 6. Stewart JH, Cole GW, Klein JA Neutralized lidocaine wirh epinephrine for local anesrhesia. J DermatolSurgOncol1989;15(0cr 10):1081-3
PAINLESS LOCAL ANESTHESIA • VOL 89/NO 3/FEBRUARY 15, 1991/POSTGRADUATE MEDICINE
