Numbing skin

[smarterchild]

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Curious to hear what techniques you all use to numb skin. I always get complaints how the lidocaine skin wheal is the worst part.

Some have said raise a skin wheal first and then anesthetize deeper. Others say go straight in with a 30g needle and leave a skin wheal as the needle exits the skin.

Have you all found any successful ways to reduce the sting? The gebauers spray is too expensive to use on every patient so I tabled that idea

 

[pastafan]

No skin wheal, that is the part that hurts. Insert needle fully and inject on the way out without stopping to raise a wheal.

You can also alkalinize the local.

 

[SommeRiver]

Needle deep, then inject local on way out (as stated above). I put 1cc of bicarb per 5cc of local.

 

[swamprat]

I use the skin wheel to mark my needle entry. I bend the needle go down on a perpendicular angle and make a wheel and then inject all the way to the hub. If its just a CESI/LESI sometimes ill just go straight in, leave the needle in as my mark and then place the Tuohy as I am withdrawing the other needle.

 

[SSdoc33]

no local unless an RF or ILESI. i rarely do ILESI in lumbar spine.

if you use a thin needle and are relatively quick, this is the most comfortable way.

 

[witothewi]

I had an attending during my residency say that bending the needle is risky as the white gummy material keeping the needle attached to the Luer lock is not super strong and can allow the needle to break off, especially when you purposely bend and weaken the needle.

He had a needle get stuck in a patient localizing this way, which required a minor cut down to retrieve. If you’re dunking it down and hubbing the bent needle against skin, be careful!

 

[callmeanesthesia]

Certainly avoid skin wheal - Try with and without and watch how much they flinch with the skin wheal. Just give some time for the local to work. I’ve done side by side comparisons though (local on one side and no local on the other) and for 22 and 25g, most patients find the no local less painful, especially if you apply some distraction/gate theory by applying pressure next to the insertion site. I know there’s at least one study out there that also came to the conclusion that without local was slightly less painful but I’m too lazy to go find it right now.

 

[lobelsteve]

Always a skin wheal. 27G needle.
1% plain lidocaine 9:1 NaHCO3.

 

[deleted131481]

Certainly avoid skin wheal - Try with and without and watch how much they flinch with the skin wheal. Just give some time for the local to work. I’ve done side by side comparisons though (local on one side and no local on the other) and for 22 and 25g, most patients find the no local less painful, especially if you apply some distraction/gate theory by applying pressure next to the insertion site. I know there’s at least one study out there that also came to the conclusion that without local was slightly less painful but I’m too lazy to go find it right now.

Just for fun here it is.

 

[georgiamd]

no local unless an RF or ILESI. i rarely do ILESI in lumbar spine.

if you use a thin needle and are relatively quick, this is the most comfortable way.

I did it this way, honestly stopped bc nurses etc were complaining I wasn’t “numbing” the patient.

 

[SSdoc33]

I did it this way, honestly stopped bc nurses etc were complaining I wasn’t “numbing” the patient.

well, i think you have your answer right there.

if you are quick, it is a LESS painful way to do it

 

[Ferrismonk]

I've always been a lots-of-local guy, but I noticed that as I've improved over time and started using 25G needles instead of 22, the local was often the worst part. I've thus slowly been leading to less and less local for skin. Every single patient I've done this with states it hurts less than when I used to local the skin.

So basically I'll use skin local in the following situations:
1) Whenever I'm using a 22G or large needle
2) The patient tends to move a lot. Local everything first (which they'll move to) then they won't move much for your deeper needles (cervical MBB for example).

I've tried all the local-less-sting techniques I can find with mixed results
1. Bicarb in local - Local still stings
2. Drop a little on skin immediately before injecting, reportedly helps via gate theory, minimally effective
3. Ethyl Chloride - I don't use this for spinal procedures because it's technically not sterile.
4. Ice packs - Uncomfortable and wears off too quickly
5. EMLA cream - Takes too much time to set up
6. I've considered using the Buzzy device, but haven't pulled the trigger to purchase one yet.

I also don't do a skin wheal, that hurts the most. Drop it to hub and inject on way out.

This technique also seems to help fwiw:
If you do use local and are good with two hands, I find that inserting your 22G into the skin AT THE SAME TIME your local needle is coming out of the skin and leaving it there for little bit tricks the patient. I wait 30s or so then advance to final destination. Works well and they don't feel that second "pinch" for your quinke.

 

[drusso]

Ballers don't numb. Numbing is for P*ssies.

 

[Orin]

Anyone still going old school and doing skin wheals with bacteriostatic saline?

 

[gdub25]

Ballers don't numb. Numbing is for P*ssies.

Truth.

Like Farris I did some testing on patients. MBBs with 22ga, numb some of them with local before the 22ga poke and just poke with others, most said the local hurt the most. Switched to 25ga on all MBBs and haven’t used local in a couple years now. Don’t use local on SI, troch bursa, TFESI... Really just numb before a Tuohy for ESIs.

 

[drusso]

Truth.

Like Farris I did some testing on patients. MBBs with 22ga, numb some of them with local before the 22ga poke and just poke with others, most said the local hurt the most. Switched to 25ga on all MBBs and haven’t used local in a couple years now. Don’t use local on SI, troch bursa, TFESI... Really just numb before a Tuohy for ESIs.

Two words, "Freeze spray."

 

[callmeanesthesia]

Two words, "Freeze spray."

Doesn’t seem to do much either. I only use that, or local in the skin, at patient request for procedures with 25g. For 22g tuohys I still use local but more out of residual habit, and on the off chance it will reduce movement for cervical epidurals. I too have done my own test - numb one side and not the other. Patients almost all felt it hurt less without lidocaine.
Regarding bicarb in lido, I’ve looked at a few studies on it. It’s lido with epi that is much more acidic, so bicarb will have more effect than with plain lido. Adding bicarb causes degradation of epi but not lido.

 

[deleted993114]

Ballers don't numb. Numbing is for P*ssies.

Youch!

Having had MANY medical procedures done on me, I always use copious amounts of local and wait for it to work- it doesn't take long. That cold spray stuff helps too.

I put myself in the patient's position and try to do what I can to make things less miserable. I really feel sorry for the majority of patients I see.

I have a cystitis from treatment for bladder CA. The urologists never wait for the local and slam the thing in; prior to a cystitis, it was a walk in the park. Now it is like breaking glass in the bladder and urethra and is an exercise in endurance. I really look forward to that every three months- everyone needs something to look forward to.

 

[Ferrismonk]

Truth.

Like Farris I did some testing on patients. MBBs with 22ga, numb some of them with local before the 22ga poke and just poke with others, most said the local hurt the most. Switched to 25ga on all MBBs and haven’t used local in a couple years now. Don’t use local on SI, troch bursa, TFESI... Really just numb before a Tuohy for ESIs.

I need learn 25G TFESI trick. I already use 25G quinke with CLO for ESIs.

 

[Ferrismonk]

Youch!

Having had MANY medical procedures done on me, I always use copious amounts of local and wait for it to work- it doesn't take long. That cold spray stuff helps too.

I put myself in the patient's position and try to do what I can to make things less miserable. I really feel sorry for the majority of patients I see.

I have a cystitis from treatment for bladder CA. The urologists never wait for the local and slam the thing in; prior to a cystitis, it was a walk in the park. Now it is like breaking glass in the bladder and urethra and is an exercise in endurance. I really look forward to that every three months- everyone needs something to look forward to.

100% agree to wait for the local to work. Makes a HUGE difference. However, for many injections, the lido hurts more than the needle itself and it's actually kinder to use the 25G without skin local than to use it with local.