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 Infection Bleeding/bruising Intravascular injection Local skin reaction Equipment Antiseptic solution, bacteriostatic normal saline 3-, 5-, or 10-mL syringe 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 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 days) d Lidocaine 1% or 2% with epinephrine (may alkalinize with NaHCO3 ) i Maximum dose of 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 to hours and analgesia up to 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) 25-, 27-, or 30-gauge needles 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 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 hour 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 The J-tip is a single-use device in which compressed carbon dioxide gas rapidly expels lidocaine through intact skin to a depth of to 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 )