Foot abscess I&D anesthesia question

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Random Anesthesiologist

Random Anesthesiologist

Random Anesthesiologist
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I'm in week 14 of a rural family med rotation (M4, getting ready to graduate), and I saw this gal in the office this week:

37yo (female), PMH DM II, hyperlipidemia, morbid obesity (327lb @ 5'4"), current pack-a-day smoker. Stepped on something in the yard barefoot and ended up with severe heel pain and inflammation. Examined her and found an abscess on plantar portion of left heel. Lanced it with local, drained, debrided, sent home on Bactrim. Culture ended up positive for MRSA. 2.5 days later she is back in more pain and with abscess again, bigger this time with more induration. My preceptor saw her this time and sent her to general surgeon for urgent afternoon visit, who admitted her to hosp for surgical I&D in the morning (it was like 6pm when she was seen in his office).

When I rounded on her early next morning at the hospital she told me the anesthesiologist was going to give her general anesthesia - she didn't have a preference one way or another about the type of anesthesia, just wanted the abscess to go away.

This got me thinking, with her being so big and a smoker with high lipids, why not do a regional block. Or what about a spinal or "twilight"? I didn't get to see the anesthesiologist to ask why he chose general, so maybe someone here could explain better. It's been bugging me for a couple days now, so I thought I'd ask.

(My school heavily emphasizes rural medicine...)
 
Her medical history isn't very scary...every other patient is morbidly obese...she's young at least

And regional in an infection on a fatty can suck...every "mac" case ive done like that you end up pushing enough prop that it's basically general without a tube...and that goes south real quick w large necks
 
Please don't ever use the term twilight again.
Choices are local +/- sedation, regional, or general.
I'd probably go general as well for a 5 min procedure that will be very painful and difficult to cover with local.
A spinal will take longer than the procedure and last hours.
I suppose you could try to do an ankle block if you were a masochist, and a bit of a sadist as well. Though I wouldn't want to be sticking an obese diabetic patient in the ankle multiple times. That's a recipe for disaster, and a bad block.
Prop, sux, tube.
 
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There's many ways to skin this cat safely. Personally, I would just put a tube in because it is safe, quick, efficient, and the patient is comfortable.

But for your question about doing a block, the issue is with the infection the pH of the area changes to become more aciditic in that the local anesthetic probably won't work. This is actually an interesting question worth googling. And remember, local anesthetics work through sodium channels.
 
cincincyreds said:
There's many ways to skin this cat safely. Personally, I would just put a tube in because it is safe, quick, efficient, and the patient is comfortable.

But for your question about doing a block, the issue is with the infection the pH of the area changes to become more aciditic in that the local anesthetic probably won't work. This is actually an interesting question worth googling. And remember, local anesthetics work through sodium channels.
Click to expand...

uuhhh...not if you block it at the knee?
 
IlDestriero said:
Please don't ever use the term twilight again.
Choices are local +/- sedation, regional, or general.
I'd probably go general as well for a 5 min procedure that will be very painful and difficult to cover with local.
A spinal will take longer than the procedure and last hours.
I suppose you could try to do an ankle block if you were a masochist, and a bit of a sadist as well. Though I wouldn't want to be sticking an obese diabetic patient in the ankle multiple times. That's a recipe for disaster, and a bad block.
Prop, sux, tube.
Click to expand...

Anesthesiologists at this hospital use this term 😕

Thanks everyone for input.
 
Oggg said:
Not everyone has the skills to do a nerve block, much less a block on a fatty. Some can't even do a spinal on a fatty
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This. I am disappointed by some of my colleagues who think it is okay to coast and have not kept their skills up to date.
 
Once in a while you get a morbidly obese patient with tree trunk legs with extra fat just above the popliteal crease, and it's a bit hard to place the probe and see the nerve.

To continue the devils advocate thing, I have seen some foot I&D patients who have some weird looking stuff when I scan the popliteal region. I presume it's edema, but the mushroom cloud like stuff in the subcutaneous tissues makes me
Nervous and I have aborted the block in the past.
 
Can she even feel her foot? You might be able to do this at the bedside 😀


I like blocks for patients who are going to be in a lot of pain post-operatively, and most of these wounds aren't really that painful in the scheme of things. From the surgery point of view, I'd rather she were just under general.
 
TheProwler said:
Can she even feel her foot? You might be able to do this at the bedside 😀


I like blocks for patients who are going to be in a lot of pain post-operatively, and most of these wounds aren't really that painful in the scheme of things. From the surgery point of view, I'd rather she were just under general.
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LOL yeah, she wasn't that far gone neuropathy-wise. I was able to numb her around/under the abscess (not on/in it, I know about the pH issues), to lance it the first time. She did pretty good once she got over the initial needlestick on the bottom of her foot. I don't blame her. That's sensitive.
 
Partial ankle block (tibial + sural)--10 mL of .5% bupivacaine deposited posterior to posterior tibial artery and 10mL fanned into soft tissues behind lateral malleolus. Done.

You've saved time and side effects of GA.
 
Tuohy said:
Same colleagues making 500K+ and indefinitely certified by the ABA...sad...
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actually it's usually the ones making 200K and working for big name academic institution that lack the skills

If you are making big bucks in PP and can't cut it clinically...don't let the door hit you
 
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