Here are 10 strategies for keeping the costs of local anesthetics down while promoting patient satisfaction that you can share with your anesthesia personnel.

1. Buffer the solution.
Using 12.5cc NaHCO3 (sodium bicarbonate) in 1,000cc for the wetting solution, or 1cc bicarb for every 10cc 0.5-2% lidocaine, will reduce the sting of the local anesthetic injection. A dissociative approach for injection decreases the value of buffering the solution and usually is unnecessary anyway. A slower injection rate with lidocaine at body temperature is the administration method least stimulating to the patient.

2. Dose adequately.
Don't limit your total lidocaine to only 500mg with epinephrine. This is an outdated and overly conservative restriction. More damage will be done by having inadequate local analgesia than by getting it with 1,000mg to 2,000mg of lidocaine with epinephrine (200cc to 400cc as 0.5% lidocaine). Well-oxygenated patients tolerate 1,000mg to 2,000mg of lidocaine with epinephrine without risking lidocaine toxicity.

3. Mix an alternative.
Try mixing the 500mg of lidocaine with 1mg epinephrine into a 1,000cc bag of lactated ringers or normal saline solution. This is a wetting or tumescent solution, typically used for liposuction. It's also effective for other indications, particularly in plastic surgery. Only in a small patient (90 pounds, for example) will 1,000ccs of wetting solution be adequate for analgesia.

More often than not, 2,000ccs to 5,000ccs will be required depending on the patient's size.

4. Look for peau d'orange.
If you do use a wetting solution, take care to obtain a peau d'orange (orange skin) appearance by injecting the dermis. Otherwise, the skin incision will receive inadequate analgesia.

5. Use a 30-gauge needle for periocular injections.
Take a page from the ophthalmologists and use a 30-gauge needle for injections around the eyes. Fewer hematomas will result.

6. Develop procedure-specific protocols.
When treating the three B's - browlifts, breast augmentations and bellies (or abdominoplasties) - use up to 50cc 0.25% bupivicaine in the operative field before waking the patient. This provides better post-op pain management in addition to the po clonidine (Catapres) 0.2mg and rofecoxib (Vioxx) 50mg or valdecoxib (Bextra) 40mg given 30 minutes to 60 minutes pre-op.

Some additional guidelines: Plan to re-inject the supraorbital ridge for browlifts; leave 20cc to 25cc of bupivicaine in each of the breast pockets for augmentations; and inject the rectus sheath and the incisional area for the abdominoplasties. Do not exceed 50cc of 0.25% bupivicaine (125mg total) to avoid potential cardiac toxicity.

7. Start with a skin wheal.
If providers perform local anesthetic injections without the benefit of a dissociative anesthetic, it's preferable to start with a skin wheal. The provider follows the injection by advancing the injected fluid ahead of the needle's path, as opposed to sticking the needle in and injecting on the way back out. One may even use a 0.5-inch 30-gauge needle and follow the subsequent deeper injection with a 1.5-inch 25-gauge needle or longer spinal needle.

8. Give general before local.
Injecting local anesthesia under general anesthesia before incision produces better post-op pain management. But note that the preemptive analgesia will be variable because general anesthesia does not block the incoming stimulus from the injection. The response is affected only by the general anesthetic state.

9. Practice preemptive analgesia.
Preemptive analgesia can be given predictably when using a dissociative state before the injection of lidocaine. The dissociative state blocks the incoming stimulus - by blocking the NMDA receptors in the spinal cord and midbrain - from reaching the cerebral cortex. This means no wind-up phenomenon occurs with the lidocaine injection.

10. Obtain the dissociative state.
The dissociative state - defined by a lack of patient movement with the lidocaine injection - is typically obtained with ketamine two minutes to three minutes before the local anesthesia injection. Using a consciousness monitor along with a gradual induction makes ketamine (or other agents) predictable through numerical measurement of the hypnotic state before the ketamine injection. The number of NMDA receptors does not vary substantially in adults and is unrelated to body weight. A 25mg dose of ketamine will dissociate about 80 percent of patients, and a 50mg dose about 98 percent.

Absorb what's useful
While not all of these tips will apply to every facility, many will. Clinicians who improve their local anesthesia skills save facilities money and keep their patients more comfortable.