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are risks to this procedure, including seizures, coma, confusion, and cardiac
arrest, if the child were to unintentionally receive a massive amount of
lidocaine rapidly. Three randomly controlled trials involving Bier blocks
found no adverse effects among more than 500 procedures. Still some
physicians prefer to perform the Bier block or mini-Bier block in the
operating room, where circumstances can be better controlled.

NONPHARMACOLOGIC METHODS FOR PAIN CONTROL
Regardless of the procedure performed or the medications used during PSA,
the patient’s developmental level and acute level of anxiety will directly
impact the success of a procedure and the patient’s experience. There are
many nonpharmacologic methods to decrease the child’s fear and
incorporate the family into achieving the therapeutic objectives. In general,
these methods are low cost, consume very little time, and have few, if any,
side effects. Thus, nonpharmacologic techniques can be used alone or as
adjuncts to sedation and analgesic drug therapy.
Children need gentle reassurance and carefully chosen words to reduce
fear and pain. One should keep in mind that young children understand more
than they say. Avoid casual teasing, condescension, or talking about the child
while excluding him or her. As many choices as possible should be offered,
but only if they are real choices. Do not tell a child that something will not
hurt unless you are sure that it will not. It is important to be honest with the
child about any pain or discomfort that he or she will experience. Once a
child is surprised by a painful stimulus, he or she will become more vigilant
and less amenable to distraction or relaxation techniques. In general, the
time between informing the child about potential discomfort and the actual
procedure performance should be brief. Long delays between the
explanation and the actual procedure increase anticipatory distress prior to
the procedure. One study showed that an empathic (age-appropriate)
explanation of an upcoming needle stick reduced crying among patients
compared with a group of children who received impersonal instructions.

Allowing an older child to read about a procedure and then allowing roleplaying and discussion was helpful in reducing pulse rates, as well as other
physiologic and behavioral responses to pain. Such explanations and roleplaying are time-consuming, and it is helpful to enlist the child’s parents to
assist in these techniques.