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