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Table 7 Patient management in the operating theater

From: Multicentre consensus recommendations for skin care in inherited epidermolysis bullosa

Procedure

Measures to be adopted

Operating table

• Place an anti-decubitus mattress and cushion on the table

• Use the sheet to lift the infant and move him/her to the operating table; older patients should move themselves

• Pad trauma-exposed sites (e.g. chin, occiput, elbows, heel, hands, feet)

Premedication

• Administer oral premedication 45 minutes prior surgery in order to reduce/prevent:

Patient anxiety (midazolam 0.5 mg/kg)

Oral secretion (atropine 40 mcg/kg)

Gastro-esophageal reflux (ranitidine 1 mg/kg)

Vomiting (metoclopramide 150 mcg/kg)

• Prefer intravenous induction in presence of intravenous line, otherwise inhalational anaesthesia. In the latter case, protect the face from the mask with silicon foam (e.g. Mepilex®) or a water-based lubricant.

• Protect the eyes with a moisturizing ophthalmologic gel and the eyelids with moistened gauzes

Patient monitoring

• Use tape with a silicon contact layer (Mepitac®) to fixe all tubes (e.g. endotracheal tube) and catheters

• Lubricate all tubes with a water-based lubricant

• Remove the adhesive part of electrodes allowing only the lubricated central portion to be in contact with the skin; then secure with a non adhesive dressing (e.g. Mepilex ®)

• Use clip sensors for pulse oximetry

• Use a lubricated disposable thermometer

• Pad the skin with cotton or advanced dressings under the blood pressure cuff

• Use bipolar diathermy to avoid a monopolar pad

• Avoid carefully all kinds of trauma and friction for the entire duration of surgery

Intubation

• Evaluate microstomia, esophageal strictures and prominent incisors in RDEB* patients who need intubation

• Prefer fiberoptic-assisted intubation to laryngoscopy in case of difficult intubation

Recovery room

• Administer a moderate sedation before emergence to avoid cutaneous lesions due to irritability

• Perform tracheal aspiration gently using soft and small tubes

  1. *RDEB, recessive dystrophic epidermolysis bullosa.