Local Anesthesia

Purpose

This document provides guidance for the perioperative registered nurse (RN) caring for a patient receiving local-only anesthesia by injection, infiltration, tumescent infiltration, or topical application. This document includes guidance about patient assessment, patient monitoring, and documentation of patient care as well as guidance on recognition, assessment, and treatment of adverse reactions to local anesthesia, including local anesthetic systemic toxicity (LAST), local anesthetic allergies, and other adverse reactions (eg, methemoglobinemia). It is not the intent of this guideline to address situations that require the services of an anesthesia professional or to substitute the services of a perioperative RN in those situations that require the services of an anesthesia professional.

Local anesthetics have been in use for more than 100 years.¹  In 1884, the first surgery in which the surgeon used a local anesthetic, a cocaine solution, was performed for a patient with glaucoma.²  Because cocaine had undesirable effects (eg, toxicity, addiction), new local anesthetics were sought to replace it.

A local anesthetic that appeared to be safer than cocaine, novocaine, was discovered in Germany in 1905. However, novocaine produced adverse effects (eg, allergic reaction) and had a short duration of action,³  so the search continued. Lidocaine, which has a rapid onset of action and a lower toxicity incidence, was developed in the 1940s and was quickly followed by the development of mepivacaine, bupivacaine, prilocaine, etidocaine, and articaine.²  The addition of epinephrine to local anesthetics produced the desirable effect of vasoconstriction, which extended the duration of anesthesia, reduced systemic absorption, and reduced toxicity.⁴ 

Epinephrine has historically been associated with causing tissue necrosis related to vasoconstriction of end arteries, particularly the digits.^5,6  The critical evaluation of the literature and investigation into the safe use of epinephrine in fingers and toes,⁷  the current use of lidocaine with epinephrine by hand surgeons, and the introduction of the epinephrine vasoconstriction rescue agent, phentolamine, contributed to the increased use of the wide awake local anesthesia no tourniquet (WALANT) technique for hand surgeries.⁸  The benefits of the WALANT technique include no tourniquet pain,^8,9  cost savings,^8,10-19  no preoperative testing,^8,12  no need for fasting,⁸  less procedure and postanesthesia care time,^{8,16,18,20-22}  decreased use of supplies,^23,24  increased patient satisfaction,^12,17,25,26  and decreased anesthesia-related complications (eg, adverse effects of opiates, sedation for patients with comorbidities).^8,21  Potential risks of using the WALANT technique include vasoconstrictor-induced ischemia, bleeding, and reduced visibility at the surgical site.²⁷  The WALANT technique is successfully used for carpal tunnel release^13,26,28-30 ; trigger finger release^9,13,29 ; ganglion excision^21,29 ; open reduction internal fixation radius fracture^31-34 ; hardware removal^13,20 ; tendon reconstruction³⁵ ; open reduction internal fixation ankle fractures³⁶ ; knee arthroscopy²² ; wrist arthroscopy³⁷ ; and fracture fixation of the hand,³⁸  ulna,³⁹  and olecranon.⁴⁰ 

The goal of the perioperative team is to provide safe care while minimizing pain and anxiety to the patient receiving local anesthesia. Local anesthesia is safe and effective, although, rarely, a patient may have a toxic systemic, allergic, or adverse reaction to the local anesthetic. Local anesthetic systemic toxicity may occur as serum levels of the local anesthetic increase. The symptoms of LAST may present as central nervous system (CNS) or cardiovascular system (CVS) complications or both.^41-47  Although the incidence of LAST is rare,^48-52  the consequences may be severe and potentially fatal.^41,43  Historically, allergic reactions to local anesthetics are also rare, occurring in less than 1% of all patients who receive a local anesthetic,^1,4,5,53,54  but allergic contact dermatitis from lidocaine is increasing, with a prevalence of 2.4%.⁵⁵  This increase is likely due to the increase in the number of over-the-counter medications containing lidocaine.⁵⁵ 

The topics of moderate sedation analgesia; regional anesthesia; use of local anesthetics as an adjunct to general, regional, or moderate sedation; postoperative pain pumps; dental procedures; and the use of intravenous intralipid for drug toxicities resulting from non-local anesthetic medications are outside the scope of this document. Guidance for medication administration and documentation is provided in the Guideline for Medication Safety.⁵⁶ 

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2013 through August 2019. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until January 2020. Additional articles were requested by the lead author that were not identified in the original search (ie, did not fit the search criteria) or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included ACLS, ACLS certified, advanced cardiac life support, allergic reaction, allergy, ambulatory surgical procedures, analgesia, anaphylactic reaction, anaphylaxis, anesthesia (local), anesthetics (local), blood pressure, blood pressure determination, bupivacaine, complications (intraoperative), complications (postoperative), drug hypersensitivity, elective surgical procedures, epinephrine, Exparel, heart rate, heart rate determination, hypersensitivity, infiltration anesthesia, intraoperative complications, LAST assessment, lidocaine, lidocaine with epinephrine, liposomal bupivacaine, liposomal lidocaine, local anesthesia, local anesthetic systemic toxicity, local only anesthesia, Marcaine, minor surgical procedures, monitoring (physiologic), nurse’s role, nurse’s scope of practice, patient monitoring, perioperative nursing, physical examination, physical reaction, physiologic monitoring, postoperative complications, pulse, risk assessment, SALANT, Sensorcaine, sodium bicarbonate, straight local procedures no anesthesia provider, surgeon administered local or regional anesthesia, surgery (elective), surgery (operative), surgical nursing, surgical procedures (operative), topical anesthesia, vital signs, WALANT, wide awake local anesthesia, and Xylocaine.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and those published prior to January 2013 when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available (Figure 1).

Figure 1

Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. Embase is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Exparel is a registered trademark of Pacira Pharmaceuticals, Inc, Parsippany-Troy Hills, NJ. Marcaine is a registered trademark of Hospira, Inc, Lake Forest, IL. Sensorcaine and Xylocaine are registered trademarks of Fresenius Kabi, Lake Zurich, IL.