SESSION 2 8:45 10am Procedures You Can Do In Your Office SPEAKER Roger W. Bush, MD, MACP Presenter Disclosure Information The following relationships exist related to this presentation: Roger Bush, MD, MACP, has no financial relationships to disclose. Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Learning Objective In-office Procedures Learn the basic techniques for performing office based procedures such as soft tissue injections, skin biopsies, and incision and drainage Introduction Joint and Soft Tissue Injection Contraindications and risks Informed consent Injectate used: Local anesthetic and corticosteroids used Aseptic technique General aftercare Contraindications to Injection ABSOLUTE Broken skin or cellulitis over injection site, including psoriasis or eczema Evidence of systemic bacteremia or febrile illness Evidence of joint infection Prosthetic joint Hypersensitivity to local anesthetic or the steroid preservative 1
Contraindications to Injection RELATIVE Major clotting disorder (correct before injection) Anticoagulation (consider correcting before injection of shoulder; knee and bursae, probably OK with INR below 1.8) Immunosuppressed (by disease or by drugs) Diabetic (blood sugars may rise for a few days, greater risk of infection) Risks of Joint and Soft Tissue Injection Joint infection (1 in 17-77K if done as an office procedure) Soft-tissue infection (1 in 10K) Bleeding (rare) Acceleration of a septic joint Subcutaneous fat atrophy and skin depigmentation (<1%); higher risk if injection is superficial to the skin surface or in dark-skinned individuals Steroid flair with pain 6-12 hours after injection (2%-5%) Exacerbation of diabetes (rare) Cartilage damage, particularly in weight-bearing joints (rare) McNabb, J.W. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. Philadelphia: Lippincott Williams & Wilkins, 2005. Risks of Joint and Soft Tissue Injection, cont. Tendon rupture (<1%); very uncommon if injecting the joint capsule rather than injecting around or near a specific tendon. Facial flushing (1%-5%) comes on within 24-48 hours and lasts 1-2 days Asymptomatic pericapsular calcifications (43%) Allergic or hypersensitivity reactions ask the patient about history of allergies to local anesthetics Anaphylactic reaction rare, usually will begin 5-10 minutes after exposure, have the patient wait for 20-30 minutes after injection to make sure this does not occur McNabb, J.W. A Practical Guide to Joint & Soft Tissue Injection & Aspiration. Philadelphia: Lippincott Williams & Wilkins, 2005. Informed Consent What does the patient need to know? Risks of procedure Infection, bleeding, allergic reaction, some pain Benefits of procedure Relatively simple office procedure to relieve pain when conservative measures have failed Realistic expectations Might not be efficacious Effect may not be complete until 5-7 days Usual duration of triamcinolone hexacetonide effect is 3 months or less Which Steroid? Short-acting Preparations (soluble) Hydrocortisone (hydrocortisone phosphate) 25, 50 mg/ml Prednisolone 20 mg/ml Long-acting Preparations (Depot or Time Released) Triamcinolone acetonide 40 mg/ml Triamcinolone hexacetonide 20 mg/ml Methylprednisolone acetate 20-40-80 mg/ml Dexamethasone phosphate 20 mg/ml Which Steroid? Combination Preparations (Soluble and Depot Suspension ) Betamethasone sodium phosphate plus Betamethasone acetate 6 mg/ml 2
Which Steroid? Preparation changes based on site: T. Hexacetonide for large joints/ trochanteric bursa T. Acetonide for medium joints T. Acetonide for soft tissues Hydrocortisone for fingers Aseptic Injection Technique Wash and thoroughly dry hands Use alcohol swab to clean the top of the vials before drawing into syringe Change needles after drawing up solution into the syringe Use non-sterile exam gloves sterile gloves only necessary if you plan to re-examine the site after the skin is cleansed Mark the area for injection Aseptic Injection Technique cont. Use povidone-iodine swabs, start at the center of the marked area and swab in a circular fashion. Repeat this step at least once. Allow povidone-iodine to dry Do not touch the skin after marking and cleansing the site When injecting a joint, aspirate to confirm location and to check that the fluid does not look infected General Aftercare Passive ROM after instillation Remind the patient that the immediate effect is the local anesthetic. The steroid effect may take a few days Minimize use for 5-7 days, avoid exacerbating activities Do not submerge injection site in tub or whirlpool for 2 days after injection OK to use ice/otc non-aspirin containing pain relievers do not use heating pad Call if signs of infection/allergic reaction Introduction Skin Biopsy Biopsies may exclude disease or establish a clinical diagnosis Specimen type, area of lesion, depth of biopsy are crucial to diagnosis Clinical data improves histologic interpretation Margins clear does not equate with surgical margins for malignancies Perform Shave Biopsy Cleanse with antiseptic, let dry Raise the lesion with a wheal of injected anesthetic Prop up and stabilize the wheal between the thumb and forefinger. Shave the lesion, using a #15 blade held parallel to the skin and use a smooth sweeping stroke. Place the index finger on top of the lesion to stabilize it and avoid tearing Biopsy depth is determined by the angle of the blade. 3
Perform Punch Biopsy Cleanse with antiseptic, let dry Raise an intradermal wheal of injected anesthetic Select the appropriate size punch Stabilize and stretch skin with the two fingers Position punch 90 degrees to the skin Apply constant downward pressure and a circular motion When the punch clears the full thickness of the skin remove the punch, and apply pressure at the side of the core and pop it up Perform Punch Biopsy Elevate the biopsy core with forceps and free it up with tissue scissors Apply pressure to the wound with gauze Scalp biopsies can bleed profusely. Have someone else present to apply pressure After Incision Care And Skin Drainage Biopsy Incision And and Drainage Dressing clean, dry, and intact for the day May shower day after; no bath Peroxide may be used to clean wound, if needed, otherwise, simple daily changes Local anesthetic lasts 1-2d; mild soreness may ensue subsequently No strenuous activity for rest of biopsy day Discoloration will fade with time Commercial kits typically contain: Items for Universal Precautions Antiseptic Anesthesia items: syringe/ needle, lidocaine Scalpel Irrigation items, angiocath, saline Items for packing and dressing Incision and Drainage Incision and Drainage Make a stab incision at the center of the abscess (where the abscess is pointing ) Extend the incision in both directions allowing adequate drainage and access for packing (1/2 to 3/4 the length of the abscess) Obtain cultures of the interior of the wound Express additional contents with pressure on all sides of the wound Disrupt loculations and sweep the interior with a swab or hemostats 4
Incision and Drainage After Care Irrigate wound using a syringe, saline and a catheter Pack all 4 quadrants of the wound using sterile gauze Cover wound with a dressing An abscess without surrounding cellulitis requires no antibiotics APAP is adequate analgesia, consider re exploration for retained abscess material if pain is not resolved in 48 hours Check wound at 48 hours and repack only if there is continued drainage Coding CPT Code: for Procedures e.g. 20600 E & M Code: only if you have done a visit that required collecting history and performing physical exam Add -25 modifier to E & M for a procedure done in the context of a visit Questions? 5