What is the best type of anesthesia for a patient with a history of heart disease undergoing removal of a small lesion on the ear pinna?

Local Infiltration with 1% Lidocaine is the Best Choice

For a patient with stable heart disease requiring removal of a small ear pinna lesion, local infiltration anesthesia with 1% lidocaine (with or without epinephrine) is the optimal anesthetic choice. 1, 2

Rationale for Local Anesthesia Over Regional Techniques

• Local infiltration minimizes cardiovascular stress compared to regional or general anesthesia, which is critical for patients with cardiac disease 2
• The ear pinna is an ideal anatomical site for local anesthesia due to its small size, superficial nature, and minimal anesthetic volume requirements 2
• Small amounts of local infiltrative anesthesia have been demonstrated to be safe in patients with stable cardiac disease 1, 2

Why 1% Lidocaine Specifically

• 1% lidocaine provides adequate anesthesia for minor dermatologic procedures while minimizing potential cardiac effects 2
• The American Academy of Dermatology guidelines specifically support using lidocaine for local infiltration in patients with stable cardiac disease (Level B recommendation, Evidence Level I-II) 1, 2
• For a small ear lesion, typically only 3-10 mL of solution is required, well below the maximum safe dose of 7 mg/kg (up to 500 mg total) 2, 3

Addition of Epinephrine is Safe and Beneficial

• The addition of epinephrine to local infiltration anesthesia is safe and recommended for use on the ear (Level A recommendation, Evidence Level I-II) 1
• Epinephrine provides superior hemostasis, prolongs anesthetic duration by approximately 200%, and reduces systemic toxicity by limiting absorption 1, 3
• Local infiltrative anesthesia with epinephrine may be administered to patients with stable cardiac disease; if uncertain of the patient's ability to tolerate epinephrine, consult with the cardiologist 1, 2
• Use the lowest effective concentration of epinephrine (typically 1:100,000 or 1:200,000) 1, 3

Why Not the Other Options

Regional Anesthesia (Options B & C)

• Regional nerve blocks are unnecessarily complex for a small, superficial ear lesion 2
• Regional techniques provide no cardiovascular advantage over local infiltration for minor procedures 1
• Bupivacaine and levobupivacaine have longer durations of action but offer no benefit for a simple lesion excision and carry higher cardiac toxicity risk if inadvertently injected intravascularly 1

Ropivacaine with Adrenaline (Option D)

• While ropivacaine is a valid local anesthetic, lidocaine has more extensive safety data in cardiac patients and is the guideline-recommended agent 1, 2
• The question specifies "local anesthesia" rather than "local infiltration," which may cause confusion, but the clinical context clearly indicates local infiltration is appropriate 2

Critical Safety Considerations

• If the patient's cardiac condition is unstable or severe, consultation with the cardiologist is mandatory prior to the procedure 1, 2
• Continuous monitoring of blood pressure and cardiac rhythm is advisable even for minor procedures in patients with significant cardiac disease 1, 2
• Aspirate before each injection to avoid intravascular injection 1, 3
• Adding sodium bicarbonate (1:9 or 1:10 ratio) to buffer the lidocaine solution decreases injection pain (Level A recommendation) 1, 3

Common Pitfalls to Avoid

• Do not exceed the maximum safe dose of lidocaine: 7 mg/kg with epinephrine (500 mg maximum for adults) 2, 3
• Do not withhold epinephrine from ear procedures based on outdated "end-artery" dogma—extensive research has refuted this concern 3
• Ensure the patient's cardiac disease is truly "stable" before proceeding; unstable angina, recent MI, or decompensated heart failure require cardiology clearance 1, 2

Answer: A. Local infiltration 1% lidocaine (with epinephrine if cardiac status is stable and confirmed with cardiology if uncertain)