Can You Help?
(continued)
Anesthesiology
CYH1201
QUESTION: The NEW doctor (not the one I mentioned below) who will do my MOHS* asked me to ask if you would please send him a copy of whatever you send to me in response to my question below.
Joan Headley suggested I ask for your wisdom about this: The lab report says I have a basal cell carcinoma on my face and the doctor has scheduled me for a MOHS procedure. I have post-polio syndrome with a great deal of upper-body paralysis and weakness – arms, shoulders, neck, jaws. I use a volume ventilator (PLV-100) at night. My right side is considerably weaker than my left, and this lesion is on my right cheek near my nose about 3/4 inch under my eye.
The doctor uses lidocaine for this, and when he did the biopsy I asked him to use half the amount he normally would. He said he used one (I don't know how this is measured – but one of whatever that would be) – he thought that was a small amount. The lesion is 6 (? again I don't know about these measurements, but it's six whatevers, about the diameter of a pencil eraser). I felt the affects of the lidocaine even after four hours, and the muscles in the right side of my throat always become affected at such times. I feel as if I never truly regain the function I had before I'm given these locals. Now I'm concerned because this doctor indicates he will re-inject me between each swipe he takes during the procedure, and these will be an hour and a half apart. He may only need to do two of them, but it could be three or more, he says.
Is there something safer for me than lidocaine? I saw in the Handbook that bupivacane could cause less nerve damage in certain cases. Should I suggest that? Is it possible that the anesthesia risk is greater than the cancer risk?
I worry about losing more swallowing or speaking or breathing ability.
I'm in Omaha. This doctor has never seen someone with my limitations before. I'm willing to talk with him – I just need to know what to say.
Thanks for any suggestions you have for me. Nancy Baldwin Carter, Posted July 2009
*MOHS micrographic surgery is a procedure often used to remove skin cancer. The surgeon takes a layer of tissue and submits it for immediate examination while the patient waits for results. If cancer is still present, the surgeon takes another layer of tissue for examination and repeats this until there is no remaining cancerous tissue. The surgery may be completed in only two or three stages, but since there is no way to predict how extensive the cancer is ahead of time, the procedure could take the entire day. MOHS is usually done in the surgeon's office, and is performed with local anesthesia. It is said to be the skin cancer treatment with the highest cure rate.
RESPONSE: This is an interesting, difficult-to-answer, question, because there is just NO information to work with. First, the issue of whether this surgery is worth the risk for Ms Carter: In the absence of any information on post-polio in this surgical situation, we (the doctors) can’t help very much except to say that basal cell carcinoma can easily grow and invade nearby structures and become a very ugly, life-threatening problem. It’s a lot better to have this small surgery now than to leave the basal cell there, to grow and invade. MOHS surgery is a well-established technique, with excellent results.
Second, what kind of anesthesia is best? Lidocaine is the standard, in my experience, for local anesthesia by dermatologists. The concentration and the addition of epinephrine (to vasoconstrict the nearby blood vessels and decrease bleeding while the surgeon works and also to prolong the duration of the numbness) are the variables. (Added epinephrine was why Ms. Carter still felt numb 4 hrs after an injection, most likely.) There is no information about the effects of local anesthetics in polio-damaged peripheral nerves; normal nerves and muscles in rats were not damaged by lower concentrations of lidocaine (1%) but were by 4% lidocaine. Added epinephrine was not studied. (Ms Carter: the statement that bupivicaine could cause less nerve damage relates only to major nerve blocks, epidurals and spinals; that data comes from normal human studies and has led to lidocaine hardly ever being used in those situations anymore, for anyone. It has slow onset and very long duration and really isn’t suitable in this situation)
Third, what about anesthetizing this particular area of the face? The area would be innervated by the infra-orbital nerve, a branch of V2 (trigeminal nerve). There should be few motor fibers in this area, below the eye. If the local anesthetic dissected backwards, through the infraorbital foramen, it’s possible that some motor fibers to tongue, throat, etc, could be blocked. Use of infiltration (not an infra-orbital nerve block) only, small amounts of local anesthetic and a head-up position should help prevent that possibility.
Finally, what do I suggest? In addition to Ms Carter’s safety (pain relief, no long-term effects), the surgeon’s needs have to be considered, so that all of the lesion is removed as quickly as possible. He/she needs a dry field (no XS bleeding), which means added epinephrine, and techniques he/she is used to. The lowest concentration of lidocaine and the lowest concentration of epi he/she thinks suitable would be helpful, and the head-up position will decrease bleeding and also help with ventilation. In relation to ventilation, I’m concerned about the 1½ hr gaps between procedures and wonder if there is any way to shorten that (do the procedure closer to the person doing the pathology)? Another aspect is whether she would be in the supine position for long periods; she may not be able to tolerate this ventilation-wise. (Dr. Watts: She probably uses her diaphragm only for ventilation; in supine position, abdominal contents move up and interfere with diaphragmatic excursion. They usually tolerate head-up position much better – diaphragm excursion is better.) I’d like to suggest a check of her Vital Capacity in upright and supine positions before making a decision on how to proceed. These can be easily done at her pulmonologist’s. If there is severe compromise of VC in the supine position, this procedure might be better done with the patient monitored by an anesthesiologist in a hospital. Dr. Watts: She has significant respiratory compromise, and we need to carefully consider how to proceed. She is a very special contributor to the post-polio community, as a very fine writer, and has been a great communicator at the national level. We want to take the very best care of her!
Please keep me informed of the VC results, and I’ll be glad to give further suggestions. Again, there is no real information to work from, and I’m postulating on what is available and from knowledge of ventilation issues in post-polio patients.
–Selma Calmes, MD, Retired, Anesthesiology Department, Olive View/UCLA Medical Center, Sylmar, California
