Cleanse the area to be punctured circumferentially with antiseptic solution. Use
a 25- or 27-gauge needle attached to a 3-mL syringe to inject 1% lidocaine into
the skin and subcutaneous tissues to achieve local anesthesia or, alternatively,
spray ethyl chloride topically. Avoid injecting into the joint space prior to
obtaining fluid for testing and culture.

FIGURE 130.44 Arthrocentesis of the knee joint.

Wearing sterile gloves, attach an 18-gauge needle to a 10-mL syringe. Hold the
syringe in one hand while palpating the lateral margin of the patella with the
other. Puncture the skin with the syringe held 10 to 20 degrees above the
horizontal at the anesthetized site. Advance the needle, applying suction on the
plunger of the syringe, until it passes into the joint space near the margin of the
patella. When the joint space is entered, the syringe will fill with synovial fluid.
Stabilize the syringe by placing the heel of the hand against the patient’s leg
during the aspiration. Move the needle gently in varied directions to effectively
evacuate the joint being careful to minimize the risk of injury to the synovium
and cartilage.
At completion, remove the needle and apply a sterile gauze pad over the
puncture site. Send the aspirate for the appropriate studies.

TOPICAL ANESTHESIA AND DIRECT WOUND INFILTRATION


Indications
Anesthesia for laceration repair, removal of foreign body, venipuncture, or other
simple procedures of the skin

Complications
1. Infection
2. Bleeding/bruising

3. Intravascular injection
4. Local skin reaction

Equipment
1. Antiseptic solution, bacteriostatic normal saline
2. 3-, 5-, or 10-mL syringe
3. Local anesthetic
a. LET gel (lidocaine 4%, epinephrine 0.05%, tetracaine 0.5%)
b. EMLA (eutectic mixture of local anesthetics) or ELA-Max (4% lidocaine)
c. Lidocaine 1% or 2%
i. Maximum dose of 5 mg/kg or 0.5 mL/kg of 1% solution
ii. May alkalinize with NaHCO3 to raise pH and decrease pain of injection
(8.4% NaHCO3 :lidocaine [1:10] mixed and bottle labeled with additive,
date, and time; expires in 7 days)
d. Lidocaine 1% or 2% with epinephrine (may alkalinize with NaHCO3 )
i. Maximum dose of 7 mg/kg or 0.7 mL/kg of 1% solution
ii. Use on highly vascular regions to minimize bleeding
iii. Do not use on end-arterial locations (fingers, toes, penis, nose, and
earlobes)
e. Bupivacaine 0.25% may be used to obtain long-lasting anesthetic and
analgesic effects, with anesthesia lasting 2 to 4 hours and analgesia up to 8
to 12 hours
i. Maximum dose 1.5 mg/kg or 0.6 mL/kg of 0.25% solution
f. Needle-free jet injection system with 0.2 mL of 1% buffered lidocaine (J-tip)
(National Medical Products Inc, Irvine, CA)
4. 25-, 27-, or 30-gauge needles
5. Cotton balls, occlusive dressing (i.e., Tegaderm)

Procedure
Check the region for blood supply, sensation, and motor nerve function before

applying or injecting the anesthetic. Prepare materials before the child enters the
treatment room or out of view of the child. Have all equipment ready to use


before beginning the procedure. Consider procedural sedation for complex or
painful procedures if topical or local anesthesia is not anticipated to provide
adequate pain relief.
Topical Anesthetic
1. The application of LET (lidocaine, epinephrine, tetracaine) gel is particularly
useful in well-vascularized areas such as the head and neck. Prepare the wound
by removing any debris and blood clot. Apply the gel directly into the wound
using a syringe and/or a cotton-tipped swab. Cover with an occlusive clear
dressing, such as Tegaderm. The wound is ready for closure or other
procedures when blanching of the skin appears in a halo distribution around the
wound, usually in 30 to 45 minutes. The duration of anesthesia is
approximately 1 hour.
2. EMLA and ELA-Max are effective topical anesthetics that continue to gain
popularity in use. They are applied to intact skin to achieve local anesthesia for
procedures such as venipuncture, LP, a simple local procedure, or needle
aspiration. The cream is placed on the skin and then covered with an occlusive
dressing. The time to anesthetic effectiveness varies between brands so you
should consult the labeling.
3. The J-tip is a single-use device in which compressed carbon dioxide gas
rapidly expels lidocaine through intact skin to a depth of 5 to 8 mm in 0.2
second without a needle ( Fig. 130.45 ). This allows quicker anesthesia (less
than a minute) than topical anesthetics (30 to 45 minutes) and is most
commonly used prior to IV insertion as it avoids vasoconstriction caused by
topical anesthetics. The J-tip may be a good option for younger children or
patients with a severe needle phobia, though patients should be informed of the
loud popping and hissing sound the device makes when the medication is

released (similar to opening a can of soda). The J-tip is contraindicated for
patients receiving chemotherapeutic agents.


FIGURE 130.45 Image of J-Tip device. (Reprinted with permission from National Medical
Products, Inc.)

Direct Wound Infiltration
Immobilize the young child by wrapping him/her in a sheet, using a papoose
restraint, or having an assistant restrain the child. Use developmentally sensitive
methods. A calm, reassuring approach that engages the child in conversation or
distraction may avoid the need for sedation. Topical anesthetic should be applied
first if time and wound location/size permits.
Cleanse the area well with antiseptic solution. Dry with sterile gauze. Instill a
few drops of the anesthetic directly into the wound.
When anesthetizing a possible moving target, the operator should hold both
sides of the wound with the nondominant hand. The syringe containing lidocaine
can be pressed firmly against the operator’s nondominant thumb. This allows the
patient, operator, and syringe to move in a unified fashion if the child struggles.
Begin injection proximally on the side of the wound closest to the spinal
efferent nerve. If the proximal portion of the wound is anesthetized first, then
through blockage of nerve conduction, the distal portion may become partially
anesthetized. Injecting the anesthetic slowly can reduce pain caused by the rapid
distension of tissues.
Insert a 25-, 27-, or 30-gauge needle through the subcutaneous tissue exposed
by the laceration. The subdermis of the wound is used because it is less painful
than either direct injection through intact skin or into the dermis ( Fig. 130.46A ).
Slowly inject a small bolus of the lidocaine solution ( Fig. 130.46B ). Continue to
advance, aspirating prior to injecting if in the vicinity of large vessels. Otherwise,
aspiration before injection is rarely necessary.

Remove the needle and reinsert subcutaneously into adjacent tissue that has
already been anesthetized. Slowly inject another bolus of anesthetic and advance
the needle while injecting ( Fig. 130.46C ).