During PV, it is common to use both local anesthetics and conscious sedation to make the patient comfortable and relaxed. Patients who request not to receive intravenous sedation or cannot have it for safety reasons still can be treated with only mild discomfort if appropriate attention is given to local anesthetic placement. To reduce the sting and discomfort associated with locally administered anesthetics (lidocaine, etc.), one may buffer the anesthetic by the addition of a mixture of 1 mL of bicarbonate and 9 mL of lidocaine. This mixture reduces, but does not eliminate, the anesthetic sting. I commonly use a mixture that includes both bicarbonate and Ringer's lactate (Table 14.1), which essentially eliminates the sting of the local anesthetic. At my institution, this mixture is prepared daily for all procedures requiring local anesthetics. The excess is discarded at the end of each day. This preparation has a low concentration of lidocaine (0.5%) and allows the use of a more generous volume locally with less risk of toxicity.

Whatever the chosen local anesthetic preparation, the skin, subcutaneous tissues along the expected needle tract, and periosteum of the bone at the bone entry site must be thoroughly infiltrated. When this has been accomplished, the patient will experience only mild discomfort while the bone needle is being placed, regardless of whether conscious sedation is used.

Conscious sedation has become a common adjunctive method of pain and anxiety control in awake patients who undergo minimally

Table 14.1. Modified local anesthetic solutions

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