Office-based surgery clinical guidelines
Office-based surgery guideline
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Addresses the clinical use and safety of local anesthetics (topical, infiltrative, and infiltrative tumescent) commonly used in office-based dermatologic surgery for adult and pediatric patients.
While anxiolytics, sedatives, and other systemic medications may be used for office-based procedures, these methods are not discussed in this guideline, as they are forms of systemic and not local anesthesia.
Anesthetic toxicity is rare in the dermatologic office setting, and therefore management of local anesthetic toxicity is not addressed in this guideline.
Other aspects, such as physician and staff certification, credentialing and privileging, facility accreditation, office equipment and set-up requirements, and legal/regulatory compliance, or any other administrative requirements and regulations fall beyond the scope of this guideline.
The work group was composed of dermatologist experts in different areas (including pediatric population), an anesthesiologist, and a patient advocate from the Dermatologist Nurses’ Association.
Gaps in research
This guideline has examined the most current and highest level of evidence to create this guideline.
It has revealed several areas in which further investigation is needed regarding the use of local anesthesia for dermatologic procedures.
Additional emphasis on specific gaps in research; need of high-quality studies/additional data to (see guideline for specifics):
Compare topical anesthetic to infiltrative local anesthetic for minor dermatologic procedures in children and adults.
Examine the effect of occlusion and type of vehicle (cream, gel, ointment) on the safety and efficacy of topical anesthetics.
Compare the pain of administration and anesthetic efficacy of infiltrative anesthesia vs regional nerve block for dermatologic surgery on the face, hands, feet, and digits.
Determine the maximum safe dosage of local infiltration anesthesia for large, multistage procedures such as Mohs micrographic surgery.
Establish the effectiveness of techniques used to decrease the pain of administering infiltrative anesthesia, including methods of auditory and visual distraction in children.
Determine the utility of combining different infiltrative anesthetics for the same procedure.
There is very limited evidence comparing topical agents in dermatology.
Topical anesthesia alone may be acceptable for minor skin procedures (such as skin biopsy, small excisions, and filler and botulinum toxin injection).
Can be considered as an alternate to infiltration anesthesia.
In cases where infiltration anesthesia is necessary, the adjunctive use of topical agents can be used to reduce the dose, as well as the pain of injection of local anesthetic.
If the procedure is of urgent medical necessity, it is preferable for it be delayed until at least the second trimester.
If it is not urgent (or is elective), it should be postponed until after delivery.
Use of topical lidocaine is recommended; the safety of other topical anesthetics during pregnancy has not been thoroughly studied.
The dermatologist may use topical anesthesia alone to repair dermal lacerations, and for other minor procedures. For other cases, they may use it to lessen the discomfort of injection of additional anesthesia.
Local infiltration anesthesia, part I
Topical, infiltrative, local nerve block, and tumescent local anesthesia are all considered to be safe for use in the office-based setting.
Examples of dermatologic procedures considered safe under local infiltrative anesthesia include (but are not limited to) skin biopsy, excision, wound closure, tissue rearrangement, skin grafting, cauterization, non-ablative laser, and ablative laser resurfacing.
If the cutaneous procedure affects a larger area, or is more complex, your dermatologist may combine local infiltrative anesthesia with other forms of local anesthesia.
True allergy to lidocaine is very rare, but in these patients the dermatologist may suggest injection of bacteriostatic normal saline or 1% diphenhydramine as an alternative.
Toxicity monitoring and prevention
This guideline encourages physicians to be aware of the signs of early and advanced local anesthetic systemic toxicity (LAST), and to follow procedural steps to decrease the risk of LAST and to continually assess and communicate with the patient to monitor for signs of early toxicity.
This clinical practice guideline also discusses several compounds that are often added to local anesthetics with different purposes, including prolonging its effect or lessening the pain of injection, among others.
Addition of epinephrine
Epinephrine (adrenaline) has vasoconstrictor properties, and can be combined with local anesthetics to prolong their localized action and to minimize blood loss.
This guideline emphasizes the safe use of epinephrine in the ear, nose, hands, feet, and digits, despite a widespread misbelief that it may induce tissue necrosis.
Epinephrine may be safely used in patients with stable cardiac disease. In case of doubt, the dermatologist should consult with the patient’s cardiologist.
Addition of hyaluronidase
Hyaluronidase may be added to infiltration anesthesia with the intent of enhancing diffusion of the anesthetic solution.
Although addition of hyaluronidase is considered generally safe, the benefits of hyaluronidase in dermatologic procedures remain unclear.
It is more commonly used in other specialties than in dermatology.
It should not be administered to patients with a history of bee sting allergy.
When allergy to hyaluronidase is in question, prick testing may be used for confirmation.
Local infiltration anesthesia, part II
Addition of sodium bicarbonate
There is substantial high-quality evidence showing that addition of sodium bicarbonate to local anesthetics (buffering), decreases patient pain during drug delivery via subcutaneous or intradermal infiltration.
Clinical experience suggests that buffering anesthetic also decreases injection pain in children.
Buffering is recommended for lidocaine, and solutions of 1% lidocaine may be prepared up to one week prior to use. However, buffering is not recommended for bupivacaine, as precipitation of the anesthetic agent may lead to decreased efficacy.
Mixing multiple anesthetics
Although generally safe and effective, mixing multiple anesthetics does not seem to provide any benefit over a single agent.
The decision of when and how to use a mixture of drugs therefore currently rests on the experience and comfort level of the clinician.
Further research is needed.
Minimizing pain of administration and alternate methods of analgesia
Slow rate of infiltration, vibration of the skin, use of a warm solution, or cold air skin cooling should be considered to decrease the pain of local anesthetic injection.
There is no clear indication of which local anesthetics hurt the least upon injection, although it seems that lidocaine elicits less discomfort than etidocaine or mepivacaine.
Further research is needed.
It is unclear whether pre-treatment with ethyl chloride spray, pre-injection with normal saline, or verbal distraction decreases the pain of local anesthetic infiltration.
The effectiveness of ethyl chloride as analgesic in dermatologic procedures is unclear, and its use as the sole method for analgesia should not be considered.
There is sufficient evidence to consider cold air skin cooling to reduce patient discomfort during non-ablative laser therapy.
There is also evidence to support the use of vibration to reduce the pain of skin injections, particularly the injection of botulinum toxin.
Also for children and anxious adults.
Although limited research exists for use in dermatologic procedures, the evidence has found the technique to be safe when performed in this setting.
Neither nerve damage nor other major adverse events have been reported.
Regional cutaneous nerve block anesthesia is recommended for ablative laser resurfacing of the face and for botulinum toxin injection of the palm.
For other specific indications, there is not enough evidence to demonstrate the effectiveness of nerve block anesthesia as compared to other forms of local anesthesia.
Nerve block should be considered as an alternative or in addition to infiltrative anesthesia for procedures on the face, hands, feet, and digits.
It may provide the benefits of decreased tissue swelling/distortion, prolonged anesthesia, and reduced postoperative discomfort for the patient.
This can facilitate more precise surgery, albeit with the loss of benefit provided from epinephrine as a vasoconstrictor when used locally.
Studies comparing nerve block and infiltrative anesthesia for procedures on the nose, cheeks, lips, eyelids, hands, feet, digits and nails would be helpful.
Tumescent local anesthesia
There is substantial evidence to support the safety of tumescent local anesthesia when used for office-based liposuction.
There are no reports of death associated with liposuction performed under tumescent local anesthesia by dermatologists, and multiple studies estimate the rate of serious adverse events to be 0.04-0.16%.
Lidocaine with epinephrine is the most commonly studied solution and has been shown to be effective at multiple concentrations; prilocaine is also safe and recommended for this use.
Use of bupivacaine is not recommended for tumescent local anesthesia for office-based liposuction, while prilocaine is not approved in the United States for this use.
A maximum dose of 55 mg/kg of lidocaine with epinephrine has been extensively demonstrated to be safe.
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