Pain Management for Dermatologic Laser Surgery: A Nursing

, I
Pain Management for
Dermatologic Laser Surgery:
A Nursing Perspective
Kathryn Huber
Louisa Huband
Tina Alster
Pain after laser surgery is one of
the most commonly experienced
patient problems. It is a pervasive part
of laser treatment and a problem with
which nurses and physicians are
expected to deal. The nurse's most
important role is preoperative patient
teaching. Prior to undergoing the prescribed treatment, patients must havea
realistic understanding of the laser procedure, including the expected sensations associated with the surgery.
Education will not only correct misconceptions and reduce anxiety, but will
also allow patients to play an active role
in their surgery and to optimize fully
from pain-reducing techniques and
strategies.
Kathryn Huber, BSN, RN, is a Nurse, The
Washington Institute of Derrnatologic
Laser Surgery, Washington, DC.
Louisa Huband, BA, is a Medical
Assistant, The Washington Institute
of Dermatologic
Laser Surgery,
Washington, DC.
Tina Alster, MD, BSN, is Director, The
Washington Institute of Dermatologic
Laser Surgery, Washington, DC.
DERMATOLOGY
NURSING/December
Pain after laser surgery is one
of the most commonly experienced patient problems. It is a pervasive part of laser treatment and
a problem with which nurses and
physicians are expected to deal.
Interventions to deal with pain
during laser treatment can be as
simple as providing distraction
and relaxation or as complicated
as requiring general sedation and
analgesia. The goal in laser pain
management is to reduce the incidence and severity of patients'
intraoperative and postoperative
pain, to enhance patient comfort
and satisfaction, and to contribute
to fewer postoperative complications. For this to be achieved, one
must employ both pharmacologic
and nonpharmacologic interventions. The challenge for nurses is
to balance pain control with concern for patient safety due to medication side effects.
Pain Management with
Pulsed Dye and Q-Switched
Lasers
Because laser treatment of
cutaneous lesions is associated
with the production of heat, pain
and temperature nerve endings
are activated, resulting in discomfort to the patient. The magnitude
of this discomfort is variable, so
the method chosen for intraopera-
1998Nol. 101No. 6
tive pain management should be
individualized. The lasers specifically designed to treat vascular,
pigmented, and tattooed cutaneous lesions usually do not
require anesthesia (Alster, 1997a;
1997b). The "snapping sensation"
associated with the pulsed-dye
laser and the Q-switched (QS)
ruby, alexandrite, and Nd:YAG
lasers can be tolerated by most
adult patients. However, when the
treatment area is large or in a particularly sensitive area (for example, periorbital region, upper lip,
nose, fingertip), or when the
patient is a child, intravenous
sedation, intralesional injections,
or topical anesthesia may be
required.
Intravenous or general anesthesia are anesthetic modalities that are
effectivein minimizing the pain and
discomfort associated with laser
treatment with only minimal sequelae (Grevelink, White, Bonoan, &
Denman, 1997). The use of general
or intravenous anesthesia allows
treatment of a larger surface area
without having the additional task
of quieting an agitated younger
child. Intravenous sedation and general anesthesia require administration by a certified nurse anesthetist
or anesthesiologist and necessitates
monitoring of heart rate, blood pressure, and pulse oximetry. Recovery
427
time after laser surgery is prolonged
, when compared to topical or intrale, ~ional anesthesia and there are, of
course, risks associated with the use
of systemic anesthetics. Although
laser treatment in children without
general anesthesia is often difficult,
it is certainly possible (and preferable) to general anesthesia if the
physician and laser nurse have
,enough patience and allow adequate time for each session.
Topical lidocaine is effective in
decreasing the subjective assessment of pain and can easily be
administered by the attendant
nurse (Alster, 1997b; Ashinoff &
Geronemus, 1990). Patients who
may necessitate topical lidocaine
are children between the ages of 2
to 12 years, patients with low tolerance to pain, and patients who may
become anxious before or during
the procedure (Tan & Stafford,
1992). If the patient desires intralesional or topical lidocaine, the
nurse should instruct the patient to
arrive one-half hour before his or
her scheduled procedure. This
allows ample time to either inject
the area or to apply a topical anesthetic and allow it to take effect.
Topical lidocaine does not provide
100% analgesia, but can reduce the
discomfort and allow the patient to
tolerate therapy relatively comfortably (Rabinowitz & Esterly, 1992).
Care must be taken to avoid eye
exposure to the cream, since it may
cause severe irritation and burning,
but no permanent ocular damage
has been observed. Percutaneous
absorption of lidocaine is not typically a problem even with its topical application over a large body
surface area, except in instances
where there are metabolic disturbances known to be present in the
patient (for example, methemoglobinemia) who is receiving a prilocaine-containing compound (for
example, EMLA). Exacerbation of
underlying methemoglobinemia
(or other disease) may, therefore, be
avoided.
Patient education regarding
intraoperative and postoperative
pain should be provided prior to
the procedure.
The patient
should be informed that the laser
treatment produces a sensation
428
similar to that of a "snapping rubber band" or "hot grease" hitting
the skin and that the area may
feel like a sunburn. A small,
high-powered
fan should be
held six inches from the treatment site throughout the procedure to help minimize
the
burning
sensation.
Preoperative teaching is a simple nonpharmacologic
method
that
will increase
the patient's
understanding
of the procedure, reduce anxiety, and minimize the risk of intraoperative
and postoperative
complications. When treating a young
child, the sensation of heat and
the bright flash of the laser may
be upsetting,
and limit the
child's ability to stay still. Even
when complete local analgesia
has been achieved, the nurse
may need to restrain small children during
the procedure
which may lead to a particularly unsatisfactory experience for
the patient, the parent, and
those providing the treatment
(Epstein, Halmi, & Lask, 1995).
Intraoperatively, the use of
other non pharmacologic interventions will also reduce stress
and pain. Relaxation
techniques such as slow, deep
breathing, guided imagery, or
the presence of a significant
other promote a sense of control
and
reduce
anxiety.
Distraction can also be used by
having the patient count the
laser pulses backward and forward to 20 throughout the procedure. This also gives the
patient
a sense of control
throughout the procedure and
breaks the session into manageable "segments."
Giving the
patient a sense of control can
decrease patient anxiety and
objective
measurements
of
pain.
Additional pain relief is not
typically necessary following
treatment with the pulsed-dye
and Q-switched laser systems.
The patient may be instructed
postoperatively to apply ice to
the treated area and to take
acetaminophen
every 4 to 6
hours as needed for pain.
DERMATOLOGY
Pain Management with the
Erbium:YAG and Carbon
Dioxide Lasers
While
excellent
clinical
results have been achieved after
either carbon dioxide (C02)' or
erbium:YAG laser resurfacing,
pain 'control is more difficult to
achieve. A full-face laser procedure typically requires intravenous sedation by a nurse anesthetist or anesthesiologist
to
achieve an adequate level of comfort during the surgery (Alster &
Apfelberg, 1998). Facial and intraoral nerve blocks are administered
by the anesthetist or attendant
physician to temporarily block
transmission of pain and sensory
impulses. These nerve blocks are
an invaluable means of establishing field blocks in a comfortable
and easily tolerated manner
(Bisaccia,
Scarborough,
&
Shumaker, 1997)
If the patient is having regional facial areas (for example, periorbital or perioral units) resurfaced or elects not to undergo
intravenous sedation, the nurse
should monitor his or her level of
pain intraoperatively and offer an
oral sedative and analgesic if necessary. Relatively short-acting
sedatives and analgesics, such as
Valium®, Versed®, clonidine, and
Demerol® are recommended.
The nurse should provide
emotional support to the patient
throughout the procedure as well.
Again, it is important to stress the
need for preoperative teaching by
the nurse. If the patient is prepared for what the procedure
entails and how he or she will feel
during the postoperative period,
anxiety and postoperative complications will be decreased (Formica
& Alster, 1997).
Immediately following a fullface laser procedure, the patient
may awake from anesthesia with a
"hot, burning" sensation to the
face. Applying ice packs or cold
compresses will help to alleviate
this pain along with additional oral
pain medications (for example,
Lortab®, Toradol®, Demerol, oxycodone, Tylenol with Codeine®) if
necessary. It is important that the
NURSING/December
1998Nol. 10/No. 6
nurse remain with the patient at all
,jimes during the recovery period
not only to ensure adequate postoperative supervision (for example, monitoring blood pressure,
heart rate, oxygenation status), but
also to provide reassurance and to
create a calm environment so as to
decrease patient anxiety as he or
she awakens. To promote comfort
.and relaxation, the patient should
be placed under a heated blanket
and assume a comfortable position. The patient is reminded that
postoperative pain is expected and
that analgesics should reduce pain
to a tolerable level, but not necessarily eliminate it altogether. The
patient should be asked to rate his
or her pain on a scale of 1 to 10
(with 10 being most severe) and
also be monitored for nonverbal
expressions of pain.
Once the patient returns
home, he or she is instructed to
apply ice packs or cold compresses to the face consistently for the
first 72 hours and to keep the head
elevated. Analgesics are taken
every 4 to 6 hours for pain and a
sleeping medication may be prescribed. The patient should be
instructed to take an oral analgesic
before the pain becomes severe in
order to maintain better pain control and promote patient participation in postoperative care.
Conclusion
The pharmacologic approach
to laser surgery is shaped by both
the needs of an individual patient
and the type of laser procedure to
be performed. Dermatologic laser
procedures require a management
plan that may include both drug
and non drug approaches. When
planning the management of procedure-related pain and anxiety, a
series of questions/issues should
be addressed with the patient.
1. Why is the procedure being
performed?
2. What is the expected intensity
of pain?
3. What is the expected duration
of pain?
4. What is the expected intensity
of anxiety?
5. How often will the procedure
need to be repeated?
DERMATOLOGY
NURSING/December
The nurse's most important
role is preoperative patient teaching. Prior to undergoing the prescribed treatment, the patient
must have a realistic understanding of the laser procedure, including the expected sensations associated with the surgery. Appropriate
patient participation in post-operative care and pain management
should be emphasized.
The
patient should receive both written as well as verbal instructions
and be given the opportunity to
speak with another patient who
has undergone the procedure.
Education will not only correct
misconceptions and reduce anxiety, but will also allow the patient
to play an active role in his or her
surgery and to optimize fully from
pain-reducing techniques and
strategies.D
References
Alster, T.S. (1997a). The essential guide to
cosmetic laser surgery. New York:
Alliance Publishing.
Alster, T.S. (1997b). Manual of cutaneous
laser
techniques.
Philadelphia:
Lippincott-Raven Publishers.
Alster, T.S., & Apfelberg, D.B. (199S).
Cosmetic laser surgery (2nd ed.). New
York: John Wiley & Sons, Inc.
Ashinoff, R, & Geronemus, RG. (1990).
Effect of the topical anesthetic EMLA
on the efficacy of pulsed dye laser
treatment of port-wine stains. Journal
of
Dermatologic
Surgery
and
Oncology, 16, 100S-1011.
Bisaccia,
E., Scarborough,
D.A., &
Shumaker, B. (1997). Intraoral nerve
blocks. Cosmetic Dermatology, 10, S10.
Epstein, R.H., Halmi, B., & Lask, G. (1995).
Anesthesia for cutaneous laser therapy. Clinics in Dermatology, 13,21-24.
Formica,
K., & Alster,
T.S. (1997).
Cutaneous laser resurfacing: a nursing guide. Dermatology Nursing, 9(1),
19-22.
Grevelink, ].M., White, V.R, Bonoan, R, &
Denman, w.T. (1997). Pulsed laser
treatment in children and the use of
anesthesia. Journal of the American
Academy of Dermatology, 37, 75-S1.
Rabinowitz, L.G., & Esterly, N.B. (1992).
Anesthesia
and/or
sedation
for
pulsed dye laser therapy. Pediatric
Dermatology, 9, 132-153.
Tan, O.T., & Stafford, T.J. (1992). EMLA for
laser treatment of portwine stains in
children.
Lasers in Surgery and
Medicine, 12, 543-54S.
1998NoI.10/No.
6
Heparin-Induced Skin
Necrosis
continued from page 423
Mar, A., Dixon, B., Ibraham, K., & Parkin, J.
(1995). Skin necrosis following subcutaneous
heparin
injection.
Australian Journal of Dermatology,
31l(4), 201-203.
O'Toole, R (1973). Heparin: Adverse reaction. Annals of Internal Medicine, 73,
759.
Pharmacia & Upjohn Company (1996).
Heparin
sodium injection,
USP.
Package Insert. Kalamazoo, Michigan.
Plath, J., Schulze, R, Barz, D., Krammer,
B., Steiner, M., Anders, 0., & Mach, J.
(1997). Necrotizing
skin lesions
induced by low molecular weight
heparin after total knee arthroplasty.
Archives of Orthopaedic &' Trauma
Surgery, 116(67), 443-445.
Real, E., Graau, E., Rubio M., & Torrecilla,
T. (1995). Skin necrosis after subcutaneous low molecular weight heparin
injection.
American
Journal
of
Hematology, 49, 253-254.
Scully, R, Mark, E., McNeely ,w., &
McNeely, B. (19S9). A 71 year old
man with thrombocytopenia
and
hypotension after resection of a colon
carcinoma:
Case 49-19S9,
case
records of the Massachusetts General
Hospital. New England Journal of
Medicine, 321(23), 1595.
Shahak, A., Posan, E., Szucs, G., & Boda, Z.
(1996). Coumadin
induced
skin
necrosis following heparin induced
thrombocytopenia and thrombosis: A
case report. Angiology, 47(7), 725727.
Tonn, M., Schaiff, R, & Kolief, M. (1997).
Enoxaparin associated dermal necrosis: A consequence of cross reactivity
with heparin mediated antibodies.
Annals of Pharmacotherapy, 31(3),
323-326.
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