What is the best anesthetic choice for wound repair on a patient's leg?

Best Anesthetic Choice for Leg Wound Repair

For simple wound repair on a patient's leg, infiltrated lidocaine with epinephrine is the best choice, providing effective local anesthesia with hemostatic benefits and an excellent safety profile. 1

Primary Recommendation: Infiltrated Lidocaine

• Lidocaine infiltration is the standard local anesthetic for wound repair, offering rapid onset (2-5 minutes) and adequate duration (approximately 1 hour) for most simple repairs 2
• Adding epinephrine (1:200,000 or 5 μg/mL) is strongly recommended as it reduces systemic absorption, promotes local hemostasis, and increases the duration of anesthesia 2
• Lidocaine does not negatively affect wound healing, unlike bupivacaine which impairs collagen maturation and wound tensile strength at 21 days 3

Administration Technique

• Use the lowest effective dose to avoid high plasma levels and serious adverse effects 2
• Inject slowly with frequent aspiration before and during injection to avoid intravascular administration 2
• Fractional administration with constant patient monitoring is preferred over rapid bolus injection 2
• Ensure adequate lighting and patient positioning before beginning the repair 4

Alternative Considerations

Topical Anesthetics

• Topical agents (such as LET: lidocaine-epinephrine-tetracaine) can be considered for superficial lacerations, particularly on highly vascular areas like the face and scalp where absorption is highest 1
• However, for leg wounds requiring deeper tissue manipulation or suturing, topical anesthesia alone is typically insufficient 1
• Non-cocaine formulations are strongly preferred over cocaine-containing preparations due to lower cost and reduced potential for adverse effects 1

Regional Nerve Blocks

• For extensive leg trauma or complex repairs, low-concentration local anesthetic peripheral nerve blocks may be appropriate 1
• When used for lower leg trauma, employ low concentrations without adjuncts to preserve some sensation and motor function, allowing detection of complications like compartment syndrome 1
• This approach is particularly relevant for traumatic injuries rather than simple wound repairs 1

Critical Safety Considerations

Contraindications and Precautions

• Avoid procaine (Novocain) in patients with sulfite sensitivity, as it contains acetone sodium bisulfite which can cause anaphylactic reactions 2
• Use caution in patients with hepatic disease, as ester-type anesthetics like procaine are metabolized by plasma cholinesterase produced by the liver 2
• Do not use epinephrine-containing solutions in areas supplied by end arteries (digits, nose, external ear, penis) due to risk of ischemic injury 2
• Patients with peripheral vascular disease may exhibit exaggerated vasoconstrictor responses 2

Monitoring Requirements

• Resuscitative equipment, oxygen, and emergency drugs must be immediately available before administering any local anesthetic 2
• Monitor for early signs of systemic toxicity: restlessness, anxiety, metallic taste, tinnitus, dizziness, tremors, or drowsiness 2
• Maintain IV access during major procedures to ensure a functioning pathway for emergency treatment 2

Multimodal Analgesia Approach

• Combine local anesthesia with systemic analgesics (acetaminophen, NSAIDs if not contraindicated) for optimal pain control 1
• This multimodal approach reduces reliance on opioids while maintaining effective analgesia 1

Common Pitfalls to Avoid

• Never inject without aspirating first - intravascular injection can occur even with negative aspiration 2
• Avoid using bupivacaine or levobupivacaine for simple wound repairs, as they impair wound healing compared to lidocaine 3
• Do not exceed maximum recommended doses: toxicity is dose-related and can cause cardiac arrest 2
• Ensure the wound is clean and dry before any closure attempt 4