Is it safe to perform an incision without anesthetic, such as lidocaine (local anesthetic), in this case?

Performing Incisions Without Anesthesia is Not Safe and Should Be Avoided

Performing an incision without anesthetic is not safe and should be avoided due to significant pain, potential for increased morbidity, and negative impact on patient quality of life. 1

Why Anesthesia is Necessary for Incisions

• Local anesthetics are essential for pain control during surgical procedures, with lidocaine being the most commonly used agent for office-based dermatologic and minor surgical procedures 1
• Incisions without anesthesia cause significant pain, which can lead to:
  • Patient distress and movement during the procedure, compromising surgical precision 1
  • Increased stress response, which can negatively impact healing 1
  • Potential psychological trauma, affecting future medical care compliance 1

Appropriate Anesthetic Options Based on Procedure Type

For Minor Procedures:

• Topical anesthetics are recommended as first-line for:
  • Dermal lacerations repair, especially in children 1
  • Minor skin procedures including small biopsies and excisions 1
  • Nonablative laser treatments 1

For More Extensive Procedures:

• Infiltrative local anesthesia (e.g., lidocaine) is recommended for:
  • Larger incisions and excisions 1
  • Procedures requiring deeper tissue manipulation 1
  • Areas with thicker skin where topical agents may be insufficient 1

For Special Situations:

• Combination approaches may be necessary:
  • Topical anesthesia followed by infiltrative anesthesia to reduce injection pain 1
  • For extensive surgery, consider regional blocks or systemic analgesia 1

Safety Considerations with Local Anesthetics

• Proper dosing is critical to prevent toxicity:

  • Use the lowest effective concentration and volume 1
  • Calculate doses based on ideal body weight for IV administration 1
  • Be aware of maximum safe doses (typically not exceeding 4.5 mg/kg for lidocaine with epinephrine) 2

• Monitor for signs of local anesthetic toxicity:

  • Early signs: perioral numbness, metallic taste, lightheadedness 2
  • Progressive signs: confusion, seizures, cardiovascular depression 2
  • Have resuscitative equipment and drugs immediately available 2

Special Technique for Abscess Drainage

• For abscesses specifically, an aspiration-injection technique can be used:
  • Aspirate pus from the abscess
  • Inject local anesthetic into the now-decompressed cavity via the same needle
  • This reduces pain compared to traditional infiltration around an abscess 3
  • However, this still requires anesthetic and does not support incision without anesthesia 3

Common Pitfalls to Avoid

• Never perform incisions without anesthesia based on misconceptions:

  • Myth: "Quick incisions hurt less" - Even brief incisions cause significant pain 4
  • Myth: "Some areas don't need anesthesia" - All incisions through innervated tissue require anesthesia 1

• Avoid inadequate anesthesia techniques:

  • Insufficient waiting time after application (topical agents need 20-30 minutes) 1
  • Injecting too rapidly (causes more pain and tissue distortion) 4
  • Failure to buffer lidocaine when appropriate 4

Conclusion for Clinical Practice

Performing incisions without anesthesia is not appropriate standard of care in modern medical practice. The pain caused would negatively impact patient outcomes including increased morbidity and decreased quality of life. Even for seemingly minor procedures, appropriate anesthesia should always be used to minimize pain, optimize surgical conditions, and maintain patient trust 1, 2.