Treatable Body

Surface Area (%)

Spectrum,

Total (nm)

Bandwidtha

(nm)

Peak

(nm)

Footprint

Irradiance

(mW/cm2

/nm)

Mean ± SD

Light Emitting

Diodes

NeoBLUE

Natus Medical, San Carlos, CA 30 100 420–450 20 462 30 ± 7

Fluorescent

BiliLite CW/BB

BiliLite BB

BiliLite TL52

BiliBed

Olympic Medical, San Carlos, CA

Olympic Medical, San Carlos, CA

Olympic Medical, San Carlos, CA

Medela,

McHenry, IL

45

45

45

0

100

100

100

71

380–720

400–550

400–626

400–560

69

35

69

80

578

445

437

450

8 ± 1

17 ± 2

19 ± 3

36 ± 2

Halogen

MiniBiliLite

Phototherapy Lite

Olympic Medical, San Carlos, CA

Philips Inc, Andover, MA

45

45

54

54

350–800

370–850

190

200

580

590

7 ± 5

5 ± 5

Halogen

fiberoptic

Biliblanket

Wallaby II Preterm

WallabyII Term

SpotLight 1000

PEP Model 2000

BiliSoft

Ohmeda,

Fairfield, CT

Philips, Inc, Andover, MA

Philips, Inc, Andover, MA

Philips, Inc, Andover, MA

PEP

Fryeburg, ME

GE Healthcare, Laurel, MD

0

0

0

45

23

0

24

19

53

54

100

71

390–600

400–560

400–560

400–560

400–717

400–670

70

45

45

45

63

40

533

513

513

513

445

453

20 ± 6

16 ± 6

8 ± 1

6 ± 3

28 ± 11

25 ± 16

a

Spectral bandwidth defined as the width of the emission spectrum in nm at 50% of peak light intensity.

From Bhutani VK, the Committee on Fetus and Newborn. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

Pediatrics. 2011;128:e1046.

 

a

Rhesus disease, perinatal asphyxia, hypoxia, acidosis, hypercapnia.

From Maisels MJ, Watchko JF. Treatment of jaundice in low birthweight infants.

Arch Dis Child Fetal Neonatal Ed. 2003;88:F459.

Chapter 49 ■ Phototherapy 359

b. The pad emits insignificant levels of heat, so it can

be placed in direct contact with the infant to deliver

up to 35 mW/cm2

/nm of spectral irradiance, mainly

in the blue–green range (16).

c. The orientation of the fiberoptic fibers determines

the uniformity of emission and is unique to each of

the commercially available devices.

d. The main advantages of these systems are that,

while receiving phototherapy, the infant can be held

and/or nursed, thereby minimizing infant–parent

separation. In addition, covering the infant’s eyes is

not necessary, preventing further parental anxiety.

e. The main disadvantage of the fiberoptic pads is that

they cover a relatively small surface area and, therefore, have less efficacy compared to overhead

sources. They should not be used as the sole means

of providing phototherapy in an infant with significant hyperbilirubinemia (1,2,11).

f. These devices are often used as an adjunct to conventional overhead application of phototherapy to

provide “double” phototherapy (circumferential

phototherapy), which has greater efficacy because

greater body surface area is exposed to the light

(10,16).

7. Gallium nitride light-emitting diodes (LEDs)

a. These systems are semiconductor phototherapy

devices capable of delivering high spectral irradiance levels of >200 μW/cm2

/nm with very little generation of heat within a very narrow emission spectrum in the blue range (460 to 485 nm), with low

infrared emission and no ultraviolet emission

(10,17,18).

b. LEDs have a longer lifetime (>20,000 hours) and

have become cost-effective for use in phototherapy

devices. LEDs and compact fluorescent tubes are

equally efficacious in the management of hyperbilirubinemia (19).

D. Technique (Conventional

Phototherapy)

Intensive phototherapy is defined as the use of light in the

430- to 490-nm band delivered at 30 mW/cm2

/nm or higher

to the greatest body surface area possible (1,10).

1. Position the phototherapy unit over the infant to obtain

desired irradiance (10 to 40 μW/cm2

/nm). The maximal amount of irradiance achieved by the standard

technique is generally 30 to 50 μW/cm2

/nm. The distance of the light from the infant has a significant effect

on the intensity of phototherapy, and to achieve maximal intensity, the lights should be positioned as close as

possible to the infant. Fluorescent tubes may be

brought within approximately 10 cm of term infants

Table 49.2 Phototherapy Devices Commonly Used in the United States, and Their

Performance Characteristics

Device Manufacturer

Distance to

Patient (cm)

 

Sepideh Nassabeh-Montazami

49 Phototherapy

Phototherapy is the most common therapeutic intervention

used for the treatment of hyperbilirubinemia (1).

Phototherapy causes three reactions: configurational and

structural isomerization of the bilirubin molecule and

photo-oxidation, leading to polar, water-soluble photoproducts that can be excreted in bile and urine without the need

for conjugation or further metabolism (2).

The aim of phototherapy is to reduce serum bilirubin

levels to decrease the risk of acute bilirubin encephalopathy

and the more chronic sequel of bilirubin toxicity, kernicterus (1). High-intensity phototherapy significantly reduces

the total serum bilirubin (TSB) and decreases the need for

exchange transfusion (3).

A. Indications

1. Clinically significant indirect hyperbilirubinemia.

Indications to start phototherapy in babies with hyperbilirubinemia vary depending on gestational age, birthweight, hours of life, presence of hemolysis, and other

risk factors such as acidosis and sepsis (1,4).

2. The TSB level must be considered when making the

decision to commence treatment, as there is significant

variability in laboratory measurement of direct bilirubin levels (5).

3. The American Academy of Pediatrics has published

clinical practice guidelines for phototherapy in

newborn infants at 35 weeks’ or more gestation (1)

(Fig. 49.1).

4. These guidelines do not apply to preterm infants <35

weeks’ gestation. Preterm infants are at higher risk of

developing hyperbilirubinemia compared to term

infants. Although guidelines have been proposed, the

decision to initiate phototherapy in this group of infants

remains variable and highly individualized (4,6)

(Table 49.1).

B. Contraindications

1. Congenital porphyria or a family history of porphyria is

an absolute contraindication to the use of phototherapy. Severe purpuric bullous eruptions have been

described in neonates with congenital erythropoietic

porphyria treated with phototherapy (7).

2. Concomitant use of drugs or agents that are photosensitizers is also an absolute contraindication (8).

3. Concurrent therapy with metalloporphyrin heme oxygenase inhibitors has been reported to result in mild

transient erythema (9).

 

4. Although infants with cholestatic jaundice may develop

the “bronze baby syndrome” when exposed to phototherapy (see H), the presence of direct hyperbilirubinemia is not considered to be a contraindication (1).

However, because the products of phototherapy are

excreted in the bile, the presence of cholestasis may

decrease the effectiveness of phototherapy.

C. Equipment

In order to have an understanding of the equipment available for phototherapy, it is necessary to be familiar with the

terminology involved (10).

1. Spectral qualities of the delivered light (wavelength

range and peak). Bilirubin absorbs visible light within

the wavelength range of 400 to 500 nm, with peak

absorption at 460 ± 10 nm considered to be the most

effective (2).

2. Irradiance (intensity of light), expressed as watts per

square centimeter (W/cm2

), refers to the number of

photons received per square centimeter of exposed

body surface area.

3. Spectral irradiance is irradiance that is quantitated

within the effective wavelength range for efficacy and is

expressed as mW/cm2

/nm. This is measured by various

commercially available radiometers. Specific radiometers are generally recommended for each phototherapy

system, because measurements of irradiance may vary

depending on the radiometer and the light source

(1,10).

A variety of phototherapy equipment devices exist

and may be free-standing, attached to a radiant warmer,

wall-mounted, suspended from the ceiling, or fiberoptic

systems. These in turn may contain various light sources

358 Section IX ■ Miscellaneous Procedures

to deliver the phototherapy. The clinician is, therefore,

 

14. Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant

Staphylococcus aureus disease in three communities. N Engl

J Med. 2005;352:1436.

15. Rudoy RC, Nakashima G. Diagnostic value of needle aspiration

in Haemophilus influenzae type b cellulitis. J Pediatr.1979;94:

924.

16. Garcea G, Lloyd T, Jacobs M, et al. Role of microbiological investigations in the management of non-perineal cutaneous abscesses.

Postgrad Med J. 2003;79:519.

17. Jarratt M, Ramsdell W. Infantile acropustulosis. Arch Dermatol.

1979;115:834.

18. Kahn G, Rywlin AM. Acropustulosis of infancy. Arch Dermatol.

1979;115:831.

19. Loyer EM, DuBrow RA, David CL, et al. Imaging of superficial

soft-tissue infections: sonographic findings in cases of cellulitis

and abscess. Am J Roentgenol. 1996;166:149.

20. Cardinal E, Bureau NJ, Aubin B, et al. Role of ultrasound in musculoskeletal infections. Radiol Clin North Am. 2001; 39:191.

21. Blick PW, Flowers MW, Marsden AK, et al. Antibiotics in surgical

treatment of acute abscesses. Br Med J. 1980;281:111.

22. Fine BC, Sheckman PR, Bartlett JC. Incision and drainage of

soft-tissue abscesses and bacteremia. Ann Intern Med. 1985;

103:645.

23. Feder HM Jr, MacLean WC, Moxon R. Scalp abscess secondary

to fetal scalp electrode. J Pediatr. 1976;89:808.

24. Rudoy RC, Nelson JD. Breast abscess during the neonatal period.

A review. Am J Dis Child. 1975;129:1031.

357

 

7. If indicated, insert plain, 0.5-inch gauze into abscess

cavity to stop bleeding and/or to serve as a wick to promote drainage (Fig. 48.2B).

8. Apply dry, sterile dressing.

9. Remove half of gauze packing in 24 hours and remainder within 48 hours. (Some larger wounds may require

multiple packing changes.)

10. Check abscess wound, and apply sterile warm soaks for

20 to 30 minutes, three times a day, until healing has

commenced, as indicated by

a. Cessation of drainage

b. Formation of granulation tissue

c. Resolution of local tissue inflammation

A B

Fig. 48.2. Drainage of a superficial abscess. A: Breaking the

septa with a clamp. B: Packing the wound.

Fig. 48.1. Superficial abscess in the site of a Broviac central

venous line insertion in the left anterior chest wall.

356 Section IX ■ Miscellaneous Procedures

G. Complications

1. Introduction of infection into sterile abscess or hematoma

2. Local bleeding

3. Injury to blood vessels, nerves, or tendons (deep to

abscess cavity) (5)

4. Incomplete drainage with recurrent abscess formation

(1,3)

5. Systemic infection (21,22)

6. Scar formation at drainage site, requiring skin graft (23)

7. Reduction of breast size following incomplete drainage

of breast abscess (24)

References

1. Meislin HW, Lerner SA, Graves MH, et al. Cutaneous abscesses.

Anaerobic and aerobic bacteriology and outpatient management.

Ann Intern Med. 1977;87:145.

2. Meislin HW, McGehee MD, Rosen P. Management and microbiology of cutaneous abscesses. JACEP. 1978;7:186.

3. Macfie J, Harvey J. The treatment of acute superficial abscesses: a

prospective clinical trial. Br J Surg.1977;64:264.

4. Butler KH. Incision and drainage. In: Roberts JR, Hedges JR, eds.

Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia:

WB Saunders; 2004:717.

5. Albom MJ. Surgical gems. Surgical management of a superficial

cutaneous abscess. J Dermatol Surg. 1976;2:120.

6. Brook I. Microbiology and management of human and animal

bite wound infections. Prim Care.2003;30:25.

7. Folz BJ, Lippert BM, Kuelkens C, et al. Hazards of piercing and

facial body art: a report of three patients and literature review. Ann

Plast Surg. 2000;45:374.

8. Duong M, Markwell S, Peter J, et al. Randomized, controlled trial

of antibiotics in the management of community-acquired skin

abscesses in the pediatric patient. Ann Emerg Med. 2010;55:401.

9. Lee MC, Rios AM, Aten MF, et al. Management and outcome of

children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatr Infect

Dis J. 2004;23:123.

10. Llera JL, Levy RC. Treatment of cutaneous abscess: a doubleblind clinical study. Ann Emerg Med. 1985;14:15.

11. Rajendran PM, Young D, Maurer T, et al. Randomized, doubleblind, placebo-controlled trial of cephalexin for treatment of

uncomplicated skin abscesses in a population at risk for

community-acquired methicillin-resistant Staphylococcus aureus

infection. Antimicrob Agents Chemother. 2007;51:4044.

12. Zetola N, Francis JS, Nuermberger EL, et al. Communityacquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275.

13. Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and

drainage in the emergency department–Part I. J Emerg Med.

1985;3:227.

 

14. Hiss J, Horowitz A, Kahana T. Fatal haemorrhage following male

ritual circumcision. J Clin Forensic Med. 2000;7:32.

15. Pieretti RV, Goldstein AM, Pieretti-Varmarcke R. Late complications of newborn circumcision: a common and avoidable problem. Pediatr Surg Int. 2010;26(5):515.

16. Kirkpatrick BV, Eitzman DV. Neonatal septicemia after circumcision. Clin Pediatr. 1974;13:767.

17. Woodside JR. Necrotizing fasciitis after neonatal circumcision.

Am J Dis Child. 1980;134:301.

18. Trier WC, Drach GW. Concealed penis—another complication

of circumcision. Am J Dis Child. 1973;125:6.

19. Limaye RD, Hancock RA. Penile urethral fistula as a complication of circumcision. J Pediatr. 1968;72:105.

20. Cook A, Koury AE, Bagli DJ, et al. Use of buccal mucosa to simulate the coronal sulcus after traumatic penile amputation. Urol.

2005;66:1109.

21. Horowitz J, Sussheim A, Scalettar HE. Abdominal distention following ritual circumcision. Pediatrics. 1976;57:579.

22. Pearce I. Retention of urine: an unusual complication of the

Plastibell device. Br J Urol Int. 2000;85:560.

23. Mackenzie AR. Meatal ulceration following neonatal circumcision. Obstet Gynecol. 1966;28:221.

24. Yildirim S, Taylan G, Akoz T. Circumcision as an unusual cause

of penile lymphedema. Ann Plast Surg. 2003;50:665.

25. Ly L, Sankaran K. Acute venous stasis and swelling of the lower

abdomen and extremities in an infant after circumcision. Can

Med Assoc J. 2003;169:216.

26. Van Duyn J, Warr WS. Excessive penile skin loss from circumcision. J Med Assoc Ga. 1962;51:394.

27. Auerbach MR, Scanlon JW. Recurrence of pneumothorax as a

possible complication of elective circumcision. Am J Obstet

Gynecol. 1978;132:583.

 

28. Peker E, Cagan E, Dogan M. et al. Methemoglobinemia due to

local anesthesia with prilocaine for circumcision.J Pediatr Child

Health. 2010;46(6):362.

29. Moran LR, Hossain T, Insoft RM. Neonatal seizures following

lidocaine administration for elective circumcision. J Perinatol.

2004;24:395.

30. Feinberg AN, Blazek MA. Mechanical complications of circumcision with a Gomco clamp. Am J Dis Child. 1988;142:813.

354

An N. Massaro

Khodayar Rais-Bahrami

48 Drainage of Superficial Abscesses

A. Definitions

A Superficial abscess is

1. A localized collection of pus resulting from bacterial

organisms that cause necrosis, liquefaction, accumulation of leukocytes and debris, which presents as a fluctuant soft tissue swelling that may have associated erythema and induration (Fig. 48.1) (1–5)

2. In newborns, usually caused by invasion of local bacterial flora (2), direct inoculation, (e.g., animal bites) (6)

or skin piercing (7)

B. Indications

1. To establish free drainage of contents from a superficial

abscess

Surgical incision and drainage is the definitive

treatment for soft tissue abscesses. Antibiotic therapy

alone is ineffective in the setting of localized abscess

(1,2,8–11)

2. To identify pathogens and direct antimicrobial therapy

if needed (2,12–16)

3. To differentiate infectious from noninfectious lesions

(15,17,18)

C. Contraindications

1. Carefully identify and avoid

a. Cephalohematoma

b. Hemangioma

c. Cystic hygroma

d. Encephalocele

2. Avoid premature incision and drainage of abscesses that

have not yet fully matured (i.e., in the initial stages of

induration and inflammation prior to formation of pus)

(4). This may lead to

a. A noncurative intervention

b. Possible extension of infectious process

c. Bacteremia

Premature incision may be avoided by the use of

ultrasound with or without diagnostic needle aspiration (19,20).

D. Equipment

Sterile

1. Gloves and gown

2. Antiseptic swabs or cup containing antiseptic solution

3. 1-mL syringe

4. Nonbacteriostatic, isotonic saline without preservative

5. 23-gauge needle

6. 2- × 2-inch gauze squares

7. Scalpel with no. 11 blade

8. Cotton-tipped culture swab

9. Mosquito hemostat

10. 0.5-inch, fine-mesh, plain gauze

Nonsterile

1. Ethyl chloride spray as topical anesthetic. (For larger

lesions, local anesthesia with lidocaine may be used.)

2. Mask and cap

3. Adhesive tape

E. Precautions

1. Use appropriate isolation techniques to safeguard other

infants.

 

Buried penis is usually the result of inappropriate

circumcision in a chubby baby with a small or concealed penis. Excessive removal of skin should be

treated with application of antiseptic (iodophor) daily

and not with grafting or burying the penis in scrotum.

The skin will grow back.

15. Recurrence of pneumothorax (27)

16. Reaction to epinephrine used to control bleeding

a. Tachycardia

b. Local vasospasm (may lead to necrosis of the glans)

17. Complications due to local anesthetic

a. Methemoglobinemia has been reported following

exposure to prilocaine, procaine, benzocaine, and

lidocaine (28).

b. Hematoma; those reported in neonates have

resolved spontaneously.

c. Seizures (29)

18. Mechanical problems with Gomco clamp (30)

a. Loss of a part

b. Warping of the plate after multiple use

c. Breakage of arm during tightening

d. Grooves and nicks in bell at junction of bell and plate

References

1. Gairdner D. The fate of the foreskin—a study of circumcision. Br

Med J. 1949;2:1433.

2. History of circumcision: a religious obligation or a medical necessity. J Nephrol. 2011;Suppl 17:S100.

3. Farley SJ. Neonatal circumcision: the controversy rages on. Nat

Clin Pract Urol. 2009;6(2):59

4. Yellen HS. Bloodless circumcision of the newborn. Am J Obstet

Gynecol. 1935;30:146.

5. Dubrisin R, Zaprudsky P. Circumcising neonates with the Mogen

clamp. Contemp OB/Gyn. 1991;36:79.

6. Fette A, Schleef J, Haberlik A, et al. Circumcision in pediatric

surgery using an ultrasound dissection scalpel. Technol Health

Care. 2000;8:75.

7. Gough DCS, Lawton N. Circumcision—which dressing?. Br

J Urol. 1990;65:418.

8. Garry DJ, Swoboda E, Elimian A, et al. A video study of pain relief

during newborn male circumcision. J Perinatol. 2006;26:106.

9. Kirya C, Werthmann MW Jr. Neonatal circumcision and penile

dorsal nerve block—a painless procedure. J Pediatr. 1978;92:998.

10. Essid A, Hamazaoui M, Sahli S, et al. Glans reimplantation after

circumcision accident. Prog Urol. 2005;15:745.

11. Gesundheit B, Grisaru-Soen G, Greenberg D, et al. Neonatal genital herpes simplex type 1 infection after Jewish ritual circumcision:

modern medicine and religious tradition. Pediatrics. 2004;114:e259.

12. Barnes S, Ben Chaim J, Kessler A. Postcircumcision necrosis of

the glans penis: gray scale and color Doppler sonographic findings. J Clin Ultrasound. 2007;35(2):105.

13. Bode CO, Ikhisemojie S, Ademuyiwa AO. Penile Injuries from

proximal migration of the Plastibell circumcision ring. J Pediatr

Urol. 2010;6(1):23.

 

6. Inflammation/ulceration of meatus (9,23)

7. Circumcision of hypospadias

8. Chordee most commonly is the result of dense ventral

scarring from inflammation; may be due to removal of

excess skin from shaft or secondary to a skin bridge

9. Inclusion cyst of prepuce

10. Lymphedema (24)

11. Venous stasis (25)

12. Displacement with lodging of Plastibell around penile

shaft or glans penis (9)

13. Death

a. Anesthetic (1)

A B

Fig. 47.5. Circumcision with a Plastibell. A: The prepuce is pulled forward onto the bell. Inset: The

prepuce is compressed into the groove by the circumferential suture. B: Appearance of the completed

circumcision.

352 Section IX ■ Miscellaneous Procedures

A

C

B

D

Fig. 47.6. Complication of circumcision. A: Glans injury

6 months after circumcision. B: Trapped penis following contraction of wound after circumcision. C: Penile amputation following cautery injury during circumcision. D: Cicatrix following

circumcision.

Chapter 47 ■ Circumcision 353

b. Infection

c. Hemorrhage (14)

14. Wound separation/removal of excess skin (Fig. 47.6) (26)

 

f. Check that prepuce is freed from entire surface of

glans. Complete separation if necessary.

11. Complete circumcision using method of choice.

a. Use of circumcision clamp

(1) Check clamp to ensure that all parts are present,

fit well, and are in good working order.

(2) Assemble clamp, ensuring that yolk (arm)

articulates correctly with baseplate.

(3) Draw prepuce backward gently to expose

entire glans penis.

(4) Break down all residual adhesions, and observe

position of meatus. If meatus is abnormal,

cease at this point.

(5) Sponge glans dry with gauze swabs.

(6) Select stud (bell) of adequate size (see C), and

place over glans (Fig. 47.4A).

(7) Pull prepuce over stud.

(a) Approximate edge of dorsal slit. (A sterile

safety pin may be used.)

(b) Observe amount of skin remaining under

baseplate for accuracy.

Proper placement of prepuce over stud

is essential. Pulling too taut may lead to

removal of excessive penile skin. Insufficient

tension may lead to incomplete circumcision.

(8) Place baseplate of clamp over stud (with pin

perpendicular to shaft of penis) so that prepuce

is sandwiched between them (Fig. 47.4B).

(9) Continue to pull upward on stud until entire

prepuce is drawn through baseplate and stud

engages with baseplate.

(10) Hook yoke (arm) of clamp under side arms on

shaft of stud and bolt firmly to baseplate, after

checking position of prepuce between stud

and baseplate (Fig. 47.4C).

(11) Remove safety pin.

(12) Wait 10 minutes.

Hemostasis is produced by pressure between

baseplate and rim of stud. If the clamp is

removed before 10 minutes has elapsed, wound

edge hemostasis may be inadequate. If significant bleeding occurs during the procedure,

remove the device and search for bleeding

vessel—avoid blindly placing sutures.

(13) Remove prepuce with scalpel held parallel to

and flush with upper surface of baseplate. Never

use electrocautery; however, use of an ultrasound dissection scalpel has been described as a

safe alternative to electrocautery (6).

(14) Loosen bolt on clamp and remove.

(15) Optional: Dress with loose, noncircumferential sterile gauze impregnated with Vaseline.

Gough and Lawton (7) have shown that the

addition of tincture of benzoin to the dressing

adversely affected wound healing and the

addition of topical antibiotic did not produce

better results than those achieved with ordinary paraffin gauze.