Lidocaine w/ epi avulsion/matrixectomy

[p100]

In school and residency I was taught to not use lidocaine with epi for toe procedures. Is this still true?

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[Pronation]

I was taught not to use any anesthetics at all. Is this still true?

I’m looking for alternatives because the screams are exacerbating my fibromyalgia.

 

[Shiyuan]

Had a doc in residency get a pt with necrotic toe after routine HT sx. He was using lidocaine with epinephrine for around 30 years for HT procedures. Of course, his luck this happened to him a couple years before retirement. Got sued.

I would just play it safe and go with straight local without epinephrine. They’re not gonna bleed out anyway, unless you hit the jugular vein... so don’t do that.

 

[Feli]

You'd be a R-word to use epi lido (1:100k) in a digit, yeah...

I use epi/reg lido 50/50 (1:200k overall mix) for most OR surgery injected at the proximal met or midfoot level, posterior heel, etc. That has a fair amount of research evidence for it being fine (mostly PI pubs), but the relative hemostasis from epi only lasts for ~60mins. It doesn't work too well for major recon or RRA trauma or when you need to do many procedures, but you can always go up on cuff for 30 or 60mins or whatever. You don't want to do it on amps or in vasculopaths (those can just be plain lido). The epi lido works for many common procedures, 0 min tourniquet time and better outcomes in my hands. I think it's a DPM myth that you need a tourniquet to toes, most bunions, metatarsals, Achilles, amps, HWR, etc etc. I do all of those with proximal block 50/50 epi for relative hemostasis for visualization, see the vessels to avoid/bovie them, minimize pain/edema, etc... so I don't use a tourniquet and crush the ankle or thigh... or use the cuff very minimally. You also want to avoid dorsal venous arch or any big veins with intravascular epi if you value your CRNA relationships

MPJ or IPJ level epi? In office. Nah. You'd be up a creek in terms of EBM if you had an issue. Use plain lido.
If you're out of stock on that plain, order some. If you can't, use bupi and get the lido plain on backorder.
The only real application I see for lido with epi in office is raising a wheal or proximal V-block for biopsy, lac repair, etc mid/rear/ankle skin stuff (not on digits).

 

[p100]

I was taught not to use any anesthetics at all. Is this still true?

I’m looking for alternatives because the screams are exacerbating my fibromyalgia.

I had an elderly British pt with terrible ingrowing nail one time. He said he waited a long time because he remembered getting it removed as a child without anesthetic and didn't know it is used now.

 

[Pronation]

I had an elderly British pt with terrible ingrowing nail one time. He said he waited a long time because he remembered getting it removed as a child without anesthetic and didn't know it is used now.

Oh wow, that’s very interesting. Anyway I refuse to treat the British because they tried to tax us without representation which is unforgivable.

 

[dtrack22]

You'd be a R-word to use epi lido (1:100k) in a digit, yeah...

Well call me Rain Man.

Lido in a toe is a lot like liver toxicity with terbinafine. Probably a case report once. Everyone was taught not to. Epi doesn’t cause long enough lasting vasoconstriction to cause necrosis. There is more than enough data to show you can safely inject fingers and toes with lido or Marciane w Epi. I use something with epi on all surgical cases, except for pus, since I want to see what will bleed. I guess that means I don’t use it in vasculopaths.

The toe didn’t die because of Epi in the HT procedure, it died because of dissection/surgical technique/fixation.

 

[dtrack22]

Add the need for DVT prophylaxis in most foot surgery to the list of things podiatrists worry about and teach that is not supported by evidence at all. Most of the surgery we do does not need anti coagulation and aspirin does nothing, ie not defensible in court if that’s what you’re worried about. The only patients of mine who get anticoagulated are those who are already on them. Never had a DVT which is consistent with the literature that demonstrates a minuscule risk of DVT and those studies generally show 0% of those going to PE.

 

[PeaJay]

aspirin does nothing,

There is fair amounts of literature supporting ASA 325mg BID for DVT prophylaxis following hip surgery. If I remember correctly there was a jama meta-analysis on this. Hip surgery has a significant DVT risk.

 

[Feli]

Well call me Rain Man.

Lido in a toe is a lot like liver toxicity with terbinafine. Probably a case report once. Everyone was taught not to. Epi doesn’t cause long enough lasting vasoconstriction to cause necrosis. There is more than enough data to show you can safely inject fingers and toes with lido or Marciane w Epi. I use something with epi on all surgical cases, except for pus, since I want to see what will bleed. I guess that means I don’t use it in vasculopaths.

The toe didn’t die because of Epi in the HT procedure, it died because of dissection/surgical technique/fixation.

Yep, I do same... much better visualization, saves time, better results generally. I know it's probably fine for digits also, but I wouldn't feel good doing epi dorsal + plantar (as you'd need for an ingrown, hammertoe) at MPJ or IPJ level on the rare chance of a complication. It's also crazy painful for epi lido injects in the office vs regular lido.

Maybe there is more new research on epi in toes now. Most of the EBM I've seen - at least in pod journals - is midfoot / proximal metatarsal level... and it wasn't great quality of studies, but still says no issues in hundreds or 1k+ foot surgery cases with the 50/50 (1:200k).

I think a lot depends on the practice situation also... PP/owner buying/getting own malprac vs hospital/govt employ with more med-mal protections.

...my honest guess, as I alluded, is that this kid just can't find regular plain lido since it's on backorder everywhere. Bupi plain is a much better sub for most office procedures than epi lido.

 

[Pronation]

There is fair amounts of literature supporting ASA 325mg BID for DVT prophylaxis following hip surgery. If I remember correctly there was a jama meta-analysis on this. Hip surgery has a significant DVT risk.

Literature or not, if your patient dies from a DVT/PE and the lawyer asks why your patient got nothing while other doctors in the area are prescribing ASA for DVT prophylaxis… well… good luck, they will argue that it’s the standard of care in your area. I agree, ASA is probably BS for DVT PPx, but I’m not dying on this hill.

 

[HardRoadPaved]

I use lido+epi with marcaine in a 1:2 ratio and it works great. I dont think you are getting necrotizing toes with such a small amount.

https://www.podiatryinstitute.com/pdfs/Update_1994/1994_39.pdf

Evaluation of the safety of epinephrine in digital nerve blockade: Retrospective case series analysis of 1334 toe surgeries

To evaluate the safety profile of lidocaine containing 1:200 000 to 1:100 000 epinephrine with concurrent tourniquet use in patients undergoing toe surgery.A retrospective case series analysis of toe procedures performed under digital blockade with adjuvant ...

www.ncbi.nlm.nih.gov

The toe didn’t die because of Epi in the HT procedure, it died because of dissection/surgical technique/fixation.

Bingo.

 

[PeaJay]

Literature or not, if your patient dies from a DVT/PE and the lawyer asks why your patient got nothing while other doctors in the area are prescribing ASA for DVT prophylaxis… well… good luck, they will argue that it’s the standard of care in your area. I agree, ASA is probably BS for DVT PPx, but I’m not dying on this hill.

I totally agree. I use ASA and TEDs as cya treatments.

 

[wakaflocka88]

Lido with epi for my ankle fracture cases so I don’t have to use a thigh cuff. Works great especially along the fibula incision. Or for a gastroc.

A tournicot or lido with epi for nail avulsion is dumb. Not necessary at all unless you’re trying to cut their toe off.

I agree on ASA 81/325, I’ve had one DVT before and I’m never going to want that to happen again, but the consulting cardiologist did agree it likely wasn’t because of his recent ankle surgery. I still felt bad regardless.

 

[PatchAdamsFan]

I have anesthesia do a straight epi pop/saph block for my cases - I do my procedures just in time for limb necrosis to occur, vascular swoops in for the BK, and I don't have to see that patient for the global period. Or ever again.

 

[dtrack22]

ASA is probably BS for DVT PPx

if your patient dies from a DVT/PE and the lawyer asks why your patient got nothing while other doctors in the area are prescribing ASA for DVT prophylaxis… well… good luck, they will argue that it’s the standard of care in your area.

Well the American academy of pulmonologists says that it’s inadequate for DVT prophylaxis so if you’re doing it for CYA reasons you still don’t have a defense in court. And if your patient dies of a PE it’s almost guaranteed that you either A) should have actually prescribed an anticoagulant and not ASA and/or B) missed a DVT which is where the real negligence (aka the case they have against you) comes into play. Either way the aspirin prophylaxis is not defensible and therefore pointless from a medical-legal standpoint.

I’ve never understood how doing something that literature and other medical professionals say is inadequate for the thing you are theoretically trying to accomplish, makes people feel better about their ability to defend said decision if it really did go to trial.

 

[DYK343]

Well the American academy of pulmonologists says that it’s inadequate for DVT prophylaxis so if you’re doing it for CYA reasons you still don’t have a defense in court. And if your patient dies of a PE it’s almost guaranteed that you either A) should have actually prescribed an anticoagulant and not ASA and/or B) missed a DVT which is where the real negligence (aka the case they have against you) comes into play. Either way the aspirin prophylaxis is not defensible and therefore pointless from a medical-legal standpoint.

I’ve never understood how doing something that literature and other medical professionals say is inadequate for the thing you are theoretically trying to accomplish, makes people feel better about their ability to defend said decision if it really did go to trial.

Ill admit its been 3-4 years since Ive done extensive literature review on DVT prophylaxis on foot/ankle but from what ive read in the past its extremely inconsistent. Can find studies that contradict eachother right and left.

Ive heard people say that ASA does nothing and in not defensible in court. I think it was at an ACFAS lecture a few years back. It was one of those roundtable lectures where they throw a question up and have 6-8 attendings up there discuss what they would do and banter back and forth. Basicually the conclusion of the lecture was we really dont know. What I got from that lecture was basically what I had read on my own regarding DVT/PE prophylaxis. We really dont know.

In foot/ankle surgery unless its achilles tendon surgery or ankle ORIF the complication risk of any blood thinner (beyond ASA) is higher than the risk of PE. I think thats why many chose ASA.

That said if patients are ambulatory in post op shoe or CAM boot I do nothing for prophylaxis

I have patients take one 325 ASA BID when splinted.

If casted I usually start Xarelto or plavix (definately with ankle ORIF/achilles repair).

Is that perfect? Nope. But so far havent had any problems.

I did have an attending in residency have a patient die from PE from a lapidus. The guy was pretty wrecked after that.

 

[Feli]

I totally agree. I use ASA and TEDs as cya treatments.

There is the other side of that coin where if you realize there's DVT risk, Rx ASA or chart it, then you have a thromboem... "Dr. X, you clearly thought there was a chance of this with your stated ASA recommendations.... why didn't you use something proven to be much more effective???" (lovenox, eliquis, xeralto, heparin inpt, etc etc)
...dtrack was spot on for that.

Personally, I just tell pts that there are no clear F&A guidelines, they can take ASA 325 in place of a.m. NSAID dose for the first month (all of mine have an NSAID unless contra). That is what the ortho practice surveys repeatedly say for ankle fx and what makes sense to me (most obviously do more for total joints). I definitely don't Rx or chart anything about prophylaxis even for RRA or stuff that'll be in a cast or boot NWB, though. Basically, on paper, you want to use nothing or use the most effective. Common sense is seldom legally optimal

 

[PeaJay]

Dr. X, you clearly thought there was a chance of this with your stated ASA recommendations.... why didn't you use something proven to be much more effective???" (lovenox, eliquis, xeralto, heparin inpt, etc etc)
...dtrack was spot on for that.

You can think of this from another angle.

It is standard practice in surgical specialties to use a Caprini score to stratify DVT risk. The scoring system has not been directly studied in foot/ankle but has been adopted and verified in multiple sub specialties. Unfortunately there doesn’t necessarily have to be great evidence to justify standard of care and most government/credentialing agencies qualify a DVT/PE a never event.

“Dr. X it is standard for patients to undergo DVT risk stratification. It appeared you did not document any thought on prophylaxis.”

In my area, it is standard to discuss DVT, stratify, and if there is a Caprini greater than or equal to 3 they get lovenox. ASA is used for people with scores less than 3 that I believe have risk via gestalt. Otherwise the rest have documentation hydration/compression/mobility.

 

[dtrack22]

Dr. X it is standard for patients to undergo DVT risk stratification. It appeared you did not document any thought on prophylaxis.

Hammertoe surgery is not hip surgery…your honor.

 

[PeaJay]

Hammertoe surgery is not hip surgery…your honor.

Of course….

Immobilized patient (scope/medial double/Achilles) with bmi greater than 25 in 60s cannot get by with the same argument.

Edit: This can be debated forever similar to vit d testing and voodoo.

 

[Pronation]

But one thing we can all agree on is that the dremel should spin at 10,000rpm with the flux capacitor set at 3.14 jiggawatts.

 

[PointyNippers]

I've done a ton of ingrown nail procedures using 2.5cc lido mixed with a splash of 0.5cc w/ epi - works like a charm and no complications. I can't attest for other procedures

 

[NatCh]

Can you guys even get local with epi right now? We've been told for months that it's on backorder.

 

[HardRoadPaved]

Can you guys even get local with epi right now? We've been told for months that it's on backorder.

Cant get plain on my end haha.

 

[NatCh]

Cant get plain on my end haha.

We’re limited to one box of 0.25% plain bupivacaine per order

 

[DYK343]

Can you guys even get local with epi right now? We've been told for months that it's on backorder.

I got it. Didnt even know there was a current shortage.

Why is there a shortage of anesthetics though? It seems it happens quite frequently.

I can not get augmentin. All pharmacies around here are on back order. Its my go to antibiotic with doxy for infected DFUs.

 

[NatCh]

Why is there a shortage of anesthetics though? It seems it happens quite frequently.

The explanation used to be something about the factory in Cuba getting demolished by a hurricane (or something like that) but that was a few years ago.

Since you brought it up I decided to look into it. According to the following article it says that the shortage of anaesthetics is due to the supply not keeping up with the increased demand. However, I use anesthetics and not anaesthestics so I still don’t know what’s going on.

Anaesthesia drugs worst-hit by US drug shortages - Pharmaceutical Technology

An analysis of FDA data shows the majority of drugs in short supply in the US are anaesthetics.

www.pharmaceutical-technology.com

 

[GreenHousePub]

But one thing we can all agree on is that the dremel should spin at 10,000rpm with the flux capacitor set at 3.14 jiggawatts.

What I usually do is set the dremel to "15" for patients that I think can tolerate it, but the ones that are a little squirrely (especially dementia patients) or those that are very ticklish I start out at a "10."

It doesn't get that great of a grind at 10 but it still is good enough. I can't reduce the giant marshmellow hallux nails with it but patient's are still happy.

I've also sustained some injuries to my fingers from patient's pulling away on a 15 (big chunk of my left cuticle gone), but it comes with the territory. I've also tried to use an N-95 when grinding but its more of a hassle to put it off an on each time when I'm in the zone.

We've been using a new "ceramic" burr in the office that I've found works great for calluses as well.

Also I'll use lido with epi for pretty much any procedure in office.

 

[DYK343]

What I usually do is set the dremel to "15" for patients that I think can tolerate it, but the ones that are a little squirrely (especially dementia patients) or those that are very ticklish I start out at a "10."

It doesn't get that great of a grind at 10 but it still is good enough. I can't reduce the giant marshmellow hallux nails with it but patient's are still happy.

I've also sustained some injuries to my fingers from patient's pulling away on a 15 (big chunk of my left cuticle gone), but it comes with the territory. I've also tried to use an N-95 when grinding but its more of a hassle to put it off an on each time when I'm in the zone.

We've been using a new "ceramic" burr in the office that I've found works great for calluses as well.

Also I'll use lido with epi for pretty much any procedure in office.

I refuse the dremmel. It cant be good for you long term.
Plus post ops coming in and sitting in same chair it cant be clean. No way you can get all that nail dust clean. It goes everywhere suction or no suction.

 

[wakaflocka88]

I’m ready to drop all nail pathology like DYK. I really enjoy ingrowns as it pays well but denying unqualified nail care everyday is tanking my patient satisfaction scores. No matter how you explain it, their last question is always “so what do I do now?” Zero hope.

 

[NatCh]

I’m ready to drop all nail pathology like DYK. I really enjoy ingrowns as it pays well but denying unqualified nail care everyday is tanking my patient satisfaction scores. No matter how you explain it, their last question is always “so what do I do now?” Zero hope.

I stopped toenail debridement years ago and I haven’t regretted the decision one little bit.

“Can you trim my toenails?”

“Nope.”

 

[wakaflocka88]

I stopped toenail debridement years ago and I haven’t regretted the decision one little bit.

“Can you trim my toenails?”

“Nope.”

The hard part is their deceptive chief complaints to get on the schedule. “Fungus” “ingrown nail” “foot pain”. It’s the elderly patients that think they’re entitled to this service. Honestly even if they did meet one of the Q modifiers I still tell them I don’t do it. Why risk increasing your chances of carpal tunnel for a non life threatening issue?

I truly hope all 1105x and 1172x codes are banned from any type of reimbursement. Imagine the riot we will hear on all podiatry networks. Keith Greer and Barry Block teaming up to champion for rightful foot care.

 

[Creflo]

My pod school taught (or at least our surgery professor did) that its ok to use lido with epi on toes. The literature I've read says it's safe.

 

[HardRoadPaved]

I’m ready to drop all nail pathology like DYK. I really enjoy ingrowns as it pays well but denying unqualified nail care everyday is tanking my patient satisfaction scores. No matter how you explain it, their last question is always “so what do I do now?” Zero hope.

The worst is when its a young(er) female who is devistated that their one "fungal" nail is really just dystrophic and there is no cure. But even recently I've had vain older women in their 50s-70s who are sad when they get nail dystrophy as theyll never get cat called again with their talons.

 

[Adam Smasher]

The worst is when its a young(er) female who is devistated that their one "fungal" nail is really just dystrophic and there is no cure. But even recently I've had vain older women in their 50s-70s who are sad when they get nail dystrophy as theyll never get cat called again with their talons.

Find A KeryFlex Nail Restoration Provider Near You!

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Turn her into someone else's problem

 

[DYK343]

The hard part is their deceptive chief complaints to get on the schedule. “Fungus” “ingrown nail” “foot pain”. It’s the elderly patients that think they’re entitled to this service. Honestly even if they did meet one of the Q modifiers I still tell them I don’t do it. Why risk increasing your chances of carpal tunnel for a non life threatening issue?

I truly hope all 1105x and 1172x codes are banned from any type of reimbursement. Imagine the riot we will hear on all podiatry networks. Keith Greer and Barry Block teaming up to champion for rightful foot care.

Gotta keep in mind we both hate it because were wRVU based and it pays us dog$hit.

I stopped taking all new referrals last week for anything nails because I cant make decent income at it. That said I still have some scheduled. Had a lady Friday "Cant you just cut a little more?" "I think that one right there needs to be rounded more" "Can you just look at this one, I think it needs a little more" She went through every nail one by one and inspected them with a fine tooth comb. She had no qualifying factors and it was if billed truthfully a 11719 (which zero podiatrists bill...). I told her I only do acute care and cant reschedule her. BYE.

If I was getting $100 a pop for 5 minutes work I might start lubing them up with the 3 WEA and cranking out 8 an hour. But when I have experiences like yesterday and it reminds me I made the right choice.

Ugh we lost topic again. I degress.

 

[NatCh]

"Cant you just cut a little more?" "I think that one right there needs to be rounded more" "Can you just look at this one, I think it needs a little more" She went through every nail one by one and inspected them with a fine tooth comb.

That’s the worst.