I didn't see any other threads when I searched, so just thought I would bring this topic up for discussion.
First, to use bicarb or not? I used it in fellowship, but then when I joined a group, the others were not using it, so I stopped. Now I am reconsidering using it again, but with regulations regarding multiuse vials, not sure how best to do it. Would it be reasonable to use a single multiuse vial for one day? Would you use it for more than one day?
Then as for technique...excuse my lengthy story here in advance. I use 25g needle for most procedures. For interlaminar epidurals, I use 22g Tuohy. Not too long ago, I was using a 25g 1.5 inch needle for local (that's what came in our kit). I would enter the skin with needle perpendicular, anesthetize deep, then inject as I withdraw the needle, and finally inject subcutaneous. Yes, I have heard recommendations not to create a wheal because it is painful, but I was also taught that a wheal is ok if you inject slowly which decreases the pain. I find if I don't create at least a small wheal, then I may not have good anesthesia of the most superficial layer, so that when I enter with the spinal needle, they still feel pain. So I was using skin wheal technique. Then after a while, I went through a phase where I did not use local for 25g procedures, as the lidocaine stings anyway (realizing it is without bicarb), and not to mention that it saves a little time. In the end, regardless of technique, some patients did just fine, and others found it painful. Recently, I have been using 27g 0.5 inch needles for local sometimes, and find that it helps (perpendicular entry with wheal). So I will order my kits with 27g 1.25 inch needles in the future. I also plan to try some with 30g 0.5 inch needle. Saving time is important, but I feel more now that minimizing pain will make it more likely that patients will continue to return for procedures, so I guess I am still experimenting. I am open to suggestions and curious to know others' thoughts on this.
First, to use bicarb or not? I used it in fellowship, but then when I joined a group, the others were not using it, so I stopped. Now I am reconsidering using it again, but with regulations regarding multiuse vials, not sure how best to do it. Would it be reasonable to use a single multiuse vial for one day? Would you use it for more than one day?
Then as for technique...excuse my lengthy story here in advance. I use 25g needle for most procedures. For interlaminar epidurals, I use 22g Tuohy. Not too long ago, I was using a 25g 1.5 inch needle for local (that's what came in our kit). I would enter the skin with needle perpendicular, anesthetize deep, then inject as I withdraw the needle, and finally inject subcutaneous. Yes, I have heard recommendations not to create a wheal because it is painful, but I was also taught that a wheal is ok if you inject slowly which decreases the pain. I find if I don't create at least a small wheal, then I may not have good anesthesia of the most superficial layer, so that when I enter with the spinal needle, they still feel pain. So I was using skin wheal technique. Then after a while, I went through a phase where I did not use local for 25g procedures, as the lidocaine stings anyway (realizing it is without bicarb), and not to mention that it saves a little time. In the end, regardless of technique, some patients did just fine, and others found it painful. Recently, I have been using 27g 0.5 inch needles for local sometimes, and find that it helps (perpendicular entry with wheal). So I will order my kits with 27g 1.25 inch needles in the future. I also plan to try some with 30g 0.5 inch needle. Saving time is important, but I feel more now that minimizing pain will make it more likely that patients will continue to return for procedures, so I guess I am still experimenting. I am open to suggestions and curious to know others' thoughts on this.
