Effective pain control for I&D

[quietmedic]

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We all know the tagline, I&D is always gonna just hurt. But maybe not. Has anyone witnessed or performed any technique which provides effective pain control during these procedures? I was taught, just load them up with some percocet, inject the skin locally, and go to town...but inevitably, this is of little help. Squeezing out the abscess, as well as blunt dissection to break up loculations, hurts like absolute hell, judging by my patient's tears and cursing, and no one yet has mentioned a better, perhaps novel, way to control I&D pain. Anyone have any thoughts?

 

[DocEspana]

Regional nerve block, when abscess location allows it

 

[deleted109597]

ketamine

 

[RustedFox]

Lidocaine with epinephrine right into the abscess. Cruciform injection pattern.

 

[Janders]

(1) regional nerve block if applicable.
(2) sedation is completely reasonable if needed.

That said, I use the aforementioned techniques on <5% of my abscesses.

(3) 2% lido with epi, injected slowly and gently in a large ring around the abscess, and as much as you can deep under the edges of the abscess, allowed to set up for 5-10 minutes give excellent anesthesia the great majority of the time. You can add a touch right in the middle before you slice as well. The tricks are to use plenty of local, block all nerves coming into the abscess, and give it appropriate time to actually work before you start slicing.

 

[alpinism]

Put that old undergrad general chem to use.

Abscesses are acidic which prevents lido from diffusing into nerve fibers. Lido acts by blocking Na channels from the inside. If it can't diffuse into the nerve it can't prevent pain signal transmission. That's why oftentimes even after using tons of local anesthetic it can be really hard to get good pain control with an I&D.

There's a simple solution. Mix some bicarb into the lido. I usually add 1mL of bicarb to 9mL of lido.

https://books.google.com/books?id=U...ergency bicarbonate lidocaine abscess&f=false

Otherwise a regional block also works in certain circumstances.

 

[The White Coat Investor]

I'm convinced part of the issue is hyperalgesia as many of these patients are heroin users.

 

[WilcoWorld]

First try Jander's method - anesthetize all the nerves around the abscess. I do a triangle of anesthesia with 3 pokes, depositing a wheal on my way out each time.

If your patient tolerates it well, give it a minute or two to set in, then I&D as quickly and with as little manipulation as possible. Or I'll do 2 small (<5mm) incisions - one for the loop to go in, one for it to come out.

If your patient won't even let you touch them without flipping out, consider procedural sedation (or autonomous discharge).

 

[BoardingDoc]

Same approach as Janders and meeting with good success. If they're super squeamish and won't tolerate the anesthesia, if you've got cold spray in house, just blast the area before you inject and they won't feel it.

As an aside, I'm also a huge fan of making your own numbing spray for inserting NGTs. Bottle of afrin, stick a 25g needle in the nozzle to inject 10cc of lido, mix it up and spray the hell out of their nostril and the back of their OP before you start.

 

[Petypet]

Used just ice for 20 minutes and then the simple lido with epi. The ice provided enough analgesia for them not to feel the lido and got them involved with the care.

 

[deleted245139]

Ice is a great idea, never thought to use that.... Going to try it next shift.

Also, caveat. The bicarb w lido is a great adjunct, but as a caveat don't mix the bicarb with bupivicaine/marcaine (if you do the half/half for longer analgesia locally)... It will precipitate crystals

 

[ianjustlellis]

My technique requires a relatively large abscess (at least a cc of pus or so), but I have had great success with it. Take a 25g needle and make a skin bubble right at the surface of the abscess (like a TB test). Take an 18 gauge needle attached to a 10cc syringe and enter the skin right through this skin bubble into the core of the abscess and aspirate out as much as possible. This will relieve any pressure that might cause pain for the patient, as well as have the added benefit of keeping most of the pus safe and scent-free inside your 10cc syringe. After the aspiration, the patient will already be much more comfortable. Then, take your 25 gauge needle, extend your anesthesia to a larger wheal, and make your standard incision. Follow with breakage of loculations and some pressure irrigation with a 60cc syringe.

Sounds like a lot, but in practice it's lickety-split and I have had tremendous success with making my patients more comfortable.

 

[deleted109597]

Ice is a great idea, never thought to use that.... Going to try it next shift.

Also, caveat. The bicarb w lido is a great adjunct, but as a caveat don't mix the bicarb with bupivicaine/marcaine (if you do the half/half for longer analgesia locally)... It will precipitate crystals

Don't ever do half and half. It doesn't speed up the onset appreciably, and if you're not doing regional anesthesia, it isn't really lasting a ton longer. And it has a lower toxic dose.

 

[deleted109597]

My technique requires a relatively large abscess (at least a cc of pus or so), but I have had great success with it. Take a 25g needle and make a skin bubble right at the surface of the abscess (like a TB test). Take an 18 gauge needle attached to a 10cc syringe and enter the skin right through this skin bubble into the core of the abscess and aspirate out as much as possible. This will relieve any pressure that might cause pain for the patient, as well as have the added benefit of keeping most of the pus safe and scent-free inside your 10cc syringe. After the aspiration, the patient will already be much more comfortable. Then, take your 25 gauge needle, extend your anesthesia to a larger wheal, and make your standard incision. Follow with breakage of loculations and some pressure irrigation with a 60cc syringe.

Sounds like a lot, but in practice it's lickety-split and I have had tremendous success with making my patients more comfortable.

This is true for everything with lidocaine. You get better analgesia at the dermis/epidermis border. So in practice, this is what you should be doing for anything with lido (lacs, etc). Just make a wheal right at the skin layer, not deeper. Those nerves don't have the sharp pain recepters anyway. That's why you see people with enormous wounds and not much pain. Because the skin is numb from the trauma and everything else doesn't hurt.