Explain that their hand operation will be a little like a visit to the dentist for a minor procedure. No preoperative testing or fasting is required as lidocaine and epinephrine are the only administered medications, just like at the dentist. They will be able to get up and leave right after the surgery with no nausea or uncomfortable sequelae or inconveniences of sedation. They will not need to suffer the discomfort of the tourniquet.

In the office consultation, we also tell them that putting in the local anesthesia is like baking a cake. After we put it in the oven, we need to give it at least a half an hour to “bake.” We tell them to bring a book or music, as they will have to wait a while after we inject the local anesthesia.

It takes an average of 26 minutes for 1:100,000 epinephrine to reach maximal vasoconstriction (2). Inject two to three patients before taking the first one into the operating room.

It only takes an average of 5 minutes to inject local anesthesia for carpal tunnel surgery so that the patient consistently only feels the first poke of a 27-gauge needle (3). We inject them on stretchers in the preoperative holding area, or in the postoperative anesthetic care unit.

Fainting happens because of a decrease in cerebral blood flow. The body’s response forces the patient to lie down by fainting to increase the blood flow with gravity. More patients will faint sitting up than lying down, but they can faint lying down as well. If they do faint, it can look like a seizure with patients going stiff and eyes rolling back. We have all seen this with the occasional cast or dressing change.

You will get warning signs before the patient actually faints. The patient will tell you that he or she is not feeling well, that the patient thinks he or she may be sick or will throw up, or that he or she is feeling really hot. When you look at the patient, you may see perioral pallor, or paleness between the eyes, upper nose, and glabella.

When you see or hear the warning signs, get more blood to the head with the following five maneuvers, and patients will feel better in less than 5 minutes:

After you inject, always warn patients that they “may feel nervous or shaky” like “they may feel if they drank too much coffee.” Tell them that this is a normal reaction to a little adrenaline in the numbing medicine and that the shaky feeling will go away in half an hour or so if they get it.

If patients are not warned about it, fear of the unknown will add to unnecessary concern. They may even walk away feeling that they are allergic to the medication, which they are not.

The author prefers to only use lidocaine with epinephrine. The two main reasons are the following. Firstly, these two medications have an incredibly good safety record in their 65 years of use with no monitoring in dental offices (4). Secondly, although bupivacaine pain relief dose last longer than lidocaine, bupivacaine and ropivacaine are more cardiotoxic than lidocaine. Annoying bupivacaine numbness to touch and pressure lasts twice as long (30 hours) as the pain anesthesia (15 hours) (5). This is why patients sometimes complain that their finger is still numb but it hurts 20 hours after bupivacaine block.

We know that the 7 mg/kg maximum lidocaine with epinephrine rule is extremely safe because 35 mg/kg has been shown to produce safe blood levels of lidocaine in liposuction (6). The author therefore feels comfortable without monitoring unless the patient has severe preexisting cardiac challenges. In these situations, the concentration of epinephrine can be reduced to 1:400,000 or even 1:1,000,000 with good effect (7). High-risk patients can be monitored.

In order to stay below 7 mg/kg, the author uses up to 50 mL of 1% lidocaine with 1:100,000 epinephrine for most 70-kg patients. When 50 to 100 mL of volume of local anesthetic is required, the basic 50 mL can be diluted with 50 mL of saline to provide 1/2% lidocaine with 1:200,000 epinephrine. If 100 to 200 mL of volume is required for big forearm cases, add 150 mL of saline to the basic 50 mL of 1% lidocaine with 1:100,000 epinephrine to make 1/4% lidocaine with 1:400,000 epinephrine for good anesthesia and visualization. The only problem with dilute solutions is that the lidocaine and the epinephrine both take a little longer to achieve maximal effect and do not last quite as long.