Anesthesia for I n D

Q: 77 years old male bedbound patient at home is admitted to ICU with sepsis. A 3-inch wide abscess in the calf region is expected to be the source of infection. What is the pitfall of using local anesthetic infiltration before incision and drainage (I n D) for such an abscess?

Answer: 

A regional field block with a local anesthetic is preferred in large abscesses - because local infiltration is less effective due to the lower pH of infected tissue.  The acidic environment decreases the proportion of anesthetic in the more active, uncharged form.  Either higher doses or repeat infiltration is required.  

If a pain/Anesthesia service is unavailable to perform a regional block, local infiltration (1 or 2 percent lidocaine) is the second choice. A field block should be performed by infiltrating local anesthetic around and under the tissue surrounding the abscess. The maximum dose for lidocaine is 4 mg/kg, and for lidocaine with epinephrine, it is 7 mg/kg.

Topical local anesthetics can be applied as an adjuvant before local injection or anesthetic blocks.

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Recommended readings:

1. Poulton T, Hogston SP, Bolton WS, Burke JR, Jayne DG. Anaesthetic management of subcutaneous abscesses: current status. Br J Anaesth. 2020 Aug;125(2):e227-e229. doi: 10.1016/j.bja.2020.03.018. Epub 2020 May 5. PMID: 32386836.

2. Elkadi HH, Dodd E, Poulton T, Bolton W, Burke JR, Tiernan J, Jayne D. The effect of anaesthetic use on healing in sub cutaneous abscess management: a retrospective before and after cohort study. Ann R Coll Surg Engl. 2023 Mar;105(3):241-246. doi: 10.1308/rcsann.2021.0362. Epub 2022 May 26. PMID: 35616446; PMCID: PMC9974350.