II. Technique: Helpful hints to make local anesthetic more comfortable

  1. Use smaller gauge needles (higher numbers)
    1. Elective procedures: 27 to 30 gauge needle
    2. Avoid using anything larger than a 25 gauge needle
  2. Prepare the injection solution
    1. Warm Xylocaine to Body Temperature
    2. Use Buffered Lidocaine
      1. Bicarbonate 1 part to Xylocaine 9 part ratio
      2. Stable at room temp for one week
  3. Prepare the site
    1. Cool skin before injection
      1. Ice
      2. Quick spray of Liquid Nitrogen or frigiderm
      3. Avoid ethyl chloride when using electrocautery
    2. Consider topical anesthetic use before injection
      1. See topical pre-anesthetics below
  4. Employ a less painful injection technique
    1. Rapidly insert needle (do not allow to needle to linger on surface)
    2. Infiltrate skin slowly and steadily while withdrawing
    3. Inject through wound edge if possible
    4. Inject into subcutaneous tissue (equivalent efficacy to injecting into skin, and less painful)
    5. Be generous with local anesthetic
      1. However, may distort wound edges
  5. Employ distraction techniques
    1. Patient lifts their own leg (Gate theory of pain)
    2. Vibrate skin or pinch skin as you inject
    3. Have patient keep eyes open (analgous to Lamaze birth)
    4. Talk calmly to patient

III. Pharmacokinetics

  1. Amide and Ester anesthetic metabolism and excretion
    1. Metabolized by liver
    2. Excreted by Kidney
  2. Dose calculations
    1. Solution of 0.5%: 5 mg/ml
    2. Solution of 1%: 10 mg/ml
    3. Solution of 2%: 20 mg/ml

IV. Preparations: Topical pre-anesthetics

  1. Ethyl Chloride Spray
    1. Do not use with electrocautery
    2. Site sprayed for 1-2 seconds
    3. Offers 1-2 seconds of anesthesia
  2. Lidocaine-Epinephrine-Tetracaine (LET)
    1. Replaces Tetracaine, Adrenaline, Cocaine (TAC)
    2. Indicated for open wound
    3. May be especially useful in children
  3. EMLA cream (Eutactic Mixture of Local Anesthetic)
    1. Indicated in closed wounds
    2. Apply ointment under Occlusion
    3. Use 90 minutes prior to injection
    4. ELA-Max (OTC) may offer similar effect (see below)
  4. Iontophoresis
    1. Lidocaine sponges applied to intact skin
    2. DC current applied to electrodes over anesthetic
    3. Onset within 10 minutes and duration of 15 minutes
    4. Penetration depth of 1-2 cm
    5. As effective as EMLA cream
  5. Other measures with unknown efficacy in procedures
    1. Lidocaine 4% in liposomal matrix (ELA-Max)
      1. Similar application as with EMLA cream
    2. Anesthetic Patch (Lidoderm)

V. Preparations: Local Anesthetics - Short acting Amide Anesthetics

  1. Local Lidocaine (Xylocaine) 0.5%, 1% or 2%
    1. Onset: 2 minutes
    2. Duration: 1 hour (up to 1.5 to 2 hours in some cases)
    3. Max dose: 4 mg/kg to 300 mg/dose (15 ml 2%, 30 ml 1% or 60 ml 0.5%)
  2. Mepivacaine (Carbocaine) 1%
    1. Onset: 3 to 5 minutes
    2. Duration: 1.5 to 2 hours
    3. Max dose: 4 mg/kg up to 280 mg/dose (28 ml))
  3. Prilocaine (Citanest) 1%
    1. Onset: 2 minutes
    2. Duration: 1 hour
    3. Max dose: 7 mg/kg up to 500 mg/dose (50 ml)

VI. Preparations: Local Anesthetics - Long acting Amide Anesthetics

  1. Lidocaine with Epinephrine 1:100,000 or 1:200,000
    1. Onset: 2 minutes
    2. Duration: 1 to 4 hours (up to 6 hours in some cases)
    3. Max dose: 7 mg/kg to 500 mg/dose (25 ml 2%, 50 ml 1%)
  2. Bupivacaine (Marcaine) 0.25% or 0.5%
    1. Onset: 5 minutes
    2. Duration: 2 to 4 hours
    3. Max dose: 2 mg/kg up to 175 mg/dose (35 ml 0.5%, 70 ml 0.25%)
    4. Avoid in pregnancy (increased bioavailability)
    5. Always confirm not intravascular (withdraw first) as risk of lethal arrhythmias (Ventricular Fibrillation)
  3. Etidocaine (Duranest) 0.5% or 1%
    1. Max dose: 4 mg/kg to 280 mg/dose (25 ml 1%, 50 ml 0.5%)

VII. Preparations: Local Anesthetics - Esters

  1. Background: Mnemonic to distinguish the Ester Anesthetics from the Amide Anesthetics
    1. Amides have two "i"
    2. Esters have one "i"
  2. Chloroprocaine (Nesacaine)
  3. Procaine (Novocain) 1%, 2%
    1. Onset: 2-5 minutes
    2. Duration: 15 to 60 minutes
    3. Max Dose: 7 mg/kg up to 600 mg/dose (30 ml 2%, 60 ml 1%)
  4. Tetracaine (Pontocaine) 0.5%
    1. Onset: 5-10 minutes
    2. Duration: 2-3 hours
    3. Max Dose: 1.4 mg/kg up to 120 mg/dose (24 ml 0.5%)

VIII. Adverse Effects: Allergy to Local Anesthesia

  1. True amide anesthetic is rare
    1. Usually a reaction to preservative methylparaben
  2. Novocain allergy does not predict Lidocaine allergy
    1. Lidocaine is an amide and novocaine an ester
    2. Lidocaine may be used if novocain allergy
  3. Options if history of Lidocaine allergy
    1. Preservative-free Lidocaine (single use bottles)
    2. Select an ester anesthetic (e.g. Nesacaine, Procaine, Tetracaine)
    3. Diphenhydramine Hydrochloride 1%
      1. Dilute 50 mg (1 ml) in 4 ml Normal Saline
      2. Equivalent to Lidocaine 1% activity
      3. Avoid use in peripheral Nerve Block

X. References

  1. Pfenninger (1994) Procedures, Mosby, p. 135-155
  2. Mortiere (1996) Wound Management, p. 27-39
  3. Achar (2002) Am Fam Physician 66(1):91-4 [PubMed]
  4. Latham (2014) Am Fam Physician 89(12): 956-62 [PubMed]

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Cost: Medications

marcaine (on 6/22/2016 at Medicaid.Gov Survey of pharmacy drug pricing)
MARCAINE 0.5% VIAL $0.09 per ml

Ontology: Carbocaine (C0006987)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D008619
Portuguese Carbocaína
Spanish Carbocaína
German Carbocain
French Carbocaïne
English carbocaine, Carbocaine, Scandicaine, Astra Brand of Mepivacaine Hydrochloride, AstraZeneca Brand of Mepivacaine Hydrochloride, Sanofi Brand of Mepivacaine Hydrochloride, Scandicain, Abbott Brand of Mepivacaine Hydrochloride, Carbocaïne

Ontology: Etidocaine (C0015120)

Definition (MSH) A local anesthetic with rapid onset and long action, similar to BUPIVACAINE.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005041
SnomedCT 88485001, 370282009
English Etidocaine, Butanamide, N-(2,6-dimethylphenyl)-2-(ethylpropylamino)-, (+-)-, 2-(Ethylpropylamino)-2',6'-butyroxylidide, etidocaine, Etidocaine [Chemical/Ingredient], Etidocaine (substance), Etidocaine product (product), Etidocaine product, ETIDOCAINE
Swedish Etidokain
Czech etidokain
Finnish Etidokaiini
Italian 2-(Etilpropilamino)-2,6-butir-xilidide, Etidocaina
Russian ETIDOKAIN, ЭТИДОКАИН
Japanese エチドカイン, ズラネスト
Spanish etidocaína (producto), producto con etidocaína (producto), producto con etidocaína, etidocaína (sustancia), etidocaína, Etidocaína
Polish Etidokaina
French Étidocaïne
German Etidocain
Portuguese Etidocaína

Ontology: Mepivacaine (C0025384)

Definition (NCI) An amide-type local anesthetic agent. At the injection site, mepivacaine binds to specific voltage-gated sodium ion channels in neuronal cell membranes, which inhibits both sodium influx and membrane depolarization. This leads to a blockage of nerve impulse initiation and conduction and results in a reversible loss of sensation. Compared to other local anesthetics, this agent has a more rapid onset and moderate duration of action.
Definition (MSH) A local anesthetic that is chemically related to BUPIVACAINE but pharmacologically related to LIDOCAINE. It is indicated for infiltration, nerve block, and epidural anesthesia. Mepivacaine is effective topically only in large doses and therefore should not be used by this route. (From AMA Drug Evaluations, 1994, p168)
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D008619
SnomedCT 370291008, 59560006, 391673008
LNC LP14721-2, MTHU001813
English Mepivacaine, 2-Piperidinecarboxamide, N-(2,6-dimethylphenyl)-1-methyl-, Mepivacaine [Chemical/Ingredient], Mepivacaine product (product), mepivacaine, MEPIVACAINE, Mepivacaine (substance), Mepivacaine product, Mepivacaine (product)
Swedish Mepivakain
Czech mepivakain
Finnish Mepivakaini
Russian KARBOKAIN, MEPIVAKAIN, КАРБОКАИН, МЕПИВАКАИН
Japanese カルボカイン, 塩酸メピバカイン, メピバカイン
Polish Mepiwakaina, Karbokaina
Spanish producto con mepivacaína, producto con mepivacaína (producto), mepivacaína (sustancia), mepivacaína, mepivacaína (producto), Mepivacaína
French Mépivacaïne
German Mepivacain
Italian Mepivacaina
Portuguese Mepivacaína

Ontology: Prilocaine (C0033124)

Definition (MSH) A local anesthetic that is similar pharmacologically to LIDOCAINE. Currently, it is used most often for infiltration anesthesia in dentistry.
Definition (NCI) A toluidine derivative and intermediate-acting amino amide with local anesthetic property. Prilocaine stabilizes the neuronal membrane by preferential binding to and inhibiting depolarization of the voltage-gated sodium channel. This results in a decrease in membrane permeability and subsequent inhibition of the ionic sodium influx required for the initiation and conduction of impulses.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D011318
SnomedCT 19232009, 387107003
LNC LP32686-5, MTHU016255
English Propitocaine, Propanamide, N-(2-methylphenyl)-2-(propylamino)-, o-Methyl-alpha-propylaminopropionanilide, o-Propionotoluidide, 2-(propylamino)-, 6,7-Epoxytropine Tropate, Propanamide, N-(2-methylphenyl)-2-(propylamino)-(9CI), Prilocaine, prilocaine, PRILOCAINE, Prilocaine [Chemical/Ingredient], Prilocaine (product), Prilocaine (substance)
Swedish Prilokain
Czech prilokain
Finnish Prilokaiini
Russian TSITANEST, PROPITOKAIN, PRILOKAIN, ПРИЛОКАИН, ПРОПИТОКАИН, ЦИТАНЕСТ
Japanese プロピトカイン, プリロカイン
Italian Propitocaina, Prilocaina
Polish Prilokaina
Spanish prilocaína (producto), prilocaína (sustancia), prilocaína, propitocaína, Propitocaína, Prilocaína
French Prilocaïne
German Prilocain, Propitocain
Portuguese Prilocaína, Propiocaína

Ontology: Citanest (C0591261)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D011318
English citanest, Citanest, Inibsa Brand of Prilocaine Hydrochloride

Ontology: Sensorcaine (C0699883)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D002045
English Carbostesin, sensorcaine, AstraZeneca Brand of Bupivacaine Hydrochloride, Sensorcaine, Astra Brand of Bupivacaine Hydrochloride

Ontology: Duranest (C0733378)

Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005041
English Duranest