脊柱干预协会(SIS)标准部门和证据分析委员会的代表为在局部麻醉药短缺的情况下进行介入性疼痛程序制定了以下最佳实践建议。实践咨询已得到SIS的认可,美国疼痛医学学会,美国放射学院,美国神经放射学学会,美国脊柱放射学会,北美神经调节协会,北美脊柱协会,介入放射学学会,他们支持以下关于关节内性能的最佳实践建议和声明,关节外,椎旁,在局部麻醉药短缺的情况下进行硬膜外注射。1.在进行神经轴手术时,不鼓励使用含防腐剂的局部麻醉药,其中注射剂可能进入硬膜外(或鞘内)空间。当执行有动脉注射风险的程序时,由于存在结晶和栓塞的风险,罗哌卡因不应与地塞米松混合注射3.根据疾病控制和预防中心(CDC)和联合委员会指南[1],由于感染风险,医师不应直接从多个患者的局部麻醉药小瓶中撤出。只有药剂师可以为多名患者重新包装局部麻醉小瓶。这必须在严格的情况下进行,无菌条件,只在急需的时候。在这种情况下,医生必须遵守重新包装标签上的过期使用日期和储存条件[2,3].5.接头,肌腱,Bursa,和/或韧带注射可以用局部麻醉剂进行,有或没有保存6.介入疼痛医生在进行关节注射时,应权衡与每种麻醉剂相关的相对软骨毒性风险。局部麻醉药,用苯海拉明渗透,和非药物疗法(即,认知行为疗法,引导图像,虚拟现实,机械脱敏)可用作局部麻醉药皮肤浸润的替代方法,以减少手术疼痛。使用小规格针头(25号或更细)可以减轻插入针头之前对局部麻醉的需求。9。对于插入大孔针头或切口之前的局部麻醉浸润,0.5%的利多卡因可能和1%一样有效,因此,利多卡因的当前供应可以通过用正常的盐分稀释来延长。如果由于酰胺局部麻醉药短缺而使用酯局部麻醉药,介入疼痛医生应该意识到(一如既往)潜在的过敏反应,并且应该能够做出相应的反应。局部麻醉药的全身毒性(LAST)在不同的局部麻醉药之间有所不同,而介入疼痛医生在切换局部麻醉药时应该很好地了解这些差异。医师应仔细权衡在没有局部麻醉或使用替代药物的情况下进行手术的风险和益处,并应在继续之前让患者参与共同决策。程序应按照脊柱干预协会指南[4]进行。医师应确认针在至少两个成像平面中的放置。请参阅SIS实践指南,了解与每个独特程序相关的全部细节和标准[4]。
Representatives from the Spine Intervention Society (SIS) Standards Division and Evidence Analysis Committee have developed the following best practice recommendations for the performance of interventional pain procedures in the setting of a local anesthetic
shortage. The practice advisory has been endorsed by SIS, the American Academy of Pain Medicine, the American College of Radiology, the American Society of Neuroradiology, the American Society of Spine Radiology, the North American Neuromodulation Society, the North American Spine Society, and the Society of Interventional Radiology, who support the following best practice recommendations and statements for the performance of intra-articular, extra-articular, paraspinal, and epidural injections in the setting of a local anesthetic
shortage. 1.Use of preservative-containing local anesthetics is discouraged in the performance of neuraxial procedures where the injectate may enter the epidural (or intrathecal) spaces.2.When performing procedures with risk of arterial injection, ropivacaine should not be mixed with dexamethasone and injected due to the risk of crystallization and embolization.3.Physicians should not withdraw directly from vials of local anesthetic for multiple patients due to infection risk as per Centers for Disease Control and Prevention (CDC) and Joint Commission guidelines [1].4.Only pharmacists may repackage local anesthetic vials for multiple patients. This must be performed under strict, sterile conditions and only in times of critical need. In such situations, physicians must adhere to the beyond-use-date and storage conditions on the repackaged label [2,3].5.Joint, tendon, bursa, and/or ligament injections may be performed with local anesthetic with or without preservative.6.Interventional pain physicians should weigh the relative chondrotoxicity risks associated with each anesthetic when performing joint injections.7.Topical anesthetics, infiltration with diphenhydramine, and nonpharmacologic therapies (i.e., cognitive behavioral therapy, guided imagery, virtual reality, mechanodesensitization) may be used as alternatives to skin infiltration of local anesthetic for reducing procedural pain.8.Use of small-gauge needles (25 gauge or thinner) mitigates the need for local anesthetic prior to needle insertion.9.For local anesthetic infiltration prior to insertion of large bore needles or incision, 0.5% lidocaine may be as effective as 1%, and for that reason current supplies of lidocaine can be stretched by dilution with normal saline.10.If using an ester local anesthetic due to an amide local anesthetic
shortage, interventional pain physicians should be aware (as always) of the potential for an allergic reaction and should be able to respond accordingly.11.Local anesthetic systemic toxicity (LAST) differs between the varying local anesthetics, and interventional pain physicians should be well acquainted with these differences when switching between local anesthetics. Physicians should carefully weigh the risks and benefits of performing procedures without local anesthetic or using an alternative agent in the context of each unique patient\'s situation and should involve patients in shared decision making before proceeding. Procedures should be performed following Spine Intervention Society Guidelines [4]. The physician should confirm placement of the needle in at least two imaging planes. Please refer to the SIS Practice Guidelines for the full details and standards related to each unique procedure [4].