Local Anesthetics: What's New in Minimal Pain Injection and Best Evidence in Pain Control

Anestesia local con epinefrina, sin manguito hemostático, para la liberación del túnel carpiano. Estudio comparativo de dos variantes técnicas en 89 casos

Objetivo: Evaluar la eficacia intra- y posoperatoria, y la comodidad para el paciente de dos variantes de la anestesia en dos grupos con síndrome del túnel carpiano. Materiales y Métodos: Estudio descriptivo, comparativo, retrospectivo, observacional mediante un cuestionario telefónico de 12 ítems sobre la anestesia local sin manguito. Se incorporó a pacientes con síndrome del túnel carpiano operados entre 2008 y 2019, mediante un miniabordaje abierto. Se  dividió en: grupo 1: lidocaína al 2% más bupivacaína al 0,5% más epinefrina 1:200.000 más sedación ligera (n = 32) y grupo 2: lidocaína al 2% más epinefrina 1:200.000 (n = 57). Resultados: Se evaluó a 89 pacientes (media de edad 66.9 años). Todos se mostraron satisfechos, confirmaron que volverían a elegir este procedimiento. No hubo diferencias significativas en la comodidad o el posible desarrollo de síntomas intra- o posoperatorios entre ambos grupos. La permanencia posoperatoria fue de 1-3 h, sin hospitalización. El sangrado fue mínimo. Conclusiones: La liberación del túnel carpiano bajo anestesia local más epinefrina, sin manguito hemostático, resultó segura y sin complicaciones. Los pacientes no refirieron dolor local intraoperatorio ni posoperatorio inmediato, ni en el sitio del torniquete. La permanencia en el centro asistencial fue breve. La estancia corta y la menor cantidad de elementos empleados (anestésicos, manguito) implican una reducción de los costos del procedimiento. Si bien es recomendable la presencia de un anestesiólogo, puede llegar a realizarse en ámbitos adecuados sin él. No se recomienda su empleo sin estudios prequirúrgicos ni fuera del quirófano.Nivel de Evidencia: III

Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies

Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control.

Methods

A review study based on multimodal analgesia was conducted.

Results

We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices.

Conclusion

This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.

Awake Plastic Surgery Procedures: The Use of a Sufentanil Sublingual Tablet to Improve Patient Experience

Background

Awake plastic surgery performed under minimal sedation has advantages including patient preference, affordability, and easier recovery compared to when performed under deeper sedation. Commonly used oral analgesics may not be adequate for awake procedures resulting in moderate to severe pain. Sufentanil sublingual tablet (SST) 30 mcg has been shown to provide timely analgesia with a safety profile appropriate for minimal-sedation settings.

Objectives

To examine perioperative outcomes in patients who underwent awake plastic surgery with local anesthesia and SST 30 mcg for pain control.

Methods

This study was a prospective single-group cohort study conducted at a single plastic surgery center. SST 30 mcg was administered approximately 30 minutes prior to the procedure. Outcome measures included the number of patients with adverse events, the number of patients requiring medications in the post-anesthesia care unit (PACU), and recovery time.

Results

Among the 31 patients, the most common procedures were liposuction (71%), facelift (10%), and blepharoplasty (6%). The mean (± standard error [SE]) procedural duration was 81 ± 9 minutes. No vital sign instability or oxygen desaturation was observed. Three patients (10%) experienced nausea, only one of which required treatment with oral ondansetron 4 mg in the PACU. One patient (3%) experienced dizziness that did not require treatment. No patients required opioids or other analgesics in the PACU for pain. The mean (±SE) recovery time was 15 ± 4 minutes.

Conclusions

Awake plastic surgery can be performed using SST 30 mcg with minimal side effects and a rapid recovery time.

Level of Evidence: 4

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

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."

Anesthesia using microcannula and sharp needle in upper blepharoplasty: A randomized, double-blind clinical trial evaluating pain, bruising, and ecchymoses

INTRODUCTION

With the emergence of blunt-tipped microcannulas, there is a hypothesis that these could cause less damage and reduce pain as compared to conventional sharp needles in eyelid surgery. The purpose is to determine whether an 18G blunt-tipped cannula can be better than a 26G needle.

METHODS

This prospective, observer-blinded, randomized clinical trial was conducted from June 2017 to December 2018. Sixty-eight patients were randomized to receive local anesthesia injections for upper blepharoplasty. Infiltration was performed by using a 26-gauge sharp needle on one side and on the other side, infiltration was performed by using an 18-gauge stainless-steel blunt-tipped microcannula. A numeric rating scale (NRS) from 0 to 10 was used to blindly assess pain in patients receiving anesthesia injections with both needle types. Photographs of the eyelids of each patient were taken in five different periods and used by three blinded observers to identify bruise or ecchymoses.

RESULTS

A total of 136 eyelid operations were performed. There was no statistically significant difference when both groups were compared; however, the average score of pain was higher in patients taking the infiltration through the needle (2.85 versus 2.50). Regarding the evaluation of bruising and ecchymoses, the results showed that, in the five periods evaluated, there was no statistical difference in bruising and ecchymosis in the eyelids when taking the infiltration through a sharp needle when compared with that of the eyelids taking infiltration through a (blunt-tipped) microcannula.

CONCLUSION

The evaluation of the blunt-tipped microcannula showed a lower pain score mean than that obtained for the sharp needle (2.5 versus 2.85) (p > 0.05). There was no statistically significant difference in the bruising and ecchymosis courses.

Basics and Best Practices of Multimodal Pain Management for the Plastic Surgeon

Pain management is a central focus for the plastic surgeon’s perioperative planning, and it no longer represents a postoperative afterthought. Protocols that rely on opioid-only pain therapy are outdated and discouraged, as they do not achieve optimal pain relief, increase postoperative morbidity, and contribute to the growing opioid epidemic. A multimodal approach to pain management using non-opioid analgesic techniques is an integral component of enhanced recovery after surgery protocols. Careful perioperative planning for optimal pain management must be achieved in multidisciplinary collaboration with the perioperative care team including anesthesiology. This allows pain management interventions to occur at 3 critical opportunities—preoperative, intraoperative, and postoperative settings.

Hilaire H, Stalder M, Tessler O. American Society of Plastic Surgeons Member Post-Operative Opioid Prescribing Patterns

INTRODUCTION

Despite the widespread use of opioids in pain management, there are currently no evidence-based guidelines for the treatment of postoperative pain with opioids. Although other surgical specialties have begun researching their pain prescribing patterns, there has yet to be an investigation to unravel opioid prescribing patterns among plastic surgeons.

METHODS

Survey Monkey was used to sample the American Society of Plastic Surgeons (ASPS) members regarding their opioid prescribing practice patterns. The survey was sent randomly to 50% of ASPS members. Respondents were randomized to 1 of 3 different common elective procedures in plastic surgery: breast augmentation, breast reduction, and abdominoplasty.

RESULTS

Of the 5,770 overall active ASPS members, 298 responses (12% response rate) were received with the following procedure randomization results: 106 for breast augmentation, 99 for breast reduction, and 95 for abdominoplasty. Overall, 80% (N = 240) of respondents used nonnarcotic adjuncts to manage postoperative pain, with 75.4% (N = 181) using nonnarcotics adjuncts >75% of the time. The most commonly prescribed narcotics were Hydrocodone with Acetaminophen (Lortab, Norco) and Oxycodone with Acetaminophen (Percocet, Oxycocet) at 42.5% (N = 116) and 38.1% (N = 104), respectively. The most common dosage was 5 mg (80.4%; N = 176), with 48.9% (N = 107) mostly dispensing 20-30 tablets, and the majority did not give refills (94.5%; N = 207).

CONCLUSIONS

Overall, plastic surgeons seem to be in compliance with proposed American College of Surgeon's opioid prescription guidelines. However, there remains a lack of evidence regarding appropriate opioid prescribing patterns for plastic surgeons.

Optimal Pain Control in Abdominal Wall Reconstruction

Lack of physician familiarity with alternative pain control strategies is a major reason why opioids remain the most commonly used first-line treatment for pain after surgery. This is perhaps most problematic in abdominal wall reconstruction, where opioids may delay ambulation and return of bowel function, while negatively affecting mental status. In this article, we discuss multimodal strategies for optimal pain control in abdominal wall reconstruction. These strategies are straightforward and are proven to improve pain control while minimizing opioid-associated side effects.

Latest Advances in Wide Awake Hand Surgery

Injection of tumescent local anesthesia should no longer be painful. WALANT anesthesia, strong sutures, a slightly bulky repair, intraoperative testing of active movement, and judicious venting of the A2 and A4 pulleys improve results in flexor tendon repair. WALANT K wire finger fracture reduction permits intraoperative testing of K wire stability with active movement to facilitate early protected movement at 3 to 5 days after surgery. WALANT can decrease costs and garbage production while increasing accessibility and affordability. Several surgeons have found no infection difference when the K wires are inserted with full operating room sterility versus field sterility.

Postoperative Nausea and Vomiting with Plastic Surgery: A Practical Advisory to Etiology, Impact, and Treatment

Ambulatory surgery is common in plastic surgery, where many aesthetic and reconstructive procedures can be performed in hospitals, ambulatory surgery centers, or office-based surgery facilities. Outpatient surgery offers advantages to both the patient and the surgeon by increasing accessibility, flexibility, and convenience; lowering cost; and maintaining high-quality care. To optimize a patient's experience and comfort, postoperative nausea and vomiting (PONV) should be prevented. However, in those patients who develop PONV, it must be appropriately managed and treated. The incidence of PONV is variable. It is often difficult to accurately predict those patients who will develop PONV or how they will manifest symptoms. There are a variety of recommended "cocktails" for PONV prophylaxis and treatments that are potentially effective. The decision regarding the type of treatment given is often more related to provider preference and determination of side-effect profile, rather than targeted to specific patient characteristics, because of the absence of large volumes of reliable data to support specific practices over others. Fortunately, there are several tenets for the successful prevention and treatment of PONV we have extracted from the literature and summarize here. The following is a summary for the practicing plastic surgeon of the current state of the literature regarding PONV cause, risk factors, prophylaxis, and treatment that may serve as a guide for further study and practice management.

Conceptual origins, current practice, and views of wide awake hand surgery

This article reviews historical background, essential practice principles, and the new emerging area of wide awake hand surgery. It outlines the reasons that wide awake, local anaesthesia, no tourniquet surgery has emerged so quickly in the last 10 years over the world. I explain the origin of the concepts and some of the challenges of getting the technique accepted; in particular, the debunking of the myth of epinephrine danger in the finger. I review the most recent developments in several operations in this rapidly changing field of the tourniquet-free approach. Finally, this review includes speculations on the future of this technique.

Managing Opioid Addiction Risk in Plastic Surgery during the Perioperative Period

Opioid addiction is a public health crisis that affects all areas of medicine. Large numbers of the population across all racial and economic demographics misuse prescription opioids and use illicit opioids. The current understanding is that opioid misuse is a disease that requires treatment, and is not an issue of choice or character. Use of opioid medication is a necessary part of postoperative analgesia, but many physicians are unsure of how to do this safely given the risk of patients developing an opioid misuse disorder. This review gives an update of the current state of the opioid crisis, explains how current surgeons' prescribing practices are contributing to it, and gives recommendations on how to use opioid medication safely in the perioperative period.

Topical cryoanesthesia for the relief of pain caused by steroid injections used to treat hypertrophic scars and keloids

Intralesional steroid injections are the standard treatment for hypertrophic scars and keloids. The procedure is, however, quite painful and is unpopular with patients because of this. Topical application of anesthetic creams, such as Ametop gel (tetracaine) and EMLA cream (lidocaine and prilocaine), has limited efficacy because of poor drug penetration. The onset of the analgesic effect is also slow, which means that the use of topical anesthetics is time-consuming in clinical practice.We hypothesized that a commercially available cryotip could be used to provide fast-acting topical cryoanesthesia that would reduce the pain associated with steroid injections.Thirty patients with hypertrophic scars or keloids were enrolled in the study. Scars were injected with the steroid, triamcinolone acetonide, with or without prior application of the cryotip (-10 °C) for 15 seconds. The degree of pain was evaluated in each case using the visual analogue scale (VAS) and the verbal descriptor scale (VDS), together with any side-effects caused by application of the cryotip.The VAS pain scores showed a statistically significant (P < .01) difference between the pretreated and the control scars (pain scores 7.87 ± 1.31 and 2.7 ± 1.37, respectively). The VDS pain scores also showed a statistically significant (P < .01) difference between the pretreated and the control scars. And its average scores were 7.89 ± 0.32 and 2.68 ± 0.25, respectively.Application of the cryotip before injection could provide a rapid and effective means of reducing the pain associated with steroid injections. Painless would result in better therapeutic effect.

Digital Anaesthesia and Relevant Digital Anatomy for the Dermatologist

Cutaneous surgery requires a precise understanding of anatomy. This review describes the clinically relevant anatomy of the hand and relates it to the most common methods of digital anaesthesia.

Wide Awake Open Reduction of Irreducible Metacarpal Phalangeal Joint Dislocations

Supplemental Digital Content is available in the text.

Is it safe to use local anesthesia with adrenaline in hand surgery? WALANT technique

In the past it was taught that local anesthetic should not be used with adrenaline for procedures in the extremities. This dogma is transmitted from generation to generation. Its truth has not been questioned, nor the source of the doubt. In many situations the benefit of use was not understood, because it was often thought that it was not necessary to prolong the anesthetic effect, since the procedures were mostly of short duration. After the disclosure of studies of Canadian surgeons, came to understand that the benefits went beyond the time of anesthesia. The WALANT technique allows a surgical field without bleeding, possibility of information exchange with the patient during the procedure, reduction of waste material, reduction of costs, and improvement of safety. Thus, after passing through the initial phase of the doubts in the use of this technique, the authors verified its benefits and the patients’ satisfaction in being able to immediately return home after the procedures.

Minimal Pain Local Anesthetic Injection with Blunt Tipped Cannula for Wide Awake Upper Blepharoplasty

Supplemental Digital Content is available in the text.

Local Anesthesia Techniques in Hair Restoration Surgery

Pain during hair restoration surgery and other dermatologic surgery procedures is one of patients’ main fears. The authors briefly describe local anesthesia techniques they use in their surgical practice that make these procedures more pleasant for patients. The ability to provide a pain-free experience during hair restoration surgery will increase patients’ satisfaction and allow patients to return for subsequent procedures.