Basic Guide to Suturing


Providing adequate analgesia to patients prior to performing procedures is not only beneficial to patient, but also aids the clinician. Importantly, the patient's experience of the entire process will often determine how happy they feel about the eventual outcome. Often the most painful part of the procedure in community and emergency department settings will be the infiltration of the local anaesthetic.

With infiltrating local anaesthetic there are a number of tips, tricks and steps that you can take to simplify the process and minimise the pain. I have sourced this advice from my fellow clinicians, the literature and across the web. If you have any tips please feel free to share them in the comments section below. This is an adjunct post to the Basic Guide to Suturing Series.

So here is the quick users guide to reducing the pain of and improving your local anaesthetic administration.

Dose Correctly

Getting the right dose either using the traditional calculations or this handy little dosing nomogram - http://www.aliem.com/pv-card-local-anesthetic-toxicity-calculations/
And from the literature http://onlinelibrary.wiley.com/doi/10.1111/anae.12679/full

IBW Calculator - http://www.mdcalc.com/ideal-body-weight/#about-calculator
 

Onset (min) Duration (min) Max dose (mg/kg) Max mg (70kg person)
Lignocaine (1% or 2%)
(Xylocaine)
2 15-60 3mg/kg 220mg
(11mL 2%)
(22mL 1%)
Lignocaine with adrenaline
(1% or 2%)
2 120-360 7mg/kg 500mg
(25mL 2%)
(50mL 1%)
Bupivicaine (0.25%)
(Marcain)
5 120-240 2.5mg/kg 175mg(50mL)
Bupivicaine with adrenaline 5 180-420 3mg/kg 225mg
Prilocaine (0.5% or 1%)
(Citanest)
2 30-90 7mg/kg 500mg<70kg 1="" ml="" td="">
Ropivocaine (0.25%)
(Naropin)
5 120-360 3mg/kg 225mg

Solution preparation for minimal pain

  • Appropriate dosing
  • Buffer with sodium bicarbonate(e.g. 1mL of 8.4% sodium bicarbonate to 9 mL of 1% lignocaine.)
  • Warm the LA

Equipment

  • Smallest needle
  • Longer needle: requiring fewer injection points to cover the same area
  • Consider using a diabetic needle for first infiltration
  • Use fresh needles (i.e. sharper needles)
  • Appropriate syringe size (less pressure, and less likely to overdose)

Patient preparation

  • Look away
  • Distraction (e.g. smartphones, music, tv)
  • Gentle pinching or vibration adjacent to the site of injection

Paediatric Population

  • Use 1% for paeds patients.
  • Play specialist
  • Topical Analgesia
  • - ALA (Laceraine): a combination of 0.5% amethocaine, 4% lignocaine and 0.1% adrenaline
  • - EMLA is non-sterile and not approved for application to broken skin
  • Consider other options; e.g. gas, procedural sedation etc.

Further reading;

Procedural

  • Topical Anaesthetic
  • Inject into Subcutaneous Fat if There Is an Open Wound
  • Infiltrate through wound edges, rather than unbroken skin (clean wound)
  • Stabilise the Syringe Holding Hand to Minimise Needle Movement
  • Inject Very Slowly
  • Keep the Local Anaesthetic Wheal 10 mm ahead of the Needle Tip
  • Decrease number of insertions
  • Use smallest volume necessary

Get feedback from your patients

  • Getting feedback from your patients can help learn what works and what does not when administering local anaesthetic, to give the patient the most ideal experience.

References/Further Reading

  • http://www.ncbi.nlm.nih.gov/pubmed/17499653 
  • http://www.mdedge.com/cutis/article/100528/practice-management/minimize-pinch-and-burn-tips-and-tricks-reduce-injection

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