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Artz C, Ward MA, Miles MVP, Brennan P, Alexander KM, Lintner A, Bright A, Kahn SA. Intraoperative liposomal bupivacaine for skin graft donor site analgesia: A retrospective cohort study. Burns 2020; 47:1045-1052. [PMID: 34034954 DOI: 10.1016/j.burns.2020.06.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Burn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures. METHODS A retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful. RESULTS Fifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p<0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p<0.0001). CONCLUSION Patients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.
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Affiliation(s)
- Christina Artz
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Mark A Ward
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Majel V P Miles
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Phillip Brennan
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Kaitlin M Alexander
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Alicia Lintner
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Andrew Bright
- Department of Surgery, University of South Alabama Medical Center, 2451 USA Medical Center Dr, Suite 10-I, Mobile, AL 36617, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States
| | - Steven A Kahn
- Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas St, CSB420/MSC613, Charleston, SC 29425, United States; Department of Pharmacy Practice, Auburn University, Harrison School of Pharmacy, 650 Clinic Drive, Suite 2100, Mobile, AL 36688, United States.
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McNamara SA, Hirt PA, Weigelt MA, Nanda S, de Bedout V, Kirsner RS, Schachner LA. Traditional and advanced therapeutic modalities for wounds in the paediatric population: an evidence-based review. J Wound Care 2020; 29:321-334. [PMID: 32530778 DOI: 10.12968/jowc.2020.29.6.321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Children can have non-healing wounds due to a wide range of pathologies, including epidermolysis bullosa (EB), pilonidal disease and Stevens-Johnson syndrome, with some causes being iatrogenic, including extravasation injuries and medical device-related hospital-acquired pressure ulcers. Furthermore, paediatric wounds are vastly different from adult wounds and therefore require a different treatment approach. While there are numerous types of dressings, topical remedies, and matrices with high-tier evidence to support their use in adults, evidence is scarce in the neonatal and paediatric age groups. The purpose of this review is to discuss the basic principles in paediatric wound management, as well as to present new treatment findings published in the literature to date. The benefits and risks of using different types of debridement are discussed in this review. Various topical formulations are also described, including the need to use antibiotics judiciously. METHOD Databases were searched for relevant sources including Pubmed, Embase, Web of Science and DynaMed. Search terms used included 'wound care', 'wound management', 'paediatrics', 'children', 'skin substitutes', and 'grafts'. Additionally, each treatment and disease entity was searched for relevant sources, including, for example: 'Apligraf', 'dermagraft', 'Manuka honey', 'antibiotic', 'timolol', and 'negative pressure wound therapy' (NPWT). RESULTS Amniotic membrane living skin equivalent is a cellular matrix that has been reportedly successful in treating paediatrics wounds and is currently under investigation in randomised clinical trials. Helicoll is an acellular matrix, which shows promise in children with recessive dystrophic EB. NPWT may be used as a tool to accelerate wound closure in children; however, caution must be taken due to limited evidence to support its safety and efficacy in the paediatric patient population. Integra has been reported as a useful adjunctive treatment to NPWT as both may act synergistically. Hospitalised children and neonates frequently have pressure ulcers, which is why prevention in this type of wound is paramount. CONCLUSION Advancements in wound care are rapidly expanding. Various treatments for non-healing wounds in paediatric and neonatal patients have been reported, but high tier evidence in these populations is scarce. We hope to shed light on existing evidence regarding the different therapeutic modalities, from debridement techniques and dressing types to tissue substitutes and topical remedies. There have been promising results in many studies to date, but RCTs involving larger sample sizes are necessary, in order to determine the specific role these innovative agents play in paediatric wounds and to identify true safety and efficacy.
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Affiliation(s)
- Stephanie A McNamara
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Penelope A Hirt
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Maximillian A Weigelt
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Sonali Nanda
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Valeria de Bedout
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Robert S Kirsner
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
| | - Lawrence A Schachner
- University of Miami Miller School of Medicine, Dr. Phillip Frost Dermatology and Cutaneous Surgery, 1321 NW 14th Street, Suite 506, Miami, FL 33125, US
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Shoham Y, Krieger Y, Rubin G, Koenigs I, Hartmann B, Sander F, Schulz A, David K, Rosenberg L, Silberstein E. Rapid enzymatic burn debridement: A review of the paediatric clinical trial experience. Int Wound J 2020; 17:1337-1345. [PMID: 32445271 DOI: 10.1111/iwj.13405] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/20/2020] [Accepted: 05/05/2020] [Indexed: 01/22/2023] Open
Abstract
NexoBrid (NXB) has been proven to be an effective selective enzymatic debridement agent in adults. This manuscript presents the combined clinical trial experience with NXB in children. Hundred and ten children aged 0.5 to 18 years suffering from deep thermal burns of up to 67% total body surface area were treated with NXB in three clinical trials. Seventy-seven children were treated with NXB in a phase I/II study, where 92.7% of the areas treated achieved complete eschar removal within 0.9 days from admission. Thirty-three children (17 NXB, 16 standard of care [SOC]) participated in a phase III randomized controlled trial. All wounds treated with NXB achieved complete eschar removal. Time to complete eschar removal (from informed consent) was 0.9 days for NXB vs 6.5 days for SOC (P < .001). The incidence of surgical excision was 7.9% for NXB vs 73.3% for SOC (P < .001). Seventeen of these children participated in a phase III-b follow-up study (9 NXB and 8 SOC). The average long-term modified Vancouver Scar Scale scores were 3.4 for NXB-treated wounds vs 4.4 for SOC-treated wounds (NS). There were no significant treatment-related adverse events. Additional studies are needed to strengthen these results.
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Affiliation(s)
- Yaron Shoham
- Plastic Surgery Department and Burn Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel
| | - Yuval Krieger
- Plastic Surgery Department and Burn Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel
| | - Guy Rubin
- Orthopaedic Department, Central Emek Hospital, Afula, Israel
| | - Ingo Koenigs
- Department of Pediatric Surgery, Pediatric Burn Unit, Plastic and Reconstructive Surgery in Children, Altonaer Kinderkrankenhaus & University Medical Center, Hamburg-Eppendorf, Germany
| | - Bernd Hartmann
- Burn Center with Plastic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Frank Sander
- Burn Center with Plastic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Alexandra Schulz
- Department of Plastic Surgery, Hand Surgery, Burn Center, University of Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany
| | | | | | - Eldad Silberstein
- Plastic Surgery Department and Burn Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheba, Israel
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Singh A, Bhatnagar A. The postburn severe flexion contracture neck correction with split-thickness skin graft: Our experience. INDIAN JOURNAL OF BURNS 2020. [DOI: 10.4103/ijb.ijb_12_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Herlihy CR, Barry C. Anesthesia and Burns. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Goenaga Díaz EJ, Carter JE, Templeton TW. Nitroglycerin: An unusual solution to intraoperative hypothermia in a 4-year-old burn patient. Paediatr Anaesth 2018; 28:71-72. [PMID: 29148139 DOI: 10.1111/pan.13292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2017] [Indexed: 11/28/2022]
Abstract
We describe the case of a 4-year-old child undergoing extensive burn surgery with refractory intraoperative hypothermia. A low-dose nitroglycerin infusion was initiated to reverse vasoconstriction and improve heat absorption, after which the child's temperature steadily improved. In hypothermic burn patients, topical vasoconstrictors may hinder surface warming efforts. A vasodilator infusion may aid in warming the pediatric patient undergoing extensive excision and grafting.
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Affiliation(s)
| | - Jeffrey E Carter
- Department of Trauma Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - T Wesley Templeton
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Mathias E, Srinivas Murthy M. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. MEDICINES (BASEL, SWITZERLAND) 2017; 4:medicines4040091. [PMID: 29232903 PMCID: PMC5750615 DOI: 10.3390/medicines4040091] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/07/2017] [Accepted: 12/08/2017] [Indexed: 05/17/2023]
Abstract
Burn injuries are a devastating critical care problem. In children, burns continue to be a major epidemiologic problem around the globe resulting in significant morbidity and death. Apparently, treating these burn injuries in children and adults remains similar, but there are significant physiological and psychological differences. The dermal layer of the skin is generally thinner in neonates, infants, and children than in adults. Enhanced evaporative loss and need for isotonic fluids increases the risk of hypothermia in the pediatric population. The pain management of the children with major burns challenges the skills of the personnel of every unit. Managing these wounds requires intensive therapeutic treatment for multi-organ dysfunction, and surgical treatment to prevent sepsis and other complications that further delay wound closure. Alternatives to the practice of donor site harvest and autografting for the treatment of severe burns and other complex skin defects are urgently needed for both adult and pediatric populations. This review article focuses on thermal burn pathophysiology and pain management and provides an overview of currently approved products used for the treatment of pediatric burn wounds. A new promising approach has been presented as a first-line therapy in the treatment of burns to reduce surgical autografting in pediatric patients.
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Affiliation(s)
- Elton Mathias
- Department of Clinical Research, Mallinckrodt Pharmaceuticals, Bedminster, NJ 07921, USA.
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Abstract
Burn patients provide numerous challenges to the anesthesiologist. It is important to understand the multiple physiologic disruptions that follow a burn injury as well as the alterations in pharmacokinetics and pharmacodynamics of commonly used anesthetics. Thought must be given to surgery during initial fluid resuscitation and the airway challenges many of these patients present. Finally, the central role of pain management through all phases of care is a constant concern.
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Affiliation(s)
- T Anthony Anderson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA.
| | - Gennadiy Fuzaylov
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, USA
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Rode H, Cox SG, Numanoglu A, Berg AM. Burn care in South Africa: a micro cosmos of Africa. Pediatr Surg Int 2014; 30:699-706. [PMID: 24906348 DOI: 10.1007/s00383-014-3519-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 11/29/2022]
Abstract
Burn injuries in Africa are common with between 300,000 and 17.5 million children under 5 years sustaining burn injuries annually, resulting in a high estimated fatality rate. These burns are largely environmentally conditioned and therefore preventable. The Western Cape Province in South Africa can be regarded as a prototype of paediatric burns seen on the continent, with large numbers, high morbidity and mortality rates and an area inclusive of all factors contributing to this extraordinary burden of injury. Most of the mechanisms to prevent burns are not easily modified due to the restraint of low socio-economic homes, overcrowding, unsafe appliances, multiple and complex daily demands on families and multiple psycho-social stressors. Children <4 years are at highest risk of burns with an average annual rate of 6.0/10,000 child-years. Burn care in South Africa is predominantly emergency driven and variable in terms of organization, clinical management, facilities and staffing. Various treatment strategies were introduced. The management of HIV positive children poses a problem, as well as the conflict of achieving equity of burn care for all children. Without alleviating poverty, developing minimum standards for housing, burn education, safe appliances and legislation, we will not be able to reduce the "curse of poor people" and will continue to treat the consequences.
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Affiliation(s)
- H Rode
- Department of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa,
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Eich C, Sinnig M, Guericke H. Akutversorgung des brandverletzten Kindes. Notf Rett Med 2014. [DOI: 10.1007/s10049-013-1809-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Management of Burns and Anesthetic Implications. ANESTHESIA FOR TRAUMA 2014. [PMCID: PMC7121311 DOI: 10.1007/978-1-4939-0909-4_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Burn injuries are highly complex and affect almost every major organ system in the body. The treatment of burn patients requires the presence of a well-organized team of caregivers who understand the multifaceted consequences of burn injuries and who are adept at coordinating care. An understanding of the multitude of abnormalities that must be addressed helps to guide therapy in these patients. Careful anesthetic and perioperative management of these patients carries special importance in this fragile patient population as a part of their often lengthy recovery and rehabilitation.
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Current world literature. Curr Opin Pediatr 2010; 22:246-55. [PMID: 20299870 DOI: 10.1097/mop.0b013e32833846de] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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