Procedural analgesia and sedation are both safe and applicable to office setting surgical procedures in children as long as support personnel are appropriately trained and monitoring and resuscitation equipment is available.
Emergent and scheduled surgical procedures are both amenable to an office location site. Incision and drainage of a superficial abscess is a common such procedure.
Infection drainage is best accompanied with enteral antibiotic therapy in the face of local cellulitis and even lymphangitis; however, when proximal lymphadenitis is present, parenteral antibiotics are indicated.
In the presence of a truncal or extremity penetrating/puncture wound in a child, a retained foreign body should be suspected and excluded.
Many commonly encountered minor pediatric surgical problems can be diagnosed and treated in the pediatric surgeon’s office. The office setting is ideal for the management of such problems and there has been substantial growth of office-based surgery in recent years. The reasons for this include patient satisfaction, surgeon convenience, and cost savings. Certain preparations are required to facilitate office procedures, including training of office staff, making available appropriate surgical instruments, and provision of suitable analgesia.
Provision of safe and effective anxiolysis and pain control during procedures for children in the ambulatory setting is a challenge for the surgeon, which may effectively limit the spectrum of procedures that can be provided in the surgical clinic. A variety of methods should be considered as possible solutions.
Clinical experience with a variety of local anesthetic agents applied topically to reduce discomfort during painful procedures in children has demonstrated efficacy during venipuncture and intravenous (IV) cannulation. In our clinic, we have noted a substantial reduction in discomfort when topical anesthetics are used prior to tissue infiltration with local anesthetics. Topical application of 2.5% lidocaine and 2.5% prilocaine cream (EMLA cream) has been used in clinical practice for more than 25 years. Efficacy is enhanced by application of a thick layer of cream for 60 to 90 minutes prior to the procedure, and this is facilitated by use of small occlusive dressing. Parents can be instructed to apply the medication to the anticipated wound site for up to 1 hour in advance of the procedure in infants up to 3 months and for up to 4 hours for older infants and children.
Other topical anesthetic agents, including tetracaine (4%) gel and liposomal lidocaine (4%), have a more rapid onset of action, so, application time required is only 30 to 60 minutes.
Other needle-free strategies for local anesthetic administration include a lidocaine/tetracaine topical patch with an integrated heating component, which accelerates penetration of local anesthetic agents through the stratum corneum. Iontophoresis allows an ionic form of a local anesthetic to be accelerated into the subcutaneous or submucosal tissue under the influence of low-voltage direct electrical current. De Cou and co-workers described successful utilization of iontophoresis to administer lidocaine and epinephrine for a series of pediatric surgery office procedures with satisfactory results.
Infiltration of local anesthetic into tissue at the site of surgical procedures is the most basic method to provide analgesia. Local anesthetics such as lidocaine and bupivacaine are useful in office procedures, although each has important differences in rate of onset, duration of blockage, and safe dosage limits (Table 14-1). Signs and symptoms of toxicity range from tinnitus, lightheadedness, and nausea to seizures, arrhythmias, and cardiovascular collapse. Local anesthetics must be administered with strict attention to dosage limitations to avoid serious complications.
| Local Anesthetic | Maximum Dose | Onset/Duration of Action |
|---|---|---|
| 1% Lidocaine plain (no epinephrine) | 4.5 mg/kg (0.45 mL/kg) (not to exceed 300 mg) | Rapid/60-120 min |
| 1% Lidocaine with epinephrine | 7 mg/kg (0.7 mL/kg) (not to exceed 300 mg) | Rapid: 60-120 min |
| 0.25% Bupivicaine plain (no epinephrine) | 2 mg/kg (0.8 mL/kg) (not to exceed 175 mg) | Slow: 240-480 min |
| 0.25% Bupivicaine with epinephrine | 3 mg/kg (1.2 mL/kg) (not to exceed 225 mg) | Slow: 20-480 min |
The block is performed by injecting the local anesthetic with a small-bore needle into the web space along each lateral surface of the selected digit (Fig. 14-1). Epinephrine-containing anesthetics are best avoided because of the risk of tissue ischemia due to vasoconstriction of the digital arteries.
Figure 14-1
Anatomy and technique of administering a digital nerve block anesthetic. The block can be administered proximally or distally on the lateral aspect of the digit using small volumes of agent (A) and the infiltration should be completed with additional injection along flexion and extension surfaces (B, C).
A penile block can be used for circumcision or other penile procedures. This block is performed by infiltrating around the dorsal penile nerves at the level of the pubic bone using an epinephrine-free local anesthetic. A ring block can be used, as well, with good efficacy.
Provision of analgesia, immobilization, and anxiolysis in the clinic setting has long been a challenge for the pediatric surgeon. However, for many surgical clinics associated with a children’s medical center, a balance of patient comfort and safety is currently possible due to improvements in monitoring due to routine availability of pulse oximetry, development of new pharmacologic agents of shorter duration but greater potency, evolution of procedural sedation safety guidelines, and the development of hospital-based procedural sedation services devoted to provision of moderate to deep sedation at sites outside the operating room.
Ketamine has been long used for painful procedures as a sedative/hypnotic with analgesic properties. This medication produces a dissociative state that allows painful procedures to be performed with tolerable patient movement. Patients usually maintain a stable airway with spontaneous respiration, but at times, may experience apnea, hypotension, laryngospasm, and postprocedural hallucinations and nightmares.
Benzodiazepine or propofol, in combination with a narcotic, may be used to achieve moderate sedation. Patients receiving these combinations of sedatives and analgesics require continuous monitoring and supplemental oxygen during the procedure along with postanesthesia recovery unit-like care following the procedure.
Low concentration (<50%) nitrous oxide inhalation appears to be an efficacious technique to achieve procedural analgesia and sedation while maintaining protective laryngeal reflexes. This agent has a rapid onset, is short-acting, and has a well-documented safety record. Reported advantages of using this modality include excellent pain control, minimal need for advance preparation of the patient, low complication rate, and lack of need for postoperative monitoring. Early experience with this technique in a pediatric surgical clinic practice indicates it to be a cost-effective and safe alternative to conscious sedation or general anesthesia for minor pediatric surgical procedures.
Superficial infections are a common problem among pediatric patients. Suppuration occurs frequently and often requires surgical drainage. Infection of a variety of congenital lesions may lead to abscess formation, including thyroglossal cyst, branchial cleft cyst, and preauricular cyst and sinus. Conservative incision and drainage with packing may be required to clear the acute infection. Definitive resection of the predisposing lesion will be required once the acute infection has resolved.
During the last decade, there has been a dramatic worldwide increase in community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin and soft tissue infections (SSTI). CA-MRSA now accounts for more than 75% of community-acquired infections.
Surgical drainage of abscesses is an essential component of treatment for these patients. Traditionally, the procedure involved an adequate incision to allow evacuation of pus and necrotic tissue, hemostat disruption of loculated pockets, irrigation of the abscess cavity, and insertion of a small penrose drain or gauze wick packing. A culture should be performed to clarify antibiotic sensitivities.
Several recent reports have described a minimally invasive technique of abscess drainage involving placement of a silastic vessel loop or one-fourth inch penrose drain introduced through a central stab incision into the abscess cavity and exteriorized through a second peripheral incision made at the cavity margin. The results reported in 2 small retrospective reviews suggest that this technique is safe and equivalent in outcome to standard incision and drainage, although one study reported a need for additional drainage procedures in 5% of patients.
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