Dr. Joel Cohen discusses the lidocaine shortage, including the use of varied anesthetic formulations and need for recognizing the symptoms of lidocaine toxicity.
Joel L. Cohen, MD, Director, AboutSkin Dermatology and DermSurgery, Denver, Colorado
“First, I want to point out that many people are having a difficult time getting lidocaine. There has definitely been a shortage over the past year,” said Joel Cohen, MD, who presented “Filler and Aesthetic Pearls” at Maui Derm Hawaii.
“And we, in medical school and in residency and fellowship and clinical practice, really think about how much lidocaine we’re using. So for folks who are doing Mohs surgery or excisions, we really try to keep an accurate count of how much lidocaine with epinephrine we’re using.”
According to Dr. Cohen, it’s typically 1% lidocaine with epinephrine, with a cutoff of around 50 cc in an average size (70 kg) adult male. When using plain lidocaine, it’s often about 30 cc.
“But with the shortage of lidocaine, people are actually mixing and matching different types of anesthetics. So in some cases, it’s plain lidocaine. In some cases, it’s 2% lidocaine, and then other people are getting lidocaine or other anesthetics from other types of formulations. And some people are actually getting different types of injected anesthesia like articaine, which also goes by the trade name Septocaine. People are using long-acting Marcaine which is also goes by the trade name Bupivacaine.”
Herein lies the need for dermatologists to understand how to account for the amount of anesthetic they are using, said Dr. Cohen.
“So, when you’re mixing and matching, we really have to think about how to tally up the levels of what we’re actually using. And of course we need to be familiar with these symptoms of potential toxicity.”
For many cosmetic dermatology procedures with the exception of liposuction, anesthetic levels don’t tend to be that high, but they do become a concern when performing multiple procedures over large surface areas, such as deep full face resurfacing with nerve blocks and also when resurfacing the neck and chest with topical anestesia, he said.
“So for people out there who use high concentration topical anesthetic on the face, neck, and then chest [and] also doing nerve blocks or sulcus blocks in addition to that to get patients through the resurfacing, I think we need to be really, really diligent about documenting the levels and understanding 2% if we’re using plain lidocaine around the mouth, and then 1% with epinephrine for our nerve blocks.”
According to Dr. Cohen, he often uses a lower topical lidocaine concentration, but he will often reach for a topical 5% lidocaine in one formulation or another.
“I think people should be familiar with the symptoms of lidocaine toxicity. Numbness of the tongue [and] lightheadedness are some of the early symptoms. Sometimes people then developed muscle twitching and visual or auditory disturbances, but it could go very quickly at that point to unconsciousness or convulsions and respiratory or cardiac arrest.”
At the beginning of the year, the American Academy of Dermatology Association met with lidocaine manufacturers Fresenius Kabi and Pfizer to discuss the shortage, due in part, they said, to a significant increase in demand. The manufacturers anticipate some relief by the end of the year, according to the Association.1
“So I think people in these times where lidocaine is very difficult to get should understand really the pharmacokinetics of what products they’re using, and think about overall levels that you’re using and familiarize your staff with the symptoms of lidocaine toxicity.”
Reference:
Academy Tackles Lidocaine Shortage. American Academy of Dermatology Association Website. Accessed: April 21, 2023. Available at: https://www.aad.org/member/publications/impact/2023-issue-1/academy-tackles-lidocaine-shortage