SURGERY SECTION 21

Anesthesia
George J. Hruza
143
solution, the salt equilibrates between the ionized and non-ionized
Key features form. The ionized form is water-soluble, allowing injection into and
„ Local anesthetics are classified into two groups – amides and diffusion through tissue. However, it is the non-ionized, lipid-soluble
esters – depending upon the linkage in their intermediate chain base that can diffuse into the nerve cell membrane. Within the sodium
„ “Anesthetic allergies” vary from palpitations secondary to channel’s inner pore, it is the ionized cation that is responsible for
epinephrine and vasovagal reactions, to urticaria and anaphylaxis blocking nerve conduction (see above)3.
from preservatives or the local anesthetic (especially esters) The dissociation constant (pKa) of each anesthetic determines the
proportion of the anesthetic base and its cation at a given pH. The pKa
„ Additives to the local anesthetic include epinephrine, sodium
of all local anesthetics is higher than physiologic pH. For most local
­bicarbonate, and hyaluronidase
anesthetics at a pH of 7.4, 80% or more is in the cationic ionized form.
„ Nerve blocks are particularly helpful when performing procedures Alkalinization of the anesthetic solution, as is done with the addition
on the face, digits, and palmoplantar surfaces of sodium bicarbonate, will speed its onset of action as more of the
anesthetic will be in the non-ionized form. However, if the pH is raised
too much, the anesthetic may precipitate out of solution. Anesthetic
INTRODUCTION sensitivity to pH also helps explain why infected tissue is difficult
to effectively anesthetize4. The inflammatory response surrounding
Effective anesthesia is an essential component of dermatologic surgery, the infection acidifies the site (reduces the pH), which reduces the
and almost all dermatologic surgical procedures can be performed under proportion of the anesthetic in the non-ionized, lipid-soluble form.
local anesthesia. Local anesthetics have been in use since the 1880s with
the introduction of cocaine hydrochloride, which was extracted from
the leaves of the South American bush Erythroxylon coca1. This was Pharmacology
followed by procaine in 1904, tetracaine in 1930, and lidocaine, the first Local anesthetics are classified into two groups, depending on the
amide local anesthetic, was introduced in 19431. The introduction of linkage in the intermediate chain (Table 143.1). Amide anesthetics
lidocaine was a major breakthrough because lidocaine is far less likely to have an amide linkage and ester anesthetics have an ester linkage
cause an allergic reaction than the ester-type anesthetics that preceded it. (Fig. 143.1). They differ in how they are metabolized and in the risk of
Local anesthesia has several advantages over general anesthesia, sensitization. Ester anesthetics are hydrolyzed by plasma pseudocholin-
including reduced morbidity (especially in poor-risk patients), reduced esterase, and the metabolites are excreted by the kidneys. Patients with a
cost, reduced procedure time, and faster recovery. The main disadvan- deficiency of functional pseudocholinesterase, who are often diagnosed
tages are some limitation on the extent of a procedure and the possi- after prolonged paralysis following administration of standard doses of
bility of greater patient discomfort from the injections. Knowledge of the succinylcholine, are at an increased risk of ester anesthetic toxicity. The
physiology, dosage, side effects, and proper “painless” local anesthesia metabolite para-aminobenzoic acid (PABA) is responsible for the allergic
technique are essential for performing dermatologic surgery and to keep reactions seen with ester anesthetics. Amide anesthetics are metabo-
patients safe and satisfied2. lized by the hepatic microsomal cytochrome P450 enzyme system, and
the metabolites are excreted by the kidneys. Patients with severe liver
disease may be at increased risk of amide anesthetic toxicity.
DISCUSSION
Physiology and Structure CHEMICAL STRUCTURE OF ESTER AND
Fig. 143.1 Chemical
structure of the ester
Local anesthetics act by blocking sodium channels in the axon cell AMIDE LOCAL ANESTHETICS
and amide group local
membrane, and this prevents sodium from entering the nerve cell. The anesthetics. The aromatic
nerve cell is not depolarized and consequently the action potential is Ester group anesthetics (hydrophobic and
blocked. The cationic form of the anesthetic appears to bind to the lipophilic) end is joined to
Aromatic Intermediate Amine the amine (hydrophilic)
inner pore of voltage-gated sodium channels, possibly leading to both portion portion portion
narrowing of the pore lumen (steric block) and creation of an electro- end with an ester or
(hydrophobic) (hydrophilic) amide linkage.
static barrier to permeation3. Smaller unmyelinated C-type nerve fibers
R
that conduct pain sensation are blocked more quickly and easily than
intermediate fibers that also carry sensations of heat and cold. The
C O R N
myelinated A-type fibers that carry pressure sensation and motor fibers
are blocked last. Clinically, this is evident when an area seems fully O R
anesthetized for scalpel surgery, but the patient still feels the pressure Ester
of the surgeon’s fingers at the surgical site. link
All local anesthetics consist of three parts (Fig. 143.1):
● a secondary or tertiary amine end
Amide group anesthetics
● an aromatic end
● an intermediate connecting chain that contains an ester or amide.
H R
The aromatic portion is hydrophobic and lipophilic. This is essential
to allow the anesthetic to diffuse through nerve cell membranes. The N C R N
amine portion is hydrophilic and is responsible for the anesthetic’s
water solubility, which is important for preparing, storing, and admin- O R
istering the anesthetic3. Amide
Local anesthetics are weak organic bases, which, to be water-soluble link 2479
and injectable, require the addition of a hydrochloride salt. In aqueous

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SECTION

21 LOCAL ANESTHETICS FOR INFILTRATIVE AND NERVE BLOCK ANESTHESIA

Maximum dose plain Maximum dose with epinephrine
SURGERY

Generic name Trade name® Onset (min) Duration plain (h) (mg for 70 kg person) (mg for 70 kg person)
Amides
Articaine Septocaine 2–4 0.5–2 350 500
Bupivacaine hydrochloride Marcaine 5–8 2–4 175 225
Etidocaine Duranest 3–5 3–5 300 400
Levobupivacaine hydrochloride Chirocaine 2–10 2–4 150 Not available
Lidocaine Xylocaine Rapid 0.5–2 350 500 (3500 dilute)
Mepivacaine Carbocaine 3–20 0.5–2 300 500
Prilocaine hydrochloride Citanest 5–6 0.5–2 400 600
Ropivacaine* Naropin 1–15 2–6 200 Not available
Esters
Chloroprocaine hydrochloride Nesacaine 5–6 0.5–2 800 1000
Procaine Novocaine 5 1–1.5 500 600
Tetracaine Pontocaine 7 2–3 100 Not available
*Addition of epinephrine has no effect on onset or duration of action of ropivacaine.
Table 143.1 Local anesthetics for infiltrative and nerve block anesthesia. In clinical practice, the duration of anesthesia appears to be less than stated, especially for
head and neck areas. Addition of epinephrine prolongs anesthesia by a factor of two. 1% lidocaine solution = 10 mg/ml.

Local anesthetics differ in the speed of onset, duration of action, and Epinephrine is premixed with local anesthetics at a concentration of
potency, depending on each compound’s intrinsic chemical charac- 1 : 100 000 or 1 : 200 000. However, concentrations as low as 1 : 1 000 000
teristics (Table 143.1). A low pKa leads to rapid onset of anesthesia, achieve effective vasoconstriction, while concentrations >1 : 100 000
as more of the anesthetic will be in the non-ionized form. Greater are associated with a greater risk of side effects. The concentration used
lipid solubility is associated with higher anesthetic potency, as the in a given patient should be individualized. Patients who have relative
compound penetrates the nerve cell membrane more easily. Duration contraindications to epinephrine should receive lower concentrations,
of action is determined by the strength of anesthetic binding to the while highly vascular areas such as the scalp should receive higher
sodium channel pore. concentrations. At an epinephrine concentration of 1 : 100 000, the
For pregnant women, the local anesthetic of choice is lidocaine. It is maximum dosage used is determined by the anesthetic with which the
historically classified as FDA pregnancy category B, which means that, epinephrine is premixed (Table 143.1).
in animal studies, no teratogenic effects have been documented. Studies Epinephrine is a strong β- and α-agonist and, as such, it must be
in pregnant women who received lidocaine during the first trimester of used cautiously in patients with altered β- and α-receptors. Absolute
pregnancy have shown no increase in anatomic abnormalities in the contraindications to the use of epinephrine include hyperthyroidism
newborns. However, it is recommended that lidocaine, as with all other and pheochromocytoma. Patients taking β-blockers, monoamine
pharmacologic agents, be used cautiously during the first 4 months oxidase inhibitors, tricyclic antidepressants, and phenothiazines are
of pregnancy, when maximum organogenesis takes place. Lidocaine more sensitive to epinephrine. Therefore, epinephrine should be used
crosses the placenta into the fetus. Lidocaine can be safely used in with caution, with the dose and concentration reduced accordingly.
nursing mothers with the realization that some of the anesthetic may In patients taking β-blockers, severe hypertension developing after
be excreted in the mother’s milk. injection of epinephrine-containing anesthetics has been reported6.
Lidocaine can be safely used in children, but the maximum recom- This is probably due to unopposed α-adrenergic activity with its
mended dosage should be adjusted downward based on the child’s associated vasoconstriction. Fortunately, this reaction seems to be quite
weight and age. Care must be taken in premature infants due to cardio- rare7, and mainly occurs when higher doses are used. Patients with
vascular effects. Parabens, used as preservatives, are bound to albumin. severe hypertension or with severe cardiovascular disease (especially
In a jaundiced newborn, they could displace bilirubin from the albumin, coronary artery disease) may have their underlying disease exacer-
worsening the hyperbilirubinemia5. For this reason, only paraben-free bated if large amounts of epinephrine are administered with the local
anesthetics should be used in newborns. anesthetic. High doses of epinephrine can induce labor. However, the
low doses of epinephrine used in cutaneous surgery can be safely used
during pregnancy. Epinephrine use in the periorbital area in patients
Additions to Local Anesthetics with narrow angle glaucoma should be avoided, as it may aggravate the
patient’s glaucoma.
Epinephrine The use of epinephrine on digits has been controversial. Historically,
All local anesthetics, except for cocaine hydrochloride, relax vascular epinephrine was not used on digits for fear of causing vasocon-
smooth muscle, which results in vasodilation. This causes increased striction that might result in digital necrosis. More recent studies
bleeding at the operative site and reduced duration of anesthetic have not demonstrated any increased risk from epinephrine in digital
action as the anesthetic is rapidly removed from the surgical site via anesthesia. It appears that most cases of digital necrosis occurred
the dilated blood vessels. The addition of epinephrine (adrenaline) due to vessel compression from too much anesthetic volume being
has the beneficial effect of constricting blood vessels, which prolongs injected (tamponade), constricting circumferential dressings, tourni-
the duration of anesthesia 100% to 200% by slowing removal of the quets, postoperative hot soaks (possibly due to heat-induced edema),
anesthetic from the surgical site. Also, there is reduced intraoperative infection, use of vasoconstrictive anesthetics such as cocaine hydro-
bleeding due to the vasoconstriction. The addition of epinephrine chloride, or non-standard mixing of lidocaine with epinephrine8. There
provides more effective anesthesia by decreasing the volume of is no evidence of digital necrosis due solely to commercially available
anesthetic needed. The reduced absorption rate decreases anesthetic lidocaine with epinephrine8. However, epinephrine is contraindicated
toxicity and allows larger doses to be used safely. The vasoconstrictive for digital anesthesia in patients with peripheral artery disease. We have
effect of epinephrine, manifested by skin blanching, takes about found that combining lidocaine with dilute epinephrine (1 : 500 000)
2480 15 minutes to fully develop. While they usually coincide, blanching and small volumes provides safe digital anesthesia. Ring blocks of the
does not always denote the anesthetized area. digit should be avoided.

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 CHAPTER
Self-limited systemic side effects of epinephrine include palpitations,
anxiety, fear, diaphoresis, headache, tremor, weakness, tachycardia, and
anesthetics to diffuse further away from the injection point. In addition,
there is less distortion of the injected structures11. The greater diffusion 143
elevated blood pressure. These signs and symptoms can be seen on of anesthetic may decrease its duration of action. Hyaluronidase is

Anesthesia
occasion even with normal doses used for skin surgery, but they usually most useful for periorbital surgery and to increase the rate of successful
resolve within a few minutes (Table 143.2). They are more commonly nerve blocks. It is prepared by adding 150 units (U) to 30 ml of local
seen when injecting highly vascular areas, especially the face and scalp. anesthetic. Allergic reactions to hyaluronidase are rare, but they can
Skin necrosis from vasoconstriction is an extremely rare complication occur. Some surgeons recommend an intradermal skin test before using
of epinephrine injection and would be an issue only in patients with hyaluronidase. In addition, the preparation may contain thimerosal
severe vascular compromise at the injection site. preservative, which can cause contact dermatitis.
Serious side effects of epinephrine injection include cardiac arrhythmias
(e.g. ventricular tachycardia, ventricular fibrillation), cardiac arrest, and
cerebral hemorrhage. None of these should be expected to occur at the Anesthetic Mixtures
doses used for skin surgery. However, it is prudent to limit the total dose In an attempt to take advantage of different anesthetic properties, some
injected in patients with severe cardiac disease. surgeons combine two local anesthetics in one syringe. For example,
Epinephrine is stable only in an acidic environment. Therefore, when a combination of lidocaine, for its rapid onset of action, with bupiva-
epinephrine is premixed with local anesthetics, the pH is lowered into caine hydrochloride, for its longer duration of action, is often used.
the 3.5 to 5.5 range with the addition of acidic preservatives such as However, a study looking at such combinations has found that these
sodium metabisulfite to stabilize the epinephrine. This acidic solution mixtures do not live up to their promise. The mixture seems to take on
not only is more painful at the time of injection9, but also slows the the properties of one of the components to the exclusion of the other12.
onset of anesthetic action, as less anesthetic is in the non-ionized form. Therefore, most surgeons will inject the rapid-onset anesthetic first and
By preparing the mixture fresh daily and using it by the end of the the longer-acting anesthetic later, to minimize the pain of injection and
day, the mixture has a higher pH, which is less painful. Adding 0.5 ml maximize the duration of action.
epinephrine (1 : 1000) to 50 ml plain lidocaine will give a final concen-
tration of 1 : 100 000 epinephrine. Alternatively, the lidocaine with Side Effects
epinephrine can be neutralized with sodium bicarbonate (see below).
Vasovagal reactions
Sodium bicarbonate By far the most common side effect of local anesthetic injection is a
Injecting the standard mixture of lidocaine with epinephrine at a pH of 3.5 vasovagal reaction, in which the vagus nerve discharges due to patient
to 5.5 is quite painful, with significant stinging due to the acidic pH. The anxiety, resulting in an increase in parasympathetic tone (Table 143.2).
pH can be neutralized with the addition of sodium bicarbonate. Adding one Vasovagal reactions are manifested by dizziness, diaphoresis, syncope,
part of 8.4% sodium bicarbonate to ten parts lidocaine with epinephrine bradycardia, and hypotension. Placing the patient in the Trendelenburg
will bring the pH into a more physiologic 7 to 8 range. This mixture signif- position will rapidly relieve the patient’s symptoms. A cold towel on the
icantly reduces the pain of anesthetic injection9,10. Both components can forehead can also be helpful. Oxygen, fluids, atropine, or epinephrine are
be drawn up into the syringe, immediately before injection. Alternatively, usually not necessary. To avoid significant vasovagal reactions, patients
5 ml sodium bicarbonate (8.4%) can be added to a 50 ml bottle of lidocaine should have local anesthetic infiltrated in the recumbent position.
with epinephrine. As the epinephrine activity is lost at a rate of 25% per
week in an alkaline or neutral environment, the mixture should be labeled Allergic reactions
with the date prepared, kept refrigerated, and used within about 1 week. The most important side effect of local anesthetics is the development
There is evolving FDA and United States Pharmacopeia (USP) <https:// of allergic reactions. The allergy is usually a type I IgE-mediated reaction
www.usp.org/compounding/general-chapter-797> guidance that requires manifested by urticaria, angioedema, bronchospasm, and, on rare
any buffered local anesthetic (in office “compounding”) to be used within occasions, anaphylaxis with associated hypotension and tachycardia
4 hours of preparation. As state boards of pharmacy adopt this guidance, (Table 143.2). Most true local anesthetic allergies have been reported
physicians in those states will be required to comply. Several dermatology with ester anesthetics; amide anesthetics are implicated only very
societies are developing a USP monograph to extend the time that buffered rarely. Preservatives added to multidose vials, especially methylparaben
lidocaine can be used after preparation. and sodium metabisulfite, have frequently been shown to be the cause
of “local anesthetic” allergy13.
Hyaluronidase There is some allergy cross-reactivity amongst the various ester
Hyaluronidase (derived from bovine testicular hyaluronidase) depoly- anesthetics and amongst the amide anesthetics, but there is no cross-
merizes hyaluronic acid, which breaks up ground substance, allowing reactivity between the ester and amide anesthetic classes. It is PABA

DIFFERENTIAL DIAGNOSIS OF LOCAL ANESTHETIC SYSTEMIC REACTIONS

Diagnosis Pulse rate Blood pressure Signs and symptoms Emergency management
Vasovagal Low Low Excess parasympathetic tone; diaphoresis, Trendelenburg position, cold compress,
reaction ­hyperventilation, nausea reassurance
Epinephrine High High Excess α- and β-adrenergic receptor stimulation; Reassurance (usually resolves within minutes),
reaction palpitations phentolamine, propranolol
Anaphylactic High Low Peripheral vasodilation with reactive tachycardia; Epinephrine 1 : 1000 0.3 ml subcutaneous,
reaction stridor, bronchospasm, urticaria, angioedema antihistamines, corticosteroids, fluids,
oxygen, airway maintenance
Lidocaine overdose
1–6 mcg/ml Normal Normal Circumoral and digital paresthesias, restlessness, Observation
drowsiness, euphoria, lightheadedness
6–9 mcg/ml Normal Normal Nausea, vomiting, muscle twitching, tremors, blurred Diazepam, airway maintenance
vision, tinnitus, dysgeusia (e.g. metallic taste),
confusion, excitement, psychosis
9–12 mcg/ml Low Low Seizures, cardiopulmonary depression, arrhythmia Respiratory support
>12 mcg/ml Severely low Severely low Coma, cardiopulmonary arrest Cardiopulmonary resuscitation and life support
Table 143.2 Differential diagnosis of local anesthetic systemic reactions. In case of systemic reactions during or after local anesthetic injections, hemodynamic 2481
signs are helpful in determining the cause of the reaction.

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SECTION

21 (the metabolite of ester anesthetics) that is thought to be responsible

for ester anesthetic allergic reactions. Ester anesthetics can also cause
which is an oxidizing agent capable of converting hemoglobin to methe-
moglobin. This can become significant with large doses of more than
type IV delayed hypersensitivity reactions and cross-react with several 500 mg. Benzocaine has also been implicated in causing methemoglo-
SURGERY

contact sensitizers, including PABA, para-amino salicylic acid, and binemia when used on mucosal surfaces19. The treatment of methemo-
para-phenylenediamine (PPD). globinemia is methylene blue infusion.
Patients who present with a history of “local anesthetic” allergy need
to be questioned in detail about the “allergy” with a review of relevant
medical records whenever possible. Often, the “allergy” is a result of a Topical Anesthetics
vasovagal reaction or epinephrine sensitivity. If the reaction seems to
represent a true allergic reaction and the offending anesthetic is known Skin
(usually an ester), using an anesthetic from the other class (usually Historically, the only anesthetic used for topical anesthesia of keratinized
an amide) in a preservative-free solution is a reasonable option. Skin skin was benzocaine, which is an ester anesthetic. Anesthesia was
testing, by an allergist, may be warranted if the offending agent is not generally effective only when applied to traumatized skin. Little, if any,
certain14. The testing should include pinprick followed by intradermal anesthesia was achieved in intact normal skin. Of greater concern was
tests of an ester anesthetic, an amide anesthetic, methylparaben, and the high rate of allergic contact dermatitis seen with benzocaine.
sodium metabisulfite. Alternatively, for small procedures, adequate There are now several topical anesthetics that achieve moderate super-
anesthesia can be obtained with intradermal injection of 1% diphen- ficial anesthesia of intact skin (Table 143.3). EMLA® is available in a
hydramine solution. Epinephrine may be added to counteract vasodi- cream formulation or as a disc. It is a eutectic mixture of 2.5% lidocaine
lation caused by diphenhydramine, to enhance the anesthetic effect, and 2.5% prilocaine hydrochloride. EMLA® is able to achieve super-
and to reduce systemic antihistamine symptoms15. Intradermal normal ficial anesthesia, with the degree of anesthesia related to the amount
saline with benzyl alcohol preservative will achieve very brief anesthesia and duration of application before surgery. The cream is applied as a
through pressure effects on cutaneous nerve endings and the anesthetic thick layer under occlusion at least 1 hour before the procedure while
properties of the benzyl alcohol preservative. It can be used for very the disc itself provides occlusion. It is especially useful for reducing the
short procedures such as a shave biopsy16. pain of non-ablative laser procedures and to reduce the pain of local
Limited allergic reactions can be managed with oral antihistamines anesthetic or other injections. Some dermatologists who perform CO2
and prednisone. However, patients developing bronchospasm, angio- laser ablative resurfacing solely under EMLA® anesthesia prepare the
edema, or hemodynamic compromise require immediate emergency skin with vigorous degreasing followed by two applications of EMLA®
management including subcutaneous epinephrine, bronchodilators, 1 hour apart under occlusion. Additional EMLA® is applied to the skin
parenteral antihistamines, corticosteroids, intravenous fluids, and after the first pass with the laser has removed the epidermis.
oxygen (Table 143.2). EMLA® appears to be safe, but some caution is advised when using
large amounts on skin with a damaged skin barrier and in infants who
Local side effects might be susceptible to methemoglobinemia from too much prilocaine
Bruising and edema are frequently seen after local anesthetic infiltration, hydrochloride absorption. For recommended applications in children,
especially in the periorbital area. Periorbital edema will often develop see Table 143.4. It should not be used in patients with G6PD deficiency.
after surgery on the forehead and frontal scalp. Transient motor nerve EMLA® often blanches the skin after application, followed by vasodi-
paralysis is sometimes seen. This may be delayed for some time after the lation 30–60 minutes after its removal. The vasodilation is usually of
sensory nerves have become anesthetized, because of the large myelinated no clinical significance, but there are reports of petechiae and purpura
nerve fibers involved. The paralysis may persist for several hours after the developing at the site of EMLA® application. Additional reported side
sensory nerves have returned to normal. Informing the patient when a effects include occasional burning and irritation, chemical injury to the
motor nerve has been affected by the anesthetic will eliminate distressed eye, contact urticaria, and allergic contact dermatitis, with the latter
patient telephone calls. Prolonged sensory nerve paresthesia may develop two reactions most often due to the prilocaine component.
if a sensory nerve is injured due to intraneural injection. This is most Other preparations that have been optimized for epidermal penetration
commonly seen after nerve blocks. It can be minimized by avoiding include: LMX®, containing 4% or 5% lidocaine (Table 143.5); Topicaine®,
intraneural injections and by using small-gauge needles for injection. containing 4% lidocaine; 4% tetracaine gel; 30%–40% lidocaine in acid
mantle cream; and various other compounded mixtures of lidocaine,
Overdosage benzocaine, and tetracaine (Table 143.3). Due to safety issues reported
If the local anesthetic dosage administered is kept within recommended with compounded medications (see below), the FDA has severely
ranges, clinical symptoms of local anesthetic overdose are unlikely to be restricted access to compounded topical anesthetics.
encountered. Maximum recommended dosages of lidocaine are 5 mg/kg In a comparison study, EMLA® and LMX® 4% were found to achieve
plain (i.e. with no epinephrine), 7 mg/kg if with epinephrine and at superior anesthesia to tetracaine 4% gel, which was superior to Betacaine
standard (1%–2%) concentrations, and 35–50 mg/kg for tumescent LA®, which was superior to control20. According to the manufac-
lidocaine anesthesia consisting of dilute 0.05%–0.1% lidocaine with turer, LMX® does not require occlusion to be effective. A comparison
1 : 1 000 000 epinephrine (Table 143.1)17,18. of EMLA® under occlusion and LMX® unoccluded found that LMX®
The symptoms of local anesthetic overdose are directly related to achieved equivalent anesthesia to EMLA® after less than one-third of
its serum blood level, with worsening CNS and cardiovascular signs application time21. None of the topical anesthetics have any significant
and symptoms as the level increases (Table 143.2). CNS symptoms effectiveness for palmar or plantar surfaces.
start with circumoral and digital numbness and tingling, followed Pliaglis® is a 7% lidocaine/7% tetracaine preparation that, when cold,
by lightheadedness, tinnitus, visual disturbances, slurred speech, is a cream, but when placed on the skin and exposed to air it becomes
muscle twitching, and, finally, seizures and coma. Cardiovascular and a flexible membrane. Once anesthesia has been achieved (after about
pulmonary symptoms develop at significantly higher doses than do 30 minutes), the membrane can be peeled off prior to the procedure.
early CNS symptoms and include hypotension, arrhythmias, respi- This product is useful for laser procedures22. The anesthetic level is
ratory depression, and cardiac arrest. equivalent to that of the other topical anesthetics.
When lidocaine is administered, there are over 150 potential drug– Iontophoresis of 1%–4% lidocaine with epinephrine can enhance the
drug interactions. Most are minor or only relevant when large doses of depth and effectiveness of topical anesthesia. It is practical only for
lidocaine are used. Patients receiving medications that inhibit the liver’s rather small areas, but anesthesia can be achieved within a few minutes
cytochrome P450 system (e.g. erythromycin, ketoconazole, itraconazole; with a 1 mA current. The main drawback is the additional equipment
see Ch. 131), and therefore inhibit lidocaine metabolism, can exhibit and supplies needed. Ultrasound or warm steaming of the skin also
signs of lidocaine overdose at lower doses. With large doses of lidocaine, enhances the effect of topical anesthetics, probably by enhancing
patients taking class I and III antiarrhythmic drugs (e.g. amiodarone) anesthetic penetration. In addition, fractionated ablative lasers and
are at increased risk of cardiac arrhythmias and those taking CNS skin microneedling devices have been shown to enhance penetration
depressants (e.g. opiates) are at increased risk of CNS toxicity. of topical anesthetics, leading to improved local anesthesia23. When
2482 Bupivacaine hydrochloride has a greater risk of cardiac toxicity than performing multi-pass laser treatments of large areas, these techniques
lidocaine. Prilocaine hydrochloride metabolizes to ortho-toluidine, may reduce the need for injectable anesthetics.

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 CHAPTER

Generic name
TOPICAL ANESTHETICS FOR MUCOUS MEMBRANE AND INTACT SKIN ANESTHESIA
Trade name® Concentration (%) Type Primary use
143

Anesthesia
Benzocaine Americaine otic 20 Ester Tympanic membrane
Benzocaine gel, liquid, spray HurriCaine 20 Ester Mucous membranes
Benzocaine/tetracaine/butamben (butyl Cetacaine, Exactacain Esters Mucous membranes
­aminobenzoate) gel, liquid, spray
Benzocaine/lidocaine/tetracaine compounded Various Ester/amide/ester Intact skin
Cocaine hydrochloride nasal solution Goprelto, Numbrino 2–10 Ester Nasal mucosa
Dibucaine (cinchocaine) Nupercainal 1 Amide Mucous membranes
Lidocaine cream LMX 4–5 Amide Intact skin (4%); anorectal (5%)
Lidocaine gel Topicaine 4 4 Amide Intact skin
Lidocaine solution Xylocaine 2–5 Amide Mucous membranes
Lidocaine in acid mantle cream compounded 30–40 Amide Intact skin
Lidocaine/prilocaine eutectic mix [cream or disc] EMLA 2.5/2.5 Amides Intact skin
Lidocaine/prilocaine cream Lidopril 2.5/2.5 Amides Intact skin
Lidocaine/tetracaine peel Pliaglis 7/7 Amide/ester Intact skin
Lidocaine/tetracaine patch Synera 7/7 Amide/ester Intact skin
Proparacaine (proxymetacaine) ophthalmic solution Alcaine 0.5 Ester Conjunctiva
Tetracaine gel Tetracaine gel 4 Ester Intact skin
Tetracaine ophthalmic solution Pontocaine 0.5 Ester Conjunctiva
Table 143.3 Topical anesthetics for mucous membrane and intact skin anesthesia. Anesthetics for topical skin anesthesia require application 0.5–2 hours prior to
surgery under occlusion for maximal effect. Benzocaine is a potent topical sensitizer.

MAXIMUM RECOMMENDED EMLA® APPLICATION IN CHILDREN MAXIMUM RECOMMENDED LIDOCAINE 4% LIPOSOMAL CREAM
(LMX4®) APPLICATION IN CHILDREN
Maximum
Weight total dose Maximum Maximum Maximum
Age (kg) of cream (g) area (cm2) time (hours) Age Weight (kg) Maximum area time (hours)
<3 months <5 1 10 1 <12 months <10 100 cm2 1

3–12 months 5–10 2 20 4 (4 × 4 in)

1–6 years 10–20 10 100 4 1–6 years 10–20 200 cm2 2

7–12 years >20 20 200 4 (5.5 × 5.5 in)

Table 143.4 Maximum recommended application of eutectic mix of lidocaine 7–12 years >20 600 cm2 2*
2.5%/prilocaine 2.5% (EMLA®) in children. Because of the prilocaine, the (9 × 9 in)
product should not be used in: (1) premature neonates with a gestational age
<37 weeks because of increased risk of methemoglobinemia due to immature *0.072 mg 4% lidocaine absorption/cm2/h × 600 cm2 × 2 h = 86 mg (≤4 mg/kg).
reductase pathways; and (2) young children (especially those <1 year of age) Table 143.5 Maximum recommended lidocaine 4% liposomal cream (LMX4®)
receiving medications that may increase the risk of methemoglobinemia application in children. Cream should be applied to intact skin, with or without
(e.g. acetaminophen, antimalarials, dapsone, nitrofurantoin, nitroglycerin, occlusion. Currently not FDA approved for children <2 years of age, so its application
phenobarbital, phenytoin, sulfonamides). in that age group represents an off-label use. Courtesy Julie V. Schaffer, MD.

Topical skin anesthetics are useful for primarily non-invasive laser, One to two drops of 0.5% tetracaine into each eye achieves complete
intense pulsed light, and other energy-based therapies (see Ch. 137). conjunctival anesthesia after a few seconds of stinging. This allows for
They are very helpful in reducing the pain of needle insertion as well as insertion of eye shields or painless injection through the conjunctiva.
some of the pain of injection when injecting local anesthetics, botulinum Proparacaine (proxymetacaine) hydrochloride is an equally effective
toxin, or filler materials such as the various hyaluronic acid-based filler alternative conjunctival anesthetic that has less associated stinging
materials that, due to their acidity, sting on injection. Of note, filler sensations.
materials are now frequently premixed with lidocaine to reduce the pain A 2%–10% solution of cocaine hydrochloride is the topical anesthetic
of their injection (see Table 158.4). However, anesthesia is too unpre- of choice for intranasal anesthesia because of its excellent vasocon-
dictable to use topical skin anesthetics even for minor surgical proce- strictive and hemostatic properties. However, onerous record-keeping
dures such as skin biopsies, curettage, or electrodesiccation. requirements make it relatively impractical for in-office use. Due to its
The various preparations have different recommendations regarding significant cardiac stimulatory effects, cocaine hydrochloride should be
times of application and need for occlusion. However, for maximal used with caution in patients with significant heart disease.
effectiveness, the anesthetic should be applied as a thick layer under Oral and anal mucosa can be effectively anesthetized within a
occlusion to the proposed treatment area for at least 1 hour. Caution couple of minutes with 2%–4% lidocaine jelly or viscous lidocaine as
should be exercised when large areas are to be anesthetized, especially well as various benzocaine-containing preparations. Topical intraoral
when using compounded mixtures with high lidocaine concentrations, anesthesia is especially helpful in reducing the pain of nerve block injec-
as several deaths have been reported in patients applying compounded tions done via the intraoral route.
topical anesthetics under occlusion to their entire lower extremities.
Cryoanesthesia
Mucous membranes Rapid cooling of the skin surface is used routinely for many non-ablative
Topical anesthetics for mucous membranes are far more effective than laser procedures. The anesthesia is achieved with one of the following: a 2483
skin anesthetics, as the stratum corneum barrier is absent (Table 143.3). short burst of cryogen sprayed onto the skin surface (Dynamic Cooling

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SECTION

21 Generic name
COMPRESSED AIR DELIVERY SYSTEMS FOR LIDOCAINE
Delivery system Trade name® Amount/concentration Type Primary use
SURGERY

Lidocaine HCl monohydrate powder Pressurized helium Zingo 0.5 mg (pre-filled) Amide Intact skin
Lidocaine buffered powder Compressed carbon dioxide J-tip 1% or 2% Amide Intact skin
Table 143.6 Compressed air delivery systems for lidocaine. Lidocaine is delivered into the dermis.

Device™); a cold glass window placed directly onto the site being treated TUMESCENT ANESTHESIA FORMULA
(contact cooling); an iced gel placed on the surface being treated (passive
cooling); or −5°C refrigerated air blown onto the skin surface with a Ingredient Quantity (ml)
coupling gel in place (Cryo 5™). All of these methods cool the skin to Lidocaine 1% 50–100
reduce pain of laser treatment and to protect the epidermis from laser-
induced heat injury. Epinephrine (1 : 1000) 1
Cryoanesthesia can also be helpful in skin surgery. Dermabrasion Sodium bicarbonate 8.4% 10
can be done entirely under cryoanesthesia by freezing the skin with a Hyaluronidase 150 U/ml 6 (optional)
cryogen spray before dermabrading. Unfortunately, the most effective
and safe cryogen sprays (Frigiderm®, Fluro-Ethyl®) contain chlorofluo- Triamcinolone acetonide 40 mg/ml 0.25 (optional)
rocarbons that are harmful to the ozone layer, and their manufacture Normal saline 0.9% 900–950
has been discontinued. Ethyl chloride spray can, through evaporative
cooling, achieve brief anesthesia to reduce the pain of needle insertion. Table 143.7 Tumescent anesthesia formula. For tumescent anesthesia, a
final concentration of 0.05% to 0.1% lidocaine with 1 : 1 000 000 epinephrine is
An ice cube or −5°C forced air cooling (see above) will likewise numb
prepared. Hyaluronidase may be added to enhance diffusion and corticosteroids
the skin just long enough to reduce the pain of needle insertion. We may be added to reduce inflammation, edema, and possibly fibrosis.
have found forced air cooling helpful in reducing the pain of palmar and
finger injections of botulinum toxin A for hyperhidrosis. However, if the
cold air is aimed directly onto the needle, the liquid within the needle There are also compressed air delivery systems for adminis-
may freeze momentarily, making it seem that the needle is clogged. tering lidocaine into the dermis and they may be useful in children
Moving the cold air blower away from the needle for 5 to 10 seconds (Table 143.6).
will permit the contents of the needle to thaw out, allowing injection
to continue. Field block anesthesia
Field block anesthesia involves injecting a ring of anesthetic around the
Anesthetic Injection Techniques proposed surgical site. It is useful for anesthetizing large areas while
conserving the amount of anesthetic used and minimizing distortion
Local infiltration of the surgical site. Injecting a ring of anesthesia around a cyst will
The great majority of dermatologic surgical procedures are done avoid puncturing the cyst. Ring block anesthesia is practical only in
under anesthesia achieved with local infiltration. There are several areas where innervation arrives horizontally through the skin, such
maneuvers that can significantly reduce the pain of injection24. The as is seen on the scalp, rather than vertically from deeper tissues, as
pain of needle insertion is reduced by reassurance, verbal distraction, is seen on the eyelid. A ring block may achieve anesthesia, but there
and mechanical distraction such as a pinch at the site of injection. will be no hemostasis at the incision site. Therefore, the addition of
Mechanical distraction works via the gate theory of pain. The pinching intradermal anesthetic with epinephrine at the proposed incision site
stimulates cutaneous nerves, making them somewhat refractory to the is recommended. The most frequent use of ring block anesthesia is on
immediately following pinprick sensation from needle insertion. A very the scalp, nose (for rhinophyma repair), ear pinna, and on the trunk
useful adjunct, which also takes advantage of the gate theory of pain, and extremities (where the injection is started as a ring block but often
is the use of vibration at or immediately proximal to the injection site. finished with infiltration inside the ring block).
This is very useful when injecting anesthetic in very anxious or young
patients and has made it feasible for us to eliminate the need for nerve Tumescent anesthesia
block anesthesia when injecting botulinum toxin A into the palms and Tumescent anesthesia involves the subcutaneous infiltration of large
soles in many patients. Care must be taken when applying a vibrator to amounts of dilute 0.05%–0.1% lidocaine with 1 : 1 000 000 epinephrine
the injection site, as the needle may move unpredictably across the skin (Table 143.7). It has been used most extensively for liposuction under
surface due to the vibration before being inserted into the skin. Small local anesthesia (see Ch. 156), ambulatory phlebectomy, hair transplan-
30-gauge needles that are inserted quickly further reduce pain. Slow, tation, and dermabrasion. The anesthetic is infiltrated with the help
timid needle insertion is felt more by the patient than a quick needle of a pump, with the injection carried out through long 18- to 20-gauge
insertion. Topical anesthesia, as noted above, can almost completely 3.5 inch (8.9 cm) spinal needles or specially designed multiport
eliminate the pain of needle insertion. cannulas. The infiltration is started slowly with small needles and then
The actual injection of the anesthetic causes a significant stinging gradually speeded up utilizing spinal needles and finally infiltration
sensation that is usually far more painful than the needle insertion. cannulas. Infiltration of the deep subcutaneous plane is done first,
Buffering the anesthetic to a physiologic pH and using an anesthetic followed by the superficial fat compartment. The solution is injected
that has been warmed to body temperature will reduce the stinging until firm tumescence of the tissue has been achieved. Anesthesia and
sensation9,10,25. Injecting the anesthetic as slowly as practical will epinephrine-induced hemostasis develop within about 20 minutes and
reduce the pain from tissue distention by the anesthetic fluid, and this last for several hours, which is significantly longer than the duration
also allows the injection of additional anesthetic to be done through an of anesthesia achieved with conventional concentrations of lidocaine
already numb area. Additional sticks should be made through an already with epinephrine. In the subcutaneous fat, dilute lidocaine is absorbed
numb area, and the injection should start on the side that the sensory at a much slower rate than standard lidocaine concentrations. Doses as
innervation is coming from and proceed distally. Using the smallest high as 35–50 mg/kg lidocaine have been found to be safe when used in
practical syringe size, usually 1 or 3 ml, will allow for low pressures tumescent anesthesia17,18.
of injection, which are less painful. Subcutaneous anesthetic injection
is less painful than intradermal injection, but the onset of anesthesia
is slower and of shorter duration. We usually start by creating a small
Nerve Block Techniques
intradermal wheal, followed by subcutaneous injection, and finishing Nerve blocks are an effective and efficient way to anesthetize large
2484 with intradermal injection at the incision line to enhance anesthesia areas using the least amount of anesthetic, minimizing both patient
and hemostasis. discomfort and distortion of the operative site. When injecting in the

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 CHAPTER
Fig. 143.2 Sensory innervation
SENSORY INNERVATION OF
THE CENTRAL FACE
of the central face. SKULL EXIT POINTS OF CENTRAL FACE
SENSORY NERVES
Fig. 143.3 Skull exit points of
central face sensory nerves. 143

Anesthesia
ST

SO
SO
SO

ST
IT
AE
IT
IO
IO AE IO

M M M

AE External nasal branch of the AE External nasal branch of the

anterior ethmoidal nerve (V1) anterior ethmoidal nerve (V1)
IO Infraorbital nerve (V2) IO Infraorbital nerve (V2)
IT Infratrochlear nerve (V1) IT Infratrochlear nerve (V1)
M Mental nerve (V3) M Mental nerve (V3)
SO Supraorbital nerve (V1) SO Supraorbital nerve (V1)
ST Supratrochlear nerve (V1) ST Supratrochlear nerve (V1)

Fig. 143.4 Locations

region of a nerve, care must be taken not to inject the accompanying of needle insertions
for central face nerve
blood vessels. Using larger, 25- to 27-gauge needles allows one to draw
blocks. From superior to
back to make sure that the needle is not intravascular. To reduce pain inferior, the supraorbital,
of injection, an intradermal wheal using a 30-gauge needle should be infraorbital, and mental
placed first. The aim of nerve block injections is to deposit the anesthetic nerves are marked with
near, but not into the nerve, as intraneural injection may cause nerve an “x” and the supra-
injury and subsequent dysesthesia. Insertion of the needle into a nerve trochlear, infratrochlear,
is usually felt by the patient as a sharp pain radiating along the nerve. and external nasal
If this happens, the needle should be pulled back and repositioned nerves are marked with
slightly. Intra-foramina injections should also be avoided to minimize a rectangle.
risk of nerve injury. With proper placement, most nerves can be blocked
with a 1–2 ml injection. The addition of hyaluronidase will enhance
diffusion of the anesthetic and increase the rate of nerve block “take”.
For most nerve blocks, 1% lidocaine with epinephrine and sodium
bicarbonate is used. If prolonged anesthesia is desired, 0.25% bupiva-
caine hydrochloride with epinephrine can be added. As the sensory
nerves are large and myelinated, anesthetic effect may take 10 to 20
minutes to develop26. Using 2% lidocaine may increase success of the
nerve block. Articaine 4% with or without epinephrine supplied in
dental carpules seems to be especially effective for relatively painless
facial nerve blocks, with very small volumes (often <0.2 ml/injection
site) of anesthetic needed for effective anesthesia. This seems to be
due to its more effective diffusion from the site of injection compared
to lidocaine. Some surgeons omit epinephrine from the nerve block
anesthetic as it is not needed for vasoconstriction at the site of the
nerve. We use it as part of our anesthetic mix to prolong the duration
of the nerve block. Once a nerve has been effectively blocked, local
infiltration of lidocaine with epinephrine along the proposed incision
line to achieve local vasoconstriction may be helpful in reducing medial portion of the orbit (Fig. 143.3). Injecting 1 ml of anesthetic
bleeding. immediately superficial to the periosteum at the superomedial orbital
rim at the junction of the glabella and eyebrow will block the supra-
Facial nerve blocks trochlear nerve (Fig. 143.4). To achieve complete forehead and frontal
The forehead and frontal scalp above the eyebrows are innervated by scalp anesthesia requires extending a line of anesthetic injected into
the supraorbital nerve (Fig. 143.2), which exits the skull through the the subcutaneous plane laterally from the supraorbital nerve to the
supraorbital foramen at or immediately above the orbital rim in the region immediately superior and posterior to the attachment of the ear
midpupillary line (Fig. 143.3). The notch can often be palpated on pinna. This will block the auriculotemporal nerve and greater auricular
the patient. Approximately 1 ml of anesthetic is infiltrated through a nerve branches that innervate the forehead, temple, and frontal scalp
0.5 inch (1.3 cm) needle inserted perpendicularly into the skin immedi- (see Ch. 142).
ately superficial to the periosteum at the orbital rim in the midpupillary The infraorbital nerve exits the skull through the infraorbital foramen
line (Fig. 143.4). The supratrochlear nerve innervates the midforehead, (Fig. 143.3) and innervates the medial cheek, upper lip, and nasal ala 2485
glabella, and frontal scalp (Fig. 143.2). It exits the skull at the upper (Fig. 143.2). With a 1 inch (2.5 cm) needle inserted perpendicularly to

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SECTION

21 the skin, 2 ml of anesthetic is injected approximately 1 cm inferior to

the orbital rim in the midpupillary line, immediately superficial to the
used by dermatologists blocks the sensory nerves coursing laterally
along the digit. A 0.5 inch (1.3 cm) needle is inserted perpendicular to
maxillary bone periosteum (Fig. 143.4). A less painful and more the digit near its base in the horizontal plane until the bone is touched.
SURGERY

reliable alternative is to block the infraorbital nerve through the At this point, the needle is withdrawn slightly, positioned dorsally
intraoral approach. The needle is inserted between the first and second and anesthetic is injected. Next, the needle is positioned ventrally
premolars (bicuspids), moving cephalad parallel to the periosteum and additional anesthetic is injected. This process is repeated on the
until the horizontal portion of the maxillary bone is reached (Fig. other side of the digit. This block can be done without epinephrine
143.5). The needle is pulled back slightly and the anesthetic is or with dilute 1 : 500 000 epinephrine, and small volumes (usually
injected. The pain of needle insertion can be lessened by applying a <1.5 ml) should be injected to minimize the risk of ischemic injury
topical anesthetic to the mucosa a couple of minutes prior to injection. from mechanical circumferential compression of the blood supply to
The infratrochlear nerve, which innervates the lateral and dorsal the digit. However, as noted previously, there is no documented risk
nose (Fig. 143.2), can be blocked by injecting anesthetic superficial to of ischemic injury from standard 1 : 100 000 epinephrine concentra-
the periosteum at the inferomedial orbital rim at the superior end of tions when used for digital anesthesia in patients without significant
the nose–cheek concavity (Fig. 143.4). The nasal tip receives inner- peripheral vascular compromise (as long as the injected anesthetic
vation from the external nasal branch of the anterior ethmoidal nerve volume is limited).
(Fig. 143.2), which emerges at the nasal cartilage and bone junction Alternatively, the digit can be blocked at the level of the metacarpal
slightly lateral from the midline (Fig. 143.3). Perichondrial infiltration or metatarsal bone. A 1.5 inch (3.8 cm) needle is inserted dorsally
of anesthetic at this spot will anesthetize the nasal tip (Fig. 143.4). To between the metacarpal/metatarsal bones, and anesthetic is infiltrated
complete nasal anesthesia, a few drops of anesthetic at the base of the as the needle is advanced ventrally, with most of the anesthetic injected
columella may be needed as well. just dorsal to the palmar/plantar skin. This injection will block the
The lower lip and portions of the chin are innervated by the mental metacarpal/metatarsal nerve, which travels immediately superficial to
nerve (Fig. 143.2), which exits the mandible through the mental the flexor retinaculum. The process is repeated on the other side of
foramen in the midpupillary line (Fig. 143.3). A 0.5 inch (1.3 cm) needle the metacarpal/metatarsal bone of the digit being anesthetized. The
is inserted perpendicular to the skin to the level of the periosteum in advantage of this block is that there is less risk of compression injury
the midpupillary line halfway cephalad along the mandible, and 1 ml than can occur with the more commonly performed digital block.
of anesthetic is injected to block the mental nerve (Fig. 143.4). The
intraoral route is less painful and more reliable. The needle is inserted Penile nerve block
between the first and second premolars (bicuspids) caudally along the The dorsal nerve of the penis is a branch of the pudendal nerve. It
periosteum to a halfway point down the mandible (Fig. 143.6). divides into major anterior (dorsal) and minor posterior (ventral)
branches at the base of the penis. By injecting a ring of anesthesia
Digital nerve blocks without epinephrine or with 1 : 500 000 epinephrine in the subcuta-
Nerve blocks for the fingers and toes are technically very similar. There neous plane around the base of the penis, most of the penis will be
are two options to anesthetize a digit. The technique most commonly anesthetized. The only areas that may require additional anesthetic
infiltration will be the periurethral region of the glans and, sometimes,
the ventral glans and frenulum.
Fig. 143.5 Intraoral
route for infraorbital
Hand nerve block
nerve block. The needle With the popularity of botulinum toxin A for palmar and plantar
is inserted cephalad hyperhidrosis, a method to anesthetize the palmar surface is necessary.
between the premolar Topical anesthetics are ineffective on palmoplantar skin, and local
(bicuspid) teeth in the anesthetic injections into the palms and soles are very painful. Nerve
midpupillary line. block of the median nerve will anesthetize the palmar surface of the
first three and a half fingers plus two-thirds of the palmar surface (Fig.
143.7). Block of the ulnar nerve will anesthetize the rest of the fingers
and palm (Fig. 143.7). The median nerve lies in the carpal tunnel, deep
to the palmaris longus tendon and between the flexor digitorum super-
ficialis and flexor carpi radialis tendons. By apposing the thumb and
fifth finger with the wrist slightly flexed, the palmaris longus tendon
will become apparent. A 0.5–1 inch (1.3–2.5 cm) needle is inserted at
the first (proximal) wrist crease, immediately medial (ulnar) to the
palmaris longus tendon (Fig. 143.8). It is then advanced deep into the

Fig. 143.7 Sensory innervation

SENSORY INNERVATION OF THE HAND of the palmar surface and
Fig. 143.6 Intraoral dorsal surface of the right
route for mental nerve hand.
block. The needle
is inserted caudally
between the premolar R
(bicuspid) teeth in the
midpupillary line. U R
U

M Median nerve
R Radial nerve
2486 U Ulnar nerve

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 CHAPTER
Fig. 143.9 Sensory innervation
SENSORY INNERVATION OF THE FOOT of the dorsal surface and
plantar surface of the right
143

Anesthesia
foot.
SU
SA
SP SP
DP

PT
SA

SP

Fig. 143.8 Cutaneous markers for the median nerve location at the wrist. Note SU
thumb and little finger apposition and wrist flexion to visualize the palmaris DP
longus (PL) tendon. X, needle entry point.

DP Deep peroneal nerve

carpal tunnel and a few milliliters of anesthetic are injected. A slight
PT Posterior tibial nerve
“popping” or reduction in resistance can be felt as the needle enters the
SA Saphenous nerve
carpal tunnel.
The ulnar nerve is most easily blocked at the elbow where it travels SP Superficial peroneal nerve
between the olecranon process and the epicondyle of the humerus. SU Sural nerve
The ulnar nerve is the “funny bone”. The patient’s arm is flexed, and
the needle is inserted between the bones with several milliliters of
anesthetic injected.
An alternative is to have an anesthesiologist perform a Bier block, in
which the blood is pushed out of the arm with a compressive bandage, POSTERIOR TIBIAL AND SURAL NERVE BLOCKS
a tourniquet is applied, and dilute lidocaine is injected intravenously.
Anesthesia of the hand will develop in 5 to 10 minutes and last for
about 1 hour. Once the procedure is complete, the tourniquet is
gradually released and the anesthetic is released into the general circu-
lation. Therefore, the dose administered should be monitored to keep
it at a safe level.

Foot nerve block Posterior

Sural nerve
Anesthesia of the plantar surface requires nerve blocks of the posterior tibial nerve
tibial nerve, which innervates the heel and middle of the sole of the
foot; the sural nerve, which innervates the fifth toe and the lateral side
of the sole of the foot; the superficial peroneal nerve, which innervates
the skin of the toes; the saphenous nerve, which innervates the instep; Medial
and the deep peroneal nerve, which innervates the skin between the malleolus Lateral malleolus
first and second toes (Fig. 143.9). Before starting injections around
the ankle, the area should be thoroughly prepped with antiseptic to Posterior
minimize the risk of infection. tibial artery
The patient is placed in the prone position. The posterior tibial artery
is palpated or located using a Doppler ultrasound probe, and a 1.5 inch
(3.8 cm) needle is directed anteriorly and laterally, immediately lateral Lateral
to the arterial pulse, until the bone is touched. The needle is pulled back
slightly, and several milliliters of anesthetic are injected in the groove
between the medial malleolus and the Achilles tendon (Fig. 143.10).
The sural nerve is blocked by injecting anesthetic in the groove between
the lateral malleolus and Achilles tendon in an identical fashion to the
tibial nerve injection (Fig. 143.10). Fig. 143.10 Posterior tibial and sural nerve blocks.
With the patient in the supine position, the saphenous and super-
ficial peroneal nerves are blocked by infiltrating anesthetic subcutane-
ously from malleolus to malleolus along the dorsum of the foot (Fig.
143.11). The deep peroneal nerve is blocked by inserting a 1.5 inch or zolpidem tartrate (Ambien®) 5–10 mg will reduce anxiety and may
(3.8 cm) needle lateral to the extensor hallucis longus tendon (toward even generate a certain degree of amnesia for the procedure. Diazepam
the middle of the foot) down to the bone (Fig. 143.11). Next, the needle (Valium®) 5–10 mg is useful for longer procedures due to its longer
is pulled back slightly, and several milliliters of anesthetic are injected. duration of action, but it does not produce amnesia for the procedure.
The tendon is identified by having the patient dorsiflex his or her great The addition of a narcotic analgesic such as oxycodone (10 mg)/
toe against resistance. Alternatively, local anesthetic can be infiltrated acetaminophen (325 mg) orally (Percocet®) or meperidine hydrochloride
between the first and second toes for easier and more expeditious (Demerol®) 50 mg intramuscularly will act synergistically with the
anesthesia. anxiolytics to achieve a greater degree of sedation as well as reducing
the pain of local anesthetic infiltration. We find these useful for longer
procedures done under tumescent anesthesia. Of course, consent for
Higher Levels of Anesthesia the procedure has to be obtained before taking any of these medica-
In anxious patients, or when relatively large areas are to be anesthetized, tions and patients must have someone else take them home after the 2487
oral or sublingual anxiolytics such as triazolam (Halcion®) 0.25–0.5 mg procedure.

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SECTION

21 SUPERFICIAL PERONEAL, SAPHENOUS,

AND DEEP PERONEAL NERVE BLOCKS
Credentialing for higher levels of anesthesia may be regulated by state
or national (outside the US) medical licensure authorities and hospitals,
and the physician must be in full compliance with the rules in his or her
SURGERY

particular state or country. Most of the regulations require procedures

done under general anesthesia or with intravenous sedation to be done
in an ambulatory surgery center or hospital with a supervising anesthe-
Superficial peroneal nerve siologist. Higher levels of anesthesia involving the use of intravenous
Saphenous nerve
medications such as midazolam hydrochloride (Versed®) and fentanyl
should be done in a monitored environment with appropriate resusci-
Deep peroneal nerve Subcutaneous injection tative equipment readily available. Nitrous oxide administration is a
malleolus-to-malleolus
useful form of moderate analgesia, with the degree depending on the
Lateral malleolus Medial malleolus concentration administered. At a 20% concentration, the analgesia is
equivalent to giving a narcotic analgesic. At an 80% concentration, most
patients will become unconscious. The advantage of nitrous oxide is the
rapid reversal of anesthetic effect as soon as the gas is turned off. With
Deep peroneal
proper training, nitrous oxide can be safely administered in the office, as
nerve block
it has been done for many years in many dental offices. An easier version
Extensor hallucis longus of nitrous oxide analgesia, Pro-Nox™ (Clarion Medical Technologies),
delivers a fixed ratio of 50% nitrous oxide and 50% oxygen. The patient
holds the mouthpiece and controls how much they inhale, remaining
conscious throughout the procedure27. General inhalation anesthesia or
Lateral Medial deep intravenous sedation with propofol should generally be performed
by anesthesiologists.

Fig. 143.11 Superficial peroneal, saphenous, and deep peroneal nerve blocks.
Great toe dorsiflexion aids in visualizing the extensor hallucis longus tendon.

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