1
|
Pruskowski KA, Feth M, Hong L, Wiggins AR. Pharmacologic Management of Pain, Agitation, and Delirium in Burn Patients. Surg Clin North Am 2023; 103:495-504. [PMID: 37149385 DOI: 10.1016/j.suc.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The majority of hospitalized burn patients experience pain, agitation, and delirium. The development of each one of these conditions can also lead to, or worsen, the others. Providers, therefore, need to thoroughly assess the underlying issue to determine the most effective treatment. Multimodal pharmacologic regimens are often used in conjunction with non-pharmacologic strategies to manage pain, agitation, and delirium. This review focuses on the pharmacologic management of these complicated patients in a critical-care setting.
Collapse
Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Maximilian Feth
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Linda Hong
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| |
Collapse
|
2
|
Muacevic A, Adler JR, Papadopoulou S, Lavrentieva A. Sedation With Dexmedetomidine in Critically Ill Burn Patients Reduced Delirium During Weaning From Mechanical Ventilation. Cureus 2022; 14:e31813. [PMID: 36579227 PMCID: PMC9782418 DOI: 10.7759/cureus.31813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Weaning of mechanical ventilation while maintaining appropriate pain control and preventing delirium is one of the most challenging aspects of burn care. Dexmedetomidine, an α2-adrenergic receptor agonist used for sedation may improve intensive care unit (ICU) patients' arousal status and enhance patient comfort. OBJECTIVES To determine the efficacy of dexmedetomidine vs. standardized usual care (midazolam or propofol) in maintaining sedation and reducing delirium in burn patients while weaning off mechanical ventilation. MATERIAL AND METHODS A total of 56 mechanically ventilated patients who fulfilled the criteria for weaning were enrolled in the study. Group 1 (26 patients) received dexmedetomidine 1 mcg/kg over 15 minutes as a loading dose, followed by 0.4-0.1 mcg/kg/h. Group 2 (30 patients) received usual sedation with midazolam 0.08 mg/kg/h or propofol 15- 30 mcg /kg/min). RESULTS Dexmedetomidine was not associated with a significantly shorter duration of mechanical ventilation (Mean {IQR}: 9.3 {4,12} versus 7.5 {4,10}, p=0.3). Patients who received dexmedetomidine had a lower delirium rate (38,4% on Day 1 to 7,7% on Day 5) in comparison with patients from the usual care group (53,3% on Day 1 to 20% on Day 5) during the five days after the onset of weaning process (p=0.02) and had less need for supplemental use of analgesia (23.1% versus 53.3%, p=0.045) and antipsychotic agents (15.4% versus 53.3%, p=0.01). The most notable adverse effect of dexmedetomidine was bradycardia. CONCLUSIONS Dexmedetomidine may provide effective light sedation and is associated with fewer sedation-related adverse effects in burn patients. Sedation with dexmedetomidine during the weaning process in adult burn patients was associated with lower delirium rates, a trend towards the earlier withdrawal of mechanical ventilation but did not seem to improve the total duration of mechanical ventilation.
Collapse
|
3
|
Lemus R, Jacobowski NL, Humphrey L, Tobias JD. Applications of Dexmedetomidine in Palliative and Hospice Care. J Pediatr Pharmacol Ther 2022; 27:587-594. [PMID: 36186237 PMCID: PMC9514772 DOI: 10.5863/1551-6776-27.7.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/10/2021] [Indexed: 08/30/2023]
Abstract
Although the use of dexmedetomidine is currently approved by the US Food and Drug Administration in the adult population for monitored anesthesia care and sedation during mechanical ventilation, clinical experience suggests the potential application of dexmedetomidine in the palliative care arena. The medication can provide sedation with lower risk of delirium, control or minimize the adverse effects of other medications, and augment analgesia from opioids. We conducted a computerized bibliographic search of the literature regarding dexmedetomidine use for the treatment of pain and provision of sedation during palliative and hospice care in adult and pediatric patients. The objective was to provide a general descriptive account of the physiologic effects of dexmedetomidine and review its potential applications in the field of palliative and hospice care in adult and pediatric patients. The sedative and analgesic effects of dexmedetomidine have been well studied in animal and human models. Published experience from both single case reports and small case series has demonstrated the potential therapeutic applications of dexmedetomidine in palliative and hospice care. In addition to intravenous administration, case reports have demonstrated its successful use by both the intranasal and subcutaneous routes. Although these experiences have suggested its safety and efficacy, larger series and additional clinical experience with prospective comparison to other agents are needed to further define its efficacy and role in palliative and hospice care.
Collapse
Affiliation(s)
- Rafael Lemus
- Department of Pediatrics (RL), The Ohio State University College of Medicine, Columbus, OH
| | - Natalie L. Jacobowski
- Department of Psychiatry and Behavioral Health (NLJ), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
- Division of Palliative Care and Advanced Illness Management (NLJ), Nationwide Children's Hospital and Department of Pediatrics, The Ohio State University, Columbus, OH
| | | | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine (JDT), Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
4
|
Ding X, Cui H, Ma P, Chen X, Sun Y, Qu M, Yan Z. Efficacy of dexmedetomidine versus midazolam when combined with butorphanol for sedation and analgesia during burn dressing changes: A randomized clinical trial. Front Pharmacol 2022; 13:965441. [PMID: 36160398 PMCID: PMC9490052 DOI: 10.3389/fphar.2022.965441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/12/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of this study was to compare dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations for sedation, and analgesia in burn patients undergoing dressing changes.Methods: A total of 56 ASA I–II burn patients were included in this single-center randomized clinical trial. The ages of these patients were between 20 and 60 years. TBSA ranged from 10% to 50%. They were randomized to group DB and group MB during dressing change. In the DB group, each patient received a bolus dose of dexmedetomidine (0.5 μg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). In the MB group, each patient received a bolus dose of midazolam (0.05 mg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). The primary outcomes were sedation scores and pain scores. The second outcomes were vital signs, side effects, and butorphanol consumption.Results: The sedation scores of these two groups did not differ significantly (p > 0.05), and the pain scores of these groups were not significantly different (p > 0.05). More patients had hypotension in the DB group than in the MB group (6 versus 0, p = 0.01), but the number of patients who had respiratory depression was higher in the MB group compared with the DB group (4 versus 0, p = 0.038). Butorphanol consumption in the MB group was higher than in the DB group (p = 0.025).Conclusion: Dexmedetomidine is comparable to midazolam when combined with butorphanol in burn patients during dressing change. Compared with midazolam, it has the advantage of opioid-sparing effect.Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx&proj=130622], identifier [ChiCTR2100049325].
Collapse
Affiliation(s)
- Xianchao Ding
- Department of Burn and Plastic Surgery, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Hengfeng Cui
- Department of General Surgery, Third People’s Hospital of Yancheng, Yancheng, Jiangsu, China
| | - Peng Ma
- Department of Anesthesiology, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Xi Chen
- Department of Surgery, The Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Yan Sun
- Department of Nosocomial Infection Management, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Minye Qu
- Department of Traditional Chinese Medicine, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
- *Correspondence: Minye Qu, ; Zhixin Yan,
| | - Zhixin Yan
- Department of Burn and Plastic Surgery, The Affiliated Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
- *Correspondence: Minye Qu, ; Zhixin Yan,
| |
Collapse
|
5
|
Qin C, Jiang Y, Yu M, Bian Y, Yu Y. Exploration of Potential Molecular Targets of Dexmedetomidine in the Intestinal Repair of Burnt Rats. J Inflamm Res 2021; 14:3197-3206. [PMID: 34285543 PMCID: PMC8286122 DOI: 10.2147/jir.s315952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background More and more burn survivors were suffering from varying degrees of damage to the intestinal barrier. Dexmedetomidine (Dex) was frequently used as sedative in more cases, but it was found to have repair effect on intestinal barrier dysfunction recently. This study aimed to explore the potential specific targets of Dex in intestinal barrier repair in burn rats model. Methods Male adult SD rats were used to establish 40% TBSA III degree scald model in our study. The samples were divided into four groups: burn rats (Burn), burn rats with Dex medication (Burn-Dex), sham rats (Sham) and sham rats with Dex medication (Sham-Dex). And plasma FITC-dextran and diamine oxidase (DAO) were detected to determine the intestinal permeability. Differentially expressed proteins were further adopted to protein-protein interaction network analysis, Gene Ontology analysis (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. Results It showed that 40% TBSA III degree scald model was successfully constructed. And plasma FITC-dextran and DAO decreased significantly after Dex administration. Additionally, differentially expressed genes Psmb10, Psmb7 among the experimental groups were screened, which were significantly enriched in proteasome and other several pathways. Conclusion The results above suggested that Q4KM35 and Q9JHW0, which are encoded by Psmb10 and Psmb7, respectively, are two possible protein targets of Dex in intestinal barrier repair.
Collapse
Affiliation(s)
- Chao Qin
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China.,Tianjin Institute of Anesthesiology, Tianjin, 300000, People's Republic of China.,State Key Laboratory of Medicinal Chemical Biology (Nankai University), Tianjin, 300071, People's Republic of China
| | - Yi Jiang
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China.,Tianjin Institute of Anesthesiology, Tianjin, 300000, People's Republic of China
| | - Mingdong Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China.,Tianjin Institute of Anesthesiology, Tianjin, 300000, People's Republic of China
| | - Yingxue Bian
- Department of Anesthesiology, Tianjin Union Medical Center, Tianjin, 300121, People's Republic of China
| | - Yonghao Yu
- Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China.,Tianjin Institute of Anesthesiology, Tianjin, 300000, People's Republic of China
| |
Collapse
|
6
|
Dexmedetomidine use and mortality in mechanically ventilated patients with severe burns: A cohort study using a national inpatient database in Japan. Burns 2021; 47:1502-1510. [PMID: 34099323 DOI: 10.1016/j.burns.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 03/13/2021] [Accepted: 05/05/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Dexmedetomidine is an alpha 2-adrenergic receptor agonist. Apart from its sedative effects, dexmedetomidine can potentially reduce mortality through its anti-inflammatory effect. However, the impact of dexmedetomidine on in-hospital outcomes of patients with severe burns remains unclear. Therefore, we aimed to elucidate the association between dexmedetomidine use and mortality in mechanically ventilated patients with severe burns, using a Japanese nationwide database of in-hospital patients. METHODS We included adults with severe burns (burn index ≥ 10) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2018, started mechanical ventilation within 3 days of admission, and received any sedative drug (dexmedetomidine, midazolam, or propofol). One-to-one propensity score matching was performed between patients who received dexmedetomidine on the day of mechanical ventilation initiation (dexmedetomidine group) and those who did not receive dexmedetomidine (control group). The primary outcome was all-cause 30-day in-hospital mortality. Secondary outcomes were length of hospital stay and duration of mechanical ventilation in patients and survivors. RESULTS Eligible patients (n = 1888) were classified into the dexmedetomidine group (n = 371) or the control group (n = 1517). After one-to-one propensity score matching, we compared 329 patients from both groups. No significant difference was observed in the 30-day mortality between patients in the dexmedetomidine and control groups (22.8% vs. 22.5%, respectively; odds ratio, 1.02; 95% confidence interval, 0.71-1.46). Moreover, there were no significant differences between patients in the dexmedetomidine and control groups in terms of the length of hospital stay or the duration of mechanical ventilation. CONCLUSIONS We found no significant association between dexmedetomidine use and in-hospital outcomes (mortality, length of hospital stay, and length of mechanical ventilation) in mechanically ventilated patients with severe burns. Dexmedetomidine use may not improve the aforementioned outcomes; therefore, its selection should be based on the patient's general condition and the target level of sedation.
Collapse
|
7
|
Motaghi E, Ghasemi Pirbalooti M, Bozorgi H, Eslami M, Rashidi M. Safety and Efficacy of Dexmedetomidine in Breast Surgeries: A Systematic Review and Meta-Analysis. J Perianesth Nurs 2020; 36:179-186. [PMID: 33303343 DOI: 10.1016/j.jopan.2020.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/22/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Pain control during and after breast surgery is still a challenging task. Dexmedetomidine (DEX) is considered as a sedative agent that is widely used perineurally or intravenously as an adjuvant in general anesthesia and critical care medicine practice. The aim of this study is to evaluate the efficacy of perineural DEX and intravenous (IV) DEX and their effects on postoperative complications in breast surgeries. DESIGN Systematic review and meta-analysis. METHODS The present study systematically reviewed all identified randomized controlled trials for efficacy and safety of IV and perineural use of DEX in breast surgeries. Databases were searched for articles published before October 2019. FINDINGS Twelve trials were identified including 803 patients undergoing breast surgery. Although administration of IV DEX and its use with pectoral nerve (Pecs) block significantly postponed time for first analgesic request and decreased pain score at 1 and 12 hours after surgery, paravertebral use of DEX had no statistically significant effect. Pooled data about perineural DEX showed no significant effect on postoperative nausea and vomiting (PONV), whereas IV DEX significantly reduced PONV. Pooled analysis also showed that DEX administration did not significantly affect postoperative complications, such as postoperative itching, bradycardia, and pneumothorax in patients undergoing breast surgery. CONCLUSIONS The results showed that unlike paravertebral DEX, both DEX use with Pecs blocks and IV DEX were effective in control of postoperative pain in patients undergoing breast surgeries. Unlike perineural DEX, IV DEX significantly reduced PONV.
Collapse
Affiliation(s)
- Ehsan Motaghi
- Department of Physiology and Pharmacology, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Hooman Bozorgi
- Department of Pharmacology, Research Center of Physiology, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran.
| | - Majid Eslami
- Cancer Research Center, Semnan University of Medical Sciences, Semnan, Iran
| | - Mohsen Rashidi
- Faculty of Medicine, Department of Pharmacology, Mazandaran University of Medical Sciences, Sari, Iran
| |
Collapse
|
8
|
Pain Management in Burn Patients. CURRENT TRAUMA REPORTS 2020. [DOI: 10.1007/s40719-020-00203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
9
|
Kim DE, Pruskowski KA, Ainsworth CR, Linsenbardt HR, Rizzo JA, Cancio LC. A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis. J Burn Care Res 2019; 40:983-995. [DOI: 10.1093/jbcr/irz111] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
Opioids are the mainstay of pain management after burn injury. The United States currently faces an epidemic of opioid overuse and abuse, while simultaneously experiencing a nationwide shortage of intravenous narcotics. Adjunctive pain management therapies must be sought and utilized to reduce the use of opioids in burn care to prevent the long-term negative effects of these medications and to minimize the dependence on opioids for analgesia. The purpose of this review was to identify literature on adjunctive pain management therapies that have been demonstrated to reduce pain severity or opioid consumption in adult burn patients. Three databases were searched for prospective studies, randomized controlled trials, and systematic reviews that evaluated adjunctive pain management strategies published between 2008 and 2019 in adult burn patients. Forty-six studies were analyzed, including 24 randomized controlled trials, six crossover trials, and 10 systematic reviews. Various adjunctive pain management therapies showed statistically significant reduction in pain severity. Only one randomized controlled trial on music therapy for acute background pain showed a reduction in opioid use. One cohort study on hypnosis demonstrated reduced opioid use compared with historical controls. We recommend the development of individualized analgesic regimens with the incorporation of adjunctive therapies in order to improve burn pain management in the midst of an abuse crisis and concomitant national opioid shortage.
Collapse
Affiliation(s)
- Daniel E Kim
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kaitlin A Pruskowski
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Craig R Ainsworth
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
| |
Collapse
|
10
|
Abstract
Critically ill patients commonly experience pain, and the provision of analgesia is an essential component of intensive care unit (ICU) care. Opioids are the mainstay of pain management in the ICU but are limited by their adverse effects, risk of addiction and abuse, and recent drug shortages of injectable formulations. A multimodal analgesia approach, utilizing nonopioid analgesics as adjuncts to opioid therapy, is recommended since they may modulate the pain response and reduce opioid requirements by acting on multiple pain mediators. Nonopioid analgesics discussed in detail in this article are acetaminophen, α-2 receptor agonists, gabapentinoids, ketamine, lidocaine, and nonsteroidal anti-inflammatory drugs. This literature review describes the clinical pharmacology, supportive ICU and relevant non-ICU data, and practical considerations associated with the administration of nonopioid analgesics in critically ill adult patients.
Collapse
Affiliation(s)
| | - Kathryn E Smith
- 1 Department of Pharmacy, Maine Medical Center, Portland, ME, USA
| |
Collapse
|
11
|
Jiang M, Sun Q, Liu G, Qu H, Ma J. Efficacy of dexmedetomidine in reducing post-operative pain and improving the quality of recovery in patients with burn wounds undergoing tangential excision skin grafting. Exp Ther Med 2019; 17:1776-1782. [PMID: 30783449 PMCID: PMC6364143 DOI: 10.3892/etm.2019.7155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 11/22/2018] [Indexed: 11/30/2022] Open
Abstract
Burn-induced acute post-operative pain and the associated stress response may result in prolonged convalescence. The present study investigated the effects of dexmedetomidine (DEX) administration on post-operative pain and the quality of recovery following surgical treatment of moderate-to-severe burn injuries. A total of 60 adult patients undergoing tangential excision skin grafting were randomized into two groups. The DEX group (Group D) received an intravenous (i.v.) single-dose bolus injection of DEX 0.5 µg/kg >10 min prior to induction of anesthesia. Patient-controlled intravenous analgesia (PCIA) was provided to the patients from the end of the surgery, which consisted of 100 µg sufentanil plus 200 µg DEX. The control group (Group C) received an equal volume of normal saline as a pre-operative bolus and post-operative PCIA of 100 µg sufentanil infusion. The Visual Analogue Scale (VAS) score at rest and during movement, the cumulative dose of sufentanil and the 40-item quality of recovery questionnaire (QoR-40) score were assessed at various time-points after the surgery. During the first 24 h post-surgery, patients in Group D exhibited a lower VAS score at rest and during movement, a lower number of PCIA pump presses (29.17±1.91 vs. 34.13±2.73) and lower sufentanil consumption (62.58±0.96 vs. 65.27±1.26) compared with those in Group C (P<0.05). Furthermore, the QoR-40 recovery score of patients in Group D at 24 h post-surgery was higher compared with that in Group C (P<0.01). In conclusion, the present study indicated that a pre-operative bolus of DEX (0.5 µg/kg) followed by DEX plus sufentanil by PCIA subsequent to surgery improved the quality of analgesia and promoted the quality of recovery at 24 h following tangential excision skin grafting treatment of patients with moderate-to-severe burn injuries compared to PCIA of 100 µg sufentanil only. The present study was retrospectively registered with the trial registration no. ChiCTR1800016646 (date of registration, 14/06/2018).
Collapse
Affiliation(s)
- Meiru Jiang
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Qiaoxia Sun
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Ganggang Liu
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Hua Qu
- Operating Room, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| | - Jiahai Ma
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong 264000, P.R. China
| |
Collapse
|
12
|
Abstract
The objective of this article is to investigate adherence to reporting standards and methodological quality in systematic reviews on burns care published in peer-reviewed journals to determine their utility for guiding evidence-based burns care. PubMed, Embase, Database of Abstracts of Reviews of Effects, Cochrane Database of Systematic Reviews, and the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports were searched from 2009. Any systematic review on any question on therapeutic interventions in burns care was eligible for inclusion. Critical appraisal and data extraction were performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist by two independent reviewers. The overall quality of the 44 included burns care systematic reviews was low, with an average methodological quality of 55% and an average compliance with reporting guidelines of 70%. Correlation analysis showed that adherence to reporting guidelines has been relatively stable, but methodological quality has deteriorated (r = -.32, P < .05). Cochrane reviews had lower citation rates than reviews published in other journals, whereas reviews that included meta-analyses had more citations. Quality did not have a significant effect on citation rate. Health professionals working in burns should be able to expect that systematic reviews published in their field are of a high standard. Unfortunately, this is not the case. To address this problem, established guidelines on the conduct and reporting of systematic reviews should be adhered to by researchers and editors.
Collapse
|
13
|
Wasiak J, Tyack Z, Ware R, Goodwin N, Faggion CM. Poor methodological quality and reporting standards of systematic reviews in burn care management. Int Wound J 2017; 14:754-763. [PMID: 27990772 PMCID: PMC7949759 DOI: 10.1111/iwj.12692] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/02/2016] [Indexed: 12/18/2022] Open
Abstract
The methodological and reporting quality of burn-specific systematic reviews has not been established. The aim of this study was to evaluate the methodological quality of systematic reviews in burn care management. Computerised searches were performed in Ovid MEDLINE, Ovid EMBASE and The Cochrane Library through to February 2016 for systematic reviews relevant to burn care using medical subject and free-text terms such as 'burn', 'systematic review' or 'meta-analysis'. Additional studies were identified by hand-searching five discipline-specific journals. Two authors independently screened papers, extracted and evaluated methodological quality using the 11-item A Measurement Tool to Assess Systematic Reviews (AMSTAR) tool and reporting quality using the 27-item Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Characteristics of systematic reviews associated with methodological and reporting quality were identified. Descriptive statistics and linear regression identified features associated with improved methodological quality. A total of 60 systematic reviews met the inclusion criteria. Six of the 11 AMSTAR items reporting on 'a priori' design, duplicate study selection, grey literature, included/excluded studies, publication bias and conflict of interest were reported in less than 50% of the systematic reviews. Of the 27 items listed for PRISMA, 13 items reporting on introduction, methods, results and the discussion were addressed in less than 50% of systematic reviews. Multivariable analyses showed that systematic reviews associated with higher methodological or reporting quality incorporated a meta-analysis (AMSTAR regression coefficient 2.1; 95% CI: 1.1, 3.1; PRISMA regression coefficient 6·3; 95% CI: 3·8, 8·7) were published in the Cochrane library (AMSTAR regression coefficient 2·9; 95% CI: 1·6, 4·2; PRISMA regression coefficient 6·1; 95% CI: 3·1, 9·2) and included a randomised control trial (AMSTAR regression coefficient 1·4; 95%CI: 0·4, 2·4; PRISMA regression coefficient 3·4; 95% CI: 0·9, 5·8). The methodological and reporting quality of systematic reviews in burn care requires further improvement with stricter adherence by authors to the PRISMA checklist and AMSTAR tool.
Collapse
Affiliation(s)
- Jason Wasiak
- Epworth HealthCareRichmondVAAustralia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive MedicineMonash UniversityMelbourneVICAustralia
| | - Zephanie Tyack
- Centre for Children's Burns and Trauma Research, Children's Health Research CentreThe University of Queensland & Centre for Functioning and Health Research Metro South HealthBrisbaneQLDAustralia
| | - Robert Ware
- Menzies Health Institute QueenslandGriffith UniversityBrisbaneQLDAustralia
| | | | - Clovis M Faggion
- Department of Periodontology and Restorative Dentistry, Faculty of DentistryUniversity of MunsterMunsterGermany
| |
Collapse
|
14
|
Abstract
This article describes pathophysiology of burn injury-related pain and the basic principles of burn pain management. The focus is on concepts of perioperative and periprocedural pain management with extensive discussion of opioid-based analgesia, including patient-controlled analgesia, challenges of effective opioid therapy in opioid-tolerant patients, and opioid-induced hyperalgesia. The principles of multimodal pain management are discussed, including the importance of psychological counseling, perioperative interventional pain procedures, and alternative pain management options. A brief synopsis of the principles of outpatient pain management is provided.
Collapse
Affiliation(s)
- Dominika Lipowska James
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Maryam Jowza
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
15
|
Henschke A, Lee R, Delaney A. Burns management in ICU: Quality of the evidence: A systematic review. Burns 2016; 42:1173-82. [PMID: 27268108 DOI: 10.1016/j.burns.2016.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study was to assess the quality of readily available evidence regarding critical care aspects of the management of patients with severe burn injuries. METHOD PUBMED, EMBASE, Cochrane Databases and bibliographies of included studies and burns review articles were searched from inception of databases to end of February 2015. We included systematic reviews, randomised controlled trials (RCTs) and cohort studies with concurrent controls on the topics of (a) fluid resuscitation (b) analgesia (c) haemodynamic monitoring and targets (d) ventilation (e) blood transfusion. The quality of the studies was assessed using validated tools. RESULTS Fifty six studies fulfilled the inclusion criteria. Twenty three on fluid resuscitation, 22 on analgesia, nine on haemodynamic monitoring and two on ventilation. No studies were found on blood transfusion practice. There were ten systematic reviews, 38 RCTs and eight cohort studies with concurrent controls. The majority of studies were single centre trials with small numbers of patients, surrogate outcomes and high risk of bias. CONCLUSIONS There is very little high quality evidence to guide clinical practice in early management of the severely burnt patient. Eleven of 56 studies found in our search of critical care topics were of good methodological quality with low risk of bias.
Collapse
Affiliation(s)
- Alice Henschke
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia.
| | - Richard Lee
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia.
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| |
Collapse
|
16
|
Gan X, Lin H, Chen J, Lin Z, Lin Y, Chen W. Rescue Sedation With Intranasal Dexmedetomidine for Pediatric Ophthalmic Examination After Chloral Hydrate Failure: A Randomized, Controlled Trial. Clin Ther 2016; 38:1522-1529. [PMID: 27229908 DOI: 10.1016/j.clinthera.2016.04.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/20/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE It is a challenge to rescue ophthalmology examinations performed in children in the sedation room after initial chloral hydrate failure. Intranasal dexmedetomidine can be used in rescue sedation in children undergoing computed tomography. The present study aimed to assess the efficacy and tolerability of intranasal dexmedetomidine use in children undergoing ophthalmic examination after chloral hydrate failure. METHODS Sixty uncooperative pediatric patients with cataract (aged 5-36 months; weight, 7-15 kg) presented for follow-up ophthalmic examination. Patients who experienced chloral hydrate failure were randomized to 1 of 2 groups to receive intranasal dexmedetomidine 1 or 2 μg/kg for rescue sedation. Each group contained 30 patients. The primary outcome was the rate of a successful ophthalmic examination. Secondary outcomes included sedation onset time, recovery time, duration of examination, discharge time, and adverse events, including percentage of heart rate reduction, respiratory depression, vomiting, and postsedative agitation. FINDINGS A successful ophthalmic examination was achieved in 93.3% (28/30) of patients in the 2-μg/kg dose group and in 66.7% (20/30) of patients in the 1-μg/kg dose group (P = 0.021). The onset time, recovery time, and discharge time did not significantly differ between the 2 groups. None of the patients required clinical intervention due to heart rate reduction, and none of the patients in either group experienced vomiting, respiratory depression, or agitation after the administration of dexmedetomidine. IMPLICATIONS In children undergoing ophthalmic examination, intranasal dexmedetomidine can be administered in the sedation room for rescue sedation after chloral hydrate failure, with the 2-μg/kg dose being more efficacious than the 1-μg/kg dose, as measured by success rate. ClinicalTrials.gov identifier: NCT02077712.
Collapse
Affiliation(s)
- Xiaoliang Gan
- Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Haotian Lin
- Department of Cataract, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jingjing Chen
- Department of Cataract, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhuoling Lin
- Department of Cataract, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Yiquan Lin
- Department of Anesthesiology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Weirong Chen
- Department of Cataract, State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, People's Republic of China.
| |
Collapse
|
17
|
Geng J, Qian J, Cheng H, Ji F, Liu H. The Influence of Perioperative Dexmedetomidine on Patients Undergoing Cardiac Surgery: A Meta-Analysis. PLoS One 2016; 11:e0152829. [PMID: 27049318 PMCID: PMC4822865 DOI: 10.1371/journal.pone.0152829] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 03/02/2016] [Indexed: 01/24/2023] Open
Abstract
Background The use of dexmedetomidine may have benefits on the clinical outcomes of cardiac surgery. We conducted a meta-analysis comparing the postoperative complications in patients undergoing cardiac surgery with dexmedetomidine versus other perioperative medications to determine the influence of perioperative dexmedetomidine on cardiac surgery patients. Methods Randomized or quasi-randomized controlled trials comparing outcomes in patients who underwent cardiac surgery with dexmedetomidine, another medication, or a placebo were retrieved from EMBASE, PubMed, the Cochrane Library, and Science Citation Index. Results A total of 1702 patients in 14 studies met the selection criteria among 1,535 studies that fit the research strategy. Compared to other medications, dexmedetomidine has combined risk ratios of 0.28 (95% confidence interval [CI] 0.15, 0.55, P = 0.0002) for ventricular tachycardia, 0.35 (95% CI 0.20, 0.62, P = 0.0004) for postoperative delirium, 0.76 (95% CI 0.55, 1.06, P = 0.11) for atrial fibrillation, 1.08 (95% CI 0.74, 1.57, P = 0.69) for hypotension, and 2.23 (95% CI 1.36, 3.67, P = 0.001) for bradycardia. In addition, dexmedetomidine may reduce the length of intensive care unit (ICU) and hospital stay. Conclusions This meta-analysis revealed that the perioperative use of dexmedetomidine in patients undergoing cardiac surgery can reduce the risk of postoperative ventricular tachycardia and delirium, but may increase the risk of bradycardia. The estimates showed a decreased risk of atrial fibrillation, shorter length of ICU stay and hospitalization, and increased risk of hypotension with dexmedetomidine.
Collapse
Affiliation(s)
- Jun Geng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ju Qian
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hao Cheng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, California, United States of America
- * E-mail:
| | - Fuhai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health System, Sacramento, California, United States of America
| |
Collapse
|
18
|
Chan IA, Maslany JG, Gorman KJ, O’Brien JM, McKay WP. Dexmedetomidine during total knee arthroplasty performed under spinal anesthesia decreases opioid use: a randomized-controlled trial. Can J Anaesth 2016; 63:569-76. [DOI: 10.1007/s12630-016-0597-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 10/18/2015] [Accepted: 01/24/2016] [Indexed: 10/22/2022] Open
|
19
|
Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2015; 13:Doc19. [PMID: 26609286 PMCID: PMC4645746 DOI: 10.3205/000223] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 02/08/2023]
Abstract
In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.
Collapse
Affiliation(s)
| | | | | | | | - Stephan Braune
- German Society of Internal Medicine Intensive Care (DGIIN)
| | - Hartmut Buerkle
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Peter Dall
- German Society of Gynecology & Obstetrics (DGGG)
| | - Sueha Demirakca
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Verena Eggers
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ingolf Eichler
- German Society for Thoracic and Cardiovascular Surgery (DGTHG)
| | | | | | | | - Lars Garten
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Irene Harth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | - Johannes Horter
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ralf Huth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Uwe Janssens
- German Society of Internal Medicine Intensive Care (DGIIN)
| | | | | | - Paul Kessler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Matthias Kumpf
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Andreas Meiser
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Anika Mueller
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Bernd Roth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | | | - Monika Schindler
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Reinhard Schmitt
- German Society for Specialised Nursing and Allied Health Professions (DGF)
| | - Jens Scholz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Stefan Schroeder
- German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)
| | | | - Claudia Spies
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | - Peter Tonner
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Uwe Trieschmann
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Michael Tryba
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Frank Wappler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Christian Waydhas
- German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)
| | - Bjoern Weiss
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Guido Weisshaar
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| |
Collapse
|
20
|
Lundy JB, Chung KK, Pamplin JC, Ainsworth CR, Jeng JC, Friedman BC. Update on Severe Burn Management for the Intensivist. J Intensive Care Med 2015; 31:499-510. [PMID: 26112758 DOI: 10.1177/0885066615592346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/01/2015] [Indexed: 11/15/2022]
Abstract
Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.
Collapse
Affiliation(s)
- Jonathan B Lundy
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kevin K Chung
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeremy C Pamplin
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Craig R Ainsworth
- Department of Medicine, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - James C Jeng
- Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | | |
Collapse
|