Local Anesthesia Administration

Guidelines for Anesthetic Use

The American Academy of Pediatrics recommends using plain local anesthetics without epinephrine, such as plain lidocaine or mepivacaine, as the first choice for local anesthesia administration, with maximum safe dosages of 4.4 mg/kg for lidocaine and mepivacaine without epinephrine, and 7.0 mg/kg for lidocaine with epinephrine, calculated based on patient weight 1
Blood pressure and heart rate should be monitored every 5 minutes during the procedure, and aspiration should be performed frequently before injection to avoid intravascular administration, as recommended by the American Academy of Pediatrics 1

The American Academy of Pediatrics and the European Heart Journal recommend monitoring blood pressure and heart rate every 5 minutes during the procedure, and being alert for signs of hemodynamic instability, including significant hypertension, tachycardia, arrhythmias, tremors, and headache, with consideration of the potential risks of combining beta-blockers and calcium channel blockers with local anesthetics 1, 2
Patients taking both nifedipine and metoprolol are at increased risk for significant hypotension, bradycardia, hemodynamic instability, and exaggerated hypotensive response to vasodilators, and should be carefully monitored, as stated by the European Heart Journal 2
Baseline blood pressure should be measured before administering local anesthesia, and blood pressure should be controlled (<180/110 mmHg) before proceeding, with consideration of postponing elective procedures for patients with uncontrolled hypertension, as recommended by the Hypertension guidelines 3
Patients on nifedipine and metoprolol should maintain their regular doses on the day of procedure, but immediate-release nifedipine should not be administered to patients with Non-ST-Elevation Acute Coronary Syndromes (NSTE-ACS) in the absence of beta-blocker therapy, as stated by the American College of Cardiology 2, 4

Amide anesthetics (lidocaine, mepivacaine) are generally safe options, and lidocaine and mepivacaine are safe local anesthetics for patients with renal failure, with lidocaine with epinephrine providing faster onset and longer duration of anesthesia compared to lidocaine alone, reducing the risk of toxicity, as stated by the Pediatrics guidelines and supported by 5, 6
The American Academy of Dermatology recommends using the lowest effective concentration of epinephrine (typically 1:100,000 or 1:200,000) when administering local anesthetics to patients taking nifedipine, to minimize cardiovascular risks, with similar recommendations from the American Heart Association for patients with stable, controlled cardiovascular conditions on nifedipine 5, 7
For patients on beta-blockers, the lowest effective concentration of epinephrine should be used, and the total dose should be limited to 1.8-3.6 mL when necessary, as recommended by the American Heart Association and the American Academy of Allergy, Asthma, and Immunology 8, 5

For pediatric patients, consider using topical anesthetic/vasoconstrictor combinations first, with a maximum safe dose of 3 mL for children >17 kg and 0.175 mL/kg in children <17 kg, as recommended by the American Academy of Pediatrics and the American Dental Association 9
Older patients may require reduced doses of both local anesthetic and epinephrine, and patients with renal impairment need careful monitoring and possibly reduced local anesthetic doses, as considered best practices in patient care, with additional considerations for patients on nifedipine with renal impairment, as recommended by the National Kidney Foundation 5, 7
Patients with uncontrolled hypertension or unstable cardiovascular disease should be evaluated on a case-by-case basis, and consultation with the patient's cardiologist is recommended before proceeding with lip procedures using local anesthetics with epinephrine, as recommended by 5, 10

Having emergency medications available, such as phentolamine (alpha-blocker) for hypertensive emergencies and sublingual nitroglycerin as a non-parenteral alternative, is essential for managing potential complications, with preparation for administration in the event of a hypertensive emergency, as recommended by 5
Contraindications for using lidocaine with epinephrine include allergy to amide anesthetics and grossly contaminated wounds, as stated by 5, 9