CHICAGO – True complications in pediatric dermatologic surgery probably aren’t that frequent, but no solid data on the topic exist in the medical literature.
“An appropriate and thorough perioperative evaluation and planning may limit complications,”, said at the World Congress of Pediatric Dermatology.
The first step is to make the child comfortable in the office or operating room (OR) setting; this can include approaching children slowly unless you know them well. “Sit at their level, because coming up very fast and being over ... them is intimidating,” she advised. “Make sure you include the child in the conversation you’re having; it elicits more trust and belief in what’s going to happen. You want to explain what’s going to happen in a friendly manner. I think sometimes we have residents who are new to pediatrics that come in and say, ‘We’re going to cut this out,’ and the next thing you know, the child’s in tears. Describe what the procedure is going to be like in words that they can understand, and whatever you do, do not lie about what’s going to happen.”
Dr. Price also makes it a point to cover surgical trays before they’re wheeled in. “They don’t need to see needles and sharp objects,” she said. “Even afterward, bloody gauze can be scary to kids.” Positioning the patient properly also is important. “We’ll wrap young children up in a swaddle,” she said. “In my opinion, you should not be forcefully restraining an older child. They need to cooperate and it needs to be a safe procedure, otherwise, you should consider doing it in the operating room. I never enlist a parent to hold or restrain a child.”
One key to managing pain during dermatologic procedures in children comes down to anticipation: What kinds of distractions might the child need? What preoperative analgesia will be required? What postoperative pain medications should be used? “We know that certain procedures in children might be more painful, such as nail procedures, ablative laser procedures, and large excisions with extensive undermining,” Dr. Price said. “Pain is subjective and differs from child to child in the way it’s experienced, so you need to consider the child’s age, coping style, and temperament, and what their history of pain is like. We know that inadequate pain control in children has a negative impact and a negative implication on their future health care interventions, as well as their reactions to further pain.”
Parental involvement can sometimes help. “I like a parent to stay in the room if I’m doing a procedure in the office, as long as they agree to stay seated,” she said. “It may make your office staff more anxious, and it may make parents more anxious, too, so it’s something to think about.” There is some evidence that having a parent present during an in-office procedure increases parental satisfaction as well.
In an effort to minimize pain and anxiety before in-office procedures, Dr. Price and her associates at Phoenix Children’s Hospital often use instant ice packs. “They get cold really fast, they’re cheap, and you don’t have to run to a refrigerator to get ice,” she said. Other beneficial measures include topical anesthetics and breathing techniques, such as having the child blow on a pinwheel, blow bubbles, or perform diaphragmatic breathing. Using distractions – stuffed animals, picture books, or video games on a tablet – can also help. “If the child is going to the OR, using preoperative midazolam can help relax the child, especially if they’re having repeated procedures,” Dr. Price said. Oral sucrose solution in infants, especially in young infants, provides about 5-8 minutes of temporary analgesia and can be placed on their pacifier or their tongue, she added, noting that ethyl chloride spray can also be helpful prior to injections.
During the procedure itself, counter-stimulatory methods can be helpful; this can include handheld devices that use a combination of vibration, ice, and distraction methods. “Buffer your lidocaine and don’t inject cold lidocaine; that hurts a lot more,” she recommended. “Inject slowly; inject deep. If you have a painful procedure and you’re in an OR setting where you give Marcaine [bupivacaine], put that in at the end of the procedure for short-term postoperative pain relief.” After the procedure, it’s better not to apologize for causing pain or if the procedure didn’t go well. “Give positive incentives like stickers and stuffed animals, and use a dressing wrap with bright colors,” she said. “We often doctor up stuffed animals in the OR so when [the children] wake up, they have something fun to look at.”
Postoperatively, the best way to prevent pain is to recommend limited physical activity. “Children become active quickly after a procedure, and then they hurt,” Dr. Price said. “For extremity wounds, consider ice and elevation. I like bulky dressings to prevent trauma, to remind the families that they’ve had a procedure done. They can usually keep them on for several days.”
Surgical site infections are uncommon, but if they do occur, it’s usually between postoperative days 4 and 10. “The biggest indicator of an infection in my opinion is pain,” she said. “If they’re having a lot of pain, I would be concerned. Causes may be the presence of bacteria on the skin or mucosa or improper wound care at home.”
The risk factors for surgical site infections in children are not well defined in dermatologic surgery, Dr. Price added, “but we know that if you’re going to be operating in the diaper area, that’s a place where you’re going to have a high risk of infection. Preoperative hair removal – if you shave the scalp before surgery creating small nicks – could [introduce] bacteria. And it’s likely that the overall health of the patient may impact their risk of infection. You want to know the difference between normal wound healing and an infection. Culture it. If you’re worried, you may want to start empiric antibiotics. If you have a severe infection, something with necrosis, fluctuance, or dehiscence, you might want to consider partially opening that wound and letting it drain and heal in by secondary intention.”
Measures to prevent postoperative infections include perioperative counseling to restrict excessive activity to prevent trauma, bleeding, and dehiscence; use of bulky dressings, and explicit wound care instructions. “My nurse calls [the patient’s family] the day after a procedure, and I usually have them come in for a wound check, even if there are no sutures to remove, just to make sure things look OK,” she said.
Suture reactions are another potential complication of dermatologic surgery in children. The incidence is unknown, but suture reactions usually occur around 6 weeks postoperatively and tend to happen more often in older children. “Excessive reactions, while uncommon, can lead to an increased risk of dehiscence, infection, and delayed healing,” Dr. Price said. Small caliber monofilament sutures are less reactive than large caliber, multifilament sutures, she added, while synthetic and nonabsorbable sutures are less reactive than natural materials such as silk and surgical gut. Dr. Price favors using poliglecaprone, polyglactin 910, and polypropylene.
Tips for minimizing suture reactions include the following: Use the smallest caliber suture appropriate for the wound; avoid buried sutures too close to the surface of the skin; use a smaller caliber suture at the end of excisions, where there tends to be less tension; and keep knots small and flat at the apexes of excision. “Manage suture reactions with reassurance,” she said. “The nice thing is that these often heal fine without any delay. When possible, remove the offending suture material. A lot of times, I’ll use sterile forceps. At home, I’ll have [parents] massage the area with warm compresses to try to extrude the suture. But, if you wait long enough, it usually comes out.”
Dr. Price reported having no financial disclosures.