Minimizing pain with local anesthesia

‘Wow doc! That freezing hurt more than the cut did in the first place!”

It’s common knowledge among our patients that the ‘freezing’ we give them as we prepare a wound for closure is often worse than the initial injury. We tell our patients that it will only hurt for a second, or that the momentary discomfort is for good reason. ‘Ouch!!’ they still yell as we inject the lidocaine and get ready to suture ‘That stuff hurts!’

Are our patients just wimps? Should they just suck it up and deal with the pain?

If you think the answer to these questions is yes then here’s a little experiment for you. Go get some 1% lidocaine and a 22 gauge needle. Now inject 1 ml into yourself, it doesn’t matter where really but for the sake of the experiment choose somewhere sensitive like your volar forearm. Okay, how did that go?  Yes, it hurts, but don’t worry we did the experiment for a good reason.

How can we minimize our patients discomfort during administration of local anesthesia? Most of us already know how to do this, but we aren’t. Perhaps we are desensitized to pain issues, but more likely we worry it will take too much time. In reality there is very minimal time requirement, and patients will be grateful. In fact, if they have had ‘freezing’ before and you do this well they will automatically think you are an amazing doctor!

  1. Minimize your patients anxiety. Tell them in a reassuring voice that you are going to minimize their pain.
  2. Consider alternatives to injected local anesthetic. Will topical anesthetic work? Should the patient have procedural sedation?
  3. Choose 2% lidocaine. High volume injections are more painful, so choose to inject a smaller volume of more concentrated lidocaine. 1% solutions are best used for large wounds where we need to get good anesthesia but are constrained by maximum doses, so need more dilute solution.
  4. Put your anesthetic somewhere warm. Warm anesthetic hurts less. I like to put a few ampules of 2% lidocaine in my scrubs pocket, or under the desk light at a work station.
  5. Buffer your lidocaine. Lidocaine has a pH of 7.4, and injection hurst less when it is buffered. Use a ratio of about 10 parts lidocaine to 1 part sodium bicarb.  I usually draw up 0.5ml of 8.4% sodium bicarb from an amp then fill the rest of a 5ml syringe with lidocaine, invert several times to mix and voila!
  6. Provide a distracting counter-sensation prior to injection. Rub the patients skin proximal to the injection site.
  7. Use a small gauge needle.
  8. Infiltrate directly into the wound rather than through intact skin.
  9. Inject the anesthetic slowly.
  10. Allow time for the anesthetic to work. Lidocaine works fast, but you need to allow a minute or two for it to take full effect.

Once we decide that providing a maximally pain free experience for our patients is important the rest is easy. These steps will become second nature to you, and patients will think you’re the best doctor ever, because ‘It didn’t hurt a bit!’


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