What are the local anesthesia options for suturing?

From the Guidelines

Lidocaine 1% or 2% with or without epinephrine is the recommended first-line option for local anesthesia in suturing, with a maximum safe dose of 4.5 mg/kg without epinephrine or 7 mg/kg with epinephrine (1:100,000) 1.

Key Considerations

• The use of epinephrine in local anesthesia is safe and recommended for most areas, including the ear, nose, hand, feet, and digits, but should be avoided in end-arterial areas like fingers, toes, penis, and nose 1.
• Buffering lidocaine with sodium bicarbonate (9:1 ratio) is recommended to decrease the pain of delivery by subcutaneous or intradermal infiltration 1.
• Alternative agents, such as bupivacaine (0.25-0.5%) for longer procedures and mepivacaine (1-2%) for moderate duration, may be considered based on the specific needs of the patient and procedure.

Administration Guidelines

• Inject 1-2% lidocaine using a 27-30 gauge needle, with careful aspiration before injection to avoid intravascular administration.
• Consider topical anesthetics like LET (lidocaine-epinephrine-tetracaine) or EMLA cream as pre-treatment for painful injections.
• Field blocks and direct infiltration are effective techniques for anesthetizing larger and smaller areas, respectively.

Special Considerations

• Patients with liver disease may require dose adjustments due to slower drug metabolism.
• Pregnant women should have elective procedures postponed until after delivery, and those with urgent medical necessity should be delayed until the second trimester when possible, with consultation from the patient's obstetrician 1.
• Patients with stable cardiac disease can receive local infiltrative anesthesia with epinephrine, but consultation with a cardiologist is recommended if there is uncertainty about the patient's ability to tolerate epinephrine 1.

From the FDA Drug Label

The application of lidocaine and prilocaine cream, 2.5%/2.5% on genital mucous membranes for minor, superficial surgical procedures (eg, removal of condylomata acuminata) was studied in 80 patients in a placebo-controlled clinical trial (60 patients received lidocaine and prilocaine cream, 2.5%/2.5% and 20 patients received placebo). Lidocaine and prilocaine cream, 2.5%/2.5% (5 to 10 g) applied between 1 and 75 minutes before surgery, with a median time of 15 minutes, provided effective local anesthesia for minor superficial surgical procedures. Lidocaine and prilocaine cream, 2.5%/2.5% applied to the genital mucous membranes as pretreatment for local anesthetic infiltration was studied in a double-blind, placebo-controlled study in 44 female patients (21 patients received lidocaine and prilocaine cream, 2.5%/2.5% and 23 patients received placebo) scheduled for infiltration prior to a surgical procedure of the external vulva or genital mucosa. Lidocaine and prilocaine cream, 2.5%/2.5% applied to the genital mucous membranes for 5 to 10 minutes resulted in adequate topical anesthesia for local anesthetic injection. LIDOCAINE HCl INJECTIONS FOR INFILTRATION AND NERVE BLOCK SHOULD BE EMPLOYED ONLY BY CLINICIANS WHO ARE WELL VERSED IN DIAGNOSIS AND MANAGEMENT OF DOSE-RELATED TOXICITY AND OTHER ACUTE EMERGENCIES THAT MIGHT ARISE FROM THE BLOCK TO BE EMPLOYED AND THEN ONLY AFTER ENSURING THE IMMEDIATE AVAILABILITY OF OXYGEN, OTHER RESUSCITATIVE DRUGS, CARDIOPULMONARY EQUIPMENT AND THE PERSONNEL NEEDED FOR PROPER MANAGEMENT OF TOXIC REACTIONS AND RELATED EMERGENCIES

Local Anesthesia Options for Suturing:

• Lidocaine and Prilocaine Cream (2.5%/2.5%): can be used for minor superficial surgical procedures, including suturing, with application times ranging from 1 to 75 minutes before surgery.
• Lidocaine Injections: can be used for infiltration and nerve block, but should only be employed by clinicians well-versed in diagnosis and management of dose-related toxicity and other acute emergencies. Key Considerations:
• Application time and dose of lidocaine and prilocaine cream (2.5%/2.5%) may vary depending on the procedure and patient factors.
• Lidocaine injections should be used with caution and only by experienced clinicians due to the risk of dose-related toxicity and other acute emergencies. 2 3

From the Research

Local Anesthesia Options for Suturing

• Lidocaine is a commonly used local anesthetic for suturing, but it has a short duration of action and may not provide adequate pain relief after the procedure is complete 4.
• Bupivacaine is a long-acting local anesthetic that can provide longer-lasting pain relief compared to lidocaine, making it a suitable alternative for suturing 4.
• The administration of lidocaine for local anesthesia in wounds requires careful preparation to ensure patient safety and a positive patient experience 5.
• Diphenhydramine is another local anesthetic that can be used for minor laceration repair, although it may be more painful to inject than lidocaine 6.
• Mixtures of lidocaine with long-acting local anesthetics such as bupivacaine or ropivacaine can provide faster onset of action and decreased duration of block, but the safety benefits of these mixtures are unclear 7.

Comparison of Local Anesthetics

• A study comparing lidocaine and bupivacaine found that bupivacaine provided significantly longer-lasting pain relief, with a mean duration of action of 5 hours compared to 2 hours for lidocaine 4.
• A study comparing 1% lidocaine and 0.5% diphenhydramine found that lidocaine was more effective as a local anesthetic for facial lacerations, but there was no significant difference between the two for other locations 6.
• A study comparing bupivacaine, ropivacaine, and their mixtures with lidocaine found that the mixtures provided faster onset of action and decreased duration of block, but the safety benefits of these mixtures are unclear 7.

Safety and Efficacy

• Local anesthetics can have adverse effects, including allergic reactions, and require careful administration and monitoring to ensure patient safety 8.
• The use of local anesthetics for suturing requires careful consideration of the patient's medical history, the location and size of the wound, and the potential risks and benefits of different local anesthetics 5, 6.