๐ ็ธฝ็ฎ้ ๏ฝ ๐ ่ฑๆๅๆ๏ผๆฌ็ฏ๏ผ ๏ฝ ๐ ๅฎๆด็ฟป่ญฏ ๏ฝ โญ ็ฒพ่ฏ็ญ่จ
Pain
Pain
The majority of healthy patients who undergo MMS experience mild to moderate postprocedure pain.86 A study of 433 MMS cases demonstrated that postoperative pain was the greatest on the day of surgery and associated most strongly with flap repairs, age less than 66 years, greater number of lesions treated, and the use of narcotics for pain relief.87 Longer-lasting LAs, particularly 0.5% bupivacaine, can be injected into the surgical site to achieve extended postoperative anesthesia. Bupivacaine has an anesthesia onset of greater than 5 minutes and duration of 4 to 6 hours, compared to lidocaine, which works in less than 2 minutes and lasts 1 to 2 hours. It is important to note that bupivacaine injected without preanesthesia with lidocaine may be painful.88 Nerve blocks can be utilized as an alternative, or, in addition to, infiltrative anesthesia for procedures on the face, hands, feet, and digits. Nerve blocks have the benefit of decreasing tissue swelling/distortion, prolonging anesthesia, and reducing postoperative discomfort for the patient.37 For a detailed discussion of nerve block options, see Chapter 12.
Management of postoperative pain with analgesics is an important consideration in dermatologic surgery. Studies have shown that a preventive, single dose of acetaminophen โค1 g, ibuprofen 400 mg, diclofenac 50 mg, or etoricoxib 120 mg immediately after surgery reduces postoperative pain and opioid use.89,90 Options for postoperative pain control include cold analgesia with ice or gel cold packs at the surgical site, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, or combination therapy.91 Acetaminophen remains the mainstay of pain management for minor dermatologic procedures. Doses of 500 mg to 1 g provide significant improvement in mild to moderate pain over 4 to 6 hours, up to a maximal daily dose of 3 g.92 At high doses of acetaminophen, rare side effects include liver failure and StevensโJohnson syndrome. Because of risks of bleeding and hepatorenal syndrome, acetaminophen at a maximum daily dose of 2 g/day is the preferred analgesic in patients with advanced liver disease.93 NSAIDS, such as ibuprofen, ketorolac, naproxen,
celecoxib, and etoricoxib, are also commonly used to treat mild postoperative pain. Risks include impairment of renal perfusion, exacerbations of pre-existing renal dysfunction, weakening of gastric mucosa resulting in bleeding or perforation, worsening of underlying conditions such as hypertension, and induction of lifethreatening hepatorenal syndrome in patients with cirrhosis.91
A common concern in dermatologic surgery is the effect of NSAIDs on hemostasis in the perioperative period. While it has been shown that NSAIDs do indeed increase bleeding time, the elevations are mostly within the normal range and last only hours.94 A case series found that, in individuals taking aspirin or NSAIDs after cutaneous surgery, postoperative bleeding could not be attributed to either medication.95 Research in the field of otolaryngology has demonstrated that the postoperative use of ibuprofen does not cause greater bleeding complications compared to acetaminophen.96 Thus, the use of NSAIDS after dermatologic procedures likely confers a low risk for bleeding complications. A 2011 randomized controlled trial showed that the combination of acetaminophen 1000 mg and ibuprofen 400 mg offers superior pain control compared with acetaminophen alone when given immediately postsurgery and every 4 hours thereafter for โค4 doses after MMS.97
Despite these favorable outcomes, some patients may still require opioid analgesics to control postoperative pain. Opioids are considered second-line therapy due to their adverse effect profile including nausea, constipation, and respiratory distress. Another potential risk of utilizing opioids for acute pain management is that regular use for as little as 1 week can result in dependence and withdrawal.91 Either manufactured or a-lacarte combination regimens including both an opioid (codeine, hydrocodone, or oxycodone) and nonopioid (acetaminophen, ibuprofen, or aspirin) analgesic are commonly used.