Alleviate the ouch

By Heidi Splete, Contributing Writer, May 1, 2024

Use of anesthesia can be tricky in adults, but even trickier in children. The use of local or general anesthesia in pediatric dermatology must not only consider the type of treatment, but also patient and physician safety — a wiggly child or baby does not make for a successful procedure.

While general anesthesia carries some risks, local anesthesia may be insufficient to keep a child calm, and a child may injure themselves, parents/caregivers, or the physician performing the procedure, by flailing, kicking, or wiggling out of reach.

Cooperative assessment

“Shared decision-making is essential in all settings where there is a need to review local vs. generalized anesthesia,” said Nanette Silverberg, MD, FAAD, chief of pediatric dermatology for the Mount Sinai Health System in New York.

“When the procedure is elective and not required, or not required immediately, we offer parents information and engage them in a shared process of planning,” she said.

“Although general anesthesia may not be required, the amnesia afforded the child under general anesthesia is preferred by some parents. However, there are different risks associated with general anesthesia, and reviewing these with an anesthesiologist or a surgeon, where applicable, can provide in-depth risk-benefit analysis,” Dr. Silverberg said.

“Some parents would rather have a disfiguring birthmark removed from their child at age three years under general anesthesia than wait until the child can sit still in office 5-10 years later,” Dr. Silverberg noted. “Other parents would like to mitigate even the smallest additional risk by waiting or holding a child down for procedures.”

AAD advice

The current American Academy of Dermatology guidelines for in-office local anesthesia recommend topical agents as a first-line anesthesia strategy for dermal lacerations and other minor procedures, including curettage, in children. The AAD also recommends topical anesthesia to help reduce the pain of infiltrative anesthesia in larger procedures such as skin biopsies or excisions.

A combination of topical and infiltrative anesthesia should be considered as an alternative to sedation or general anesthesia for more extensive surgery, according to the guidelines.

The AAD recommendations also include nerve blocks for procedures on the face, hands, feet, and digits.

Secrets of success for local anesthesia

Dr. Silverberg does not perform surgeries under general anesthesia in the office; her in-office procedures are those that can be accomplished with local anesthetic and additional agents.

In Dr. Silverberg’s practice, reducing the overall stress and potential pain of dermatologic procedures is a multi-pronged process including child-friendly music, which older children can select themselves, plus topical anesthetics and spray cooling agents to numb areas for lidocaine injections.

“Finally, we make sure parents are nearby to reassure the child,” Dr. Silverberg said. Vibrating devices (despite limited data on their effectiveness) also can serve as distractions for injections, and the promise of a sticker as a reward for bravery and a job well-done helps some school-aged children, she added.

“I talk with families about pain control, patient safety, and tolerability of the procedure when selecting patients for dermatologic procedures under local anesthesia,” said David Schairer, MD, FAAD, of Rady Children’s Hospital in San Diego. “Injection of local anesthetic is excellent for managing the pain of the procedure, but the brief pain when injecting local anesthesia needs to be minimized,” he said. Some of Dr. Schairer’s techniques include the use of warm and buffered local anesthetic, fast-acting local anesthetic, vibration, cooling, and topical numbing agents.

When to go with general

“If a child is able to handle administration of local anesthetic, many procedures can be done without general anesthesia,” said Dr. Schairer. “Patient safety concerns are procedure- and site-specific,” he explained. “For laser procedures where the laser can rapidly be turned off, we can pause the procedure if the patient is moving to avoid injury to the patient. In contrast, when excising and suturing the face, the patient needs to remain still to prevent unintended damage to surrounding skin or other structures such as the eyes,” he added.

“Even when a patient is old enough to tolerate administration of local anesthesia and can stay still for the duration of the procedure, you may still opt for general anesthesia in specific instances,” said Dr. Schairer.

“Shared decision-making is essential in all settings where there is a need to review local vs. general anesthesia.”

“For example, a child might be able to handle a biopsy of the skin under local anesthesia, but when you apply an eye protection, such as a blindfold, and deprive them of their ability to see what is happening around them, it may make them too anxious to tolerate the procedure,” he said. “Similarly, procedures on nails are not typically well tolerated by young children, even with local anesthesia, and are more often done under general anesthesia.”

Additionally, children who have undergone many medical procedures, such as those with leukemia or lymphoma who undergo frequent IVs, lumbar punctures, and bone marrow aspirations can have significant anxiety with procedures, Dr. Schairer told DermWorld. “For these patients, it is often in their best interest to do procedures under general anesthesia to limit additional medical trauma,” he said.

Cognitive concerns

Dr. Silverberg coauthored a 2017 editorial published in Cutis on the topic of pediatric anesthesia and risk management, in the wake of a 2016 FDA warning about potential neurological risks of general anesthesia for children. The warning describes the potential impact of anesthesia on children’s brain development, and focused on children younger than three years who undergo more than three hours of anesthesia, or who undergo repeated anesthesia.

The Society for Pediatric Anesthesia (SPA) offers a downloadable handout for parents that discusses anesthesia and the 2016 FDA warning, Dr. Silverberg said. The SPA document describes the FDA warning, but also states that recent studies of short duration of anesthesia exposure have not been associated with negative effects on brain development.

Given the persistent concerns about brain development, physicians push off non-essential procedures when possible, Dr. Silverberg said. “However, we cannot push off many cardiac and neurosurgical procedures, and therefore surgery should proceed where necessary.”

One way to avoid concerns about general anesthesia in young children is to postpone nonurgent surgeries and procedures until children are three years old if at all possible. Parents may want certain procedures at a younger age.

“When families ask about neurocognitive risks, I discuss the data that children requiring numerous and prolonged procedure under anesthesia before the age of three are at greatest risk for developmental delay and neurocognitive effects from anesthesia.”

More recent research has yielded reassuring, though not definitive, information on pediatric anesthesia, Dr. Silverberg said.

“Systematic reviews published in 2022 and 2023 found the potential for risk and need to mitigate risk in young patients,” she said. “However, other studies have refuted the original data of concern and suggested that confounding factors such as chronic illness were responsible for neurocognitive concerns.”

Addressing neurodevelopmental concerns is a complicated question, and the FDA recommends against elective procedures involving general anesthesia for children younger than three years, said Rita Agarwal, MD, clinical professor of anesthesiology at Stanford University.

“The animal research for neurotoxicity in the developing brain is overwhelming and compelling,” said Dr. Agarwal. “However, it is not so clear in human studies, and often the consequences on waiting to have a procedure performed can be significant.”

In Dr. Agarwal’s practice, she summarizes relevant literature with families and reassures them that the team will provide the safest possible anesthetic. “I try to use regional anesthesia whenever I can or encourage the surgeon to use local anesthesia to limit the child’s exposure to anesthesia,” she said. “Most current human studies show that a single short anesthetic does not appear to be associated with significant development issues in young children, but repeated anesthetics may.”

Recent reassuring research

In 2017, the FDA issued a drug safety communication that announced the addition of a warning to labels on general anesthetic and sedation medicines regarding use in children younger than three years. The warning states that “exposure to these medicines for lengthy periods of time or over multiple surgeries or procedures may negatively affect brain development in children younger than three years.” The updated labeling also describes studies of young animals and pregnant animals to illustrate the potential risk, according to the FDA communication.

However, a 2019 study known as the GAS trial and published in the Lancet showed no significant differences in neurological measures in children who underwent general anesthesia and those who underwent a median of 54 minutes of awake regional anesthesia. While not focused on dermatologic procedures, the study findings provide some reassurance of the safety of general anesthesia for young children, according to the authors.

The primary outcome of neurodevelopment at five years of age was measured using the Wechsler Preschool and Primary Scale of Intelligence, third edition (WPPSI-III) full-scale intelligence quotient (FSIQ) score.

The study population included 722 children with a postmenstrual age (gestational age plus chronological age) of 60 weeks who were randomized to awake-regional anesthetic or sevoflurane-based general anesthetic for inguinal herniorrhaphy. The mean scores were 99.08 and 98.97 in the general and awake groups, respectively.

Another study published in JAMA Pediatrics in 2019 retrospectively reviewed data from 2,346 sibling four- to five-year-old pairs in which one of each pair had undergone general anesthesia at preschool age. In this study, no differences appeared in any of the domains assessed using the Early Development Instrument (EDI). These domains included language and cognitive development, physical health and well-being, social knowledge and competence, emotional health and maturity, and communication skills and general knowledge.

Although the study was observational, the results support previous research showing no significant neurodevelopmental effects of general anesthesia in preschoolers.

In a 2021 study published in the Journal of Dermatology and Dermatologic Surgery, a team of researchers in Saudi Arabia reviewed safety, significant adverse events, and complications associated with general anesthesia in children who underwent skin procedures. Their study population included 211 children.

Of the 211 procedures performed under general anesthesia, 88 (41.6%) were flashlamp pulsed dye laser and 123 (58.3%) were excisional surgical procedures. The most common diagnoses were congenital melanocytic nevi (23%), nevus sebaceous (21%), port wine stain (19%), infantile hemangioma (8%), dermoid cysts (7%), and pilomatricomas (4%).

Overall, 12 of the 211 patients (5.6%) developed “clinically relevant” anesthesia-related complications: four with sore throat, nausea, and vomiting; three with mild-to-moderate postoperative frontal headache, two with postoperative minor trauma to teeth and lips, and one child experienced pain in the neck muscles postoperatively.

Expect side effects

Potential side effects of local anesthesia are mainly limited to injection site pain, and, rarely, an allergic reaction to the anesthetic, according to the American Society of Anesthesiologists.

Side effects from general anesthesia may include grogginess, nausea, dizziness on emerging from anesthesia, and sometimes a sore throat if intubation was needed.

The most common acute severe side effects involve airway management and respiratory issues, according to a systematic review and meta-analysis of 25 studies. However, the authors acknowledged that “data on pediatric anesthesia acute severe complications are poorly defined with large variation in the specificity of diagnostic reporting even within studies.”

An older study published in 2005 in JAMA Dermatology included 881 dermatology procedures performed by six physicians. The study population included 269 children and teens ranging from two months to 18 years of age. All underwent general anesthesia in a children’s hospital setting. Overall, 90% of the patients had no clinically relevant complications. A total of 4% experienced perioperative nausea and emesis, which was the most common clinically relevant adverse event.

Putting parents at ease

To help reassure parents and caregivers and inform discussions of risks and benefits, Dr. Silverberg recommends an information sheet from Smart Tots, an ongoing collaborative program created by the International Anesthesia Research Society (IARS). The handout addresses the limitations of current data and concerns about timing of anesthesia, she said.

The SPA website also provides a list of kid-friendly and family-friendly books about surgery (including the classic Curious George Goes to the Hospital), as well as abstracts of the recent studies showing no impact of neurodevelopmental outcomes with limited general anesthesia exposure, she added.

The discussion of how and when to use general anesthesia in pediatric patients is not completely resolved, said Dr. Silverberg. “Risk-benefit analysis based on need for surgery, the general health of the child, and the involvement of colleagues in pediatric anesthesia, pediatric surgery, and pediatrics may aid in the process,” she said.

Patient preferences

The decision to use general or local anesthesia for a child should be done in combination by the patient, the family, and the physician, said Dr. Schairer. “When a procedure can be done with local anesthesia, I start by asking the patient and family if they would like to do the procedure ‘awake,’” he said. “Some families will instantly say that the child needs to be asleep, and I will gently ask for their specific reasoning,” Dr. Schairer said.

“If families are willing to consider doing a procedure using local anesthesia, then don’t shy away from saying the word needle, shot, or injection when talking to patients. If the patient has a strong response in anticipation of the procedure during the consultation, then it’s unlikely that they will tolerate the procedure itself,” he said. “Starting off the procedure with the patient saying ‘wait, you’re going to use a needle?’ means the patient has lost trust in you, and they will start to question everything you told them previously, including that the local anesthetic works,” he emphasized.

“When families ask about neurocognitive risks, I discuss the data that children requiring numerous and prolonged procedure under anesthesia before the age of three are at greatest risk for developmental delay and neurocognitive effects from anesthesia. In contrast, otherwise healthy children with a brief, single procedure under general anesthesia have the least risk for such complications,” said Dr. Schairer.

When discussing the general complications from anesthesia, “I like to put the risk in perspective to the risks of daily life,” he said. “For a healthy child undergoing elective surgery, the risk of a severe complication from anesthesia is similar to the risk of taking a week-long road trip,” he noted. “For patients with risk factors, I use the American College of Surgeons’ pediatric surgical risk calculator and arrange a pre-operative consultation with an anesthesiologist.”

If possible, Dr. Schairer prefers to delay procedures requiring general anesthesia until children are older. However, “for some indications, such as an enlarging skin lesion on the face, the benefits of surgery at a young age can outweigh the risks of anesthesia,” he said.

In-hospital advantages

The anesthesiologists with whom Dr. Schairer works prefer the surgical center or hospital operating room when general anesthesia is needed, as opposed to deep sedation in the office.

“Children don’t tolerate deep sedation as well as adults, and their small airways can make managing complications difficult,” he said. “When an anesthetic complication does occur, having a team who can quickly identify the complication such as a skilled PACU nurse and anesthesiologist with experience in pediatric care can make the difference in the outcome for the child.”

“Children don’t tolerate deep sedation as well as adults, and their small airways can make managing complications difficult.”

Dr. Schairer performs pediatric dermatology procedures in a pediatric hospital operating room setting. “Having a well-trained staff member experienced in caring for children makes a big difference in the patient and family experience,” he said. Other benefits of the hospital setting include child life experts who can guide children through the process,” he said. For some children, this means providing distraction with a game or movie on a tablet. For kids who want to understand and engage in the process, “letting them see and feel the mask used for anesthesia induction and walking them through the experience translates into smoother anesthesia inductions,” he said.

After the procedure, having experienced staff who can help a child reorient and guide family members or caregivers through the anesthesia recovery creates a seamless experience, he added.

Technical tips

Dr. Schairer shared some of his clinical considerations and practical pearls for pediatric procedures under general anesthesia.

“When supplemental oxygen is being used for anesthesia, there is an increased risk for fire. You need to plan ahead with your anesthesiologists and determine when and if the patient needs to be ventilated with room air during the firing of a laser or electrocautery,” he noted. “For faint vascular lesions, vasodilation during anesthesia may make it difficult to see the full extent of a port wine stain, so marking the lesion before anesthesia can be helpful,” he said.

Local anesthetics can be used during general anesthesia procedures, with benefits to surgeons such as the use of local epinephrine to decrease bleeding, said Dr. Schairer. However, “a longer-acting anesthetic such as bupivacaine should be used in place of lidocaine, which will wear off before the patient wakes up,” he said.

In addition, physicians performing pediatric dermatology procedures with patients under general anesthesia should be familiar with proper patient positioning and support to prevent nerve damage, he emphasized.

Other tips for successful OR procedures: “Be familiar with the OR equipment; the electrocautery device in the OR may require a grounding pad and may have different energy settings than your wall-mounted office device,” said Dr. Schairer. Keep a dedicated space or a cart for dermatologic surgery supplies such as punch tools and curettes, he advised. “If you are doing laser surgery in the OR, ensure that your room has the appropriate outlet to plug in the laser, covers for any windows, and appropriate signage for the room,” he said.

Also, ensure eye protection for the anesthesiologist, circulating nurse, scrub tech, yourself, and extra eye protection to hang on the door for any staff that may need to enter during the procedure, Dr. Schairer added.

Last but not least, “speak with the families after the procedure; they are nervously waiting for the surgery to be finished and to know that their child did well,” he said.

An anesthesiologist’s expert perspective

Children receiving general anesthesia may experience the same side effects that occur in adults, the most common being nausea and vomiting, sore throat, damage to teeth, difficulty breathing, and a reaction to an anesthesia medication, said Dr. Agarwal.

“In addition, children are at higher risk for developing specific breathing-related problems, such as increased wheezing or coughing in children with asthma, or laryngospasm, a potentially life-threatening condition in which the vocal cord partially or completely closes, making the passage of air into and out of the lungs difficult or impossible,” said Dr. Agarwal, a past president of the Society for Pediatric Pain Medicine and former member of the Board of Directors for the Society of Pediatric Anesthesia. “Pediatric anesthesiologists are experts in caring for children of all ages undergoing anesthesia and are skilled in treating this condition.”

Some children may also wake up crying, agitated, or delirious after anesthesia, depending in part on age, development, and the type of surgery, Dr. Agarwal said. Managing these symptoms may include medications, darkened, quiet spaces, and being with parents or caregivers, but often it is just a matter of time until the effects wear off.

With local anesthesia, whether injected or applied topically, the most common complication is Local Anesthesia Systemic Toxicity (LAST), Dr. Agarwal said. “Local anesthesia can be absorbed into the blood, and LAST can occur if too much local anesthesia is administered,” she explained. “Patients can develop irritability, and those who are old enough can complain about funny tastes in their mouth, dizziness, ringing in their ears, or other uncomfortable sensations; some may even state that they feel like they are going to die,” she said. If left untreated, LAST can result in seizures, cardiac arrhythmias, and death, she added.

Another side effect, methemoglobinemia, can occur with any local anesthetic as a result of too much of a topical local anesthetic (such as EMLA) or the local anesthetic left on for too long, Dr. Agarwal said. To prevent these complications, it is critical to calculate the toxic level dose of any local anesthesia that will be used for a pediatric procedure, she said.

In some procedures, including dermatologic procedures performed in areas around the face and neck, intubation may be needed, but use also varies among physicians and according to the procedure, size, type, and location of a lesion, and the patient’s medical history and condition, she said. Some physicians opt for intubation if electrosurgery (Bovie) is being used near the face and the patient is receiving oxygen, she added.

General anesthesia for pediatric procedures can be provided in office settings as well as hospital operating rooms or surgical centers, and the American Society of Anesthesiologists offers guidelines for safe office-based anesthesia, and many states have additional rules and regulations for anesthesia performed in an office setting; many groups and individual anesthesiologists provide these services, Dr. Agarwal noted.

The American Academy of Pediatrics also offers guidelines for the safe provision of sedation and anesthesia to children, she said.

Additional DermWorld Resources