Topic review Skin biopsy in children How to calm pediatric patients for medical procedures Walairat...
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Transcript of Topic review Skin biopsy in children How to calm pediatric patients for medical procedures Walairat...
Topic reviewSkin biopsy in childrenHow to calm pediatric
patientsfor medical procedures
Walairat Sitthikornsawat Advisor: Voraphol, MD. Skin biopsy in
children Skin biopsy The most common surgical procedure performed
by the dermatologist Types of biopsy procedures include Punch
biopsy Superficial shave biopsy Incisional biopsy Excisional biopsy
Punch biopsy Punch biopsy Commonly used for diagnostic
purposes
Diagnostic: 3-4 mm in diameter Small lesion: mm larger than the
lesions Never punch anything over 6 mm in a cosmetically important
area Place a dot on the skin with a skin marker prior to injecting
local anesthetic Suspected pigmented lesion, punch biopsies are not
recommended dysplastic mevus, spitz nevus, MM invasion excisional
Bx w narrow margin, punch>4mm Punch biopsy Stretch the skin at
90 degree to the skin surface tension lines before applying the
punch to the skin surface If the punched skin retracts into the
wound, retrieve it by spearing the tissue with a 30-gauge needle
rather than a forceps to reduce crush artifact If bleeding occurs
from the fat that does not stop with pressure, soak a cotton-tipped
applicator in aluminium chloride and use this to apply pressure in
the hole Close with suture or heal by secondary intension This
produces a mini-elliptical excision that will close more elegantly
in the skin surface tension lines so that you can find the area you
have anesthetized and intend to punch after you have looked away.
Do not shave pigmented lesions
If the pathology is deep, remove the core of tissue then go back
into the hole and punch a second time in the base of the wound to
ensure you have an adequate specimen. If tissue is required for
immunofluorescence in a cosmetically important area, do a single
punch and bisect the tissue Do not shave pigmented lesions Place
the biopsy specimen upside-down, spear the dermis and epidermis
with 30-gauge needle to prevent slipping and cut with an 11 blade
holding the blade as parallel as possible to the hard surface
before slicing the specimen in two halves If a 6 or 8 mm punch is
used, placing a suture at each tip before the middle suture will
reduce the dog-ear Tips for punch biopsy in children
Dont push the full barrel of the punch into the tissue. With the
exception of biopsies done to look for pathology in the fat or deep
vessels This can be accomplished with the gentle pressure and more
twisting of the barrel of the punch deep vessel injury or injury to
underlying structure Tips for punch biopsy in children
Never do a punch biopsy of the dorsal hand of a moving child.
Pushing too hard or unexpected movement will injure underlying
tendons, blood vessels and nerves structure After the scoring the
skin, lower the punch handle so it os parallel to the skin. This
elevates the specimen out of the wound and reduces the need to go
fishing in the tissue for the punch specimen Tips for punch biopsy
in children
Do the injection first, then come back for the procedure. The child
can usually sit on the mothers lap for the injection of the
anesthetic and will be less traumatized when you return and can
tell them that nothing to hurt Shave biopsy razor blade
semicircular shape 15bard- parker blade handle fine tooth forcep
counteract flat lesion dermis wheal 30 90 biopsy blade no 15
counteract shave macular lesion Shave biopsy Rapid removal of
benign exophytic lesions
Useful in children presenting a large number of lesion Rapid,
inexpensive treatment with minimal scarring or pain and rapid
healing Application of aluminium chloride for hemostasis Complete
re-epithelialization occur within 7-10 days Molluscum, VV,
achrocordon lesion Incisional biopsy Incisional biopsy Histologic
confirmation of a clinical diagnosis
Diagnosis of inflammatory and infiltrative disorders ofthe dermis,
or subcutaneous tissue Method to diagnose panniculitis and other
disorders of adipose tissue Rule out malignancy in large pigmented
lesion Excisional biopsy Excisional biopsy Excisional biopsy
Complete removal of lesions
Planning excision within or parallel to natural body folds,
creases, or relaxed skin tension lines Exaggerated facial
expressions squeeze-and-pinch method Langers lines Benign lesions
can be removed with narrow margin 0.5 1 mm. Length of the incision
is determined by the width and is usually in ratio of 3:1 lesion
shave or punch .. line langer lineintrinsic effect of UV aging
muscular activity incision line line fusiform excision, yield the
most satisfactory cosmetic and functional result Langers line
fusiform by blade no 15 skin hook or fine tooth forcep soft tissue
undermine dead space dead spacehematoma or seroma formation scar
Excisional biopsy The fusiform specimen is excised using a no. 15
Bard-Parker blade, which is held perpendicular to the skin The
ellipse is freed from attached deeper structures using a scalpel or
scissors Undermining is performed with blunt-tipped dissection
scissors Recheck for any residual bleeding Underminehooksoft tissue
dead space lesion hematoma or seroma formationepidermal suture
cross-hatched scarring Excisional biopsy Wound closure
Dead space: absorbable suture e.g. Purse-string type
Surface:interrupted suture, vertical mattress, horizontal matress,
running technique etc. In general, sutures used to close excisions
performed are left Trunk: days Extremities: 7-10 days Face 5-7 days
dead space lesion hematoma or seroma formationepidermal suture
cross-hatched scarring Tips for excisional biopsy in children
Pediatric patients are usually much more active than adults. The
more activity in the postoperative period, the greater the risk of
dehiscence and the more likely the scar will spread Running
subcuticular sutures reduce these risks monofilament suture made
from polypropylene or polybustester 1 cosmetic result with no
cross-hatching scar , 2tissue reactivity ,3 or surface trauma Tips
for excisional biopsy in children
To minimize the possibility of dehiscence of the wound by
reducingtension on the surface Once the suture has been removed, it
is worthwhile to place supportive adhesive strips in thesurface for
an additional week How to calm pediatric patients for medical
procedures Factors that may influence childrens pain
perception
1. Age 2. Cognitive development 3. Fear 4. Anxiety 5. Personal
history e.g. prior painful procedures 6. Family support/interaction
7. office environment/staff interaction Pre-operative
techniques
1. The office should be child-centered 2. Physician should be at or
below patient level 3. Talk to patients and involve them. Never
have the child leave the room 4. Explain the impending procedure
carefully and throughly. There should be no surprises 5. Do not lie
6. Avoid hurtful words 7. Set boundaries and rules doctor patient
relationshipout of control Intra-operative techniques for painful
procedures
Children Parents Surgical field management Local anesthetics
Techniques to decrease the pain of injection Pharmacologic agents
Intra-operative techniques for painful procedures
Children Parents Surgical field management Local anesthetics
Techniques to decrease the pain of injection Pharmacologic agents
Children Talk to the patient as much as is comfortable
Allow the patient to select the color of suture or postoperative
dressing Variety of distraction technique can be employed Blowing
the bubble Conversation about interesting issues Ipod, MP3 or video
games Music distraction reduce perioperative anxiety, injection
pain and procedural pain Should not spend excessive time discussing
personal issues with nurses or assistant distraction technique
distract Conversation about interesting issues: musics, movies,
books, video games ,,, Parents Parents distract the child with
books or activities
Should not use parents as assistant and to restrain the young child
The parents who wish to observe the procedure should be allowed
Restrain, assist surgeon Surgical field management
Surgical site should be placed out of childs views Surgical trays
should be covered with drapes prior tothe start of the procedure
Blood-soaked material should be hidden from view at the end of
procedure Intra-operative techniques for painful procedures
Children Parents Surgical field management Local anesthetics
Techniques to decrease the pain of injection Pharmacologic agents
Local anesthetics Local anesthetics inhibit the voltage-gated
sodium channels in the neuronal cell membrane Can be combined with
vasoconstrictor such as adrenaline Classification of local
anethetics 1.Amide-based anesthetics 2. Ester-based anesthetics
sensory n. conductionvoltage gated Na channel Na action potential
threshold action potential Can be combined with vasoconstrictor, to
provide improved hemostasis, reduce systemic toxicity and increase
the duration of anesthesia Duration of action [hr]
Local anestthetics Onset [min] Duration of action [hr] Maximum dose
With adrenaline With out Amides [Others: prolocaine, mepivacaine,
levobupivacaine, ropivacaine] Lidocaine 2 1-6.5 0.5-2 6 mg/kg 4.5
mg/kg Bupivacaine 5 4-8 2-4 3 mg/kg 2 mg/kg Esters [others:
cocaine, benzocaine, chloroprocaine] Procaine 6-10 1 g in adult
Tetracaine Slow unknown Lidocaine 0.5%-2% solution
It is not advisable to use adrenaline in procedures
involvingend-arterial structure Disadvantage: pain at injection
site Distal digit, penis, pinna of earcutaneous necrosis Adverse
effects of local anesthetics
Local adverse effects: pain, hematoma, ecchymosis, nerve damage,
vasovagal syncope Ester anesthetics are more likely than amide
anesthetics to cause allergic reactions Initially, stimulation of
the nervous system occurs, causing perioral tingling and numbness
At greater dose, neurodepression and cardiovascular toxicity ,
anxiety, apprehension, restlessness, nervousness, dsorientation,
confusion, dizziness, blurring of vision, twistching, shivering or
seizures neurodepression can occur, resulting in uncomsciousness,
respiratory deprissiion or cama Intra-operative techniques for
painful procedures
Children Parents Surgical field management Local anesthetics
Techniques to decrease the pain of injection Pharmacologic agents
Techniques to decrease the pain of injection
Several techniques may be employed to decrease the pain of
lidocaine infiltration Prior treatment of the injection site with
topical anesthetics e.g. EMLA cream, LMX cream pH buffering of the
anesthetic solution Using small gauge needles e.g. 30 gauge Warming
of the anesthetic to body temperature Cooling the injected sitewith
ice or ethyl chloride spray Slow injection rate Topical and local
non-injectable anesthetics
EMLA LMX Tetracaine formulations Lopivacaine Iontophoresis EMLA
[eutectic mixture of local anesthetics]
Approved by FDA in 1992 Mixture of 2.5% prilocaine + 2.5% lidocaine
Application of the product on the skin surface with occlusive wrap
e.g. tegaderm, polyurethane film, for min. Longer application time
may be used of increase the depth of anesthesia Shorter application
time are indicated for broken, non-intact skin, genitalia and
mucosal surface intact Maximum depth of analgesia 5 mm deep biopsy
EMLA EMLA has proven to be effective as a local anesthetic for
numerous dermatologic procedure Laser therapy for Port wine stain
IL injection for keloid, cyst, hemangioma Pairing of wart EMLA is
useful as a prenumbling agent prior to the infiltration of local
injectable anesthetic Recent study has demonstrated antimicrobial
properties of EMLA cream emla bacteriostaticalcohol base
disinfectant EMLA Well tolerated and safe in most children
Methemoglobinemia is the most concerning and potentially
life-threatening condition Premature neonates, term NB < 3
months are more susceptible than older infants Symptomatic
methemoglobinemia can be treated with IV methylene blue or ascorbic
acid Local side effects: temporary erythema, edema, eye
irritationand ACD mottleing peri oral and acral cyanosis prilocain
induce methemoglobin stress immature of methemoglobin reductase
pathway prilocain oxidizing metabolized 2 4 hydroxyl, 2 methyl
aniline, and o toluidine 6 LMX-4 [liposomally encapsulated 4% or 5%
lidocaine]
Newer topical anesthetic with a competitive safety profile Equally
effective in minimizing the pain associated with simple
dermatologic procedure Several adventages over EMLA Quicker onset
[30min VS >60 min.] Longer duration of analgesia Does not
required occlusion No prilocain No reports of serious adverse
effects Tetracaine formulation
4% tetracaine gel [Amethocaine] Rapid onset [40min] and longer
duration of action than EMLA cream Widely use in Europe but is not
currently FDA approve in the USA Local side effects: transient
erythema, edema, pruritus Lidocaine + tetracaine patch was tested
for efficacy prior to venous access in adult Combination 0.5%
tetracaine + 1:1000 epinephrine + 1.8% cocaine [TAC] is widely used
in ER for facial and scalp laceration in pediatric patients patch10
EMLA 60min and less SE Less vasoconstriction than EMLA->
beneficial for venous canulation Lidocain+ tetracaine patch [Synera
in USA, Rapydan in EU] Ropivacaine New long-acting amide local
anesthetic
Widely used in Europe, but not currently approved in the USA Used
for long-acting anesthesia in subcutaneous infiltration, peripheral
nerve block and digital block 1% ropivacaine gel was recently
trialed on oral mucosa for dental procedure with equally efficacy
compared to benzocaine and EMLA Diluteinfusion pump SQ tructure
nerve vv need more study Lidocaine iontophoresis
Needlefree delivery of local anesthetics Lidocaine iontophoresis
used of a low voltage direct current for 3-5 minutes can delivered
1%-4% lidocaine painlessly into the superficial layer of the skin
rapid onset of anesthesia within 10 minutes solution or patch
Lidocaine iontophoresis Iontophoresis Successful use of this
technique for dermatologic procedure including shave biopsy, punch
biopsy, curette, and injection has been demonstrated Rare side
effect stratum corneum IV cannulation , premedpropofol , PDL of PWS
tingling sensation Techniques to decrease the pain of
injection
Sodium bicarbonate buffering of lidocaine To neutralize the acidic
pH of lidocaine with epinephrine solution may diminish the pain of
injection 1 ml of 8.4% sodium bicarbonate in every 10 ml of
anesthetic solution Warming of lidocaine: still controversy Slow
injection rate Cooling the injected site with ice or ethyl chloride
spray degrade epinephrine 25%/week Warm in body temp, study Slowly
infiltrate was less painful in several study warm to body temp
Techniques to decrease the pain of injection
Size of needle Ideally, the small gauge needles e.g. 30 gauge
should be inserted quickly to the skin into a follicular orifice at
90 degree to the skin surface This technique minimizes the number
of cutaneous nerve encountered during the entry of the needle into
the skin Needle length must be sufficient to reach the fat dermis
fatinfiltrate Intra-operative techniques for painful
procedures
Children Parents Surgical field management Local anesthetics
Techniques to decrease the pain of injection Pharmacologic agents
Pharmacological agents
Broad array of medications that can be used as sedative, hypnotic,
analgesic and anaesthetic agents Analgesia: relief of pain Amnesia:
lack of memory Hypnosis: lack of consciousmess Sedation: decrease
in consciousness Local, topical or regional anaesthesia, together
with sedatives: induced amnesia Local, topical or regional
anaesthesia, together with sedatives: induced amnesia Analgesics
Acetaminophen alone or with codeine NSAIDs Adjuvant agents
Dose 15-20mg/kg orally or 20mg/kg per rectum Codeine: mild to
moderate sedative effect NSAIDs e.g. ibuprofen and ketorolac
Effects on platelet function and hemostasis Adjuvant agents
Sedation Continuum of depth of sedation
Definitions proposed by the American society of Anesthesiologists 4
level From state of consciousness to deep sedation and on to
general anaesthsia Minimal sedation [anxiolysis] Moderate sedation
[conscious sedation] Deep sedation/analgesia General anaesthsia
Responsiveness Normal response to verbal stimulation Purposeful
response to verbal or tactile stimulation Purposeful response after
repeated or painful stimulation Unarousable, even with painful
stimulus Airway Unaffected No intervention required Intervention
may be required Intervention often required Spontaneous ventilation
Adequate May be inadequate Frequently inadequate Cardiobascular
function Uaually maintained Usually maintained May be impaired 1.
cognitive function and coordinationimpair, ventilation CVS
function-normal 2. Conscious airway maintain, spontaneous
ventilation, maintain cardiovascular fn 3. Conscious depression
repeated and painful stimulation 4. Loss of conscious airway and
ventilation , cardiovascular_impair deep, GA need anesthesiologist
conscious and deep sadation ambulatory setting Benzodiazepines
Sedative agents with potent anxiolytic effects
No analgesic properties e.g. Diazepam [Valium] Midazolam [Dormicum]
Antidote: Flumazenil Diazepam [Valium] Administration: IV, oral,
sublingual, rectal
Infants 1-6 months old: mg/kg IV Children >6 months old: mg/kg
IV, 0.4 mg/kg orally Maximum doses: 10 mg intravenously, 20 mg
orally Onset: 1-3 min [IV], 30-60min [oral] Duration:
unpredictable, 2-4 hr. IV diazepam: painful at injection site IM
route erratic 1-6 active metabolite IV diazepam: painful at
injection site propylene glycol IV midazolam Midazolam [Dormicum]
Short acting
Potent anxiolytic effect, anterograde amnesia Excellent safety
profile Administration: IV, IM, oral, nasal and rectal Dose: mg/kg
IV, mg/kgorally Onset: 1-5 min [IV] Duration: < 2 hr. Additional
analgesic agents: acetaminophen/codeine, or fentanyl diazepam
Potent anxiolytic effect, anterograde amnesia PDL midazolam iv
catheter pain significant Addrespiratory depression monitor O2 sat
high dose midazolam Flumazenil Specific antagonist for
benzodiazepines
Reverse the depressant effects Dose: 0.01 mg/kg IV, maybe repeated
every 60 s. as needed Routine post-operative use in setting of
midazolam sedation Reverse the depressant effects dose dependent
max dose 1 mg Routine post-operative use in setting of midazolam
sedation need for more study about cost effectiveness Barbiturates
Potent sedative agents, amnesic effects, no analgesic effect
Non-specific CNS depressants Administration: oral, rectal and IM
Dose: mg/kg IM or rectal Onset: 30 min Duration: 6 hr. More
profound RS CVS depressant than BDZ BDZ Ketamine Anesthetic agent
Administration: IV or IM
Profound sedation, amnesia, and analgesia trence-like state Dose;
mg/kg IM, 0.5 mg with mg/kg/min IV Onset: 1 min [IV], 5 min [IM]
Duration: < 90 min. Anti-sialogogue agent [e.g. atropine]
Post-operative nausea and prolonged unarousability Unplesant dreams
and emergence reaction C/I: active upper or lower airway disease,
head injury, epilepsy and acute eye globe injury semiconscious
state, as between sleeping and waking Anti-sialogogue agent [e.g.
atropine] Opiates analgesia E.g. morphine, meperidine, and fentanyl
Codeine
peri-, and postoperative analgesic agents Class side effects:
respiratory and cardiovascular depression, N/V sedative agents
Titrate dose hypotension Opiates Fentanyl Naloxone Synthetic opiate
agonist
Onset: within 5 min [IV] Dose: 1-3 ug/kg IV Duration: min [IV]
Naloxone Antidote for opiate overdose Dose: 0.01 mg/kg IV
incremental, repeated dose every 2-3 min as needed naloxone 1
recurrence of sedation Fentanyl lozenges: conflicting result
Chloral hydrate Sedative agents
Administration: IV, IM, oral, nasal and rectal Dose: mg/kg orally
[up to 100 mg/kg] Onset: 30-60min Duration: 6-8hr S/E: nausea,
vomiting, diarrhea Several deaths have been reported; overdosage,
use in children with underlying cardiac or systemic disease
amnestic effect, lack analgesic property , slow onset, long
duration need to monitor both during and conclusion of procedure
Propofol Intravenous anesthetic Administration: IV
Dose: mg/kg IV bolus, ug/kg/min. continuous infusion Onset:
immediate Duration: short Clean head wake-up Safe for outpatient
surgery even in children < 2 y. Respiratory depression is
dose-dependent hangover effect painful procedure Propofol induction
and halothane maintenance delirium hypoxia apnea airway and
ventilation Nitrous oxide Gas anesthetic analgesic effects,
amnestic effect
Rapid induction Dissociative state with eupholic feeling 30-50% N2O
for general anesthesia Extensive history of its use in pediatric
procedures Require extensive training personnel, monitor O2
saturation References Thank you for your attention