Grand Rounds is up-- the Scandal Edition!

Updated 3/2017-- photos and all links removed as many are no longer active.

Second year medical student Harry, Unprotected Text, has done a scandalously good job with this week's edition of Grand Rounds (4:43).

EXTRA, EXTRA, READ ALL ABOUT IT! That’s right folks, this week I shall be dishing as much dirt on the latest rumours, gossip and scandal that the blogosphere can handle, and all from a rather slanderous angle!

Next week Grand Rounds will be hosted by Grunt Doc.

Tissue Transfer in Transplant Patients--An Article Review

This is an important topic, as the number of transplant patients continues to grow. These patients are not exempt from problems (trauma, cancer resection, etc) that are best treated with tissue transfer.

Background: Traditionally, organ transplantation has been synonymous with patients with poor prognosis and outcome. Surgeons felt that the risks posed by immunosuppressive drugs outweighed the benefits of non-life-threatening procedures. With the enormous advances in the field of organ transplantation, a growing number of transplant patients present for a variety of surgical procedures. The objective of this report was to study the surgical outcome of organ transplantation patients who required reconstructive surgery using free tissue transfer.

The article is a multiple academic centers (5), retrospective patient (19) chart review. The fact that it is retrospective and that there are only 19 patients are weaknesses, but you have to start somewhere. I applaud them for this beginning. The Five academic centers that participated in the study are: Louisiana State University Health Sciences Center, Eastern Virginia Medical School, University of California, Los Angeles Medical Center, Harvard Medical School, and Tulane Health Sciences Center.

The study group included organ transplant patients who underwent elective microvascular free flap procedures. Cause of organ failure, medications, reconstruction site, flap choice, days hospitalized, complications, and outcome were examined. Delayed wound healing is defined as a wound that should have healed within 6 to 8 weeks after surgery but did not. Statistical analysis using sample t testing was performed.

Nineteen transplant patients required free flaps. Flap sites included nine lower extremity, five head and neck, three breast, and two upper extremity sites. ....... Transplant drugs being used by patients at the time of free flap surgery included cyclosporine, azathioprine, FK506, and prednisone. All free flaps survived. In our series, there were no episodes of acute rejection in the immediate postoperative period. None of the patients required changes in their immunosuppression regimen in the preoperative setting. All transplanted organs continued to function normally after flap surgery. Postoperative complications were observed in eight of 19 cases. They included partial skin graft loss, suture line dehiscence, intraoperative arterial thrombosis, and hematoma formation. Delayed wound healing was observed in two of 19 cases. In case 3, the patient with delayed wound healing was on immunosuppressive agents and insulin dependent. In case 10, the patient was on immunosuppressive agents and the recipient surgical site had been previously irradiated. In case 4, the patient had an uneventful post-free flap experience; however, a nonhealing infected foot ulcer redeveloped 6 years after surgery at the free flap recipient site. Forefoot amputation was eventually performed. Follow-up time in all cases was greater than 12 months.

The majority of transplant medications (Table 2) can cause both hypertension and thrombocytopenia, which may increase the risk of hematoma; however, this was not observed in our study. Decreased platelet activation may actually have beneficial effects. In our series, patients were not noted to have excessive bleeding or clotting dysfunction. Meticulous hemostasis and blood pressure control is warranted in any surgical procedure.

Preoperative medical evaluation and surgical planning are crucial to the outcome of a successful operation. The various disciplines (e.g., plastic surgery, transplant surgeon, internist) must maintain an open dialogue to meet the needs of the patient. It is of paramount importance that the organ transplant patient seeking any elective plastic surgery procedure have optimization of the underlying medical problem.

In addition, these patients often have other comorbid diseases such as hypertension, peripheral vascular disease, diabetes mellitus, and coronary artery disease that may adversely affect the surgical outcome. Therefore, we recommend that the patient be managed on the surgical transplant team with plastic surgery and various medical consultants available to follow the patient in the perioperative setting. This ensures that the patient continues to have careful optimal transplant organ and flap monitoring.

Part of Table 2

	Effect on Blood Pressure	Effect on Clotting	Effect on Wound Healing
Antilymphocytes ATGAM (polyclonal) Thymoglobulin Basiliximab (humanized anti-CD25 monoclonal antibody)	HTN hypotension HTN HTN	Decreased platelets, hemolysis Decreased platelets Decreased platelets	Not proven
Antimetabolites Azathioprine (imuran-1960's) Mycophenolate mofetil	HTN, hypotension (rapid IV push)	Decreased platelets Decreased platelets	Impaired Impaired
Glucocorticoids Prednisone	HTN		Impaired
Calcineurin inhibitors Cyclosporin (neoral or sandimmune) FK506	HTN HTN	Decreased platelets Decreased platelets	Not proven Not proven
Newer Drugs Sirolimus (rapamune) Mycophenolate sodium	HTN No Effect	Decreased platelets Decreased platelets	Delayed or prolonged Unknown

There results would tend to show that if a transplant patient needs a a microvascular free flap, then will careful planning and a co-operative team approach it can be successfully done.

REFERENCE

Microvascular Free Tissue Transfer in Organ Transplantation Patients: Is It Safe?; Journal of Plastic and Reconstructive Surgery, Vol 121, No 6, pp 1986-1992; Anh B. Lee, M.D.; Charles L. Dupin, M.D.; Lawrence Colen, M.D.; Neil F. Jones, M.D.; James W. May, M.D.; Ernest S. Chiu, M.D.

SurgeXperiences 202 -- Call for Submissions

Updated 3/2017--video and all links removed as many are no longer active.

I will be your host for the second edition of the second season of SurgeXperiences. I have no theme planned, so just write some surgery related posts and send them my way.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on Friday, July 18th. Please submit your posts here.

Here is the catalog of past surgXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

If you need a reminder of how to avoid heat related illness as we head into the high 90F and 100F, then review the post I did last August on Heat Related Illnesses.

Grab a cool drink and start writing. Here's a little summer music for your enjoyment

Lauren's Quilt

My neighbor recently gave me several bags of fabric. She had received them from an aunt who was moving into a retirement community and downsizing. Lots of fat quarters (approximately 18 in X 22 in size pieces of fabric for you non-quilters), some half yards, and even some that are 1-3 yd lengths.

This quilt started out with me playing around with double 4-patches made from some of the fat quarters. I had twelve 8.5 in square blocks (including seam allowances). How to set them? I looked through the fabric and found the floral. Just enough for six squares. Then I found the lovely blue for the outer triangles. While I was trying to decide if I wanted to add more to make it larger, I heard of someone who needed a baby quilt. Even better, the baby is a girl. So I decided it was a perfect size, 33.5 in X 44.5 in.

Here you can see the fabric a little better. It is machine quilted with a pale rose color thread on the front.

I wish the quilting showed up better in this picture of the back. The back is a ecru daisy pattern fabric. The bobbin thread color is ecru. It really looks nice.

Flexor Tendon Repair

Updated 3/2017-- photos and all links removed as many are no longer active.

Like the extensor tendons, there is little to protect to the flexor tendons -- thin skin (though the palm skin is thicker than skin on the back of the hand) and minimal subcutaneous tissue. The flexor tendons can be easily injured by knives, saws, splinters, etc. The flexor tendon anatomy can be reviewed here online, or in more depth offline using a good anatomy or hand surgery text. 

These injuries will often include fractures or soft tissue injuries (lacerations, crush, loss of skin, nerve/vessel injury, etc). This post is only a brief overview of the repair of "isolated" flexor tendon laceration at the time of injury, not reconstructively later. This post will in no way make the reader an expert on flexor tendon injury/repair, but will give you a general understanding (maybe).

Injuries of the flexor tendon are defined by zones. The tendon injuries in finger Zones II tend to fare worse than injuries in the other zones.

Zone I --

• defined as distal to the FDS insertion, so only the profundus tendon here.

Zone II --

• is often referred to as "Bunnell's no man's land". Frequently restrictive adhesion bands will form around lacerations in this area.
• It is defined as the area extending from the insertion of the FDS tendon to the proximal end of the A1 pulley.
• Within zone II and at the level of the proximal third of the proximal phalanx, the FDS tendons split into 2 slips, collectively known as Camper chiasma. These slips then divide around the FDP tendon and reunite on the dorsal aspect of the FDP, inserting into the distal end of the middle phalanx.

Zone III --

• extends from the distal edge of the carpal ligament to the proximal edge of the A1 pulley, which is the entrance of the tendon sheath.
• Within this zone, the lumbrical muscles originate from the FDP tendons.
• The distal palmar crease superficially marks the termination of zone III and the beginning of zone II.

Zone IV --

• includes the carpal tunnel and its contents (ie, the 9 digital flexors and the median nerve).

Zone V --

• extends from the origin of the flexor tendons at their respective muscle bellies to the proximal edge of the carpal tunnel.

Clinical Evaluation

Careful attention to the patient's history and the mechanism of injury can often alert the examiner to the extent of the injury. Finger position at the time of injury is important.

• If the injury occurred while the finger was in flexion, the level of the tendon injury will be distal to the skin laceration.
• A finger that is injured in the extended position will have a tendon injury that closely corresponds to the skin laceration.

The natural resting position of the hand should be closely observed.

• In the uninjured hand, the flexion of the fingers increases from the radial to the ulnar side. This is the "normal composite cascade".
• The finger with a tendon disruption will rest in a more extended position.
• If only the FDP tendon has been transected, the flexion of the MCP and PIP joints may be within the normal cascade but the DIP will be extended.
• A finger in which the FDS tendon and the FDP tendon are both disrupted will lie flat in an extended position, well outside the normal cascade.
• A thorough, formal examination of the FDS and FDP tendons is important because testing these tendons may reveal partial lacerations. A partial laceration may present with pain when the patient attempts to flex against resistance.

The integrity of FDS and FDP tendons should be tested independently and in tandem.

• To test the FDP tendon, the examiner holds the other fingers in extension and stabilizes MCP and PIP joints. The patient is then asked to flex the distal phalanx.
• To test the FDS tendon, the examiner holds the other fingers in extension, but the MCP and PIP joints are released. The patient is asked to flex the finger. The PIP joint and, to a lesser degree, the MCP joint should flex. About 20% of patients are missing an FDS tendon in the little finger and will therefor have limited or no PIP flexion during testing.
• For flexor pollicis longus (FPL) testing, the thumb MCP joint is stabilized in neutral position. The patient is asked to flex the interphalangeal (IP) joint against resistance. A communication may exist between the FPL and the index FDP. The examiner stabilizes the other 3 digits. The patient opposes his or her thumb to the little finger MCP joint. Flexion of the index distal phalanx proves the existence of this anomalous communication.
• Passive manipulation of the wrist through flexion and extension should result in extension and flexion of the digits, respectively. This uses the tenodesis effect of the antagonistic tendons. If a tendon is transected, then there can be no tenodesis effect.
• Compression of the forearm flexion muscles also can be used to test the integrity of the flexor tendons in the hand. As the forearm is compressed, the digits are drawn into flexion. Transected tendons in the digits do not flex with this maneuver.

PRIMARY REPAIR

The optimal time for repair of the flexor tendons is within 24 hours of the injury (primary tendon repair). Delayed primary repair (between 24 hrs and 2 weeks) is indicated in grossly contaminated wounds. Early secondary repair takes place between 2 and 5 weeks after the injury. The earlier the surgery, the less likely it is that wound edema and infection will ensue. Late secondary repair (more than 5 weeks after injury) results in poor function due to tendon swelling, muscle retraction, and extension deficit.

All flexor tendons should be repaired in the main operating room in a controlled, sterile environment under tourniquet control. Surgical exposure can be obtained through Brunner (volar zigzag) or lateral (mid-axial) incisions. Care is taken not to injure the neurovascular bundles, which can be quite superficial in the finger.

Only the lacerated edges of the tendon should be handled to avoid trauma to the uninjured area of the tendon. The proximal tendon end may retract into the palm because of the muscle tension of the profundus and lumbrical muscles.

• The tendon can be retrieved with Jacob forceps or fine clamps, aided by milking the tendon proximally to distally.
• If this doesn't work, then a counter-incision in the palm must be made to find the proximal end of the severed tendons. Once identified, a pediatric feeding tube is introduced at the distal wound site through the fibro-osseous canal, to emerge into the palm incision site. The feeding tube is sutured to the end of the tendon and pulled out distally, carrying with it the proximal end of the flexor tendon. The tendon is then held in this position with a 25-gauge needle in the palm.

Using an atraumatic technique for tendon manipulation helps prevent further injury to the tendons and decreases the amount of adhesion formation. Every traumatic site along the tendon is another potential spot for adhesion formation. Delicate forceps, such as the Bishop-Harmon or Iris forceps, should be used to pick up the tendon at its severed end, although not along the sides of the tendon.

Disruption of the pulleys, especially A2 and A4, should be avoided. If the laceration is at these pulleys or if the repair is hindered because of the pulleys, then Z-plasties in the pulleys or partial releases may be required. The pulleys are repaired after the tendon is repaired. Shredded or mutilated pulleys may need to be reconstructed. This can be done using a slip of the FDS tendon, tendon grafts, or extensor retinaculum grafts.

The goal of the tendon repair is to coapt the severed ends without bunching or leaving a gap. Bunching of the repair may inhibit tendon excursion under the pulley system. Leaving a gap left at the repair site can either weaken the repair, which will leave the tendon prone to future rupture, or foster an overabundance of adhesions (scarring), limiting excursion of the tendon.

Most tendon suture methods will use both a core suture and an epitendinous suture.
Core Suture Techniques

• Modified Kirchmayr/Kessler Suture with single knot at repair site
• Tajima Modification of Kessler Suture with double knots at repair site

  Tajima repair, core suture only; B) Tajima repair, core plus epitendon suture; C) Savage repair, core suture only; D) Savage repair, core plus epitendon suture.

• Four-strand Interlock Stitch (Tsuge)
• Double-loop Locking Suture
• Six-strand suture techniques

1. (A) The Y1 technique: combination of the Tsuge suture with a 4–0 looped thread and the modified Kessler suture using a 4–0 double strand with 2 needles.
2. (B) The TL technique using 3 Tsuge sutures with 4–0 looped thread.

Epitendinous Suture Techniques

It was once thought that the epitendinous suture was primarily of esthetic importance, as in "tidying up the ends". It has been shown that an epitendinous suture actually increases the overall strength of the repair and is important in resisting gap formation.

• Simple Continuous Running Epitendinous suture
• Running-locking Loop Suture
• Halsted Continuous Horizontal-mattress Suture
• Continous Horizontal-mattress Intrafiber Suture
• Cross-stitch

The suture material that is used to repair the severed tendon varies. The usual caliber of suture is either 3-0 or 4-0. Braided or monofilament sutures also have been used. Knots should be buried, as their exposure can promote adhesion formation. One or 2 core sutures and a running epitendinous suture should be used. There is recent interest in using barbed sutures for "knotless" repair of tendons. (photo credit)

Early initiation of rehabilitation is important for an optimal result. Here are some good sources for postop rehab guidelines:
Zones 2-5 Flexor Tendon Repair (PDF file); Dept of Rehabilitation, Brigham and Women's Hospital, Sept 2007
Flexor Tendon Repair Rehab Guidelines. Zones 1-3; Center for Orthopedics (PDF file)
Flexor tendon repair- Kleinert protocol


REFERENCES
Flexor Tendon Anatomy; eMedicine Article, May 1, 2007; Steven J Bates MD, Cato T Laurencin MD, and James Chang MD
Flexor Tendon Lacerations; eMedicine Article, Oct 19, 2007; Michael Nuemeister MD, Bradon J Wilhelmi MD, and Reuben A Bueno, Jr MD
Flexor tendon repair in zone II with 6-strand techniques and early active mobilization. J Hand Surg [Am] 31A:987–992, 2006; Osada D, Fujita S, Tamai K, et al
Flexor Tendon Repair and Rehabilitation : State of the Art in 2002; J. Bone Joint Surg. Am., September 3, 2002; 84(9): 1684 - 1706
M. I. Boyer, J. W. Strickland, D. R. Engles, K. Sachar, and F. J. Leversedge
Flexor Tendon Repair; Duke Orthopaedics Wheeless' Textbook of Orthopaedics Online
Flexor Tendon Lacerations in the Hand; UPOJ, Vol 10, Spring 1997, pp 5-11; David R Steinberg MD
Zones 2-5 Flexor Tendon Repair (PDF file); Dept of Rehabilitation, Brigham and Women's Hospital, Sept 2007
Flexor Tendon Repair Rehab Guidelines. Zones 1-3; Center for Orthopedics (PDF file)

Waiting

This past Thursday, I spent most of a day waiting.

My younger brother had told me his surgery was scheduled for 8:45 am. Since I have priviledges at the hospital I knew he had to be there two hours prior to surgery. So I showed up at 7:45 am. My intention was to get there after he had done his admission paper work, but before he went into surgery. He had ask me to be there, so I wanted to be sure to be there before he received any drugs.

There was no sign of he or his wife in the waiting area. They had not checked in, so I began the day waiting for them.

Turns out his surgery was scheduled for 10:45 am. He had been told to arrive at the hospital at 8:45 am. "We never tell the patient a surgery time. We don't want to confuse them. They might just arrive at the hospital when the surgery is scheduled. That would delay everything."

While I sat waiting, I listened in on conversations around me. [It's hard not too hear the conversations.]

7:50 am "Can you believe they don't have orders for me?" an elderly woman (EW), who was also waiting, said to her husband. "It's no fun being off your blood thinners and heart medicines when you need them?"

7:55 am "The nurse in the OR called. She said B_ is still in surgery, but everything is well. So we came in at the right time." A middle age woman (MAW) to her father and son. The cigarette aroma suggested they had been outside for a cigarette break.

8 am Morning prayer over the intercom. We're in a Catholic Hospital. I see my brother and sister-in-law come in.

8:15 am Dr. B_ (my brother's doctor) came out to give a report to C_'s family.

8:45 am My brother and sister-in-law go back to preop.

9:25 am "Finally, finally." a woman who is being escorted back to the preop area.

"How long have you been here?" asked a fellow waiter.

"Since 5 o'clock." She answers.

9:35 am My sister-in-law hands me her bag, "I have to go get medicines. They need milligrams and we don't know milligrams."

"I'm getting so mad at them. They lost my orders. There's no sense in that." says EW. [I've heard this repeated multiple times by her and her husband this morning. I have heard how the doctors office has faxed over the orders three times this morning, but the hospital staff keep repeating that they haven't received any of the faxes. They can't find the doctor's orders.]

9:45 am "B__ H__" hospital employee.

"Yes" EW

"Follow me" and escorts her back to preop. I'm glad to know they finally got her orders.

10 am "This is Cindy. Belle's daughter." said the MAW who had earlier come in from the cigarette break.

"Who was that?" dad asked daughter.

"Mom's preacher." talking loudly to her dad.

"The doctor said that things went well and if things continue to go well, she'll probably go home in 48 hours." Cindy says to the person on the other end of the line. She then repeats the conversation to several others on her list.

10:35 am "Ramona, J__ wants you to come back." So I follow the nurse back and listen to her. She tell him and my sister-in-law what to expect as the day progresses. She talks to them about what to expect when he gets to recovery and then the postoperative area (he's outpatient). She covers some postoperative care/expectations. I am impressed with her.

10:45 am The orderly comes to get my brother. We all follow him to the OR suite and wait there. Dr. B__ comes in and marks my brother's right hand (the surgery side). I tease the orderly about asking for a bonus based on number of miles/day walked. He likes the idea, but doesn't think the hospital would go for it.

10:50 am "I need to go to the bathroom" my brother.

"Let me ask the nurse if it's okay if we help you." me

She nods okay (she's on the phone), so I lower the bed. The orderly happens to walk back through the area and takes over for me, locks the bed and carries the IV bag as he walks my brother to the bathroom. He waits for my brother and walks him back.

11:00 am "I'm L__. I'll be the circulation nurse in the OR today." She goes through her questions (allergies, what are we doing today, etc) and then tells us it will be about an hour. Maybe less, as Dr B__ is usually quick. I give her my cell number, so I can take my sister-in-law to get something to eat. She had skipped breakfast since my brother couldn't have any.

11:45 am We're back in the outpatient waiting area and my cell phone rings. "We're done. Dr B__ will be out in just a few minutes." She was right about that.

"Everything went fine. I think it is benign, but the path will take about 4 days to come back. If it's not, then we'll do scans. He may need some radiation treatments in that case." Dr. B__'s report on my brother.

So now like Carol, we make our phone calls to family members. We divide the list. Then we wait, talking about the new grandbaby (their 25 yo daughter just had a baby girl), commenting now and then on the news reports (missing girl, etc), .........

12:45 pm "Ramona. He's asking for you." says a nurse.

"This is J__, his wife. I'm his sister."

"I must have misunderstood. You can both come back."

He looks good. There is color in his cheeks. His eyes are wide open and alert. "Can I have something to drink?"

Now we just have to wait for the path report.

Grand Rounds 4:42 is Up

 Updated 3/2017-- photo and  all links removed as many are no longer active.

TBTAM is the host of this weeks Grand Rounds. She calls it the Seinfeld Edition. It is hilarious, so get that coffee and go read.

Most things in life can be related, one way or another, to an episode of Seinfeld.

It's true. That TV show which claimed to be "about nothing" pretty much said everything that needed to be said about, well, everything.

Take this week's Grand Rounds, the best of the Medical Blogosphere. It's totally Seinfeld. Every post. Why I can hear Jerry, even now...

Grand Rounds? Can someone please explain what that's about? I mean, is it Grand as in "large"? Or Grand is in "Isn't that grand?"

No one says "Isn't that grand?" anymore unless they're 95 and in a nursing home for retired stage actors. In which case they should definitely not be practicing medicine.........

Review of Topical Anesthetic Creams

Updated 3/2017-- all links removed as many are no longer active. 

Topical anesthetic creams can be useful. Patients love them because there is no needle needed. Doctors love them because they make the patient less anxious and can eliminate the edema of an injection at the surgical site.

Topical anesthetic creams can not replace local injections/blocks for all procedures. When used properly and in selected situations, they are a wonderful addition. They can and have been used before routine biopsies, minor operations, laser removal of hair, veins, and tattoos, and botulinum toxin type A and filler placement.

SAFETY FIRST

It is safest to use standard formulas of anesthetic creams. With the standard formulas, it is easier to predict the systemic blood levels that will be obtained by use of the topical. Absorption of topical anesthetic creams is a side effect of the desired local effect. It is affected by the surface area covered by the cream and the duration of application. Systemic blood levels of the local anesthetic will depend on the absorption, patient size, rate of elimination, and type of surface (for example, mucosal versus extramucosal and intact versus broken skin). The blood level of lidocaine approaches that obtained after parenteral use when lidocaine is applied to a mucosal surface.

For most topical anesthetic creams, the systemic blood levels reached with proper use are a small fraction of the blood levels that will produce toxicity. A good example is: 60 gm of EMLA cream ( placed on a 400-cm² area for 4 hours produce peak blood levels of lidocaine that are 1/20th the systemic toxic level of lidocaine and 1/36th the toxic level of prilocaine. This makes its application very safe, with levels well below the concentration that would cause systemic toxicity.

When compounded (non-standard) formulas are used, it is much easier to get into trouble. Take the example (hopefully an extreme example) of the 22 yo college student who died in 2001 from lidocaine toxicity after applying a 10% lidocaine and 10% tetracaine cream from her waist to her feet for her laser hair removal. Note the high concentration of lidocaine/tetracaine and the very high surface area covered.

Ester anesthetics, such as procaine and tetracaine, stimulate the central nervous system, causing restlessness, agitation, and excitement, which may eventually lead to seizure activity.

Amide anesthetics, such as lidocaine, mepivacaine, and bupivaine, resist hydrolysis by plasma esterases and produce a more prompt and longer-lasting anesthesia. They result in central nervous depression, which can result in drowsiness, lethargy, and sleep.

AVAILABLE TOPICALS

BLT: Triple Anesthetic Gel

• is a triple anesthetic gel consisting of 20% benzocaine, 6% lidocaine, and 4% tetracaine. It is formulated in dimethyl sulfoxide and pluronic lecithin organogel, which increases its absorption through the skin.
• It is usually applied to INTACT skin 10 to 30 minutes before surgery.
• Because it contains ester anesthetics, its use is contraindicated for patients allergic to p-aminobenzoic acid, hair dyes, and sulfonides.

EMLA Cream

• an oil-in-water emulsion of 2.5% lidocaine and 2.5% prilocaine.
• It should be used on INTACT skin. An occlusive dressing increases its penetration.
• It must be left on for 0.5 to 2 hours, depending on location and depth of penetration.
• Its use must be avoided near the eyes, since sodium hydroxide is a component of the cream to allow for proper penetration.
• EMLA cream has been shown to be safe and efficacious in geriatric patients (65 years or older), but its use is controversial in neonates less than 3 months of age.
• It is similar to TAC in effectiveness.
• Transient blanching and erythema appear at the site of application due to peripheral vasoconstriction.
• Contact dermatitis is occasionally reported secondary to the prilocaine.
• A very rare methemoglobinemia can develop in patients less than 1 year of age who take medications that exacerbate the methemoglobinemia or who have a congenital methemoglobinemia or a glucose 6-PO4 dehydrogenase deficiency.
• Cost is approximately $11 per 5 gm tube and occlusive dressing.
• Recommended Dose/Area/Time use for EMLA

Pt Age/ Wgt	Max Dose	Max Area	Max Applied Time
0-3 months or less than 5 kg	1 gm	10 sq cm	1 hr
3-12 mo AND more than 5 kg	2 gm	20 sq cm	4 hr
1-6 yr AND more than 10 kg	10 gm	100 sq cm	4 hr
7-12 yr AND more than 20 kg	20 gm	200 sq cm	4 hr

LET

• composed of 0.5% tetracaine, 1:2000 epinephrine, and 4% lidocaine.
• When used for laceration repair--a shred of LET-soaked cotton or LET mixed with methylcellulose is placed directly in the wound prior to cleansing and repair. The solution or gel can be held in place with an occlusive dressing, tape, or bandage.
• The wound edges blanch when numb, usually after 20 minutes (15 - 30 min). Anesthesia lasts an average of 21 minutes after removal.
• LET has been found to be just as efficacious as TAC with no severe side effects.
• LET cost per application is approximately $3.00 compared to $35.00 for TAC

LMX-4

• LMX-4 (formerly ELA-max4) or LMX-5 (formerly ELA-max5) contains 4% or 5% liposomal lidocaine, respectively.
• The cream is usually applied for 15 to 40 minutes to intact skin with no occlusion necessary.
• The rapid absorption also results in a rapid dissipation of the drug, with diminishing anesthesia approximately 40-60 minutes after application.
• A transient erythema may occur, but no serious adverse side effects have been seen.
• To prevent toxic systemic levels, it has been recommended that LMX be applied to an area less than 100 cm² in children weighing less than 20 kg.
• Its effectiveness is similar to that of EMLA.
• LMX-4 can be purchased over the counter. Cost is similar, $6-7 per 1- to 2-gm application [approx $30 per 0.54 oz tube]
• It can be used before superficial and medium-depth peels without affecting the results of the peel.

S-Caine Peel

• developed as a local anesthetic peel (Zars Pharma).
• This cream dries on exposure to air and becomes a flexible membrane that is easily peeled off. This eases the delivery of the anesthetic to contoured regions of body.
• It has been shown to provide a highly effective local anesthesia. It should be applied 20-30 minutes prior to procedures such as dermal filler injections or facial laser ablation, and for 60 minutes prior to procedures such as laser treatment of leg veins and tattoo removal.
• It could be used for minor surgery as well.

Synera (Formerly S-Caine Patch)

• Tetracaine and lidocaine mixed 7%/7% in a self-contained patch have been studied for venipuncture.
• It is designed to look like a child's bandage and is recommended for children aged 3 years and older.
• It contains a heating element that, when activated, enhances absorption, allowing for rapid anesthesia and some degree of vasodilation.
• Cost is approximately $12 per patch.

TAC

• Was one of the first topical anesthetic creams to be developed. Initially it was composed of 0.5% tetracaine, 1:2000 epinephrine, and 11.8% cocaine.
• Later the tetracaine was increased to 1% and the cocaine decreased to 4%. It was found that the effectiveness remained the same.
• It should be applied 30 minutes before the procedure.
• Its effectiveness is comparable to that of lidocaine infiltration when used properly.
• The effectiveness of most anesthetic creams is compared with that of TAC.
• Inadvertent mucosal application or overdose can result in significant cocaine absorption, leading to serious adverse effects such as seizures and cardiac arrest.
• TAC is also very expensive at about $350 per 35-gm tube.

Topicaine

• is a 4% lidocaine gel.
• It is usually applied 30 to 60 minutes before the procedure with occlusion.
• Erythema, blanching, and edema at the site appear to be mild and transient.
• Allergic contact reactions to this ester group of anesthetics are common.
• Effective anesthesia with topicaine can be obtained after 30 minutes.

If a medical-grade occlusive dressing is not available, occlusion can be obtained with Glad Press-n-Seal. The product is not sterile, but over unbroken skin this is not an issue. It does not contain latex and has the added benefit of painless removal.

REFERENCES

Topical Anesthetic Creams [Safety and Efficacy Report]; Plastic and Reconstructive Surgery:Volume 121(6)June 2008, pp 2161-2165; Kaweski, Susan M.D.; Plastic Surgery Educational Foundation Technology Assessment Committee

Topical Anesthetics in Children; Medscape CME Article, Feb 19, 2008; Amy L Baxter MD

SurgeXperiences 2nd Season Begins!

Updated 3/2017-- photos and all links removed as many are no longer active.

The first edition of a new season of SurgeXperiences (201) is up over at Monash Medical Student. And the "gold star" goes to Jeffrey for a well done edition.

Jeffrey begins the season with the season with an edition in which he tried to focus on how we should/can strive to do better. I hope you will check out.

I think we all have a desire to be better at what we do. For the doctors in the medical profession, it probably started with that incessant drive for excellence in pre-med years. We do our best to get into medical school. In medical school, we aim to do well. If we graduated top of the class, even better. We try to boost our CVs to attain a favourable match for residency positions. Then we aim to be the Chief Resident. Get to the most prestigious fellowship program. Set up and maintain the most profitable practice. This is a gross generalization, but i think we all have an innate desire to do better. For one reason or other…

..........

I guess we all have this desire to do better in whatever we do. It boils down to whether we care enough to make that extra effort, to stay that extra hour, to do that extra thing, etc. Similarly, i suppose we can all do better in this whole surgical grand rounds/carnival thing! Click the extra click to submit your posts via the carnival form! Do the extra reading and organizing as a host. Besides, its fun and enriching. Previous hosts can attest!

The next edition will be hosted here by me on July 20th. Submissions are due by midnight Friday, July 18th. Please, remember that SurgeXperiences is a blog carnival about surgical posts. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The deadline for submissions will be midnight on July 4th. Please submit your posts here.

A catalogue of all 24 editions of Season 1 is available. If you would like to host a future edition, please take a look at the schedule and contact Jeffrey. Thank you and have a good fortnight ahead.

American Flag with Purple Heart

I love flag quilts. This one is a larger version of the one on the left side bar (that hangs in my office). It is a basic brick pattern for the strips. This large version has bricks that are 4 in X 8 in (4.5 X 8.5 in with seam allowances). I put a purple heart in the blue field. The strips are 2 in wide (2.5 in with seam allowance) and vary in length. The finished quilt top is 52.5 in X 80.5 in. I will be sending it to a long-arm quilter as part of the Quilts of Valor Foundation program (QOV). The finished quilt will be given to a soldier.

Here is a close view of the heart.
Thanks to all the soldiers and their families for their service to this country, to us all.

Thoughts on this July 4th

A recent post by Bongi and our upcoming July 4th has had me thinking about our Civil War. More accurately the fact that I am very glad that my country is still a united country.

My husband is a Civil War buff. In fact for his 40th birthday, we had a "period" dinner party at Marlsgate Plantation. We all dressed in Civil War period clothing. Some friends (a husband and wife) who did re-enacting helped outfit us all. She helped us women with our hair and jewelry. He brought his banjo and played for us after dinner. It was a wonderful evening. At the end of this post you will find some photos from that night.

My husband's fascination with the Civil War is the guns (the actual machinery, engineering, etc), the battles and strategy. None of that matters to me. The reading I tend to gravitate towards regarding that time period focuses on the home front, the ones left to tend the farms and keep the communities going. It is a period in America's history when many soldiers died, but so did many civilians. Most of the battles and therefore the destruction of homes and farms took place in the south. Both armies were unkind in how they conscripted (took, commandeered, stole)supplies, often taking the last chicken or cow from a family. Yes, the soldiers were starving, but so were the civilians. And often the civilian was killed (or if female, raped and then killed) if they resisted and tried to save that last cow so their children would have milk. Anyway.........

I won't/don't downplay the slavery issue, but another major reason for the war was the struggle over state versus federal rule. Because of the Civil War, it doesn't really matter that California passes a state law legalizing medical marijuana. The federal law supercedes the state law.

Recently this played out again with the Supreme Court ruling that it is not legal to use the death penalty for rape, even of a child. So the federal ruling overturns the state.

Many states struggle with the right (or wish to cancel that right) of legal abortion. The federal law supersedes the states. States try to find way around this. We as a country manage to do this by peaceful (mostly) means these days. New laws are passed and then challenged in court. Much ranting is done in blogs/letters to the newspaper and not by violence (mostly--I know there are still some clinic bombings).

Then there is the struggle of personal versus state/federal rights. In medicine, we are touched by this in struggles with the right to die (think Terri Schiavo).

The struggles continue. The push, the pull. We don't always agree on what is right. I don't think a pharmacist should have the right to NOT sell a drug that that federal/state laws say are legal for me to write a prescription and the patient to take. Still that is a current struggle.

I love that in this country we can disagree with each other, and at the same time still respect others rights to be different from us. I love that we can hold an election and have a change in the White House without riots in the street. I know we Americans are not perfect, but I still love my country and its people.

Happy Birthday America!

A Few Book Recommendations:

Civil War Women, the Civil War seen through women's eyes in stories by Louisa May Alcott and others; edited by Frank McSherry Jr, Charles G Waugh, and Martin Greenberg

Yankee Women, Gender Battles in the Civil War by Elizabeth D Leonard
Women in the Civil War by Mary Elizabeth Massey
The Civil War Diary Quilt: 121 Stories and the Quilt Blocks They Inspired by Rosemary Youngs
Pattern Source:  Period Impression Patterns

This is my husband, Brett Herndon, and I (1996). I made his uniform (the vest and pants you see and a jacket) and shirt. I also made my dress. Thank God the sewing machine had been invented. I did the button holes by hand (to be authentic, as my husband put it).

Buddy and Brenda McCutcheon. They were also into re-enacting. She actually helped "dress" all the ladies and did our hair so that we would look like we were from the 1860's.

Our neighbors and friends, Amy and Bill Gatewood. Don't they look like they just stepped out of the past? 

Letica and Ralph White. We were a "civil" party with both sides represented.

Raymond and Caroline Boyles. Raymond has gone to a few re-enactments with Brett.

Jay and Vickie Morgan. His pants are a little short because they were my husband's. Still I think they both look wonderful.

Cosmetic Blogosphere

Updated 3/2017-- all links removed as many no longer active as it was easier than checking each one.

I received the June edition of the PSP Journal a few days ago. I was pleasantly surprised to see that I was included in the Editor's Message on "Canvassing the Cosmetic Blogosphere". I knew of most of the blogs he mentioned, but had missed a few including theirs (The Aesthetic Blog -- I have added it to my reader and sidebar).

At another end of the spectrum, Suture for a Living (rlbatesmd.blogspot.com) is a very personal kind of blog, written by Ramona Bates, MD, a plastic surgeon in Arkansas. Bates provides well-written accounts of surgeries, her take on the profession in general, and an almost parochial view of the aesthetic arts.

Plasmetic.com describes itself as "obsessively covering the latest procedures in plastic surgery and cosmetic surgery," with a focus on the costs—medical, economical, and otherwise—of such surgery.

The personalized nature of blogging makes for some opinionated and somewhat irreverent sites, such as Plasticized.com, which divides its coverage of aesthetic surgery between hard news and celebrity-oriented "awful surgery" gossip.

In the same vein, blogs by individual physicians can be problematic. A large majority of physicians' blogs are nothing more than "puff pieces" that promote a particular practice.

Exceptions to this rule include Cosmetic Celebrity Surgery (celebritycosmeticsurgery.blogspot.com), which despite its moniker is a serious look at all things cosmetic.

Another good physician's blog, Plastic Surgery 101 (www.plasticsurgery101.blogspot.com), seems to always disseminate the relevant issues of the day.

A large number of plastic surgeon blogs mix commentary with blatant self-promotion—for example, the Plastic Surgery Institute of Los Angeles blog (psicalifornia.blogspot.com).

Thanks for the notice Jeffrey Frentzen (editor of PSP). To see the entire list, check out the article here.