and Non-excisional Surgery

, Julie Karen1 and Perry Robins1



(1)
New York University School of Medicine, New York, NY, USA

 




Preoperative History




Medical history with particular attention to:



  • Coronary artery disease


  • Hypertension


  • Arrhythmias


  • Pacemaker or defibrillator


  • Heart murmurs


  • Artificial heart valves


  • Prosthesis or shrapnel


  • Bleeding or clotting disorders


  • Hepatitis or HIV


  • Keloids or hypertrophic scars


  • Alcohol use


  • Cigarette smoking


  • Pregnancy (consider consultation with obstetrician)


Medications with particular attention to:



  • Anticoagulants (recommendations on next page)


  • Herbal and over the counter medications including but not limited to:



    • Vitamin E


    • Feverfew


    • Fish oil


    • Garlic


    • Ginger


    • Gingko biloba


    • Ginseng


    • Others: dong quai, licorice, devil’s claw, and danshen have the same antithrombotic effect and should be discontinued 7–10 days preoperatively


  • Recent use of oral retinoids (e.g., isotretinoin): may impair healing


  • Immunosuppressants (e.g., TNF-inhibitors, cyclosporine, methotrexate, mycophenolate mofetil, and prednisone): may impair healing


  • Medication allergies


Recommendations for management of anticoagulants:



  • Aspirin: irreversibly inhibits platelet aggregation via acetylation of cyclooxygenase. One aspirin affects a platelet throughout its lifespan of 6–10 days. Medically indicated aspirin should not be stopped. However, if the patient can safely discontinue aspirin without a high risk for stroke or myocardial infarction, it should be withheld for 10 days before surgery and then possibly 5–7 days after surgery (after consultation with the patient’s internist or cardiologist when appropriate). There may be a risk of rebound hypercoagulability with cessation.


  • Thienopyridines (e.g., clopidogrel, ticlopidine): irreversibly inhibit platelet aggregation via inhibition of an ADP receptor on platelets. Normal platelet function returns 5–7 days after discontinuing these medications. In patients on these drugs for cardiac or neurologic indications, it is generally not advisable to stop the drug.


  • Warfarin (Coumadin): inhibits vitamin K dependent clotting factors and is commonly used in patients with a history of atrial fibrillation, DVT, and in patients with artificial heart valves. Dermatologic surgery can be safely performed without stopping warfarin as long as the INR ≤ 3. An INR should be checked within a week of planned surgery.


  • Dabigatran etexilate (Pradaxa®): is an oral direct thrombin inhibitor used to reduce the risk of stroke and blood clots in patients with atrial fibrillation (not caused by heart valve abnormalities) and generally should be continued.

Note: The combination of two or more of these agents likely increases the risk of bleeding complications from surgery and temporary cessation of one of these agents after appropriate consultation with the cardiologist/internist/neurologist should be considered.

A308343_1_En_2_Figa_HTML.gif


Figure 2.1
Guidelines for prophylactic and empiric antibiotics. Adapted from Rossi A, Mariwalla K. Prophylactic and empiric use of antibiotics in dermatologic surgery: a review of the literature and practical considerations. Dermatol Surg 2012;38:1898–1921



Table 2.1
Commonly used prophylactic antibiotic agents for cutaneous surgery




























Antibiotic
Spectrum of activity/notes

Dicloxacillin
Staphylococcus (methicillin sensitive), Streptococcus

Cephalosporins (e.g., Cephalexin)
Gram+ cocci, E. coli, Klebsiella, Proteus

Clindamycin, Erythromycin, Azithromycin
If PCN allergy (note: approximately 30% may be resistant to erythromycin)

Fluoroquinolones (e.g., Ciprofloxacin)
Pseudomonas aeruginosa

Vancomycin (intravenous)
Methicillin-resistant Staph aureus (MRSA), Staph epidermidis, Valve <60 days

Linezolid (po)
MRSA and vancomycin-resistant enterococcus, streptococcus (note: can cause thrombocytopenia)


An oral dose is usually given 1–2 h prior to surgery. If surgery is prolonged or delayed, a second dose may be given 6 h postoperatively



Table 2.2
Antiseptic scrubs




















































Group
Spectrum
Onset
Sustained activity
Comments

Alcohol
Gram+
Fast
None
No killing of spores, antibacterial only, flammable (caution with electrocautery)

Iodine (Lugol’s)
Gram+/−
Fast
None
May sensitize patient (contact dermatitis)

Povidone-iodine (betadine)
Gram+/−, fungi
Moderate
Up to 1 h
Absorbed through skin, must dry to be effective, mucosal absorption during pregnancy may be associated with fetal hypothyroidism

Hexachlorophene (pHisohex)
Gram+
Slow
Yes
Teratogen, not sporicidal

Chlorhexidine (hibiclens)
Gram+/−
Fast
Yes
Oculotoxicity and ototoxicity

Benzalkonium (Zephiran)
Gram+/−
Slow
None
  


Note: shaving a preoperative site the night before surgery is associated with higher infection rates than with using a depilatory or not removing the hair at all. If hair must be removed, clipping the hair immediately before the procedure is preferable



Table 2.3
Local anesthetics

























































Generic name/trade name
Duration
Onset
Uses
Special considerations
Maximum dosage with epia (1:100,000)

Amides

Lidocaine (Xylocaine®)
1–2 h with epinephrine
Rapid
Most local infiltration
May cause CNS and cardiac toxicity, pregnancy class B (without epi)
7 mg/kg

Mepivacaine (Carbocaine®)
1–2 h with epinephrine
3–20 min
Most local infiltration and nerve blocks
  
7 mg/kg

Bupivacaine (Marcaine®)
12–36 h
5–8 min
Nerve blocks and long procedures
Very prolonged effect, good for post-op pain
  

Esters

Procaine (Novocaine®)
30–60 min
2–5 min
Dental procedures
Short duration; allergic reactions; and cross-reacts with topical anesthetics, hair dyes, sunscreens, and sulfur derivatives
15 mg/kg

Tetracaine (Pontocaine®)
4–6 h
15–45 min
Topical (cornea, conjunctiva)
Slow onset, long duration
  


aEpinephrine prolongs anesthesia and decreased the risk of systemic anesthetic toxicity due to decreased absorption via vasoconstriction. Also decreases bleeding via vasoconstriction


Anesthetics: Key Facts






  • Two main classes: Amides and Esters


  • Esters can cause allergic reaction due to PABA (an ester intermediate metabolite) which cross-reacts with paraphenylenediamine (PPD), sulfonamides, and other ester anesthetics


  • Esters should not be used in patients with pseudocholinesterase deficiency


  • Three portions of the chemical structure:

    1.

    Aromatic: responsible for onset of activity

     

    2.

    Intermediate (middle) chain: determines class (amide vs. ester)

     

    3.

    Amine: determines duration of action

     


  • Bupivacaine has the longest duration of action


  • Tetracaine is the most potent ester


  • Cocaine is the most vasoconstrictive ester


  • Lidocaine Pearls:

    1.

    1 % lidocaine = 10 mg/mL

     

    2.

    Pregnancy class B (without epinephrine)

     

    3.

    Lidocaine toxicity: first sign is lightheadedness/circumoral paresthesia/metallic taste→tinnitus/slurred speech/tremor/confusion→seizure/cardiopulmonary depression/death/coma

     

    4.

    Recommended maximum dosage with epinephrine = 7 mg/kg (500 mg in 70 kg person), without epinephrine (plain) 4.5 mg/kg (300 mg total in 70 kg person),

     

    5.

    Tumescent lidocaine 45–55 mg/kg (see Table 2.4/page 27)

     


  • Digital tourniquets can be left on for 10–15 min


  • Local anesthetics mechanism of action: blocking sodium influx


  • Patient loses the following in this order: sense of temperature, pain, touch, pressure, vibration, proprioception, and motor function


  • Epinephrine toxicity manifested by tremor, increased heart rate, diaphoresis, palpitations, headache, increased blood pressure, and chest pain (if hypotension consider vasovagal reaction rather than toxicity)


  • Epinephrine drug contraindications: MAOIs, tricyclic antidepressants, phenothiazines, propranolol, amphetamines, and digitalis


  • Epinephrine contraindications: peripheral vascular disease, acute angle glaucoma, severe hyperthyroidism, unstable mental status, pregnancy, severe hypertension or cardiovascular disease


  • Other options for injectable anesthesia include promethazine (Phenergan), diphenhydramine (Benadryl), and normal saline


  • Topical anesthesia:

    1.

    EMLA (eutectic mixture of 2.5 % lidocaine, 2.5 % prilocaine) under occlusion—Note: risk of methehemoglobinemia with prilocaine in infants

     

    2.

    LMX (4 or 5 % lidocaine)

     



Table 2.4
Tumescent anesthesia solution




























Agent
Amount (cc)
Final concentration

Normal saline (0.9 %)
1,000
  

Lidocaine 1 %
50
0.1 %

Epinephrine 1:1,000
1
1:1,000,000

Bicarbonate 8.4 %
10
  


Notes

aMaximum safe dose of lidocaine: 45–55 mg/kg

bLocal anesthesia persists for up to 24 h after tumescent liposuction (peak plasma levels 4–14 h)



Table 2.5
Electrosurgery




















































Modality
Terminala
Voltageb

Amperagec

Comments

Electrofulgaration
1
Very high
Very low
Sparks emanate from electrode which does not touch the skin, most superficial damage

Electrodessication
1
High
Low
Electrode touches the tissue, superficial destruction (avascular lesions)

Electrocoagulation
2
Low
High
Deeper penetration and better hemostasis than electrodessication

Electrosection
2
Low
High
Vaporizes tissues with little heat spread, minimal peripheral tissue damage

Electrocautery
1
N/A
N/A
Red, hot tip (high resistance metal tip). Works in bloody fields and nonconductive surfaces. No current passes through patient—safest to use with ICD d

Galvanic current
1
Low
Low
Direct current, used for electrolysis and iontophoresis


a Terminal: 1 terminal (aka monopolar): one active electrode, no grounding; 2 terminals (aka bipolar): one active electrode, one grounding electrode (place grounding pad close to surgery site and aware from ICD)

bVoltage: electric potential difference between the terminal and the skin

cAmperage reflects the flow of electric current

dICD (implantable cardiac device)


Cryosurgery


Defined: Targeted tissue destruction via necrosis induced by subzero temperatures


















Agent
Boiling point (°C)

Liquid nitrogen
−195.6

Nitrous oxide
−89.5

Dry ice (CO2)

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Apr 1, 2017 | Posted by in Dermatology | Comments Off on and Non-excisional Surgery

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