Infiltrative Anesthesia in Office Practice



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2014 Jun 15;89(12):956-962.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

When choosing an infiltrative anesthetic agent, the type of procedure, the length of time required for anesthesia, and the pharmacodynamics of each medication are important considerations. Distraction techniques and buffering with sodium bicarbonate can be used to decrease the pain associated with injection. Local cutaneous infiltration is the most commonly used anesthetic technique and involves direct injection into the area requiring anesthesia. Field blocks provide anesthesia by circumferentially blocking innervation to the area. Nerve blocks target the innervation to a specific area and are useful on the face and digits. Using easily identifiable landmarks, blockade of the supraorbital, supratrochlear, infraorbital, and mental nerves can provide site-specific anesthesia. Dorsal and palmar or plantar digital nerve blocks can be performed at a variety of locations on the hands and feet.

Infiltrative anesthesia is often administered in the office setting. The physician's ability to execute a variety of techniques ensures adequate pain relief while minimizing risk to the patient, leading to optimal outcomes. The standard procedure for infiltrative anesthesia is summarized in Table 1.13

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Lidocaine (Xylocaine) buffered with sodium bicarbonate decreases the pain associated with injection; this effect is enhanced when the solution is warmed to room temperature.

B

2831

The intraoral approach to infraorbital or mental nerve blocks reduces patient discomfort.

C

1, 2, 3638


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Lidocaine (Xylocaine) buffered with sodium bicarbonate decreases the pain associated with injection; this effect is enhanced when the solution is warmed to room temperature.

B

2831

The intraoral approach to infraorbital or mental nerve blocks reduces patient discomfort.

C

1, 2, 3638


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Standard Procedure for Infiltrative Anesthesia

Review anatomy and choose an anesthetic technique

Consider contraindications

Absolute contraindications: patient refusal, infection at injection site, allergy to local anesthetic, nonsterile conditions

Relative contraindications: coagulopathy, preexisting neuropathy of the target nerve

Discuss the procedure with the patient, including what he or she can expect and the possible complications; obtain signed informed consent as needed

Evaluate the surrounding area and areas distal to the injection site for signs of neurovascular compromise

Choose and label the appropriate anesthetic agent based on the technique and clinical situation; warm and buffer solutions as indicated

Cleanse the injection site (for intact skin, alcohol wipes are as effective as chlorhexidine [Peridex] or povidone/ iodine)

Rapidly insert the needle (27- to 30-gauge) through the skin into the subcutaneous layer, using distraction techniques as necessary; consider aspiration before injection

Slowly and steadily inject small volumes of anesthetic while withdrawing the needle

Test the area for adequate anesthesia


Information from references 1 through 3.

Table 1.   Standard Procedure for Infiltrative Anesthesia

View Table

Table 1.

Standard Procedure for Infiltrative Anesthesia

Review anatomy and choose an anesthetic technique

Consider contraindications

Absolute contraindications: patient refusal, infection at injection site, allergy to local anesthetic, nonsterile conditions

Relative contraindications: coagulopathy, preexisting neuropathy of the target nerve

Discuss the procedure with the patient, including what he or she can expect and the possible complications; obtain signed informed consent as needed

Evaluate the surrounding area and areas distal to the injection site for signs of neurovascular compromise

Choose and label the appropriate anesthetic agent based on the technique and clinical situation; warm and buffer solutions as indicated

Cleanse the injection site (for intact skin, alcohol wipes are as effective as chlorhexidine

The Authors

JOSHUA L. LATHAM, DO, is a faculty member at the Headquarters Air Armament Center Family Medicine Residency at Eglin Air Force Base, Fla.

SEAN N. MARTIN, DO, is a faculty member at the Headquarters Air Armament Center Family Medicine Residency.

Address correspondence to Joshua L. Latham, DO, Headquarters Air Armament Center Family Medicine Residency, 307 Boatner Road, Ste. 114, Eglin Air Force Base, FL 32542 (e-mail: joshua.latham@us.af.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Air Force Medical Service or the U.S. Air Force at large.

REFERENCES

1. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 5th ed. Philadelphia, Pa.: Saunders/ Elsevier; 2010:490–493.

2. Pfenninger JL, Moy J. Peripheral nerve blocks and field blocks. In: Pfenninger JL, Fowler GC, eds. Pfenninger and Fowler's Procedures for Primary Care. 2nd ed. St. Louis, Mo.: Mosby; 2003:37–45.

3. Dzubow LM, Halpern AC, Leyden JJ, Grossman D, McGinley KJ. Comparison of preoperative skin preparations for the face. J Am Acad Dermatol. 1988;19(4):737–741.

4. Becker DE, Reed KL. Essentials of local anesthetic pharmacology. Anesth Prog. 2006;53(3):98–108.

5. Fink BR. The long and the short of conduction block. Anesth Analg. 1989;68(5):553–555.

6. Tetzlaff JE. The pharmacology of local anesthetics. Anesthesiol Clin North America. 2000;18(2):217–233, v.

7. Achar S, Kundu S. Principles of office anesthesia: part I. Infiltrative anesthesia. Am Fam Physician. 2002;66(1):91–94.

8. McCreight A, Stephen M. Local and regional anesthesia. In: King C, Henretig FM, eds. Textbook of Pediatric Procedures. 2d ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2008.

9. Salam GA. Regional anesthesia for office procedures: part I. Head and neck surgeries. Am Fam Physician. 2004;69(3):585–590.

10. Liu W, Yang X, Li C, Mo A. Adverse drug reactions to local anesthetics: a systematic review. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;115(3):319–327.

11. Giovannitti JA, Bennett CR. Assessment of allergy to local anesthetics. J Am Dent Assoc. 1979;98(5):701–706.

12. González-Delgado P, Antón R, Soriano V, Zapater P, Niveiro E. Cross-reactivity among amide-type local anesthetics in a case of allergy to mepivacaine. J Investig Allergol Clin Immunol. 2006;16(5):311–313.

13. Berkun Y, Ben-Zvi A, Levy Y, Galili D, Shalit M. Evaluation of adverse reactions to local anesthetics: experience with 236 patients. Ann Allergy Asthma Immunol. 2003;91(4):342–345.

14. Gall H, Kaufmann R, Kalveram CM. Adverse reactions to local anesthetics: analysis of 197 cases. J Allergy Clin Immunol. 1996;97(4):933–937.

15. Speca SJ, Boynes SG, Cuddy MA. Allergic reactions to local anesthetic formulations. Dent Clin North Am. 2010;54(4):655–664.

16. Bernards CM, Kopacz DJ. Effect of epinephrine on lidocaine clearance in vivo: a microdialysis study in humans. Anesthesiology. 1999;91(4):962–968.

17. Sinnott CJ, Cogswell LP III, Johnson A, Strichartz GR. On the mechanism by which epinephrine potentiates lidocaine's peripheral nerve block. Anesthesiology. 2003;98(1):181–188.

18. Todd K, Berk WA, Huang R. Effect of body locale and addition of epinephrine on the duration of action of a local anesthetic agent. Ann Emerg Med. 1992;21(6):723–726.

19. Lalonde DH, Lalonde JF. Discussion. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast Reconstr Surg. 2010;126(6):2035–2036.

20. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30(5):1061–1067.

21. Muck AE, Bebarta VS, Borys DJ, Morgan DL. Six years of epinephrine digital injections: absence of significant local or systemic effects. Ann Emerg Med. 2010;56(3):270–274.

22. Nath S, Häggmark S, Johansson G, Reiz S. Differential depressant and electrophysiologic cardiotoxicity of local anesthetics: an experimental study with special reference to lidocaine and bupivacaine. Anesth Analg. 1986;65(12):1263–1270.

23. Rosen MA, Thigpen JW, Shnider SM, Foutz SE, Levinson G, Koike M. Bupivacaine-induced cardiotoxicity in hypoxic and acidotic sheep. Anesth Analg. 1985;64(11):1089–1096.

24. Ahlstrom KK, Frodel JL. Local anesthetics for facial plastic procedures. Otolaryngol Clin North Am. 2002; 35(1):29–53, v–vi.

25. Flanagan HL, Datta S, Lambert DH, Gissen AJ, Covino BG. Effect of pregnancy on bupivacaine-induced conduction blockade in the isolated rabbit vagus nerve. Anesth Analg. 1987;66(2):123–126.

26. Santos AC, Pedersen H, Harmon TW, et al. Does pregnancy alter the systemic toxicity of local anesthetics? Anesthesiology. 1989;70(6):991–995.

27. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132(3):675–684.

28. Cepeda MS, Tzortzopoulou A, Thackrey M, Hudcova J, Arora Gandhi P, Schumann R. Adjusting the pH of lidocaine for reducing pain on injection. Cochrane Database Syst Rev. 2010;(12):CD006581.

29. Malamed SF, Tavana S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1:100,000. Compend Contin Educ Dent. 2013;34(spec no 1):10–20.

30. Welch MN, Czyz CN, Kalwerisky K, Holck DE, Mihora LD. Double-blind, bilateral pain comparison with simultaneous injection of 2% lidocaine versus buffered 2% lidocaine for periocular anesthesia. Ophthalmology. 2012;119(10):2048–2052.

31. Hogan ME, vanderVaart S, Perampaladas K, Machado M, Einarson TR, Taddio A. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med. 2011;58(1):86–98, e1.

32. Peterfreund RA, Datta S, Ostheimer GW. pH adjustment of local anesthetic solutions with sodium bicarbonate: laboratory evaluation of alkalinization and precipitation. Reg Anesth. 1989;14(6):265–270.

33. Cheney PR, Molzen G, Tandberg D. The effect of pH buffering on reducing the pain associated with subcutaneous infiltration of bupivicaine [published correction appears in Am J Emerg Med. 1991;9(4):410]. Am J Emerg Med. 1991;9(2):147–148.

34. Jones JS, Plzak C, Wynn BN, Martin S. Effect of temperature and pH adjustment of bupivacaine for intradermal anesthesia. Am J Emerg Med. 1998;16(2):117–120.

35. Kanakaraj M, Shanmugasundaram N, Chandramohan M, Kannan R, Perumal SM, Nagendran J. Regional anesthesia in faciomaxillary and oral surgery. J Pharm Bioallied Sci. 2012;4(suppl 2):S264–S269.

36. Karkut B, Reader A, Drum M, Nusstein J, Beck M. A comparison of the local anesthetic efficacy of the extraoral versus the intraoral infraorbital nerve block. J Am Dent Assoc. 2010;141(2):185–192.

37. Lynch MT, Syverud SA, Schwab RA, Jenkins JM, Edlich R. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med. 1994;1(6):514–519.

38. Syverud SA, Jenkins JM, Schwab RA, Lynch MT, Knoop K, Trott A. A comparative study of the percutaneous versus intraoral technique for mental nerve block. Acad Emerg Med. 1994;1(6):509–513.

39. Chale S, Singer AJ, Marchini S, McBride MJ, Kennedy D. Digital versus local anesthesia for finger lacerations: a randomized controlled trial. Acad Emerg Med. 2006;13(10):1046–1050.

40. Latifzai K, Sites BD, Koval KJ. Orthopaedic anesthesia-part 2. Common techniques of regional anesthesia in orthopaedics. Bull NYU Hosp Jt Dis. 2008;66(4):306–316.


Copyright © 2014 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

Article Tools

  • Download PDF
  • Print page
  • Share this page
  • AFP CME Quiz

More in Pubmed

Navigate this Article