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Use of local anesthesia in office-based dermatologic surgery- Guidelines

Use of local anesthesia in office-based dermatologic surgery- Guidelines

In the practice of medicine (especially surgery) and dentistry, anesthesia or anaesthesia is a temporary induced state with one or more of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), amnesia (loss of memory), and unconsciousness. A patient under the effects of anesthetic drugs is referred to as being anesthetized.

In July 2016, American Academy of Dermatology Guidelines for the use of local anesthesia in office-based dermatologic surgery. Following are the major recommendations:

Recommendations for the Use of Topical Anesthesia in Dermatologic Surgery

  • Noncocaine formulations are preferred over cocaine formulations and recommended for use in office-based procedures.
  • Topical agents are recommended as a first-line method of anesthesia for nonablative laser treatments.
  • Topical anesthesia can be used for performing office-based procedures, such as skin biopsy, small excisions, and filler and botulinum toxin injections.
  • The use of topical anesthetic agents is recommended to lessen the pain of injection and reduce the dose of infiltration anesthesia needed for larger procedures.
  • Topical lidocaine is safe for use on pregnant or nursing women, but there is insufficient evidence to recommend use of other topical anesthetics.
    • Elective procedures and those not of urgent medical necessity requiring topical lidocaine in pregnant women should be postponed until after delivery.
    • Procedures of urgent medical necessity should be delayed until at least the second trimester when possible.
  • Topical agents are recommended as a first-line method of anesthesia for the repair of dermal lacerations in children and for other minor dermatologic procedures, including curettage. For skin biopsy, excision, or other cases where topical agents alone are insufficient, adjunctive use of topical anesthesia to lessen the discomfort of infiltrative anesthetic should be considered.
  • For more extensive surgery, the combination of topical and infiltration anesthesia should be considered as an alternate to sedation or general anesthesia in pediatric patients.

Strength of Recommendations for Use of Topical Anesthesia in Dermatologic Surgery

Recommendation Strength of Recommendation Level of Evidence References
Use of noncocaine topical anesthetics A II Eidelman et al., 2005
Topical anesthesia as the first-line method for nonablative laser treatments C III Bryan & Alster, 2002; Kilmer et al., 2003
Topical anesthesia for use in minor skin procedures in adults C III Bryan & Alster, 2002; Kilmer et al., 2003; Franchi et al., 2009; Jones & Nandapalan, 1999; Goodacre et al., 1988; Russell, Desmond, & Fox, 1988; Ferguson, Loryman, & Body, 2005; Hallen, Ljunghall, & Wallin, 1987; Gupta & Sibbald, 1996
Topical anesthesia to reduce the pain of local anesthetic injection C III Expert opinion
Use of limited amounts of topical lidocaine in pregnant and nursing women C III Murase, Heller, & Butler, 2014; Gormley, 1990; Richards & Stasko, 2002; Butler, Heller, & Murase, 2014
Postpone use of topical anesthesia until after delivery or second trimester when possible C III Expert opinion
Against use of nonlidocaine topical anesthetics in pregnant or nursing women C III Expert opinion
Use of topical anesthesia as the first-line method for repair of dermal lacerations in children A I,II Ferguson, Loryman, & Body, 2005; Bonadio & Wagner, 1988; Hegenbarth et al., 1990; Smith et al., 1998; Smith et al., 1996; Smith & Barry, 1990; Zempsky & Karasic, 1997
Use of topical anesthesia as the first-line method for other minor procedures in children C III Expert opinion
Adjunctive use of topical anesthesia to minimize discomfort of infiltrative anesthesia in children C III Expert opinion
Topical and infiltrative anesthesia used as an alternate to sedation and general anesthesia in children C III Ferguson, Loryman, & Body, 2005; Bonadio & Wagner, 1988; Hegenbarth et al., 1990; Smith et al., 1998; Smith et al., 1996; Smith & Barry, 1990; Zempsky & Karasic, 1997; Pierluisi & Terndrup, 1989; Priestley et al., 2003

Recommendations for the Use of Local Infiltrative Anesthesia in Dermatologic Surgery

  • Infiltrative anesthesia is safe and recommended for office-based dermatologic procedures, including but not limited to obtaining a biopsy specimen, excision, wound closure, tissue rearrangement, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing.
  • Infiltrative anesthesia may be combined with other forms of local anesthesia for larger or more complex cutaneous procedures, including but not limited to:
    • Full-face ablative laser resurfacing, combined with topical and nerve block anesthesia
    • Follicular unit hair transplantation, combined with tumescent local anesthesia.
  • The maximum safe dose of local infiltrated anesthesia is unknown.
  • For adults, no more than 4.5 mg/kg of lidocaine and 7.0 mg/kg of lidocaine with epinephrine should be administered in a single treatment.
  • For children, no more than 1.5-2.0 mg/kg of lidocaine and 3.0-4.5 mg/kg of lidocaine with epinephrine should be administered in a single treatment.
  • For a multistage procedure, such as Mohs micrographic surgery, a maximum dose of local infiltrative anesthesia of 50 mL of 1% lidocaine solution (500 mg) delivered over several hours is recommended.
  • Use of either ester-type local anesthetics, bacteriostatic normal saline, or 1% diphenhydramine is suggested as an alternate form of local infiltration anesthesia for patients with true allergy to lidocaine.
  • Steps recommended to decrease the risk of local anesthetic systemic toxicity:
    • Use the lowest effective dose of local anesthetic.
    • Aspirate the needle/catheter prior to each injection to avoid introducing the drug directly into a vessel.
    • Use incremental injections of anesthetic.
    • Continually assess and communicate with the patient to monitor for signs of early toxicity.

Strength of Recommendations for the Use of Local Infiltrative Anesthesia in Dermatologic Surgery

Recommendation Strength of Recommendation Level of Evidence References
Use of local infiltrative anesthesia for obtaining a biopsy specimen, excision, wound closure, tissue rearrangement, skin grafting, cauterization, nonablative laser, and ablative skin resurfacing C III Expert opinion
Combining methods of local anesthesia for full-face ablative laser and follicular unit hair transplantation C III Expert opinion
Maximum dose of 4.5 mg/kg of lidocaine and 7.0 mg/kg of lidocaine with epinephrine for adults C III Hancox et al., 2004; Klein, 1993; Drake et al., 1995
Maximum dose of 1.5-2.0 mg/kg of lidocaine and 3.0-4.5 mg/kg of lidocaine with epinephrine for children C III Hancox et al., 2004
Max dose of 500 mg of lidocaine for a multistage Mohs micrographic surgery B II Alam et al., 2010
Use of ester type local anesthetics for patients with lidocaine allergy C III Bhole et al., 2012
Use of diphenhydramine for patients with lidocaine allergy C III Green, Rothrock, & Gorchynski, 1994; Xia et al., 2002
Use of bacteriostatic normal saline for patients with lidocaine allergy C III Bartfield, Jandreau, & Raccio-Robak, 1998
Prevention of local anesthetic systemic toxicity A I,II Neal et al., 2010; Neal, Mulroy, & Weinberg, 2012; Mercado & Weinberg, 2011

Recommendations for Mixing and the Use of Additives to Local Infiltrative Anesthesia in Dermatologic Surgery

Epinephrine

  • The addition of epinephrine to local infiltration anesthesia is safe and recommended for use on the ear, nose, hand, feet, and digits.
  • The addition of epinephrine to local infiltration anesthesia may be considered for use during procedures on the penis.
  • Local infiltrative anesthesia with epinephrine may be used in small amounts in women who are pregnant:
    • Elective procedures and those not of urgent medical necessity requiring lidocaine with epinephrine should be postponed until after delivery.
    • Procedures of urgent medical necessity should be delayed until the second trimester when possible.
    • In case of doubt, consult with the patient’s obstetrician.
  • Local infiltrative anesthesia with epinephrine may be administered to patients with stable cardiac disease. If uncertain of a patient’s ability to tolerate epinephrine, consult with the patient’s cardiologist.
  • Use of the lowest effective concentration of epinephrine to provide pain control and vasoconstriction in local infiltrative anesthesia is recommended.

Hyaluronidase

  • Hyaluronidase may be used as an additive to local infiltration anesthesia to ease diffusion and reduce contour distortion, yet there are insufficient data to support a recommendation for its routine use in dermatologic surgery.
  • Hyaluronidase should not be administered to patients with a known bee venom allergy.

Buffering

  • The addition of sodium bicarbonate to local anesthetic, particularly lidocaine with epinephrine, is recommended to decrease the pain of delivery by subcutaneous or intradermal infiltration.
  • Preinjection of buffered lidocaine solution is suggested to reduce the pain of bupivacaine infiltration.

Mixing Local Anesthetics

It is unclear whether mixing multiple anesthetics for local infiltration poses further benefit over use of a single agent.

Strength of Recommendations for Mixing and the Use of Additives to Local Infiltrative Anesthesia in Dermatologic Surgery

Recommendation Strength of Recommendation Level of Evidence References
Addition of epinephrine to local anesthesia on the ear, nose, and digits A I,II Altinyazar et al., 2004; Chowdhry et al., 2010; Denkler, 2001; Denkler, 2005; Häfner et al., 2008; Krunic et al., 2004; Lalonde et al., 2005; Radovic, Smith, & Shumway, 2003; Sonohata et al., 2012; Wilhelmi et al., 2001; Häfner, Rocken, & Breuninger, 2005
Addition of epinephrine to local anesthesia on the penis B II Schnabl et al., 2014
Addition of epinephrine to local anesthesia in women who are pregnant or nursing B II Murase, Heller, & Butler, 2014
Addition of epinephrine to local anesthesia in patients with stable cardiac disease B I,II Serrera Figallo et al., 2012; Niwa et al., 2001
Addition of epinephrine to local infiltrative anesthesia at the lowest effective concentration B II,III Dunlevy, O’Malley, & Postma 1996; Gessler et al., 2001; Liu et al., 1995
Against addition of hyaluronidase to local anesthesia in patients with bee venom allergy B II Kirby et al., 2001
Against use of hyaluronidase to reduce tissue distortion and improve undermining C III Clark & Mellette, 1994; Landsman & Mandy, 1991
Addition of sodium bicarbonate to reduce pain of local anesthetic infiltration A I.II Masters, 1998; Stewart et al., 1990; Stewart, Cole, & Klein, 1989; Welch et al., 2012; Burns et al., 2006
Preinjection of buffered lidocaine to reduce pain of bupivacaine injection C III Expert opinion
Mixing multiple anesthetics for the same procedure C II Gadsden et al., 2011; Lai, Sutton, & Nicholson, 2003; Nicholson, Sutton, & Hall, 2000; Ozdemir et al., 2004; Ribotsky, Berkowitz, & Montague, 1996; Seow et al., 1982; Sweet, Magee, & Holland, 1982; van den Berg & Montoya-Pelaez, 2001

Recommendations for Minimizing Pain of Administration of Local Infiltration Anesthesia and Alternate Methods of Analgesia in Dermatologic Surgery

  • Slow rate of infiltration, vibration of the skin, use of a warm solution, or cold air skin cooling should be considered to decrease the pain of local anesthetic injection.
  • It is unclear whether pretreatment with ethyl chloride spray, preinjection with normal saline, or verbal distraction decreases the pain of local anesthetic infiltration.
  • There is contradictory evidence regarding the effectiveness of ethyl chloride, and its use as a sole method for analgesia in dermatologic procedures should not be considered.
  • Cold air skin cooling may be considered to reduce patient discomfort during nonablative laser therapy.
  • Use of a skin-vibrating device may be considered to help decrease the pain of botulinum toxin injection.

Strength of Recommendations for Minimizing Pain of Administration of Local Infiltration Anesthesia and Alternate Methods of Analgesia in Dermatologic Surgery

Recommendation Strength of Recommendation Level of Evidence References
Slow rate of infiltration, vibration of the skin, use of a warm solution, and cold air skin cooling are recommended to decrease the pain of local anesthetic injection. B II Fosko, Gibney, & Harrison, 1998; Kaplan & Moy, 1996; Scarfone, Jasani, & Gracely, 1998; Al-Qarqaz et al., 2012; Fayers, Morris, & Dolman, 2010
Pretreatment with ethyl chloride spray, preinjection with normal saline, or verbal distraction to decrease the pain of local anesthetic infiltration C III Expert opinion; Swinehart, 1992
Ethyl chloride as an analgesic for dermatologic procedures. C III Armstrong, Young, & McKeown, 1990; Robinson et al., 2007; Selby & Bowles, 1995; Soueid & Richard, 2007; Yoon et al., 2008; White et al., 1999
Cold air skin cooling to reduce patient discomfort during nonablative laser therapy B II Hammes & Raulin, 2005; Raulin, Greve, & Hammes, 2000
Use of a skin-vibrating device to decrease the pain of botulinum toxin injection into glabellar rhytides B II Sharma, Czyz, & Wulc, 2011


Recommendations for Nerve Blocks in Dermatologic Surgery

  • Regional cutaneous nerve block anesthesia is recommended for ablative laser resurfacing of the face and botulinum toxin injection of the palm
  • Nerve block should be considered as an alternative or in addition to infiltrative anesthesia for procedures on the face, hands, feet, and digits, and may provide the benefit of decreased tissue swelling/distortion, prolong anesthesia, and reduce postoperative discomfort for the patient

Strength of Recommendations for Nerve Blocks in Dermatologic Surgery

Recommendation Strength of Recommendation Level of Evidence References
Nerve block anesthesia for ablative laser resurfacing of the face, botulinum toxin injection of the palm, and upper lid ptosis surgery B II Lee, Khandwala, & Jones, 2009; Hund et al., 2004; Vadoud-Seyedi, Heenen, & Simonart, 2001; Wan et al., 2013
Nerve block as an alternate to local infiltration anesthesia for dermatologic surgery on the face and digits C III Expert opinion

Recommendations for Tumescent Local Anesthesia in Dermatologic Surgery

  • Lidocaine and prilocaine are both safe and recommended for use in tumescent local anesthesia for office-based liposuction. Bupivacaine is not recommended for this use.
  • Use of prilocaine is not approved in the United States for this procedure as of the date of this publication.
  • The addition of epinephrine to lidocaine is recommended and safe for use in tumescent local anesthesia for liposuction.
  • A maximum dose of 55 mg/kg of lidocaine with epinephrine has been shown to be safe and can be used for tumescent local anesthesia for liposuction in patients weighing 43.6-81.8 kg.
  • The use of warm anesthetic solution and a slow infiltration rate is recommended to decrease patient discomfort during administration of tumescent local anesthesia.

Strength of Recommendations for Tumescent Local Anesthesia in Dermatologic Surgery

Recommendation Strength of Recommendation Level of Evidence References
Lidocaine and prilocaine for use in tumescent local anesthesia for office-based liposuction A I,II Klein, 1990; Burk, Guzman-Stein, & Vasconez, 1996; Glowacka et al., 2009; Habbema, 2010; Lillis, 1988; Rubin et al., 1999; Augustin et al., 2010; Breuninger & Wehner-Caroli, 1998; Lindenblatt et al., 2004
The addition of epinephrine to lidocaine for use in tumescent local anesthesia for liposuction A I,II Klein, 1990; Burk, Guzman-Stein, & Vasconez, 1996; Glowacka et al., 2009; Habbema, 2010; Lillis, 1988; Rubin et al., 1999
A maximum dose of 55 mg/kg of lidocaine with epinephrine for local tumescent anesthesia for liposuction A I Ostad, Kageyama, & Moy, 1996
Use of a warm solution to decrease patient discomfort during administration of tumescent local anesthesia B II Kaplan & Moy, 1996
Use of a slow infiltration rate to decrease patient discomfort during administration of tumescent local anesthesia B III Hanke, et al., 1997

You can read the full Guidelines on clicking on the link :

Kouba DJ, LoPiccolo MC, Alam M, Bordeaux JS, Cohen B, Hanke CW, Jellinek N, Maibach HI, Tanner JW, Vashi N, Gross KG, Adamson T, Begolka WS, Moyano JV. Guidelines for the use of local anesthesia in office-based dermatologic surgery. J Am Acad Dermatol. 2016 Jun;74(6):1201-19. [141 references] 

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