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Related Concept Videos

Local Anesthetics: Clinical Application as Surface, Infiltration, and Conduction Block Anesthesia01:30

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Depending on the target organ, local anesthetics (LAs) can be administered via various routes. In surface anesthesia, LAs are applied directly to the surface of the skin or mucous membranes. It is widely used for topical skin numbing before venipuncture or minor surgical procedures. Commonly used surface local anesthetics are lidocaine or benzocaine sprays or creams. Surface anesthesia occurs within 5 minutes and lasts for about 60 minutes. One of the main disadvantages of topical anesthesia is...
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Local anesthetics (LAs) are commonly used for various applications in medical and dental procedures. Some of the common agents used are cocaine, lidocaine, and bupivacaine.
Cocaine is an ester of benzoic acid and methylecgogine. It is used to anesthetize and vasoconstrict locally. Currently, it is used primarily for topical applications. It is beneficial for surgeries on the upper respiratory tract, providing anesthesia and shrinking the mucosa. Cocaine in the form of cocaine hydrochloride is...
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Local Anesthetics: Pharmacokinetics01:13

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The potency and duration of action of local anesthetics (LAs) are determined by their pharmacokinetics. Pharmacokinetics describes how LAs are absorbed, distributed, metabolized, and eliminated from the body. When administered to the vascular tissues, LAs are quickly absorbed and enter the systemic circulation, reducing their localized effects. Adding vasoconstrictors such as epinephrine to LAs reduces their absorption into the systemic circulation, making them clinically effective. The...
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Local Anesthetics: Clinical Application as Spinal Anesthesia01:11

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Spinal anesthetics are given during lower abdomen and limb surgeries to block sensory and motor neurons. They are administered in the mid to low lumbar regions, primarily acting on the cauda equina's nerve roots. The blockade level depends on the local anesthetic (LA) concentration. Usually, low LA concentrations are sufficient to block sensory fibers, while only high LA concentrations block motor fibers. Other factors like injection volume and speed, the patient's posture, and the drug...
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Local Anesthetics: Clinical Application as Epidural Anesthesia01:29

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Epidural anesthetics are administered in the fat-filled epidural space, the outermost part of the spinal canal. This technique is commonly employed for pain management and anesthesia during lower abdomen and pelvis surgeries or labor and delivery.
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Local Anesthetics: Clinical Application as Intravenous Regional Anesthesia01:16

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Intravenous regional anesthesia or the Bier block technique is used to anesthetize a specific limb or extremity. It uses exsanguinated or blood-drained vessels to transport local anesthetics or LAs to the peripheral nerve trunks. Lidocaine without vasoconstrictors like epinephrine is most commonly used for this technique. Other drugs used are prilocaine, ropivacaine, and chloroprocaine. Bupivacaine is not recommended for this technique due to its high cardiac toxicity.
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Risk-Stratified Use of Topical and Infiltrative Local Anesthetics in High-Risk Dermatologic Surgery.

Seyedshayan Shojaei1, Kimia Heidari2, Alhasan Alobaidi1

  • 1Department of Translational Research, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California 91766 USA.

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Summary

Local anesthetics are safe in high-risk dermatologic areas when used with careful risk stratification. Preparedness with antidotes like phentolamine and lipid emulsion ensures patient safety in complex cases.

Keywords:
AnestheticsDermatologic Surgical ProceduresDrug ToxicityEpinephrineLocalMethemoglobinemia

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Area of Science:

  • Dermatology
  • Anesthesiology
  • Pharmacology

Background:

  • Local anesthetics are essential in dermatology.
  • High-risk scenarios require nuanced safety understanding.
  • Contemporary evidence addresses safety in end-arterial sites, compromised skin, and systemic toxicity risks.

Purpose of the Study:

  • To synthesize evidence on local anesthetic safety in high-risk dermatologic contexts.
  • To provide an integrated, risk-stratified framework for clinical decision-making.
  • To update guidance on epinephrine use, topical anesthetic absorption, and systemic toxicity management.

Main Methods:

  • Narrative review of contemporary evidence.
  • Analysis of clinical data on epinephrine use in end-arterial sites (>200,000 injections).
  • Evaluation of absorption dynamics in barrier-compromised skin and systemic toxicity management.

Main Results:

  • Epinephrine is safe in digits/acral sites at dilute concentrations with adequate perfusion; phentolamine is an effective rescue.
  • Topical anesthetics are absorbed rapidly through compromised skin, increasing toxicity risk, especially in vulnerable populations.
  • Dilute tumescent infiltration is safer than high-dose topical therapy for large denuded areas.
  • Intravenous lipid emulsion has made severe local anesthetic systemic toxicity manageable.

Conclusions:

  • Context-sensitive risk stratification (vascular status, barrier integrity, pharmacokinetics) is crucial.
  • Office preparedness with phentolamine and lipid emulsion enables safe local anesthesia in high-risk scenarios.
  • Updated understanding supports safe use of local anesthetics in challenging dermatologic situations.