Clinicians should also be aware of the risk of acute toxicity and of traumatic nerve damage when administering anesthesia. Benzodiazepines have been recommended to prevent seizure risks associated with toxicity, but they may obscure early warnings of local anesthetic systemic toxicity.


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In order to reduce pain and anxiety caused by local anesthesia, “buffered lidocaine” (a preparation consisting of sodium bicarbonate 8.4% and lidocaine 1% or 2% with epinephrine in a 1:10 ratio) or vibratory stimulation devices can be used.

TRENDING ON CPA: New Options for Migraine, Headache Management 

Perioperative anxiolytics can be helpful in high-risk APSP patients and in children to reduce perioperative anxiety and blood pressure, but their use may be limited by adverse side effects and the extra staff required for patient monitoring.

Perioperative nonsteroidal antiinflammatory drugs or gabapentin administered before, during, or immediately after surgery can reduce pain ≤24 hours after a procedure, reduce opioid use, and prevent hyperalgesia syndromes.

Pain Management Post Surgery

Small studies have suggested that ice or gel cold packs at the site during or after surgery decreases pain and/or narcotic use in the first few days after surgery. However, more research should be conducted on this low-cost and simple method of reducing APSP.

Acetaminophen remains the most commonly used pain medication for minor dermatology procedures (500 mg to 1 g provides significant pain reduction over 4 to 6 hours) and is also the preferred pain reliever in patients with advanced liver disease because of the risks of bleeding and hepatorenal syndrome. For patients with liver disease, the dose is reduced to 2 g per day.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are also commonly recommended for mild to moderate pain. They are capable of reducing pain by approximately 50% and significantly reduce future opioid requirements. For minor dermatologic procedures such as obtaining a biopsy specimen and small excisions, NSAIDs likely present a low risk for bleeding complications. For complex procedures such as flaps and grafts, evidence suggests that postoperative ibuprofen does not create greater bleeding complications than acetaminophen, but the effects of NSAIDs and bleeding deserves further research given its effectiveness in pain relief.