Anxiolysis with oral midazolam in pediatric patients undergoing dermatologic surgical procedures

Geriatric dermatologic surgery part II: Peri- and intraoperative considerations in the geriatric dermatologic surgery patient

Geriatric patients compose a growing proportion of the dermatologic surgical population. Dermatologists and dermatologic surgeons should be cognizant of the unique physiologic considerations that accompany this group to deliver highly effective care. The purpose of this article is to discuss the unique preoperative, intraoperative, and postoperative considerations geriatric patients present with to provide goal-concordant care. Preoperative considerations include medication optimization and anxiolysis. Intraoperative considerations such as fall risk assessment and prevention, sundowning, familial support, and pharmacologic interactions will be discussed. Lastly, effective methods for optimizing postoperative wound care, home care, and follow-up are reviewed.

Strategies to minimize procedure-related pain and anxiety: lessons from pediatric dermatology

PURPOSE OF REVIEW

Recent studies have suggested that prolonged or repeated episodes of general anesthesia early in childhood may adversely affect neurodevelopment. This, combined with rising healthcare costs and decreasing access, has sparked interest in performing pediatric procedures in the office setting when possible. It is essential to address the physical and psychological discomfort that often accompany this experience, particularly in children.

RECENT FINDINGS

Healthcare providers performing procedures on children can draw from a spectrum of established techniques, new technology, and novel use of medications to decrease peri-procedural pain and anxiety. These techniques include distraction, optimization of local anesthesia, and mild to moderate sedation.

SUMMARY

We recommend using a combination of techniques to minimize pain and anxiety to improve safety, decrease healthcare costs, improve patient experience, and prevent childhood trauma and persistent negative perception of the healthcare system.

Systematic review of Mohs micrographic surgery in children: Identifying challenges and practical considerations for successful application

BACKGROUND

Few data exist to guide the application of Mohs micrographic surgery (MMS) in the pediatric population.

OBJECTIVE

We sought to summarize the clinical characteristics of children undergoing MMS, identify challenges that limit the use of MMS in this population, and examine how these challenges can be overcome.

METHODS

A systematic review of PubMed and EMBASE, from inception of databases to November 2, 2019, identified all cases of pediatric skin lesions treated with MMS.

RESULTS

A total of 111 patients were included. The median patient age was 11 years (range 6 weeks to 17 years). The most commonly treated tumor was dermatofibrosarcoma protuberans (n = 62), followed by basal cell carcinoma (n = 30). The most common location was the head and neck (n = 34), followed by the trunk (n = 28) and the extremities (n = 23). The most commonly cited challenges in the application of MMS in children included patient cooperation, concerns for the safety of prolonged general anesthesia, availability of a MMS service in the pediatric setting, and access to a histopathology laboratory experienced in MMS sectioning.

LIMITATIONS

Many articles did not report specific patient characteristics.

CONCLUSION

Multiple obstacles limit the application of MMS in pediatric patients. This review describes practical methods to circumvent these obstacles to facilitate the appropriate use of MMS in children.

Addressing Practice Gaps in Cutaneous Surgery: Advances in Diagnosis and Treatment

Importance

Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making.

Objective

To present the newest and best evidence to close common practice gaps in cutaneous surgery.

Evidence Review

We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms "cutaneous surgery," "Mohs micrographic surgery," "plastic surgery," in combination with "safety," "cost," "anesthesia," "anti-coagulation," "bleeding," "pain," "analgesia," "anxiety," or "infection," among others. Bibliographies from these references, as well as meta-analyses, were also reviewed.

Findings

A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications.

Conclusions and Relevance

Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.

Achieving hemostasis in dermatology - Part 1: Preoperative, intraoperative, and postoperative management

As dermatological procedures continue to become increasingly complex, improved methods and tools to achieve appropriate hemostasis become necessary. The methods for achieving adequate hemostasis are variable and depend greatly on the type of procedure performed and the unique characteristics of the individual patient. In Part 1 of this review, we discuss the preoperative, intraoperative, and postoperative management of patients undergoing dermatologic surgery. We address oral medications and supplements that affect hemostasis, hemostatic anesthesia, and intraoperative interventions such as suture ligation and heat-generating cautery devices. In Part 2 of this review, we will discuss topical hemostats. The authors conducted an extensive literature review using the following keywords: “hemostasis,” “dermatology,” “dermatological surgery,” “dermatologic sutures,” “electrosurgery,” “hemostatic anesthesia,” and “laser surgery.” Sources for this article were identified by searching the English literature in the Pubmed database for the time period from 1940 to March 2012. A thorough bibliography search was also conducted and key references were examined.

[Special aspects of dermatologic surgery in children]

This reviews gives suggestions how to meet the needs of our young patients, especially with reference to dermatologic surgery. With the right attitude, specific knowledge and appropriate preparation, a potential disruption can be transformed into a low-conflict routine or even a rewarding experience for all persons involved.

Psychopharmacological treatment of dermatological patients – when simply talking does not help

In dermatology, primary emotional disorders with cutaneous manifestations, secondary emotional disorders caused by dermatoses and multifactorial diseases are possible indications for the use of psychopharmaceuticals. Neuroleptics (anti-psychotics) are usually used in psychiatric illnesses, while antidepressants are foremost in treating depression as well as obsessive-compulsive, anxiety and panic disorders. Minor tranquilizers may be used symptomatically. To define the indications for mid- and long-term treatment with psychopharmaceuticals, the unequivocal diagnosis of the main and secondary psychiatric symptoms as well as the primary target symptoms must be designated. At the start of therapy planning, any possible desired and undesired side effects must be taken into account, such as stimulation, sedation, anticholinergic side effects or weight gain. The main antidepressants are the well-tolerated selective serotonin reuptake inhibitors (SSRI) such as sertraline, fluoxetine or citalopram. A clear long-term plan and how to monitor it must be discussed with patient carefully because of the need for individual dose titration and the late onset of action of many of these medications. Good results can be achieved in dermatologic patients requiring psychopharmaceuticals if the indications are carefully assessed and the therapy logically structured.