Best practices for interventional pain procedures in the setting of a local anesthetic shortage: A practice advisory from the Spine Intervention Society

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].