Pearls for Reducing Pain During Procedures

NEW YORK—Several procedures in dermatology, such as excising lesions and injecting certain medications, can be distressing for patients due to anxiety and pain-related factors. Reducing a patient’s distress, whether they are an adult or child, benefits everyone, said Peter A. Lio, MD, in his presentation on pain management in dermatology at the 2019 American Academy of Dermatology Summer meeting. He presented with Alisa, McQueen, MD, on techniques for reducing patients’ experiences of pain, anxiety, and stress during a procedure.

Dr Lio’s interest in the topic started during his internship in pediatrics in Boston, where there was a tremendous emphasis on pain free procedures to reduce the risk of “ruining patients for life in terms of medicine.”

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In dermatology, the practice of reducing pain and discomfort during procedures is more variable. The value of lessening patients’ experiences of pain and discomfort benefits everyone, according to Dr Lio. Not only does it help lower pain and anxiety in patients, but the dermatologist has a smoother procedure and studies show procedure rates are better with patient comfort, he said.

Addressing Distress

Dr McQueen, who works in pediatric emergency medicine, outlined the components that contribute to distress during procedures, based on Amy Baxster’s work. Stress consists of the physical pain from the procedure, the fear and anticipation of the procedure, which is sometimes worse than the actual procedure, and attention to the experience. These combined factors cause distress, Dr McQueen said.

Using a combination of analgesic, anxiolytic, and distraction techniques can reduce stress and maximize patient comfort. Some analgesic options for infants include:

• Skin-to-skin contact. Studies showed infants who were allowed skin-to-skin contact during vaccinations or heal sticks cried and grimaced less and had an even heart rate throughout the procedure. Breastfeeding has similar effects.
• Sucrose. A sucker made from a sponge with sugar water has been found to calm infants. The effects of sucrose during painful procedures has been so rigorously studied that it has been suggested that sucrose no longer needs to be studied, said Dr McQueen. The recipe Dr McQueen gave was 10ccs of sterile water and 1 packet of sugar.

Stimulating the inhibitory fibers decreases the sensation of pain at the synapse’s point, Dr McQueen stated. Temperature change and sensory change, performed using a vibration tool, stimulate the fibers that inhibit impulses. “For injections, the mantra is to put it [the device] between the pain and the brain,” said Dr McQueen.

Anesthetics

Topical anesthetics are effective but probably underutilized, said Dr Lio. They stop the signal for a few minutes to hours and are very safe overall for reducing pain during procedures.

EMLA (2.5% lidocaine and 2.5% priolocaine can be administered 60 minutes prior to the procedure and can penetrate about 10 mm into the skin. Occlusion can get into the skin further and possibly faster, Dr Lio said. There is a risk for methemoglobinemia for patients younger than 3 months or when larger amounts of the product are used, such as during laser hair removal on the back. Two options that work within 30 minutes are tetracaine and liposomal lidocaine, which is a newer product.

Dr Lio shared a pearl for reducing immediate and delayed pain from cryosurgery. He recommended applying compounded 4% lidocaine cream immediately after freezing a wart, for example, which improves absorption and numbness in 30 seconds and makes the procedure more comfortable for the patient.

While injectable local anesthetics are safe, work rapidly, and are cost-effective, the initial injection is associated with discomfort. To reduce pain from the needle, Dr Lio recommended using a topical anesthetic. For pain associated with infiltration of the medication, he suggested warming the lidocaine to room or body temperature, injecting first into the deep dermal layer and slowly injecting to the surface to reach the superficial layer while reducing pain sensation.

Another option, which has to be compounded, is to use sodium bicarbonate as a buffer (every 1 ml of bicarb use about 9 ml of lidocaine), Dr Lio said. While issues related to potency and shelf-life, among others, have not been found for compounding lidocaine and bicarbonate in studies, some hospitals outlaw this, he added.

For patients really concerned about lidocaine, the saline kiss, which is bacteriostatic saline (with benzyl alcohol), reduces pain and is less uncomfortable, said Dr Lio.

Cooling the skin is another important part of pain management because it decreases nerve conduction and pain transmission. Commercially available sprays of ethyl chloride, ice pack, preferably made from aluminum foil as opposed to a glove, can be used to cool the skin. Vibration, as Dr McQueen discussed early, also decreases pain application and can be used with cooling agents to get the best of both worlds, Dr Lio said. These techniques are cost-effective, easy to use, reusable, and can even improve blood draws in children, he added.

Next Page: Key Takeaways

Anxiolysis

Parents are sometimes more anxious than children and contribute to the anxiety in the room, said Dr McQueen. Coaching a parent before the procedure to reduce anxiety can help, as well as being cautious with verbal reassurance, especially in children younger than 6 years, she said.

For example, instead of saying this will burn to a 4 year-old-child, say this feels warm or tingling. Another is to say, “you are very brave” instead of “I am sorry,” or tell the child to “count to 3 and blow the feeling away” instead of “tell me when you are ready.”

Dr McQueen shared some ways parents can help hold children during the procedure. “However, you have to pick the parent really well,” she cautioned. She also recommends giving patients an out when suggesting this option.

Distraction

A study that included 112 children who underwent outpatient surgery measured anxiousness at baseline and during the procedure. Children were randomized to either only having a parent with them, having a parent and video game, and parent and midazolam. The results, which were stratified by age, indicated participants aged 6 to 9 years were less anxious with a video game than those with only a parent or who had been given midazolam. Older children also had lower anxiety but not as much as those in the 6-9 age group, Dr McQueen noted.

Dr McQueen discussed the difference between active vs passive distraction. Another study she reviewed showed children who played a game did not experience a significant spike in CHEOPS scores compared with those watching a movie.

While apps and games are constantly changing, Dr McQueen recommended some general tips:

• Games should be easy to learn.
• There should be a variety of choices.
• They should have an auditory component.
• They should not require long-term investment.
• Clinicians should know the basics of how the app works just in cases there is a problem

Start the game before the procedure so the children can become deeply involved, Dr McQueen said.

When you combine analgesia, anxiolysis, and distraction techniques together, you can end up with a very successful procedure, said Dr McQueen.

Dr Lio concluded the presentation discussing a case where he used these techniques to remove a lesion from a young patient’s lip when the parents refused the help of a plastic surgeon. In addition, Dr Lio said all the options listed here work well for adults. “If I have an adult patient on their phone, I tell them to keep doing what they are doing,” he said.

—Melissa Weiss

Reference
Lio PA, McQueen. Pain-free dermatology: Minimizing discomfort in procedures for children and adults. Presented at: the 2019 American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York, NY.