ARTICLE
Auteur(s) : Kawtar Beqqal, Joëlle Debie, Stéphanie
Constantin, Evelyne Chau, Marielle Burnouf, Jean Stephanazzi,
Nicolas Dupin, Marie-Françoise
Avril
Service de Dermatologie, Hôpital Cochin, Université Paris 5,
France, Pavillon Tarnier, 89 rue d'Assas, 75006 Paris
accepté le 5 Janvier 2010
The use of local anaesthesia is an important issue in
dermatological surgery. It is defined as reversible loss of pain
perception in a circumscribed area of the body [1, 2]. The first
pharmacological agent, cocaine, was isolated by Niemannn in 1860.
Then, in 1943, Lofgren synthesized lidocaine, an amid derivate of
diethylaminoacetic acid, which has become widely used [1-4]. It was
associated later with epinephrine (a vasoconstrictor drug) to
prolong the duration of anaesthesia by decreasing the absorption of
the anaesthetics and reduce the risk of systemic toxicity. Local
anaesthesia can be classified by site and modalities of application
of pharmacological agents into: topical use, local injection and
peripheral nerve blockade, the latter impedes the conduction of
nerve impulses along the nerve.
The mechanism of action is interference between local
anaesthetic agents and specific receptor sodium channels located in
nerves, blocking the propagation of action potentials of the fibres
responsible for painful feelings. Pain is a subjective symptom that
is difficult to evaluate, and during local dermatological surgery,
the intensity of pain has been the subject of few studies. We
designed a prospective study in order to evaluate the intensity and
the duration of painful sensations during surgical excisions in a
dermatological day surgery unit when using lidocaine
injections.
Materiel and methods
This prospective study regarding the efficacy of local anaesthesia
in pain control included all consecutive patients operated in the
surgical unit of a dermatology department from October
1st to December 31 2005. Oral consent was obtained
from all patients participating in the study. Local anaesthesia was
delivered by injections of 1% lidocaine solution with or without
epinephrine. The volume of injected anaesthetic was not calculated.
Patients who had peripheral nerve blockade were excluded. The
patient's skin was cleaned with iodine povidone
(Bétadine®). Patients were operated by ten different
senior surgeons, who regularly worked in the department.
The nature, localization and diameter of lesions to be excised
were recorded in a questionnaire completed by a nurse. The
intensity of pain was scored by mean of a visual analogue scale
from 0 (i.e., no pain) to 10 (maximal pain) and patients
were asked at three different times of the surgical procedure about
painful sensations: at the time of anaesthetic injection before the
operation, during the operation, and at the end of the operation.
In addition, patients were asked at the end of the surgical
procedures if they were satisfied with the local anaesthesia or if
they would have preferred a general anaesthesia.
Patients who received a pre-medication (topical
lidocaine/prilocaine cream, hydroxyzine, cimetidine, bromazepam or
paracetamol-dextropropoxyphène) were also included. Topical
lidocaine/prilocaine cream was applied in some patients with
perineal lesions. Cimetidine was also administered to female
patients with perineal lesions in order to decrease local
secretions. Hydroxyzine and bromazepam were prescribed in some
anxious patients. One patient received paracetamol
dextropropoxyphene.
One hundred and twenty-one patients were enrolled in the study.
One patient, who had a vulvae lesion with extension to the vagina,
was excluded because this site was no longer dermatological.
Therefore 120 patients were included in the study. Patients
were separated into two groups for the analysis. The first group
included 90 patients who did not receive any pre-medication.
The second group included 30 patients who received some
pre-medication. Cimetidine was prescribed in order to decrease
vaginal secretions in perineal surgery. Although we are not aware
of any anaesthetic properties of cimetidine, we classified
cimetidine as a pre-medication.
Thirteen patients had multiple lesions excised during the same
operation and 8 other patients had a second local anaesthesia
for skin graft collection. For these patients, local anaesthesias
were performed at the same time and their answers about pain were
related to the whole procedure. For the analysis, the largest
lesion in diameter was recorded.
Results
Characteristics of the procedures, localization and maximum
diameters of the lesions are presented in table
1 and figure
1. Lesions were mainly skin cancers and localized on the
face and neck (55 patients). Other localizations were the
chest (20 cases), limbs (24 cases), and perineum
(18 cases). The site was not recorded in 3 cases. The
maximum diameter of the lesions varied from 1 cm to 10 cm
with a mean diameter of 2.53 cm (figure 1) in the
107 cases where the data was available
In 30 patients, pre-medication was used before the
operation and consisted either of lidocaine/prilocaine cream
[EMLA®] (n = 11), or hydroxyzine 25 mg (n = 10), or
cimetidine 200 mg (n = 7), or bromazepam (n = 1) and
paracetamol-dextroproxyphene for pain of the shoulders (n = 1),
according to the surgeon's prescription. The anaesthetic agent
injected was 1% lidocaine (10 mg/mL) with 0.01 mg/mL of
epinephrine in 105 patients and without epinephrine in
13 patients. In 2 cases, patients received lidocaine
injections and the association with epinephrine was not recorded.
The exact amount of anaesthetic injected was not registered.
The perception of pain according to the evaluation time point is
presented in figure
2. At the moment of anaesthetic infiltration, four patients
experienced severe pain (score 8-10), 38 patients indicated
medium to severe pain (score 5-7). There was no or little pain in
24 patients (score 0-1). Altogether, the mean analogical scale
score of pain was 2.8 (from 0 to 10). During the
operation, there was a lack of pain in 111 patients. Only one
patient reported a painful sensation scored 5. Mean pain scale
score was 0.23 (from 0 to 5). At the end of the surgical
procedure, only two patients had medium pain scored 3-4 after
perineal treatment. There was no pain in 118 patients (score
0-1) and the mean score of pain was 0.14 (from 0 to 8).
The perception of pain was evaluated separately, according to the
presence of epinephrine in the anaesthetic, to the association with
a pre-medication and to the diameter of the lesions. The results of
the pain evaluations showed that the scores of pain tended to be
higher in the group of patients receiving lidocaine and epinephrine
(figure 3) and
tended to be higher in patients without pre-medication for large
lesions (figure
4). The correlation between the diameter of lesions and the
pain score was studied in the whole series and, thereafter,
separately in the two subgroups with (30 patients) and without
(90 patients) pre-medication. Eight patients from the first
group and 7 patients from the second group were excluded
because of incomplete information. Figures 5 and 6 show the
results of these analyses.
After the surgical excision, patients were asked about their
preference for local or general anaesthesia. One hundred and
fourteen patients answered the question and six did not. Fifteen
patients (13%) would have preferred a general anaesthetic (15/114).
In these 15 cases, the sites of the treated lesions were the
perineum in 7 cases, the face in 6 cases, the arm in one
case and the nail in one case.
An analysis of patients with lesions located on the perineum was
performed. Eighteen patients had a lesion at this site. Of these,
11 patients had applied lidocaine/prilocaine topical cream
before the lidocaine injection. There was a clear difference in the
wishes for general anaesthesia between patients who had applied
lidocaine/prilocaine cream and those who did not. Among the seven
patients who would have preferred a general anaesthetic in perineal
localizations, two patients had applied lidocaine/prilocaine cream
before lidocaine injection, whereas, among eleven patients who were
satisfied with local anaesthesia, nine patients were pre-treated by
this associated topical anaesthesia. The analysis of patients with
perineal localisations also showed a correlation between the
diameter of treated perineal lesions and the preference for general
anaesthesia. The seven patients who would have preferred a general
anaesthesia in these perineal localizations had a mean diameter of
their lesions of 5.7 cm (from 1 to 10 cm) compared
to 3 cm (from 1 to 5 cm) for the patients who
considered the local anaesthesia to be suitable.
An analysis was also performed for lesions of the face. The six
patients with a lesion localized on the face who expressed a
preference for general anaesthesia tended to have larger lesions
(mean diameter of 3 cm (from 1 cm to 6 cm)) than
patients who were pleased with local anaesthesia (mean diameter
2.04 cm).
Table 1 Clinical classification of lesions and
procedures
|
Surgical procedures
|
Number of patients (n)
|
Percentage (%)
|
|
Cutanous cancers
|
59
|
49.17
|
|
Biopsy
|
20
|
16.67
|
|
Cysts
|
10
|
8.34
|
|
Naevi
|
8
|
6.67
|
|
Laser treated condylomas
|
5
|
4.16
|
|
Lipoma
|
5
|
4.16
|
|
Other
|
12
|
10.00
|
|
Ingrown nail
|
1
|
0.83
|
|
Total
|
120
|
100
|
Discussion
Local anaesthesia is widely used in dermatological surgery.
Lidocaine anaesthetic infiltration is extremely safe, and the
weight based maximum recommended dose is 7 mg/kg for lidocaine
at the standard 1.0% concentration. Despite this common
utilisation, evaluation of the perception of pain during
dermatological surgery has not been extensively studied. The
present study showed that pain occurred mainly at the moment of
lidocaine injection. Only fourteen patients did not experience any
pain (score 0) at the time of injection of the local anaesthetic
solution. Thus, 88.5% of patients had some degree of pain and 34.7%
of them indicated medium or severe pain. About a third of patients
seem to experience little or no pain on the injection of lidocaine.
The intensity of pain on the injection of local anaesthetic was
studied in Spain in a study with a similar design [5]. The
comparison is not straightforward since the scoring cut-offs are
not exactly the same. However, 44% of the 219 Spanish patients
indicated a low pain score of 0 to 2.5 on injection,
compared to 33.6% of the patients of the present study who
indicated a score of 2 or less.
Medium to severe painful sensations were recorded, on
anaesthetic injection, for 34.4% of the patients in the present
study compared to 19% of the patients in the Spanish study. Our
results may also be compared to those of a randomized study
comparing injections of 1 mL of tramadol 5% and 1 mL of
prilocaine 2% for the excision of cutaneous lesions less than
1 cm in diameter in two groups of 30 patients [6]. Pain
on injection was quoted as severe by 7/30 patients in the
tramadol group and by 4/30 in the prilocaine group. Overall,
in that study, 50% of the 60 patients expressed some degree of
pain at the time of injection. Explanations for the lower
percentages observed for medium or severe pain in the two published
studies may be the smaller size of the treated lesions in the
randomized study and consequently, the smaller injected volumes of
the anaesthetic solution, but also the nature of the anaesthetic,
since prilocaine injections have been reported to be less painful
in dental practice [7].
Analyses were performed in the present study to correlate size
of the lesion and pain, in the whole series, and then separately in
the subgroups of patients who had a pre-medication or not. In the
whole series, no correlation between the size of the lesions and
pain score on anaesthetic injection was shown.
Although statistical comparison between the group was not valid
because it was not planned in the design of the study, higher pain
scores were recorded when the size of the lesions exceeded
2 cm in diameter in the group without pre-medication (mean
pain score 5 to 7), than in the group with pre-medication
(mean pain score 0 to 1). For smaller lesions, no difference
was noted. A randomised comparative study with a single
pre-medication would be useful to verify this.
In addition to the size of the treated lesions, other factors
may explain the differences: technique of injection, site of the
lesions, anxiety of the patients. Interestingly, in the Spanish
study, patients were asked before the procedure about the pain they
were expecting to feel during the procedure, and they expected a
higher sensation of pain than they finally experienced. Two other
studies have quantified pain on injection by means of visual
analogue scales. In a study of 60 volunteers receiving
injections of 1% lidocaine mixed with epinephrine, randomised into
two groups to compare buffered pre-mixed lidocaine to freshly mixed
lidocaine, the subjects indicated on a 100 mm pain scale
scores on injection varying from 18.3 mm (± 20.3) to
23.5 mm (± 19.1) [8]. However, the percentages of subjects who
did not report any pain was not indicated and the comparison with
our results is difficult to establish. The other study compared two
concentrations of lidocaine and epinephrine solutions in Mohs
surgery for skin cancers [9]. On the 100 mm visual analogue
scale, the mean scores were 3.06 mm in one group (SD
7.38 mm) and 4.01 mm in the other group (SD
8.69 mm).
During the course of the surgical procedure in the present
study, only two patients had severely painful sensations graded
over 5 on the scale. Overall, 10 patients (8%) reported a
sensation of pain graded 2 or more on the evaluation scale in
the course of the surgical excision. In the randomized study of
Altunkaya et al., 22 among the 60 patients reported
a mild sensation of pain (36.6%) at surgical incision, with no
significant difference between tramadol and prilocaine [6].
A factor which may explain the differences, besides the drug
used for the local anaesthesia, may be the length of delay to
incision. This delay to incision was 2 minutes in the
randomised study. Unfortunately, it was not recorded in our study.
At the end of the procedure, two patients only who had been treated
for perineal lesions reported some pain, with pain scores varying
from 3 to 4.
Patients’ satisfaction with this procedure of local anaesthesia
infiltration was 86%. Among the patients who were not satisfied
with the local anaesthesia procedure, analysis showed that two main
sites were concerned: the perineum and the face. Forty-two per cent
of patients with perineal lesions and 14.6% of patients with facial
lesions would have preferred general anaesthesia because of severe
pain.
Patients with perineal lesions were especially analysed because
61% of them were told to apply lidocaine/prilocaine cream before
the anaesthetic injection. Most of the patients who had pain and
discomfort did not apply this topical pre-medication. In addition,
these patients tended to have larger lesions. Therefore, the
present results suggest that premedication with local application
of lidocaine/prilocaine cream before local lidocaine injection
should be extensively used in perineal localizations. Laser
procedures in condylomas covering an area with a maximum diameter
larger than 5 cm should be performed under general anaesthesia
or neuroleptanalgesia associated with local anaesthesia. In the
Spanish study [5], the relationship between pain, localization of
the lesions and premedication by lidocaine/prilocaine cream was
also analysed. The highest pain scores were reported in genital and
palmoplantar localizations. No significant difference was reported
for sex ratio and diameter of lesions. The authors also concluded
that patients pre-treated by lidocaine/prilocaine cream had
significantly lower pain scores. Our suggestion for general
anaesthesia indication in large perineal lesions is not in
agreement with a recent study of episiotomy or perineal laceration
surgical repair. The authors concluded that lidocaine/prilocaine
cream was effective as well as mepivacaine infiltration [10].
However, dermatological procedures, such as laser treatment for
perineal condylomas, may differ in painful sensations from perineal
repair after childbirth.
The application of lidocaine/prilocaine cream on large mucous
surfaces might raise possible complications such as
methemoglobinemia. Once strict adherence to the manufacturer's
recommendations is respected, this complication seems to be rare,
according to topical applications in adults. A recent review
of published methemoglobinemia cases related to local anaesthetics
points out the need to pay attention in patients with renal
insufficiency or patients who take oxidizing drugs (antimalarials,
nitrates…) [11].
Conclusion
The present study shows that a majority of patients (88.5%)
experienced some pain on anaesthetic injection and that the pain
was quoted as important in 34.4%. During, or at the end of the
surgical procedure, a few patients complained of pain. The local
anaesthetic procedure was convenient to 86% of the patients.
However, in some localisations, namely the perineum, the use of
pre-medication seems mandatory and large lesions on these sites may
be better treated under general anaesthesia.
Aknowledgments
We are indebted to the surgeons and dermatologists who operated the
patients: Drs Aynaud O, Bui P, Cadot M, Cerceau M, Ermisch C,
Hemery M, Paniel B, Roman P, Zeig M. Conflict of interest: none.
Financial support: none.
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