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 Lidocaine (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: 2-5 minutes
    2. Duration: 1 hour (up to 1.5 to 3 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%)
      1. Epinephrine increases Lidocaine duration or activity and maximal safe dose to 7 mg/kg (see below)
  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 (up to 6 hours, esp. when combined with Epinephrine)
    3. Max dose: 1.25 mg/kg up to 175 mg/dose (35 ml 0.5%, 70 ml 0.25%)
    4. Avoid in pregnancy (increased bioavailability, crosses placenta)
    5. Always confirm not intravascular (withdraw first) as risk of lethal arrhythmias (Ventricular Fibrillation)
      1. See LAST Reaction
      2. Less risk of systemic absorption when combined with Epinephrine
  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. Novocaine 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. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
  2. Pfenninger (1994) Procedures, Mosby, p. 135-155
  3. Mortiere (1996) Wound Management, p. 27-39
  4. Achar (2002) Am Fam Physician 66(1):91-4 [PubMed]
  5. Latham (2014) Am Fam Physician 89(12): 956-62 [PubMed]

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Cost: Medications

marcaine (on 4/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
MARCAINE 0.5% VIAL $0.09 per ml
sensorcaine (on 4/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
SENSORCAINE 0.5% VIAL $0.09 per ml

Ontology: Local anesthesia (C0002921)

Definition (NCI) The temporary suppression of sensation at a specific region of the body by pharmacological intervention. This type of anesthesia does not induce unconsciousness in the patient.
Definition (NCI_NCI-GLOSS) A temporary loss of feeling in one small area of the body caused by special drugs or other substances called anesthetics. The patient stays awake but has no feeling in the area of the body treated with the anesthetic.
Definition (CSP) blocking of nerve conduction to a specific area by an injection of an anesthetic agent.
Definition (MSH) A blocking of nerve conduction to a specific area by an injection of an anesthetic agent.
Concepts Therapeutic or Preventive Procedure (T061)
MSH D000772
SnomedCT 180897007, 20653004, 386761002
English Local anesthesia, Anesthesia, Local, Local anaesthetic NOS, Local anesthetic NOS, local anesthetics (medication), local anesthetics, Anaesthesia local, Anesthesia local, LA, Local Anesthesia Procedure, anesthetic local techniques, local anesthesia, anesthetic local procedure, laing, anaesthetic local, anaesthesia local, local anesthetic technique, anesthesia local, anaesthetics local, anesthetic local, local anaesthesia, local anesthesia in conjunction with operative or surgical procedures, Local anesthetic NOS (procedure), Local anesthesia in conjunction with operative or surgical procedures, Local anesthetic, Local anaesthesia, Local anaesthetic technique, Local anesthetic technique, Local anaesthetic, Local anesthesia (procedure), Local anesthesia, NOS, Local Anesthesia, local anesthetic, local anaesthetic
Dutch LA, anesthesie lokaal, lokaal anestheticum, lokale anesthesie, Anesthesie, lokale, Lokale anesthesie
French AL, Anesthésique local, Anesthésie locale
German LA, lokales Anaesthetikum, Anaesthesie lokal, Lokalanaesthesie, Anästhesie, Lokal-, Betäubung, örtliche
Italian Atrio sinistro, Anestetico locale, Anestesia locale
Portuguese Anestésico local, Anestesia local, Anestesia Local
Spanish Anestésico local, AL, anestesia local, SAI, anestesia local, SAI (procedimiento), anestesia local, anestesia local (procedimiento), Anestesia local, Anestesia Local
Japanese 局所麻酔, キョクショマスイ, 麻酔-浸潤, 麻酔-局所浸潤, 局所麻酔-浸潤, 浸潤麻酔法, 局所浸潤麻酔法, 浸潤麻酔, 局所浸潤麻酔
Swedish Lokalbedövning
Czech anestézie lokální, Místní anestezie, LA, Lokální anestetikum, Lokální anestezie, lokální anestezie, regionální anestézie
Finnish Paikallispuudutus
Russian ANESTEZIIA MESTNAIA, ANESTEZIIA INFIL'TRATSIONNAIA, АНЕСТЕЗИЯ ИНФИЛЬТРАЦИОННАЯ, АНЕСТЕЗИЯ МЕСТНАЯ
Croatian ANESTEZIJA, LOKALNA
Polish Znieczulenie miejscowe
Hungarian LA, Helyi érzéstelenítés, Helyi érzéstelenítő
Norwegian Lokalbedøvelse, Lokalanestesi

Ontology: Bupivacaine (C0006400)

Definition (NCI_NCI-GLOSS) A drug used to relieve pain by blocking signals at nerve endings. It is being studied in the relief of pain following surgery for cancer. It is a type of local anesthetic.
Definition (NCI) An amide-type, long-acting local anesthetic. Bupivicaine reversibly binds to specific sodium ion channels in the neuronal membrane, resulting in a decrease in the voltage-dependent membrane permeability to sodium ions and membrane stabilization; inhibition of depolarization and nerve impulse conduction; and a reversible loss of sensation.
Definition (MSH) A widely used local anesthetic agent.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D002045
SnomedCT 27196008, 387150008
LNC LP16053-8, MTHU014869
English Bupivacaine, 2-Piperidinecarboxamide, 1-butyl-N-(2,6-dimethylphenyl)-, 1-Butyl-N-(2,6-dimethylphenyl)-2-piperidinecarboxamide, Bupivacaine [Chemical/Ingredient], BUPIVACAINE, 1-Butyl-2',6'-pipecoloxylidide, local anesthetics bupivacaine (medication), local anesthetics bupivacaine, bupivacaine, Bupivacaine (product), Bupivacaine (substance), Bupivicaine
Swedish Bupivakain
Czech bupivakain
Finnish Bubivakaiini
Russian BUPIVAKAIN, БУПИВАКАИН
Japanese ブピバカイン
Polish Bupiwakaina
Croatian BUPIVAKAIN
Spanish bupivacaína (producto), bupivacaína (sustancia), bupivacaína, Bupivacaína
French Bupivacaïne
German Bupivacain
Italian Bupivacaina
Portuguese Bupivacaína

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: Local anesthesia, by infiltration (C0198813)

Concepts Therapeutic or Preventive Procedure (T061)
ICD10 92501-01
SnomedCT 44596000
English Local infiltration anaesthesia, Local infiltration anesthesia, Local anesthesia, by infiltration, Local anaesthesia, by infiltration, Local anaesthetic infiltration, Local anesthetic infiltration, Local anesthesia, by infiltration (procedure)
Spanish anestesia local, por infiltración (procedimiento), anestesia local, por infiltración

Ontology: Anesthesia, Infiltration (C0234945)

Concepts Therapeutic or Preventive Procedure (T061)
MSH D000772
English INFILTRATION ANAESTHESIA, INFILTRATION ANESTHESIA, Infiltration Anesthesia, Infiltration anaesthesia, Infiltration anesthesia, infiltration anaesthesia, infiltration anesthesia, Anesthesia, Infiltration
Spanish ANESTESIA POR INFILTRACION, Anestesia por Infiltración, Anestesia por infiltración
Dutch infiltratie anesthesie, infiltratieanesthesie, Infiltratie-anesthesie
French Anesthésie d'infiltration, Anesthésie locale par infiltration, ANESTHESIE PAR INFILTRATION, Anesthésie par infiltration, Anesthésie par infiltration locale
Japanese 浸潤麻酔, シンジュンマスイ
Portuguese Anestesia de Infiltração, ANESTESIA POR INFILTRACAO, Anestesia de infiltração
German Infiltrationsanästhesie, INFILTRATIONSANAESTHESIE, Infiltrationsanaesthesie
Czech Infiltrační anestezie, infiltrační anestézie
Hungarian Infiltrációs érzéstelenítés
Italian Anestesia d'infiltrazione, Anestesia per infiltrazione
Norwegian Infiltrasjonsanestesi

Ontology: Skin infiltration of local anesthetic (C0472454)

Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 231306007
English Skin infiltration LA, Skin infiltration of local anaesthetic, Skin infiltration of local anesthetic, Skin infiltration of local anesthetic (procedure)
Spanish infiltración de piel con anestesia local (procedimiento), infiltración de piel con anestesia local

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