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Do people have a preference for Xylocaine/Lignocaine strength i.e. 1 or 2%? What are the reasons for using 2% & I guess I'm assuming it just provides a longer lasting effect?????
I prefer 2% I feel it improves my chance of getting it anaethetised, so long as I do my calculations and don't overdo the dose, which is pretty hard to do.
Donna it might be different in Qld, but in Victoria, it is the LAs Ligoncaine and Prilocaine that are allowed to be used with no restriction on strength. And personally I use 2% for the same reason as moe, it tends to work quicker, but both 1 and 2% will have about the same duration of action
__________________ Stephen Tucker Eastern Health
Podiatry Manager
Donna it might be different in Qld, but in Victoria, it is the LAs Ligoncaine and Prilocaine that are allowed to be used with no restriction on strength. And personally I use 2% for the same reason as moe, it tends to work quicker, but both 1 and 2% will have about the same duration of action
Thanks for that Stephen, interesting stuff... I might be thinking back in the stone ages, because when I was at uni (1999 - 2002) it was only 1% that was approved for use by pods... Things could have changed...
I am a QLD pod, moving to NSW. I am excited about being able to use 2%! However, was just wondering what the maximum dosage is?
At the moment I use this:
Maximum dose permited 200mg (20ml of 1% lignocaine)
Children - 3mg per kg body weight
SO, is it just half? 10ml maximum dose of 2%?
The maximum dose for Lignocaine without adrenaline is quoted at 4mg/kg, so for a 70kg person this would be 280mg (28ml of 1% and 14ml of 2%) but this article http://bja.oxfordjournals.org/cgi/reprint/74/6/704.pdf found that rates as high as 18mg/kg to be non toxic (thats 125ml of 1%)
further I found this
Quote:
Most nerve blocks are more dependent on volume of drug injected than the total dose. Therefore if more volume is needed it is better dilute the local anaesthetic with 0.9% saline than to add more local anaesthetic and increase the dose unnecessarily.
Hi all,
I've emailed a MSD calculater program thingmy wotsit to Craig (da boss man). Having touble opening the program but he said he will try. If he's successful he said may post on here. Very useful tool as it calculates MSDs as single dose or multiples of different La agents.
If anyone wants to try opening it via email for themselves please PM me & I will forward the file.
Regards,
__________________
:)
twirly
Mandy Brooks
Brooks Podiatry
S64 0DE
Suffering a fondness for odd things.
99% of the time, a 1% solution of lignocaine will be appropriate for uncomplicated cutaneous surgery in podiatry.
2% is indicated in the presence of minor sepsis and chronic erythema (ie classic acute IGTN) where tissue pH is altered, as 1% takes forever to take effect even in large doses. Typically a 2% dose will be more uncomfortable for the patient during administration.
However, literature supports the use of bupivacaine (eg 0.5%) for procedures such as nail matrixectomy because of the additional benefit of longer duration of action and the resultant preemptive analgesia that occurs.
Queensland had Drugs & Poisons Regulations changed last year to allow podiatrists to use lignocaine up to 2% plain, as well as bupivacaine, levobupivacaine and prilocaine. An approved update course from the Board is pending, but should not be far away. Almost every State is different, so some national uniformity would be nice...:(
LL
__________________
***************************************** Remember, it's just a foot.
99% of the time, a 1% solution of lignocaine will be appropriate for uncomplicated cutaneous surgery in podiatry.
2% is indicated in the presence of minor sepsis and chronic erythema (ie classic acute IGTN) where tissue pH is altered, as 1% takes forever to take effect even in large doses. Typically a 2% dose will be more uncomfortable for the patient during administration.
However, literature supports the use of bupivacaine (eg 0.5%) for procedures such as nail matrixectomy because of the additional benefit of longer duration of action and the resultant preemptive analgesia that occurs.
Queensland had Drugs & Poisons Regulations changed last year to allow podiatrists to use lignocaine up to 2% plain, as well as bupivacaine, levobupivacaine and prilocaine. An approved update course from the Board is pending, but should not be far away. Almost every State is different, so some national uniformity would be nice...:(
LL
Hello there LL and others.
I am a new graduate who will be working in QLD next year, I have been studying at CSU in Albury. We were taught that we could use either prilocaine, lignocaine, mepivicaine, or bupivicaine. Mainly we use 2% mepivicaine.
Anyways my question is, when working in QLD next year, will I be able to use bupivacaine? You stated how an approved update course is being planned, would I still have to do this?
And is bupivacaine or lignocaine the only LAs I could use in QLD. I could not use mepivacaine?
And is bupivacaine or lignocaine the only LAs I could use in QLD. I could not use mepivacaine?
Dean
The drugs approved for general podiatry registrants in Queensland, as of 2006 (but pending Board approved upskilling) are:
(i) bupivacaine of a strength of 0.5% or less;
(ii) levobupivacaine of a strength of 0.5% or less;
(iii) lignocaine of a strength of 2% or less;
(iv) prilocaine of a strength of 2% or less;
These are all plain solutions, and general podiatrists may not use these in combination with adrenaline. However, preloaded adrenaline may be used for emergency anaphylaxis care.
Other provisions exist for 'surgical podiatrists', including the use of a range of S4/ S8 medications, and the use of adrenaline.
I would recommend you forward a letter from your course co-ordinator when you apply to be registered in Queensland outlining which anaesthetics you are trained in, however you will not be able to use mepivacaine.
Because of the variation in local anaesthetic training across the country, I think it is important for all of the course podiatry co-ordinators to get together and agree on a comprehensive list of ALL local anaesthetics (regardless of whether that particular State endorses so), so that all new podiatrists are appropritately trained across the full range of choices. This would then facilitate mutual recognition of registrants from now on.
LL
__________________
***************************************** Remember, it's just a foot.
The drugs approved for general podiatry registrants in Queensland, as of 2006 (but pending Board approved upskilling) are:
(i) bupivacaine of a strength of 0.5% or less;
(ii) levobupivacaine of a strength of 0.5% or less;
(iii) lignocaine of a strength of 2% or less;
(iv) prilocaine of a strength of 2% or less;
These are all plain solutions, and general podiatrists may not use these in combination with adrenaline. However, preloaded adrenaline may be used for emergency anaphylaxis care.
Other provisions exist for 'surgical podiatrists', including the use of a range of S4/ S8 medications, and the use of adrenaline.
I would recommend you forward a letter from your course co-ordinator when you apply to be registered in Queensland outlining which anaesthetics you are trained in, however you will not be able to use mepivacaine.
Because of the variation in local anaesthetic training across the country, I think it is important for all of the course podiatry co-ordinators to get together and agree on a comprehensive list of ALL local anaesthetics (regardless of whether that particular State endorses so), so that all new podiatrists are appropritately trained across the full range of choices. This would then facilitate mutual recognition of registrants from now on.
LL
Thankyou LL for your informed reply. As you said about the LAs being approved for registered QLD podiatrists use, does that mean next year, if the board approved the letter written by our course co-ordinator, I will be allowed to use the full range of LAs?
The difference between 1% and 2% lidocaine is the concentration of mg/ml.1% is 10mg/ml and 2% is 20mg/ml,double the concentration.Epinephrine allows increased dosage as the epi delays absorption and causes a vasoconstrictor effect.As I recall the maximum dose of xylocaine was 30ml of plain and 50ml xylocaine with epinephrine.Prudence and good judgement allow xylocaine with epi in the digits. I have never heard that 2% was used for minor sepsis.The difference in concentration allows longer duration of action.Any matixectomy could be performed with 1% or 2%.Personally,I always use 2% frequntly and regularly with epi.
I am curious...why are only certain local anesthetics permitted by certain practitioners?What are the educational differences between a surgical and non-surgical podiatrist?Does a surgical podiatrist work in a hospital?Do they have open and complete medication/ prescription writing ability?ie.narcotics,diuretics,antibiotics,anti-inflammatories,etc?Apparently podiatry is practiced differently here in the USA. dlbdpm
does that mean next year, if the board approved the letter written by our course co-ordinator, I will be allowed to use the full range of LAs?
I would expect so, but that would be up to the Board to determine and advise to you. They could ask you to complete an update course if they weren't satisfied, but you would need to contact them to find out.
LL
__________________
***************************************** Remember, it's just a foot.
I am curious...why are only certain local anesthetics permitted by certain practitioners?What are the educational differences between a surgical and non-surgical podiatrist?Does a surgical podiatrist work in a hospital?Do they have open and complete medication/ prescription writing ability?ie.narcotics,diuretics,antibiotics,anti-inflammatories,etc?
Dennis
Podiatry in most Commonwealth countries, including Australia, is very different to the USA.
In a nutshell, most podiatrists complete a 4 year undergradaute degree, and are typically only licenced to use a very narrow range of drugs (depending on the country/state jursidiction). They typically will only perform cutaneous surgical procedures.
A small percentage of podiatrists undertake podiatric surgery training to perform osseous foot and ankle procedures, and again, depending on the jurisdiction - they can prescribe a limited formulary complementary to surgical practice.
Don't ask why
LL
__________________
***************************************** Remember, it's just a foot.
Last edited by Admin : 18th November 2007 at 09:02 PM.
Reason: fixed quote
However, literature supports the use of bupivacaine (eg 0.5%) for procedures such as nail matrixectomy because of the additional benefit of longer duration of action and the resultant preemptive analgesia that occurs.
British Journal of Surgery. 1994 Mar;81(3):425-6. Local anaesthetic agents in surgery for ingrown toenail. Connolly AA, Meyer LC, Tate JJ.
Abstract:
To determine the most effective local anaesthetic for ingrown toenail surgery, 100 procedures were performed after patients had been randomized to receive lignocaine, bupivacaine or hyaluronidase and bupivacaine. The effect of each anaesthetic was monitored and 80 patients returned a follow-up questionnaire. There was no significant difference in the time for the local anaesthetic to take effect, or in the pain caused by its injection or the procedure. Significant differences were found between treatments with respect to pain at discharge and significantly fewer patients who received bupivacaine experienced pain 24 h after surgery (P = 0.002).
Quote from conclusion: “Bupivacaine provides quick-acting and long-lasting anaesthesia and should be used in preference to lignocaine”
LL
__________________
***************************************** Remember, it's just a foot.
Hi everyone:
Just speaking from experience and having anesthetized literally tens of thousands of toes/feet/ankles.... I "almost" always use 2% plain lidocaine for local or regional blocks. I rarely need to use more than 10cc and cannot recall ever having any problems with toxic reactions.
For normal digital blocks for a hallux, 2-3 cc of 2% is more than adequate.
3cc of 2% plain is enough for a Post. tibial block.
One should easily be able to block an entire foot (PT, AT, Sup. peroneals, sural) with 10 ccs.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
British Journal of Surgery. 1994 Mar;81(3):425-6. Local anaesthetic agents in surgery for ingrown toenail. Connolly AA, Meyer LC, Tate JJ.
LL
Thanks LL. This info has made me switch from Lido to Bupiv. My initial rational for Lido was that it seemingly acted quicker and stings less. However the ends justify the means.
For normal digital blocks for a hallux, 2-3 cc of 2% is more than adequate.
3cc of 2% plain is enough for a Post. tibial block.
One should easily be able to block an entire foot (PT, AT, Sup. peroneals, sural) with 10 ccs.
Steve
Thanks Steve. When doing a digital block, is there any literature / material / source that best describes the exact proximity of the nerve to the bone and surrounding tissues? ie, once the needle penetrates this skin, what is the best way of knowing that we are injecting in exactly the right place? or how deep the needle should be? and prevent the need to use unneccesary amounts of LA to achieve anaesthesia?
Thanks for any advice
what is the best way of knowing that we are injecting in exactly the right place? or how deep the needle should be?
Berms
You cannot know exactly in a lot of instances, but many of the nerves are easily palpated eg superficial peroneal, PT etc. so you can be reasonably precise.
Otherwise, revise your anatomy, do a dissection course, and hang out with a podiatric surgeon who does a lot of these injections. Anatomical variations are always possible, but are rare.
Good surface anatomy knowledge is essential to minimising the dose required overall.
LL
__________________
***************************************** Remember, it's just a foot.
You cannot know exactly in a lot of instances, but many of the nerves are easily palpated eg superficial peroneal, PT etc. so you can be reasonably precise.
Otherwise, revise your anatomy, do a dissection course, and hang out with a podiatric surgeon who does a lot of these injections. Anatomical variations are always possible, but are rare.
Good surface anatomy knowledge is essential to minimising the dose required overall.
LL
Thanks LL. Its mainly the digital ring blocks I was referring to... but the dissection course and spending some time with a surgeon sounds like a good idea.
Thanks LL. Its mainly the digital ring blocks I was referring to... but the dissection course and spending some time with a surgeon sounds like a good idea.
The technique I was taught by my surgical supervisor for digital block is as follows:
1. Use a 25g, 1.5 inch needle - it is flexible and 'bends' around the curves of the rather cylindrical anatomy of a toe.
2. Inject dorsally (medial or lateral) at the level of the metaphysis of the proximal phalanx, and raise a small weal to numb the skin. Make sure the very tip of the needle (apex) is the first point of entry (less surface area = less discomfort).
3. The dorsal, and by that matter the plantar, digital nerves are reasonably superficial but not palpable. Advance the needle about 5mm max. and deposit 1/2 a cc of solution around the nerve by gently bending the needle from side to side, such that the tip delivers solution to either side of the nerve bundle.
4. Advance the tip towards the plantar surface to approximately 5mm short of the plantar skin. Deposit a similar volume in the same manner as dorsally to the plantar digital nerve branch, ensuring that skin blanching is apparent to ensure correct position.
5. Repeat for the other side of the toe.
Note that this is not a "ring" block, but a block of the most likely location of the nerves, so that local is not being splashed all around the toe into tissue that do not relate to the digital nerves themselves. This = less volume of local, and becomes more important with a greater number of blocks (eg doing several toes at once).
Try not to ever use more than 2 points of entry. More skin penetration = more discomfort post-procedure - even though they are small puncture wounds.
Just sharing what I was taught...
LL
__________________
***************************************** Remember, it's just a foot.
Hi Berms:
When performing a digital block you want to be in the fascia plane under the sub-Q layer. There will be much less resistance, less pain and of course, this is where the nerves are. I guess this "feel" just comes with experience. There shouldn't be any resistance when injecting or moving the needle. If there is, you are most likely too superficial.
I normally use a little cold spray and inject from dorsal to plantar as proximal as you can get on the digit itself- one medial and one lateral. It works every time. I inject the lateral side first, since this is always less sensitive and it puts the patients at ease when they realize that the injection is relatively painless. Patients will feel the medial injection more.
I use a 3 cc syringe with a 25G 1 & 1/4 inch needle. I have found that this combination, when injected slowly, is less painful than using a 27G. I feel the solution comes out too fast with the smaller guage needle and is more painful.
Hope this helps.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Hi all
This question may seem dumb, but what anesthesia do you prefer Lidocaine or mepivacaine?
Currently i am using mepivacaine and feel comfortable using it, but many of my colleagues say that i should use lidocaine 1%.
Am i wrong?
What is your opinion?
Regards
André
Local Anaesthetic strength
Or have I missed out on something?
but he said he will try. If he's successful he said may post on here. Very useful tool as it calculates MSDs as single dose or multiples of different La agents. 
Linear Mode
