How to Minimize the Pain of Local Anesthetic Injection for Wide Awake Surgery

Abstract

After reading this article, the participant should be able to (1) almost painlessly inject tumescent local anesthesia to anesthetize small or large parts of the body, (2) improve surgical safety by eliminating the need for unnecessary sedation in patients with multiple medical comorbidities, and (3) convert many limb and face operations to wide awake surgery. We recommend the following 13 tips to minimize the pain of local anesthesia injection: (1) buffer local anesthetic with sodium bicarbonate; (2) use smaller 27-or 30-gauge needles; (3) immobilize the syringe with two hands and have your thumb ready on the plunger before inserting the needle; (4) use more than one type of sensory noise when inserting needles into the skin; (5) try to insert the needle at 90 degrees; (6) do not inject in the dermis, but in the fat just below it; (7) inject at least 2 ml slowly just under the dermis before moving the needle at all and inject all local anesthetic slowly when you start to advance the needle; (8) never advance sharp needle tips anywhere that is not yet numb; (9) always inject from proximal to distal relative to nerves; (10) use blunt-tipped cannulas when tumescing large areas; (11) only reinsert needles into skin that is already numb when injecting large areas; (12) always ask patients to tell you every time they feel pain during the whole injection process so that you can score yourself and improve with each injection; (13) always inject too much volume instead of not enough volume to eliminate surgery pain and the need for "top ups." (

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery

“…Techniques for minimizing the pain of administering local anesthesia are wellestablished. The anesthetic should be warmed and buffered with sodium bicarbonate, injected slowly through a 30-gauge needle introduced perpendic-ular to the skin while keeping the wheal 10 mm ahead of the advancing needle tip 72,73 . Needle reinsertion should be in an anesthetized area so that pain occurs only with the first needle stick.…”

Regional Anesthesia in Upper-Limb Surgery

“…52 Similarly, the use of blunt tipped flexible metal cannulas for tumescing large areas can further decrease pain of injection. 53 WALANT has been used for routine procedures such as carpal tunnel release, trigger finger release, and nerve repair. Unlike standard Similar incidence of tourniquet pain to infraclavicular 50 regional anesthetic techniques, WALANT can be performed in an office-based setting with a reduced number of resources and without an anesthesiologist, increasing the accessibility and affordability of hand surgery in select circumstances.…”

“…Small technical details such as the use of finer needles, for example, 30 gauge, buffering with sodium bicarbonate and injection from proximal to distal have been described as methods to reduce pain of injection 52 . Similarly, the use of blunt tipped flexible metal cannulas for tumescing large areas can further decrease pain of injection 53 . WALANT has been used for routine procedures such as carpal tunnel release, trigger finger release, and nerve repair.…”

How to Create an Exceptional Hand Surgery Patient Experience with WALANT

“…9 Use small needles (27 or 30 gauge), sensory noise for needle insertion, and follow all the other well-described rules of minimal pain local anesthesia injection available in Joukhadar and Lalonde. 9 talking with your patient throughout the injection process. Use this pain-free injection time to build trust.…”

“…Inject the patient lying down to improve cerebral blood flow and avoid vasovagal fainting. 9 Use small needles (27 or 30 gauge), sensory noise for needle insertion, and follow all the other well-described rules of minimal pain local anesthesia injection available in Joukhadar and Lalonde. 9 talking with your patient throughout the injection process.…”