inspiration pain-free dermatology: minimizing … 1 pain-free dermatology: minimizing discomfort in...

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Pain-free Dermatology: Minimizing Discomfort in Procedures for

Children and AdultsPeter A. Lio, MD, FAAD

Assistant Professor Clinical Dermatology & PediatricsNorthwestern University Feinberg School of Medicine

Alisa McQueen, MD, FAAP, FACEPAssociate Professor of Pediatrics

The University of ChicagoComer Children’s Hospital

Inspiration

• Pediatrics vs. Dermatology…

Trauma

• Me > Patient!

Minimizing Pain

• Everybody wins: – The patient has less pain– The parents have less stress– The dermatologist has a smoother

procedure!

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Outline

• The History and Science of Pain• A Model for Ensuring Procedure Success– Pharmacologic– Non-pharmacologic

• Practical Take Home Points

Procedural Distress

Pain

Baxter A. Best Practices for Outpatient Procedural Sedation. Pediatric Annals 2012; 41: 471-475.

Distress

Fear

Attention

Procedure Strategy

Pain

Procedure Strategy

Analgesia

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Procedure Strategy

FearAnalgesia

Procedure Strategy

AnxiolysisAnalgesia

Procedure Strategy

AnxiolysisAnalgesia

Attention

Procedure Strategy

AnxiolysisAnalgesia

Distraction

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Procedure Strategy

Distraction

Analgesia Anxiolysis

“Suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten; but the blank whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close upon despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so.”

Patient to Sir James Simpsonmid 19th century.

Definitions

“an unpleasant sensory and emotional experience associated with actual or potential tissue damage”

International Association of the Study of Pain

Nociception

• “perception of injury or painful stimuli by nerve endings, spinal tract, midbrain, and cortex and does not involve the affective or evaluative components of pain”

• Nociception + “OUCH” = PAIN

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Pain Transmission Theory• A delta fibers– 2-5 mm in diameter and myelinated– have a fast conduction velocity (5-40 meters/sec)– localized pain sensations, sharp pain

• C fibers– 0.4-1.2 mm in diameter and unmyelinated– slow conduction velocity (0.5-2.0 meters/sec)– transmit dull, poorly localized pain sensation– 70 % of all noxious pain transmission

MelzackR,WallPD:Painmechanisms:anewtheory.Science150:971-979,1965 TaddioAetal.Effectofneonatalcircumcis iononpainresponseduringsubsequentroutinevaccination.TheLancet1997;349:599-603.

Taddio A et al. Effect of neonatal circumcision on pain response during subsequent routine vaccination. The Lancet 1997;349:599-603.

UncircumcisedCircumcised with EMLA

Circumcised with placebo

All videotaped during routine vaccination 4-6 months later

Videotapes scored by blinded investigator

Facial action score


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Cry duration


Neural Pathways

0

20

40

60

80

100

% Grimace % Cry% O

ccur

renc

e Du

ring

Heel

Stic

k ControlContactP = < 0.0001

P = < 0.0001

Gray L, et al. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000;105(1) e14.

Skin-to-skin is analgesicHeart Rate

110

120

130

140

150

160

170

HR

(bpm

)

CONTROLCONTACT

Heel Stick RecoveryGray L, et al. Skin-to-skin contact is analgesic in healthy newborns. Pediatrics 2000;105(1) e14.

Skin-to-skin is analgesic

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0

20

40

60

80

100

% Cry % Grimace

% O

ccur

renc

e Du

ring

HS

ControlBreastfeeding

P = < 0. 0001 P = < 0. 0001

110

120

130

140

150

160

170

HR (b

pm)

BreastfeedingControl

HS REC

Breastfeeding is analgesic

Gray L, et al. Breastfeeding is analgesic in healthy newborns. Pediatrics 2002; 109(4), 590-593.

“A sucker consisting of a sponge dipped in some sugar water will often suffice to calm a baby.”

Modern Surgical Technique, 1938

Harrison D et al. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics;2010:894-902.

Harrison D et al. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics;2010:894-902.

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Sucrose is an effective analgesic in newborns

for single, limited procedures

Sucrose likely works on opioid receptors

Optimal dose is unclear but 24% does the trick

(1 packet of table sugar to 10 cc sterile water)

Baxter A et al. An integration of vibration and cold relieves venipuncture pain in a pediatric emergency department. Pediatric Emergency Care 2011;27:1151-1156.

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Procedure Strategy

Distraction

Analgesia Anxiolysis

Topical Anesthetics

• There are many different topical anesthetics available

• Act via a “numbing effect”: reversible block in nerve conduction for minutes to hours

• Very safe overall

LanderJA,Weltman BJ,SoSS.EMLAandamethocaine for reductionofchildren's painassociated withneedleinsertion. CochraneDatabaseSystRev.2006;3:CD004236.

Topical Anesthetics

• 1:1 mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA: eutectic mixture of local anesthetics)

• They melt at a lower temperature than they do separately à a liquid at room temperature

• The combination is more effective than using both drugs togetherMathewPJ,MathewJL.Assessmentandmanagementofpain in infants.PostgradMedJ. 2003Aug;79(934):438-43.

Topical Anesthetics

• Applied about 60 minutes before the intended procedure, it penetrates up to a depth of 10 mm

• Penetration can be increased with occlusion

• Possible side effects: methemoglobinemia– Usually concern in < 3 months of age and

when using large amounts (>2 g per 10 cm2)

MathewPJ,MathewJL.Assessmentandmanagementofpain in infants.PostgradMedJ. 2003Aug;79(934):438-43.

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Topical Anesthetics

• A review of 8 trials (n = 458 children) of painful procedures compared tetracaineto EMLA

• Both were comparable for pain relief with 60 min application for EMLA and 30 min for tetracaine

AnEvidence-BasedApproach toMinimizing AcuteProceduralPain in theEmergencyDepartmentandBeyond.Ali S,McGrathT,Drendel AL.Pediatr Emerg Care.2016Jan;32(1):36-42.

Topical Anesthetics

• Liposomal lidocaine is newer anesthetic• Appears to have superior effect with faster

onset (30 min)• A trial of liposomal lidocaine vs. tetracaine

found no significant difference in pain scores


Pearl• Cryotherapy pain has both immediate and

delayed component• Applying a topical anesthetic (e.g., 4%

lidocaine cream) right after freezing can render the lesion painless within 30 seconds!

• Theory: ice crystals during freezing damage epidermal barrier, thus increasing penetrationBenedettoAV.Anoveluseoftopical anesthetics toalleviate thepainofcryotherapy.Skinmed.2003Sep-Oct;2(5):307-8.

Local Anesthetics

• Injectable anesthetics are the mainstay of dermatologic procedures

• They are very safe, work rapidly, and are very cost effective

• There can be significant discomfort as they are injected, however, both from the needle and the infiltration


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For the Needle Pain

• Consider a topical anesthetic first• Dr. McQueen will talk about distraction

techniques shortly that are fantastic

For the Infiltration Pain

• pH of lidocaine solution is between 3.5-7.0

• The acidity is thought to be responsible for the pain

• Alkalinization of the lidocaine can reduce this pain


Buffer

• A systematic review of 23 studies determined that pain from injection of buffered lidocaine was less than from unbuffered lidocaine

• Buffering is generally achieved by adding 1 mL of 8.4% sodium bicarbonate to 9 mL of 1% or 2% lidocaine


Buffer

• Theoretical issues with adding sodium bicarbonate:– Causing precipitation – Decreasing potency– Reducing shelf life

• None of these found in the studies reviewedAnEvidence-BasedApproach toMinimizing AcuteProceduralPain in theEmergencyDepartmentandBeyond.Ali S,McGrathT,Drendel AL.Pediatr Emerg Care.2016Jan;32(1):36-42.

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A little out there…• In a mouse model of post-op pain:• Inhalation of atlantic cedar oil markedly

reduced mechanical hypersensitivity to painful stimulus

• This effect was prevented by pre-treatment with naloxone

• Odors may activate the descending pain modulation pathway

Inhalationof Cedrus atlantica essentialoilalleviates painbehaviorthroughactivationof descendingpainmodulationpathwaysinamousemodelof postoperativepain.MartinsDF, Emer AA, Batisti AP,DonatelloN, Carlesso MG, Mazzardo-MartinsL,Venzke D,Micke GA, PizzolattiMG, Piovezan AP, DosSantosAR.JEthnopharmacol.2015Dec4;175:30-8.doi:10.1016/j.jep.2015.08.048.Epub 2015Sep4.

Closer to home

• Aromatherapy may help with the autonomous response to pain

• 73 children with type 1 diabetes• Orange and lavender oil were dispersed

with an aromatherapy device vs. placebo• Lower ΔHR% was associated with

essential oil application (p=0.0252)

Małachowska B, Fendler W, Pomykała A,Suwała S,Młynarski W. Essential oilsreduceautonomousresponsetopainsensationduringself -monitoringof bloodglucoseamongchildrenwithdiabetes. J Pediatr EndocrinolMetab. 2016Jan1;29(1) :47-53.

Cooling• Cooling the skin may decrease nerve

conduction velocity of C and A[delta] fibers, thus decreasing the transmittance of pain

• A study of 60 subjects found no significant difference between buffered anesthetic and skin cooling in reducing pain of infiltration

• Suggests that cooling could be as effective as the pharmacologic effect of buffering

SchlieveT, MiloroM. Topicalrefrigerantsprayfor pediatricvenipuncturefor outpatientsurgery.OralandMaxillofacial SurgeryCases. 2015;1(2) ,29-32.

AlShahwan MA. Prospectivecomparison between buffered1%lidocaine-epinephrineandskincoolinginreducingthepainof localanesthetic inf iltration.DermatolSurg.2012Oct;38(10):1654-9.

More Cooling…• A study randomized 39 patients before

injecting anesthesia to skin cooling (termed “cryo-preparation”) or no skin cooling

• They found significant reduction in injection pain with cryo-preparation– 24.6% reduction in pain score that was

statistically significant (p = 0.039)

Goel S, ChangB,Bhan K,El-HindyN, etal. “Cryoanalgesic preparation”beforelocal anestheticinjectionforlidsurgery.Orbit, 2006;25:107–10.

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Many Ways to Cool• Evaporative refrigerant sprays such as ethyl

chloride to a simple ice pack• One study compared ice cubes wrapped in latex

or latex-like glove material to cubes wrapped in aluminum foil and found that the aluminum foil wrapping was more effective at reducing skin temperature before neurotoxin injection

• After 120 seconds of exposure, only the aluminum foil wrap was able to achieve a 2°C skin temperature--thought to be necessary to reduce nerve conduction and increase the pain threshold

Algaf lyAA, GeorgeKP. Theeffectofcryotherapyon nerveconduction velocity, painthresholdandpaintolerance. BrJ SportsMed.2007;41:365–369.

Good Vibrations• Application of vibration to the skin

proximal to the procedure site has been shown to decrease pain perception during procedures

• More than simple distractin, vibration physiologically mediates the transmission of painful stimuli under Melzack and Wall’s Gate Control Theory of pain

KatzJ,RosenbloomBN.The goldenanniversary of Melzack andWall’s gatecontroltheoryof pain:celebrating 50yearsof painresearchandmanagement.PainResManag.2015Nov-Dec;20(6) :285-6.

Vibration• A study of 20 neonates found application

of vibration during heel stick reduced pain (measured by the Neonatal Infant Pain Scale)

• In adults, at least one study demonstrates vibration outperforming vapocoolant for pain reduction during venipuncture

BabaLR,McGrath JM,LiuJ. The eff icacyof mechanical vibrationanalgesiaforrelief of heel stick paininneonates: anovelapproach.J PerinatNeonata lNurs.2010Jul-Sep;24(3) :274-83.

BaxterAL, LeongT, MathewB. External thermomechanicalstimulationversus vapocoolant foradultvenipuncturepain: pilotdataonanoveldevice. Clin JPain.2009.Oct;25(8) :705-10.

Vibration + Cooling• Vibration + Cooling may be even more

effective• Numerous studies demonstrate statistically

and clinically significant reduction in pain perception when both are applied proximal to the painful procedure

• A randomized prospective trial of 81 children who received standard therapy versus use of a device combining cooling and vibration lower pain scores and improved venipuncture success

BaxterAL, CohenLL, McElvery HL, LawsonML, vonBaeyer CL. Anintegrationof vibrationandcoldrelieves venipuncturepaininapediatricemergency department.PediatricEmergency Care. 2011.Dec;27(12):1151-6.

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Procedure Strategy

Distraction

Analgesia AnxiolysisWhat about Parents?

Use verbal reassurance with caution, especially for kids under 6 years.

Krauss Betal.Current concepts inmanagementofpaininchildrenintheemergencydepartment. Lancet2016;387:83-92

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Instead of:“The medicine will burn.”

Try:“Some kids say it feels warm, other kids say it feels tingly.”


Instead of:“I’m sorry.”

Try:“You’re being very brave.”


Instead of:“Tell me when you’re ready.”

Try:“When I count to three, blow the feeling away from your body.”

Procedure Strategy

Anxiolysis

Distraction

Analgesia

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Can distraction out-perform drugs?

• 112 children age 4-12 undergoing elective surgery

• Anxiety assessment at admission and at induction

• Postoperative effects measured

Patel A et al. Distraction with a hand held v ideogame reduces pediatric perioperative anxiety. Pediatric Anesthesiology 2006;16:1019-27.


• Parent presence alone (PPIA)

• Parent presence + video game (VG)

• Parent presence + midazolam (M)




Active vs Passive Distraction

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Active vs Passive Distraction

• Children 3-16 years undergoing painful procedures

• Randomized to active distraction (tablet) or passive distraction (cartoon)

• CHEOPS and self report pain scale measured at baseline, during procedure, and recovery

Results: self-reported pain

Results: CHEOPS*

*Children’s Hospital Eastern Ontario Pain Scale

Apps that work

• Are easy to learn• Have many choices• Have an auditory component• Do not require long term investment

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Strategies for App success

• Have several to choose from• Introduce it several minutes before the

procedure starts• Know the basics of how your apps work


Procedure Strategy

AnxiolysisAnalgesia

Distraction

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Take Home Points

• Encourage a calm, relaxed atmosphere• Use topical anesthetics whenever

possible• Buffer lidocaine for injection• Distraction is key: Music, apps, or talking

Thank you!

[email protected]

inspiration pain-free dermatology: minimizing … 1 pain-free dermatology: minimizing discomfort in...

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