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

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]