Local anesthesia ideal choice for in-office varicose vein surgery

Durham, N.C. - While physicians need to be aware of their own limitations, varicose vein surgeries - including the increasingly popular endovascular ablation techniques and mini-surgical phlebectomies - are ideal for performing in the office setting under local anesthesia, say John Mauriello, M.D., F.A.C.Ph.

Some patients may simply prefer general anesthesia, but the tumescent technique of using large volumes of very dilute local anesthetics allows in-office procedures to be conducted safely and effectively.

"Patients are able to get right up and go home, and the recuperation is much faster than with general anesthesia, so it's really ideal," says Dr. Mauriello, medical director of the VeinHelp Clinic in Durham, N.C.

Lidocaine is the most widely used local anesthetic in the United States, and while it has a rapid onset of action, its anesthetic duration is brief, usually requiring the addition of epinephrine.

Manufacturer's recommendations of lidocaine with epinephrine are 7 mg/kg of body weight (not to exceed 500 mg). However, studies conducted by Jeffrey A. Klein, M.D., show 35 mg/kg to be safe when using the tumescent technique with dilute lidocaine.

Even safe doses can lead to unwanted systemic reactions if placed where not intended - such as a large blood vessel - and it is therefore essential that all members of operating teams be well aware of the signs of local anesthetic toxicity. Symptoms can include the sensation of numbness in the mouth or a metal taste.

Possible side effects

"If the patients ask, 'Are your lips supposed to be getting numb?' or they have a metal taste in their mouths, that's a beginning sign of toxicity," Dr. Mauriello says.

Other signs of toxicity with increasing blood levels of local anesthetics drugs include:

The inhibitory centers of the central nervous system are more sensitive to local anesthetics, so there may be excitement (restlessness, tremors) prior to depression of the CNS leading to cardiac arrest.

Administration and precautions

In premedicating patients, Dr. Mauriello says he usually administers oral medications such as 5 mg or 10 mg of Valium (Roche) prior to the procedure, and he suggests starting an IV before the procedure as a safety precaution.

"If you already have an IV started and something were to go wrong, you have an access site to give medication, whereas if you don't have an IV going, that's not the ideal time to try to start one," he says.

Preparations for emergencies should be made by having various supplies on hand. These should include IV fluids and oxygen and an Ambu bag. Additionally, the following medications should be on hand:

Those comfortable with endotracheal intubation may want to keep a laryngoscope on hand with fresh batteries and an assortment of cuffed endotracheal tubes, and it can also be helpful to call the local 911 dispatching unit to ask the estimated response time to the office's location.

Additionally, since automated external defibrillators are available at most public places, it also makes sense to have them in every medical office, Dr. Mauriello says.