Make Effort to Create Calm Environment During Pediatric Surgery

Many factors contribute to a child's perception of pain, including their age, past experiences, and cognitive development, according to Dr. Brandie J. Metz.

Dr. Metz shared tips and techniques to improve the pediatric dermatologic surgery experience for the doctor, patient, and parent at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Create a calm environment. When talking with a pediatric patient, get down on their level – sit at or below the child's height, and talk directly to him or her. Explain the procedure in a nonthreatening way, but do not leave anything out, and be honest about what is going to happen, noted Dr. Metz, the director of pediatric dermatology at the University of California, Irvine. "There should be no surprises."

Allow the child to have some control over the situation by allowing him or her to choose a radio station to play in the background or a DVD to watch if possible. Engage children in conversation, and let them choose the color for a surgical dressing, said Dr. Metz.

During the procedure, position the parent at the head of the table and strategically drape the surgical field so the parent and child cannot see the actual procedure. Take extra time to cover surgical trays or blood-soaked gauze that could increase the anxiety of the parent or child, she said.

When performing injections, slow infiltration is best; also, consider using a topical anesthetic and 30-gauge needles, she recommended. Dr. Metz prefers buffered, warmed lidocaine, with 1 cc 8.4% sodium bicarbonate/10 cc of 1% lidocaine.

The issue of anesthesia is an important one for pediatric surgery patients. There are no set rules or guidelines about the age at which surgical procedures can be performed with local vs. general anesthesia, Dr. Metz said. She recommended local anesthesia as an option for girls aged 8-9 years and older, and boys aged 9-10 years and older, but it ultimately depends on the maturity of the child. "Consider general anesthesia for larger procedures and in younger children," she said.

Remember that some elective dermatologic surgeries can be postponed until the preadolescent or adolescent years, she noted. Few data exist on the risks of general anesthesia for young children, but the risk appears highest during the first month of life, and complications are more common in emergency procedures, compared with elective procedures, she said. According to the American Society of Anesthesiologists, the risk of a complication from anesthesia in a healthy child ranges from 1:20,000 to 1:80,000 or less.

When performing excisions in children, 2-octyl cyanoacrylate (Dermabond) is an option, Dr. Metz reported. Several studies have shown the advantage of this skin glue over sutures or staples. However, studies of Dermabond have not controlled for confounding factors including excision location, patient ethnicity, and previous keloids.

Advantages of 2-octyl cyanoacrylate include speed of use, avoidance of a follow-up visit to remove sutures, and ability to withstand getting wet. Also, the antibacterial properties of the product might reduce the risk of post-surgery infections, Dr. Metz noted.

Disadvantages of 2-octyl cyanoacrylate include cost ($30/vial), the inability to place the product in the wound, and the lack of strength for use in high-tension areas, she reported.

Dr. Metz also shared tips for the staged excision of congenital nevi in children, which is an option when tissue expansion is not advisable and primary closure is not possible. Her recommendations for a successful excision include:

• Take as much of the lesion as possible during the first stage.

• Don't wait too long between stages. The timing should be about 6 to 8 weeks; long enough for the tension on the skin to relax, but not long enough for the scar to spread.

• Consider absorbable sutures to avoid the need for a suture removal visit.

Dr. Metz disclosed having no conflicts of interest. SDEF and this news organization are owned by Elsevier.

Many factors contribute to a child's perception of pain, including their age, past experiences, and cognitive development, according to Dr. Brandie J. Metz.

Dr. Metz shared tips and techniques to improve the pediatric dermatologic surgery experience for the doctor, patient, and parent at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Create a calm environment. When talking with a pediatric patient, get down on their level – sit at or below the child's height, and talk directly to him or her. Explain the procedure in a nonthreatening way, but do not leave anything out, and be honest about what is going to happen, noted Dr. Metz, the director of pediatric dermatology at the University of California, Irvine. "There should be no surprises."

Allow the child to have some control over the situation by allowing him or her to choose a radio station to play in the background or a DVD to watch if possible. Engage children in conversation, and let them choose the color for a surgical dressing, said Dr. Metz.

During the procedure, position the parent at the head of the table and strategically drape the surgical field so the parent and child cannot see the actual procedure. Take extra time to cover surgical trays or blood-soaked gauze that could increase the anxiety of the parent or child, she said.

When performing injections, slow infiltration is best; also, consider using a topical anesthetic and 30-gauge needles, she recommended. Dr. Metz prefers buffered, warmed lidocaine, with 1 cc 8.4% sodium bicarbonate/10 cc of 1% lidocaine.

The issue of anesthesia is an important one for pediatric surgery patients. There are no set rules or guidelines about the age at which surgical procedures can be performed with local vs. general anesthesia, Dr. Metz said. She recommended local anesthesia as an option for girls aged 8-9 years and older, and boys aged 9-10 years and older, but it ultimately depends on the maturity of the child. "Consider general anesthesia for larger procedures and in younger children," she said.

Remember that some elective dermatologic surgeries can be postponed until the preadolescent or adolescent years, she noted. Few data exist on the risks of general anesthesia for young children, but the risk appears highest during the first month of life, and complications are more common in emergency procedures, compared with elective procedures, she said. According to the American Society of Anesthesiologists, the risk of a complication from anesthesia in a healthy child ranges from 1:20,000 to 1:80,000 or less.

When performing excisions in children, 2-octyl cyanoacrylate (Dermabond) is an option, Dr. Metz reported. Several studies have shown the advantage of this skin glue over sutures or staples. However, studies of Dermabond have not controlled for confounding factors including excision location, patient ethnicity, and previous keloids.

Advantages of 2-octyl cyanoacrylate include speed of use, avoidance of a follow-up visit to remove sutures, and ability to withstand getting wet. Also, the antibacterial properties of the product might reduce the risk of post-surgery infections, Dr. Metz noted.

Disadvantages of 2-octyl cyanoacrylate include cost ($30/vial), the inability to place the product in the wound, and the lack of strength for use in high-tension areas, she reported.

Dr. Metz also shared tips for the staged excision of congenital nevi in children, which is an option when tissue expansion is not advisable and primary closure is not possible. Her recommendations for a successful excision include:

• Take as much of the lesion as possible during the first stage.

• Don't wait too long between stages. The timing should be about 6 to 8 weeks; long enough for the tension on the skin to relax, but not long enough for the scar to spread.

• Consider absorbable sutures to avoid the need for a suture removal visit.

Dr. Metz disclosed having no conflicts of interest. SDEF and this news organization are owned by Elsevier.

Many factors contribute to a child's perception of pain, including their age, past experiences, and cognitive development, according to Dr. Brandie J. Metz.

Dr. Metz shared tips and techniques to improve the pediatric dermatologic surgery experience for the doctor, patient, and parent at the Las Vegas Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Create a calm environment. When talking with a pediatric patient, get down on their level – sit at or below the child's height, and talk directly to him or her. Explain the procedure in a nonthreatening way, but do not leave anything out, and be honest about what is going to happen, noted Dr. Metz, the director of pediatric dermatology at the University of California, Irvine. "There should be no surprises."

Allow the child to have some control over the situation by allowing him or her to choose a radio station to play in the background or a DVD to watch if possible. Engage children in conversation, and let them choose the color for a surgical dressing, said Dr. Metz.

During the procedure, position the parent at the head of the table and strategically drape the surgical field so the parent and child cannot see the actual procedure. Take extra time to cover surgical trays or blood-soaked gauze that could increase the anxiety of the parent or child, she said.

When performing injections, slow infiltration is best; also, consider using a topical anesthetic and 30-gauge needles, she recommended. Dr. Metz prefers buffered, warmed lidocaine, with 1 cc 8.4% sodium bicarbonate/10 cc of 1% lidocaine.

The issue of anesthesia is an important one for pediatric surgery patients. There are no set rules or guidelines about the age at which surgical procedures can be performed with local vs. general anesthesia, Dr. Metz said. She recommended local anesthesia as an option for girls aged 8-9 years and older, and boys aged 9-10 years and older, but it ultimately depends on the maturity of the child. "Consider general anesthesia for larger procedures and in younger children," she said.

Remember that some elective dermatologic surgeries can be postponed until the preadolescent or adolescent years, she noted. Few data exist on the risks of general anesthesia for young children, but the risk appears highest during the first month of life, and complications are more common in emergency procedures, compared with elective procedures, she said. According to the American Society of Anesthesiologists, the risk of a complication from anesthesia in a healthy child ranges from 1:20,000 to 1:80,000 or less.

When performing excisions in children, 2-octyl cyanoacrylate (Dermabond) is an option, Dr. Metz reported. Several studies have shown the advantage of this skin glue over sutures or staples. However, studies of Dermabond have not controlled for confounding factors including excision location, patient ethnicity, and previous keloids.

Advantages of 2-octyl cyanoacrylate include speed of use, avoidance of a follow-up visit to remove sutures, and ability to withstand getting wet. Also, the antibacterial properties of the product might reduce the risk of post-surgery infections, Dr. Metz noted.

Disadvantages of 2-octyl cyanoacrylate include cost ($30/vial), the inability to place the product in the wound, and the lack of strength for use in high-tension areas, she reported.

Dr. Metz also shared tips for the staged excision of congenital nevi in children, which is an option when tissue expansion is not advisable and primary closure is not possible. Her recommendations for a successful excision include:

• Take as much of the lesion as possible during the first stage.

• Don't wait too long between stages. The timing should be about 6 to 8 weeks; long enough for the tension on the skin to relax, but not long enough for the scar to spread.

• Consider absorbable sutures to avoid the need for a suture removal visit.

Dr. Metz disclosed having no conflicts of interest. SDEF and this news organization are owned by Elsevier.