Sample - Common Office Procedures

Local Anesthetics

2 Classes. Amides-Xylocaine (Lidocaine), Bupivacaine (Marcaine) widely used; allergic reactions rare.

Xylocaine- rapid onset of action, shorter duration adequate for most skin procedures.

Marcaine- longer duration, slower onset.

If (?) allergy to local anesthetic do not use; allergy referral

Reducing pain with injection:

1) Reassurance

2) Skin stretched taunt

3) Pressure on skin surface around site

4) 30 gauge needle

5) enter @ 90 degrees

5) Aspirate plunger-avoid intravascular placement

6) Slow injection

7) Superficial placement 1st

8) Allow to “set”. Avoid needle placement in suspected malignancies

Epinephrine use: Avoid if (+) history tachyarrhythmia, vasospastic disease (Raynaud’s). Avoid use distal to wrist, ankle and male genitalia.

Buffering Xylocaine with epinephrine- Mix 10:1 Xylocaine with epi: HCO3— from multi-dose 8.4% vial. (e.g. Add 5 cc HCO3--  to 50 cc multi-dose stock vial of Xylocaine with epi).

Skin Biopsy

Performed for diagnostic or therapeutic reasons.

Two types: Shave & Punch.

Shave- for exophytic lesions

Punch- rashes and endophytic lesions

Pre Procedure Antibiotics

Indications: 1) Prosthetic heart valve 2) Joint replacement in 2 years 3) History of endocarditis 4) Symptomatic valvular heart disease. Also, consider if biopsy lower extremity in elderly, debilitated, or institutionalized patient.

Antibiotic choice: Amoxicillin 2 grams PO 1 hour before. If PCN allergic- Clindamycin 300-600 mg. If in doubt- consult your physician.

Cryosurgery- use of liquid nitrogen (LN2) for selected viral (warts) or precancerous (actinic keratosis). Cry-AC Spray: Use “C” tip. Hold 1-2 cm away. Produce ice ball including 1-2 mm halo. Can use 2.5mm disposable otoscope speculum, trim as needed, place on surface reduce collateral spray.

Cotton tip applicator with added cotton for direct contact for sensitive areas.

Post treatment expectations: Immediate post sting gives way to throbbing then swelling and possible blister formation.

Contraindications:

1) Raynaud’s phenomenon or disease

2) Pyoderma gangrenosum

3) Cold urticaria

4) Cryoglobulinemia or cryofibrinogenemia

5) Cold intolerance

6) Connective Tissue Disease

Wart paring- use topical salicylic acid 18-40% topical @hs until dead white skin noted. Pare away with either surgical #15 blade or use rough file to remove dead skin; reapply salicylic acid, repeat.

All doses shown below are administered once as a single dose 30-60 min before the procedure.

Standard general prophylaxis

• Amoxicillin
• Adult dose: 2 g PO
• Pediatric dose: 50 mg/kg PO; not to exceed 2 g/dose

Unable to take oral medication

• Ampicillin
• Adult dose: 2 g IV/IM
• Pediatric dose: 50 mg/kg IV/IM; not to exceed 2 g/dose

Allergic to penicillin

• Clindamycin
• Adult dose: 600 mg PO
• Pediatric dose: 20 mg/kg PO; not to exceed 600 mg/dose

Allergic to penicillin

• Cephalexin or other first- or second-generation oral cephalosporin in equivalent dose (do not use cephalosporins in patients with a history of immediate-type hypersensitivity penicillin allergy, such as urticaria, angioedema, anaphylaxis)
• Adult dose: 2 g PO
• Pediatric dose: 50 mg/kg PO; not to exceed 2 g/dose
• Azithromycin or clarithromycin
• Adult dose: 500 mg PO
• Pediatric dose: 15 mg/kg PO; not to exceed 500 mg/dose

Allergic to penicillin and unable to take oral medication

• Clindamycin
• Adult dose: 600 mg IV
• Pediatric dose: 20 mg/kg IV; not to exceed 600 mg/dose
• Cefazolin or ceftriaxone (do not use cephalosporins in patients with a history of immediate-type hypersensitivity penicillin allergy, such as urticaria, angioedema, anaphylaxis)
• Adult dose: 1 g IV/IM
• Pediatric dose: 50 mg/kg IV/IM; not to exceed 1 g/dose

References: Medscape, Antibiotic Prophylactic Regimens for Endocarditis- AMA guidelines, updated May 14, 2013
Wright,T,et al: Antibiotic Prophylaxis in Dermatologic Surgery Advisory Statement 2008 JAAD 59:3;464-473,2008

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