, I

Pain Management forDermatologic Laser Surgery:A Nursing PerspectiveKathryn HuberLouisa HubandTina Alster

Pain after laser surgery is one ofthe most commonly experiencedpatient problems. It is a pervasive partof laser treatment and a problem withwhich nurses and physicians areexpected to deal. The nurse's mostimportant role is preoperative patientteaching. Prior to undergoing the pre-scribed treatment, patients must havearealistic understanding of the laser pro-cedure, including the expected sensa-tions associated with the surgery.Educationwill not only correct miscon-ceptions and reduce anxiety, but willalso allow patients to play an active rolein their surgery and to optimize fullyfrom pain-reducing techniques andstrategies.

Kathryn Huber, BSN,RN, is a Nurse, TheWashington Institute of DerrnatologicLaser Surgery, Washington, DC.

Louisa Huband, BA, is a MedicalAssistant, The Washington Instituteof Dermatologic Laser Surgery,Washington, DC.

Tina Alster, MD, BSN, is Director, TheWashington Institute of DermatologicLaser Surgery, Washington, DC.

Pain after laser surgery is oneof the most commonly experi-enced patient problems. It is a per-vasive part of laser treatment anda problem with which nurses andphysicians are expected to deal.Interventions to deal with painduring laser treatment can be assimple as providing distractionand relaxation or as complicatedas requiring general sedation andanalgesia. The goal in laser painmanagement is to reduce the inci-dence and severity of patients'intraoperative and postoperativepain, to enhance patient comfortand satisfaction, and to contributeto fewer postoperative complica-tions. For this to be achieved, onemust employ both pharmacologicand nonpharmacologic interven-tions. The challenge for nurses isto balance pain control with con-cern for patient safety due to med-ication side effects.

Pain Management withPulsed Dye and Q-SwitchedLasers

Because laser treatment ofcutaneous lesions is associatedwith the production of heat, painand temperature nerve endingsare activated, resulting in discom-fort to the patient. The magnitudeof this discomfort is variable, sothe method chosen for intraopera-

DERMATOLOGY NURSING/December 1998Nol. 101No. 6

tive pain management should beindividualized. The lasers specifi-cally designed to treat vascular,pigmented, and tattooed cuta-neous lesions usually do notrequire anesthesia (Alster, 1997a;1997b). The "snapping sensation"associated with the pulsed-dyelaser and the Q-switched (QS)ruby, alexandrite, and Nd:YAGlasers can be tolerated by mostadult patients. However, when thetreatment area is large or in a par-ticularly sensitive area (for exam-ple, periorbital region, upper lip,nose, fingertip), or when thepatient is a child, intravenoussedation, intralesional injections,or topical anesthesia may berequired.

Intravenous or general anesthe-sia are anesthetic modalities that areeffectivein minimizing the pain anddiscomfort associated with lasertreatment with only minimal seque-lae (Grevelink, White, Bonoan, &Denman, 1997). The use of generalor intravenous anesthesia allowstreatment of a larger surface areawithout having the additional taskof quieting an agitated youngerchild. Intravenous sedation and gen-eral anesthesia require administra-tion by a certified nurse anesthetistor anesthesiologist and necessitatesmonitoring of heart rate, blood pres-sure, and pulse oximetry. Recovery

427

time after laser surgery is prolonged, when compared to topical or intrale-, ~ional anesthesia and there are, ofcourse, risks associatedwith the useof systemic anesthetics. Althoughlaser treatment in children withoutgeneral anesthesia is often difficult,it is certainly possible (and prefer-able) to general anesthesia if thephysician and laser nurse have

,enough patience and allow ade-quate time for each session.

Topical lidocaine is effective indecreasing the subjective assess-ment of pain and can easily beadministered by the attendantnurse (Alster, 1997b; Ashinoff &Geronemus, 1990). Patients whomay necessitate topical lidocaineare children between the ages of 2to 12 years, patients with low toler-ance to pain, and patients who maybecome anxious before or duringthe procedure (Tan & Stafford,1992). If the patient desires intrale-sional or topical lidocaine, thenurse should instruct the patient toarrive one-half hour before his orher scheduled procedure. Thisallows ample time to either injectthe area or to apply a topical anes-thetic and allow it to take effect.Topical lidocaine does not provide100% analgesia, but can reduce thediscomfort and allow the patient totolerate therapy relatively comfort-ably (Rabinowitz & Esterly, 1992).Care must be taken to avoid eyeexposure to the cream, since it maycause severe irritation and burning,but no permanent ocular damagehas been observed. Percutaneousabsorption of lidocaine is not typi-cally a problem even with its topi-cal application over a large bodysurface area, except in instanceswhere there are metabolic distur-bances known to be present in thepatient (for example, methemoglo-binemia) who is receiving a prilo-caine-containing compound (forexample, EMLA). Exacerbation ofunderlying methemoglobinemia(or other disease) may, therefore, beavoided.

Patient education regardingintraoperative and postoperativepain should be provided prior tothe procedure. The patientshould be informed that the lasertreatment produces a sensation

428

similar to that of a "snapping rub-ber band" or "hot grease" hittingthe skin and that the area mayfeel like a sunburn. A small,high-powered fan should beheld six inches from the treat-ment site throughout the proce-dure to help minimize theburning sensation. Preoper-ative teaching is a simple non-pharmacologic method thatwill increase the patient'sunderstanding of the proce-dure, reduce anxiety, and mini-mize the risk of intraoperativeand postoperative complica-tions. When treating a youngchild, the sensation of heat andthe bright flash of the laser maybe upsetting, and limit thechild's ability to stay still. Evenwhen complete local analgesiahas been achieved, the nursemay need to restrain small chil-dren during the procedurewhich may lead to a particular-ly unsatisfactory experience forthe patient, the parent, andthose providing the treatment(Epstein, Halmi, & Lask, 1995).

Intraoperatively, the use ofother non pharmacologic inter-ventions will also reduce stressand pain. Relaxation tech-niques such as slow, deepbreathing, guided imagery, orthe presence of a significantother promote a sense of con-trol and reduce anxiety.Distraction can also be used byhaving the patient count thelaser pulses backward and for-ward to 20 throughout the pro-cedure. This also gives thepatient a sense of controlthroughout the procedure andbreaks the session into manage-able "segments." Giving thepatient a sense of control candecrease patient anxiety andobjective measurements ofpain.

Additional pain relief is nottypically necessary followingtreatment with the pulsed-dyeand Q-switched laser systems.The patient may be instructedpostoperatively to apply ice tothe treated area and to takeacetaminophen every 4 to 6hours as needed for pain.

Pain Management with theErbium:YAG and CarbonDioxide Lasers

While excellent clinicalresults have been achieved aftereither carbon dioxide (C02)' orerbium:YAG laser resurfacing,pain 'control is more difficult toachieve. A full-face laser proce-dure typically requires intra-venous sedation by a nurse anes-thetist or anesthesiologist toachieve an adequate level of com-fort during the surgery (Alster &Apfelberg, 1998). Facial and intra-oral nerve blocks are administeredby the anesthetist or attendantphysician to temporarily blocktransmission of pain and sensoryimpulses. These nerve blocks arean invaluable means of establish-ing field blocks in a comfortableand easily tolerated manner(Bisaccia, Scarborough, &Shumaker, 1997)

If the patient is having region-al facial areas (for example, peri-orbital or perioral units) resur-faced or elects not to undergointravenous sedation, the nurseshould monitor his or her level ofpain intraoperatively and offer anoral sedative and analgesic if nec-essary. Relatively short-actingsedatives and analgesics, such asValium®, Versed®, clonidine, andDemerol® are recommended.

The nurse should provideemotional support to the patientthroughout the procedure as well.Again, it is important to stress theneed for preoperative teaching bythe nurse. If the patient is pre-pared for what the procedureentails and how he or she will feelduring the postoperative period,anxiety and postoperative compli-cations will be decreased (Formica& Alster, 1997).

Immediately following a full-face laser procedure, the patientmay awake from anesthesia with a"hot, burning" sensation to theface. Applying ice packs or coldcompresses will help to alleviatethis pain along with additional oralpain medications (for example,Lortab®, Toradol®, Demerol, oxy-codone, Tylenol with Codeine®) ifnecessary. It is important that the

DERMATOLOGY NURSING/December 1998Nol. 10/No. 6

nurse remain with the patient at all,jimes during the recovery periodnot only to ensure adequate post-operative supervision (for exam-ple, monitoring blood pressure,heart rate, oxygenation status), butalso to provide reassurance and tocreate a calm environment so as todecrease patient anxiety as he orshe awakens. To promote comfort

.and relaxation, the patient shouldbe placed under a heated blanketand assume a comfortable posi-tion. The patient is reminded thatpostoperative pain is expected andthat analgesics should reduce painto a tolerable level, but not neces-sarily eliminate it altogether. Thepatient should be asked to rate hisor her pain on a scale of 1 to 10(with 10 being most severe) andalso be monitored for nonverbalexpressions of pain.

Once the patient returnshome, he or she is instructed toapply ice packs or cold compress-es to the face consistently for thefirst 72 hours and to keep the headelevated. Analgesics are takenevery 4 to 6 hours for pain and asleeping medication may be pre-scribed. The patient should beinstructed to take an oral analgesicbefore the pain becomes severe inorder to maintain better pain con-trol and promote patient participa-tion in postoperative care.

ConclusionThe pharmacologic approach

to laser surgery is shaped by boththe needs of an individual patientand the type of laser procedure tobe performed. Dermatologic laserprocedures require a managementplan that may include both drugand non drug approaches. Whenplanning the management of pro-cedure-related pain and anxiety, aseries of questions/issues shouldbe 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?

The nurse's most importantrole is preoperative patient teach-ing. Prior to undergoing the pre-scribed treatment, the patientmust have a realistic understand-ing of the laser procedure, includ-ing the expected sensations associ-ated with the surgery. Appropriatepatient participation in post-oper-ative care and pain managementshould be emphasized. Thepatient should receive both writ-ten as well as verbal instructionsand be given the opportunity tospeak with another patient whohas undergone the procedure.Education will not only correctmisconceptions and reduce anxi-ety, but will also allow the patientto play an active role in his or hersurgery and to optimize fully frompain-reducing techniques andstrategies.D

ReferencesAlster, T.S. (1997a). The essential guide to

cosmetic laser surgery. New York:Alliance Publishing.

Alster, T.S. (1997b). Manual of cutaneouslaser techniques. Philadelphia:Lippincott-Raven Publishers.

Alster, T.S., & Apfelberg, D.B. (199S).Cosmetic laser surgery (2nd ed.). NewYork: John Wiley & Sons, Inc.

Ashinoff, R, & Geronemus, RG. (1990).Effect of the topical anesthetic EMLAon the efficacy of pulsed dye lasertreatment of port-wine stains. Journalof Dermatologic Surgery andOncology, 16, 100S-1011.

Bisaccia, E., Scarborough, D.A., &Shumaker, B. (1997). Intraoral nerveblocks. Cosmetic Dermatology, 10, S-10.

Epstein, R.H., Halmi, B., & Lask, G. (1995).Anesthesia for cutaneous laser thera-py. Clinics in Dermatology, 13,21-24.

Formica, K., & Alster, T.S. (1997).Cutaneous laser resurfacing: a nurs-ing guide. Dermatology Nursing, 9(1),19-22.

Grevelink, ].M., White, V.R, Bonoan, R, &Denman, w.T. (1997). Pulsed lasertreatment in children and the use ofanesthesia. Journal of the AmericanAcademy of Dermatology, 37, 75-S1.

Rabinowitz, L.G., & Esterly, N.B. (1992).Anesthesia and/or sedation forpulsed dye laser therapy. PediatricDermatology, 9, 132-153.

Tan, O.T., & Stafford, T.J. (1992). EMLA forlaser treatment of portwine stains inchildren. Lasers in Surgery andMedicine, 12, 543-54S.

DERMATOLOGY NURSING/December 1998NoI.10/No. 6

Heparin-Induced SkinNecrosiscontinued from page 423

Mar, A., Dixon, B., Ibraham, K., & Parkin, J.(1995). Skin necrosis following sub-cutaneous heparin injection.Australian Journal of Dermatology,31l(4), 201-203.

O'Toole, R (1973). Heparin: Adverse reac-tion. 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 lesionsinduced by low molecular weightheparin after total knee arthroplasty.Archives of Orthopaedic &' TraumaSurgery, 116(67), 443-445.

Real, E., Graau, E., Rubio M., & Torrecilla,T. (1995). Skin necrosis after subcuta-neous low molecular weight heparininjection. American Journal ofHematology, 49, 253-254.

Scully, R, Mark, E., McNeely ,w., &McNeely, B. (19S9). A 71 year oldman with thrombocytopenia andhypotension after resection of a coloncarcinoma: Case 49-19S9, caserecords of the Massachusetts GeneralHospital. New England Journal ofMedicine, 321(23), 1595.

Shahak, A., Posan, E., Szucs, G., & Boda, Z.(1996). Coumadin induced skinnecrosis following heparin inducedthrombocytopenia and thrombosis: Acase report. Angiology, 47(7), 725-727.

Tonn, M., Schaiff, R, & Kolief, M. (1997).Enoxaparin associated dermal necro-sis: A consequence of cross reactivitywith heparin mediated antibodies.Annals of Pharmacotherapy, 31(3),323-326.

Reprints Available

Reprints of all DermatologyNursing articles-past, present,and future-are available inquantities of 100 or more.

For more information,contact: Dermatology Nursing,East Holly Avenue Box 56,Pitman, NJ 08071; (609) 256-2300; E-mail:dnjrnl@mail.ajj.com

429