Lidocaine vs Bupivacaine for Abscess Incision and Drainage
No, lidocaine does not provide longer anesthesia than bupivacaine—bupivacaine provides significantly longer duration of anesthesia, but when epinephrine is added to lidocaine, the duration difference becomes clinically less important for most abscess drainage procedures. 1
Duration of Anesthesia
Bupivacaine provides 27% longer anesthesia duration than lidocaine when both are mixed with epinephrine (1:200,000). 1 For plain solutions without epinephrine, bupivacaine lasts substantially longer than lidocaine, making it the clear choice when epinephrine is contraindicated. 1
However, for routine abscess incision and drainage in a healthy 28-year-old male, the addition of epinephrine to lidocaine prolongs its duration by approximately 200%, bringing it close to bupivacaine's duration. 2
Pain of Injection
Lidocaine causes significantly less pain on injection compared to bupivacaine. 1 In controlled trials, lidocaine was rated as the least painful local anesthetic for intradermal infiltration, while bupivacaine caused more discomfort. 1 This is particularly relevant for abscess drainage, where local anesthesia is already known to be painful. 3
Practical Recommendation for This Case
For a 3 cm abscess in a healthy young adult, use 1% lidocaine with epinephrine 1:200,000 as your first-line local anesthetic. 2, 1 This provides:
- Adequate anesthesia duration for the procedure (nearly equivalent to bupivacaine when epinephrine is added) 1
- Less injection pain for the patient 1
- Faster onset of action 2
- Enhanced vasoconstriction to minimize bleeding 2
Dosing Considerations
The maximum safe dose of lidocaine with epinephrine is 7 mg/kg for infiltrative anesthesia in adults. 2 For a typical 70-80 kg patient, this allows 490-560 mg of lidocaine, which is more than sufficient for a 3 cm abscess drainage. 2
When to Consider Bupivacaine
Reserve plain bupivacaine (without epinephrine) for situations where epinephrine is contraindicated and prolonged anesthesia is essential. 1 However, epinephrine is safe for use in abscess drainage and recommended for its vasoconstriction benefits. 2
Common Pitfalls
- Do not buffer bupivacaine with sodium bicarbonate, as precipitation may occur and decrease efficacy. 2
- Buffering lidocaine with sodium bicarbonate (1:9 or 1:10 ratio) decreases injection pain by 20-40% and is recommended. 2
- Antibiotics are not routinely needed after adequate surgical drainage unless the patient has sepsis, extensive cellulitis, or immunosuppression. 4, 5