Pre-Surgery Pain Management
While most dermatology procedures are short, minimally invasive, and low risk, others are more extensive and put patients at a higher risk for pain, such as excisions, skin grafting, or resurfacing. Although more studies are needed on how surgery site, size of defect, amount of wound tension, and type of closure affect APSP, clinicians can assess other risk factors to identify patients at high risk for pain. These include women and younger patients (especially those <31 years of age). Other factors that predict postsurgical pain severity are obesity, a tendency towards pain catastrophizing, a history of depression, regular opioid or anxiolytic use, or a history of an underlying hyperalgesia syndrome (such as fibromyalgia or complex regional pain syndrome).
Monitoring pain before and after treatment (especially pain that occurs while the patient is moving) is crucial for indentifying the effectiveness of pain treatment, promoting activity after surgery, and for reducing complications.
Educating patients about APSP with videos or audio-accompanied slides also improves patient attitudes towards APSP.
Pain Management During Surgery
When choosing what kind of local anesthesia to administer, both the patient’s individual characteristics as well as the objective of the anesthesia should be considered. In procedures with a low risk for APSP, an anesthetic with a short half-life such as lidocaine may be preferable; a procedure with high risk for APSP may require an anesthetic with a long half-life such as bupivacaine.
Other than screening by age and weight, specific patient characteristics to watch out for include patients with high-risk cardiac disease or who are taking medications such as beta-adrenergic blockers, digitalis preparations, calcium channel blockers, and phenylephrine. The use of less cardiotoxic anesthetics that have a short onset time and intermediate duration, such as lidocaine, mepivacaine, or a regional nerve block, should be considered in these patients to avoid cardiac arrhythmias and hypotension. Anesthesia in patients with liver disease should be reduced by ≤50% or an alternative method such as a nerve block should be used to minimize the risk of liver toxicity.