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Key Points

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  1. Procedural analgesia and sedation are both safe and applicable to office setting surgical procedures in children as long as support personnel are appropriately trained and monitoring and resuscitation equipment is available.

  2. Emergent and scheduled surgical procedures are both amenable to an office location site. Incision and drainage of a superficial abscess is a common such procedure.

  3. Infection drainage is best accompanied with enteral antibiotic therapy in the face of local cellulitis and even lymphangitis; however, when proximal lymphadenitis is present, parenteral antibiotics are indicated.

  4. In the presence of a truncal or extremity penetrating/puncture wound in a child, a retained foreign body should be suspected and excluded.

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Introduction

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Many commonly encountered minor pediatric surgical problems can be diagnosed and treated in the pediatric surgeon's office. The office setting is ideal for the management of such problems and there has been substantial growth of office-based surgery in recent years. The reasons for this include patient satisfaction, surgeon convenience, and cost savings. Certain preparations are required to facilitate office procedures, including training of office staff, making available appropriate surgical instruments, and provision of suitable analgesia.

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Sedation and Analgesia in the Office Setting

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Provision of safe and effective anxiolysis and pain control during procedures for children in the ambulatory setting is a challenge for the surgeon, which may effectively limit the spectrum of procedures that can be provided in the surgical clinic. A variety of methods should be considered as possible solutions.

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Topical Anesthesia

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Clinical experience with a variety of local anesthetic agents applied topically to reduce discomfort during painful procedures in children has demonstrated efficacy during venipuncture and intravenous (IV) cannulation. In our clinic, we have noted a substantial reduction in discomfort when topical anesthetics are used prior to tissue infiltration with local anesthetics. Topical application of 2.5% lidocaine and 2.5% prilocaine cream (EMLA cream) has been used in clinical practice for more than 25 years. Efficacy is enhanced by application of a thick layer of cream for 60 to 90 minutes prior to the procedure, and this is facilitated by use of small occlusive dressing. Parents can be instructed to apply the medication to the anticipated wound site for up to 1 hour in advance of the procedure in infants up to 3 months and for up to 4 hours for older infants and children.

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Other topical anesthetic agents, including tetracaine (4%) gel and liposomal lidocaine (4%), have a more rapid onset of action, so, application time required is only 30 to 60 minutes.

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Other needle-free strategies for local anesthetic administration include a lidocaine/tetracaine topical patch with an integrated heating component, which accelerates penetration of local anesthetic agents through the stratum corneum. Iontophoresis allows an ionic form of a local anesthetic to be accelerated into the subcutaneous or submucosal tissue under the influence of low-voltage direct ...

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