LA and infection

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Hello all,

I'm a newly qualified podiatrist, just started working 2 months back.

I got a 17 year old healthy female patient with bilateral infected ingrown toenail and areas of hyper-granulation tissue growth. It was the 1st time that she's gotten it due to inappropriate cutting technique. She was put on antibiotics (hasn't completed her dose yet,) and reports that the pain an inflammation has significantly reduced since she started 3 days back.

All what I did was cut and file the offending lateral nail wedges, cleared the sulcus and dressed the area. I did not remove the hypergranulation tissue as the patient could not tolerate the pain and I had to use LA so I prefered to wait until the infection subsides and then manage the patient.

Can LA be used on patients with an infected ingrown toenail and are on AB's or is it a contraindication?

 

Hopefully the hypergranulation tissue will resolve now that the offending nail margins have been reduced and so you may not need to do anything else to it at this stage. Also, once the course of antibiotics have been completed then the infection should have resolved to a greater or lesser extent anyway.

If you need to remove a nail spicule under digital local anaesthsia in the presence of localised soft tissue infection (e.g. along the lateral nail folds), then as long as you inject either side of the proximal phalanx of the toe then the infection does not normally constitute a contraindication to LA.

Just be aware that you should not inject through an area of soft tissue infection for a number of reasons, including: introducing infection into the deeper tissues, increased uptake of LA into systemic circulation (due to the hyperaemia) and altered pharmacokinetics of the LA in the presence of the inflammatory fluid.

Hope this helps.

Footsie 100

 

Thanks Footsie, I appreciate your rapid reply

 

Hi FrozenPod?

I sense that you didn't give an La the first time largely because you were feeling nervous about the responsibility of giving your first LA since you qualified? We've all been there.

Remember that there are only two absolute contraindications to LA: known allergy and patient refusal. Other than that all other contraindications are relative.

Almost invariably any infection is relatively local and is nowhere near the base of the toe where you will inject.

In practical terms, any increase in the rate of entry of LA solution into the venous circulation, at that distance from the heart and the brain and with such relatively small doses of LA, will not significantly increase the risk of a toxic reaction.

The reduced pH of the tissues surrounding any infection means that the LA might be less effective. If it is and the patient tells you they can feel it inject a little more LA solution.

When your patient returns next time, if there is still hypergranulation take it as a sign that there is a spike of nail or irregularity. Don't' start poking down the side of the nail don't waste time, don't think about. Ascertain that there are no absolute contraindications, lay the patient flat and give the LA. After that you and the patient can relax. After you have given your first LA on your own you will begin to relax. Eventually as more and more of your patients survive you will begin to see that it is no big deal.

If you want to make a big deal out it keep your patient sitting up when you give the injection. Then you can go through all of the stuff associated with the patient fainting.

Go for it and good luck.

Bill Donaldson

 

Thank you Bill,

I was a bit apprehensive and reluctant about giving my first LA but it was mainly because of the infection not because I was scared to do it unsupervised. I've given several LA's before and so far all my patients survived

My biggest concern was actually the localised infection because at university we always waited for the infection to resolve and then go ahead with any procedure, so I wasn't sure if it would otherwise work or not.

Anyway, I have a long way to go til i build up my confidence at doing things my own way rather than sticking to what we were told at uni, I guess it's all gonna be trial and error...

Thanks again for your help..wish me luck :drinks

 

I have seen a lot of nails that refused to calm down without surgery, rather than being infected the person was experiencing foreign body reaction (swelling, even pus as the WBC try to eat away at the now boggy nail) from the imbedded spike. I don't typically wait for oral antibiotic or hypertonic soaking to kick in before surgery in most cases.

Sarah