Analgo-sedation of patients with burns outside the operating room

Efficacy and Adverse Effects of IV Morphine for Burn Pain Management in the Emergency Department: An Observational Study

INTRODUCTION

The management of pain following a burn is extremely complex because of the multifactorial nature of burn pain (nociceptive and neuropathic). In the pre-hospital setting and emergency department (ED), the main goal of acute pain management is to reduce the patient's pain, allowing them to maintain function and to prevent the chronification of pain. Opioids are used as first-line treatment in management of burn pain. The aim of our study was to evaluate the efficacy and adverse effects of intravenous (IV) morphine for burn pain management in the ED and to evaluate pain management in the pre-hospital setting.

METHODS

In this single-center observational study, patients presenting with second- and third-degree burns were enrolled in our ED. Numerical Rating Scale (NRS) and Burn Specific Pain Anxiety Scale (BSPAS) were performed at ED admission and after 1 h. Pain medications administered before arrival in the ED were reported by the rescue team. All patients received IV acetaminophen every 8 h and IV morphine according NRS.

RESULTS

Thirty patients were included in this study. At the time of arrival to the ED, > 90% of the patients reported severe pain; 95.8% of them received IV morphine to achieve pain relief. After 1 h, > 65% of patients had NRS < 3. The total amount of IV morphine was 18.12 ± 4.26 mg in the first hour. No adverse events were recorded. The BSPAS on admission to the ED was 34.8 ± 5.6, indicating severe anxiety. After 1 h, BSPAS was 12.8 ± 4.8, indicating mild anxiety.

CONCLUSION

IV morphine used for burn pain management in the emergency setting significantly improves patient outcomes in terms of pain. IV morphine also reduced anxiety scores at 1 h.

Inhaled volatile anesthetics in the intensive care unit

The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population.

Comparison of Noninvasive Mechanical Ventilation With High-Flow Nasal Cannula, Face-Mask, and Helmet in Hypoxemic Respiratory Failure in Patients With COVID-19: A Randomized Controlled Trial

OBJECTIVES

For COVID-19-related respiratory failure, noninvasive respiratory assistance via a high-flow nasal cannula (HFNC), helmet, and face-mask noninvasive ventilation is used. However, which of these options is most effective is yet to be determined. This study aimed to compare the three techniques of noninvasive respiratory support and to determine the superior technique.

DESIGN

A randomized control trial with permuted block randomization of nine cases per block for each parallel, open-labeled arm.

SETTING AND PATIENTS

Adult patients with COVID-19 with a Pa o2 /F io2 ratio of less than 300, admitted between February 4, 2021, and August 9, 2021, to three tertiary centers in Oman, were studied.

INTERVENTIONS

This study included three interventions: HFNC ( n = 47), helmet continuous positive airway pressure (CPAP; n = 52), and face-mask CPAP ( n = 52).

MEASUREMENTS AND MAIN RESULTS

The endotracheal intubation rate and mortality at 28 and 90 days were measured as the primary and secondary outcomes, respectively. Of the 159 randomized patients, 151 were analyzed. The median age was 52 years, and 74% were men. The endotracheal intubation rates were 44%, 45%, and 46% ( p = 0.99), and the median intubation times were 7.0, 5.5, and 4.5 days ( p = 0.11) in the HFNC, face-mask CPAP, and helmet CPAP, respectively. In comparison to face-mask CPAP, the relative risk of intubation was 0.97 (95% CI, 0.63-1.49) for HFNC and 1.0 (95% CI 0.66-1.51) for helmet CPAP. The mortality rates were 23%, 32%, and 38% at 28 days ( p = 0.24) and 43%, 38%, and 40% ( p = 0.89) at 90 days for HFNC, face-mask CPAP, and helmet CPAP, respectively. The trial was stopped prematurely because of a decline in cases.

CONCLUSIONS

This exploratory trial found no difference in intubation rate and mortality among the three intervention groups for the COVID-19 patients with hypoxemic respiratory failure; however, more evidence is needed to confirm these findings as the trial was aborted prematurely.

Ultrasound Guidance Pulsed Radiofrequency Ablation of the Medial Antebrachial Cutaneous Nerve for Palliation of Chronic Pain after Burn Injury: A Case Report

Chronic burn pain persists for 6 months or longer after the wound has healed, affecting the patient's quality of life and daily activities. Pharmacological treatments are essential in the treatment of chronic pain after burns, but interventional methods come to the fore in cases where there is no response to pharmacological treatments. Radiofrequency ablation is known as a safe, effective, and minimally invasive treatment for patients with intractable chronic pain. Various pain syndromes can be successfully treated with radiofrequency ablation however, there is no publication of chronic pain management associated with burn injury. Here, we first describe the successful management of chronic burn pain using radiofrequency ablation of the medial antebrachial cutaneous nerve.

Enzymatic debridement: past, present, and future

INTRODUCTION

Early surgical debridement of the deep second and third-degree burns is still the standard of care (SOC) to prepare the wound bed for skin grafting. However, this technique has some drawbacks that explain the growing interest in enzymatic debridement as an alternative. In this article, we provide a historic overview as well as the current state-of-the-art and future prospective of this type of non-surgical debridement.

MATERIALS AND METHODS

A narrative review of the available literature was conducted using a systematic search.

RESULTS

A total of 32 articles were included. The only enzyme mixture still used nowadays for burn eschar removal is bromelain-based. There is increasing evidence that this type of enzymatic debridement is a powerful tool to selectively remove the eschar in deep burns, thereby reducing the need for autologous skin grafting compared to surgical SOC. Moreover, off-label use of enzymatic debridement with NexoBrid^® (facial, pediatric, and >15%TBSA burns) has proven to be effective and safe.

CONCLUSION

There is increasing evidence that bedside administered NexoBrid^®, preferably under regional anesthesia, is a powerful tool for selective burn eschar removal. However, the clinical wound bed evaluation post-NexoBrid^® procedure in relation to the optimal treatment decision-conservative treatment vs. surgery-is not yet completely elucidated. More high-quality prospective clinical trials are necessary to compare enzymatic debridement of objectively confirmed deep burns with the current standard treatment and assess the effectiveness of the eschar removal, the need for surgery, the healing time of such wounds, and the long-term scar quality.

Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review

BACKGROUND

The conventional way of treating burn victims with mainstream pain control modalities is costly and has many negative side effects. In this study, the authors aim to present the findings from the major clinical trials on three nonpharmacologic interventions-hypnosis, virtual/augmented reality, and yoga-as supplements to conventional pain regimens for burn management.

METHODS

A computerized literature search was conducted of the PubMed and ClinicalTrials.gov databases in April of 2020. The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research.

RESULTS

The search yielded 254 articles from 1955 to 2020. Fifty-eight studies met the authors' inclusion criteria. Yoga reduced cognitive and somatic anxiety in burn survivors, and improved body image. Virtual reality is effective in pain reduction in both the pediatric and the adult burn population, and in faster burn wound reepithelialization. Hypnosis has similar results regarding reducing pain quality and anxiety in burn patients undergoing burn wound care and dressing changes but was not found to significantly accelerate the healing process.

CONCLUSIONS

Nonpharmacologic interventions are not a substitute for conventional analgesics; however, they could help patients have better control over their pain, greater self-esteem, and less postburn traumatic experiences. Burn care centers should consider nonpharmacologic interventions to improve patient satisfaction and their participation in the treatment and rehabilitation process.

Use of Helmet CPAP in COVID-19 - A practical review

Helmet CPAP (H-CPAP) has been recommended in many guidelines as a noninvasive respiratory support during COVID-19 pandemic in many countries around the world. It has the least amount of particle dispersion and air contamination among all noninvasive devices and may mitigate the ICU bed shortage during a COVID surge as well as a decreased need for intubation/mechanical ventilation. It can be attached to many oxygen delivery sources. The MaxVenturi setup is preferred as it allows for natural humidification, low noise burden, and easy transition to HFNC during breaks and it is the recommended transport set-up. The patients can safely be proned with the helmet. It can also be used to wean the patients from invasive mechanical ventilation. Our article reviews in depth the pathophysiology of COVID-19 ARDS, provides rationale of using H-CPAP, suggests a respiratory failure algorithm, guides through its setup and discusses the issues and concerns around using it.

The Management of Burn Pain in a Pediatric Burns-Specialist Hospital

Appropriate pain management for children who have experienced an acute burn injury is critical to improve patient outcomes and reduce potential morbidities. With 60% of our patients being under the age of 4 years, pain management is crucial in reducing pain and anxiety in both patients and parents. It is imperative that appropriate pain relief is commenced from initial contact with healthcare workers as this will affect the success or failure of future wound procedures. Uncontrolled pain can negatively affect a patient, both short and long term. It may cause anticipatory anxiety for future medical procedures, increased pain and anxiety can decrease wound re-epithelialization which can lead to long-term consequences for growth and mobility, and increased pain can also influence the possibility of patients and families displaying signs of post-traumatic stress disorder. Pain management in the form of pharmaceuticals is imperative during burn wound treatment and should incorporate pain relief targeted at both background and procedural pain. It also requires a multimodal, individualized, and targeted approach combining both pharmaceutical and nonpharmaceutical techniques, including cold running water, multimodal distraction devices, hypnotherapy, and bubbles. We discuss the research and knowledge that our center has gained through treating pediatric patients with burns over the last 20 years.

Material and Technology: Back to the Future for the Choice of Interface for Non-Invasive Ventilation - A Concise Review

Non-invasive ventilation (NIV) has dramatically changed the treatment of both acute and chronic respiratory failure in the last 2 decades. The success of NIV is correlated to the application of the "best ingredients" of a patient's "tailored recipe," including the appropriate choice of the selected candidate, the ventilator setting, the interface, the expertise of the team, and the education of the caregiver. The choice of the interface is crucial for the success of NIV. Type (oral, nasal, nasal pillows, oronasal, hybrid mask, helmet), size, design, material and headgears may affect the patient's comfort with respect to many aspects, such as air leaks, claustrophobia, skin erythema, eye irritation, skin breakdown, and facial deformity in children. Companies are paying great attention to mask development, in terms of shape, materials, comfort, and leak reduction. Although the continuous development of new products has increased the availability of interfaces and the chance to meet different requirements, in patients necessitating several daily hours of NIV, both in acute and in chronic home setting, the rotational use of different interfaces may remain an excellent strategy to decrease the risk of skin breakdown and to improve patient's tolerance. The aim of the present review was to give the readers a background on mask technology and materials in order to enhance their "knowledge" in making the right choice for the interface to apply during NIV in the different clinical scenarios.

A study comparing the effect of premedication with intravenous midazolam or dexmedetomidine on ketamine-fentanyl sedoanalgesia in burn patients: A randomized clinical trial

INTRODUCTION

Dressing changes and wound care-debridement procedures often cause fear and anxiety in burn patients, as these processes are quite painful. In order to determine the best method for alleviating pain during these procedures, the current study compared the efficacy and safety of intravenous dexmedetomidine and midazolam for premedication prior to these painful burn care procedures.

METHODS

This comparative and randomized study included patients who had a burn size of 1563%, were aged 1870 years, were diagnosed with the American Society of Anesthesiologists physical status (ASA I-II), and who underwent painful burn care procedures. Patients were intravenously administered either 1 mcg/kg dexmedetomidine (Group 1) or 0.03 mg/kg midazolam (Group 2) prior to the burn care procedure. Recorded at predetermined time points for each patient were heart rhythm (HR), mean arterial pressure (MAP), peripheral oxygen saturation (SpO₂₎, standard bispectral index (BIS), and Ramsay Sedation Scale (RSS).

RESULTS

In the dexmedetomidine group, HR and MAP measurements of patients ​​at the 3rd, 5th, and 10th mins during sedation were significantly lower than the baseline values (p < 0.05). A significant decrease in SpO2 was observed in both groups at the 10th min during sedation, but the decline was higher in the midazolam group (p < 0.05). BIS measurements of the patients in both groups were significantly lower at 10 min. during sedation and at 15th and 60th mins during the procedure (p < 0.05). However, there was no significant difference between the group (p > 0.05). The RSS scales of both groups in during the sedation were higher in the 3rd, 5th and 10th mins than the baseline values (p < 0.05), but there was no significant difference between the groups (p > 0.05). The RSS scales of groups in during the burn procedure were significantly higher at 15 th min than the 0 th values, while the RSS scales of both groups were significantly lower in the 45th and 60th mins (p < 0.05).

CONCLUSION

Results of this study indicate that dexmedetomidine causes hemodynamic alterations while midazolam causes respiratory depression. However, these effects are not severe, and we conclude that both agents are safe and effective to ensure sedation prior to painful burn-care procedures.

Sedation and Analgesia for Adult Outpatient Burn Dressing Change: A Survey of American Burn Association Centers

The management of pain and sedation during burn dressing change is challenging. Previous reviews and studies have identified wide variability in such practices in hospitalized burn patients. This survey-based study aimed to determine the most commonly utilized sedation and analgesia practices in adult burn patients treated in the outpatient setting. The goal was to identify opportunities for improvement and to assist burn centers in optimizing sedation procedures. A 23-question survey was sent to members of the American Burn Association. Nonpharmacological interventions including music, television, games, and virtual reality were used by 68% of survey respondents. Eighty-one percent reported premedicating with oral opioids, 32% with intravenous opioids, and 45% with anxiolytics. Fifty-nine percentage of respondents indicated that the initial medication regimen for outpatient dressing changes consisted of the patient's existing oral pain medications. Forty-three percent indicated that there were no additional options if this regimen provided inadequate analgesia. Fifty-six percentage of respondents felt that pain during dressing change was adequately controlled 75% to 100% of the time, and 32% felt it was adequately controlled 50% to 75% of the time. Nitrous oxide was used by 8%. Anesthesia providers and an acute pain service are available in a minority of cases (13.7% and 28%, respectively) and are rarely consulted. Procedural burn pain remains significantly undertreated in the outpatient setting and the approach to treatment is variable among burn centers in the United States. Such variation likely represents an opportunity for identifying and implementing optimal practices and developing guidelines for burn pain management in the outpatient setting.

Patients' satisfaction with anesthesia in enzymatic debridement from a surgical perspective

INTRODUCTION

Various clinical studies found that enzymatic debridement (EDNX) is superior to tangential excision after severe burns. The current study evaluates patients' satisfaction with pain management in EDNX with special respect to different anesthesia techniques.

METHODS

Between 2015 and 2016, all patients at a department of plastic surgery were asked to complete a German-wide validated pain questionnaire. In a retrospective study design, satisfaction with pain management was compared between the control group (diagnosis from the whole field of plastic surgery except burns) and the EDNX group (burns treated with EDNX only). Analgosedation, general, regional and local anesthesia were chosen for pain management.

RESULTS

In the control group 403 patients (153 females, 250 males, medium age 53 years) could be included The EDNX group included 88 patients (20 females, 68 males, medium age 38 years). The mean burn size was 5.3% TBSA. Between 0.5%-10.5% of the surface was treated with EDNX. EDNX patients could be treated under analgosedation and regional anesthesia, by topical anesthesia creme and without any anesthesia. They reported less pain during stress (p = 0.04) and were less frequently affected by motion (p = 0.024) and nausea (<0.001). However, they felt that they need more information about alternative anesthetic treatments (<0.001).

CONCLUSION

EDNX can be performed sufficiently either under analgosedation, regional or local anesthesia. Thus, side effects of general anesthesia can be reduced and treatment costs can be decreased. However, it was found that neither after topical anesthetic creme nor after hand block pain treatment was sufficient.

Regional Anesthesia and Analgesia for Acute Trauma Patients

Regional anesthesia for the acute trauma patient is increasing due to the growing appreciation of its benefits, development of newer techniques and equipment, and more robust training. Block procedures are expanding beyond perioperative interventions performed exclusively by anesthesiologists to paramedics on scene, emergency medicine physicians, and nurse-led services using these techniques early in trauma pain management. Special considerations and indications apply to trauma victims compared with the elective patient and must be appreciated to optimize safety and clinical outcomes. This review discusses current literature and future directions in the growing role of regional anesthesia in acute trauma care.

Sedation and Analgesia for Dressing Change: A Survey of American Burn Association Burn Centers

Pain and sedation management for patients undergoing burn dressing change can be challenging. Variations appear to exist in the selection of medications before and during burn dressing change. To determine if institutional variations exist in pain and sedation management for burn dressing change, an online survey was sent to ABA Burn Center nurses and physicians. Three hundred seventy-eight anonymous responses were received from nurses (72%), nurse practitioners (10%), and physicians (18%). Burn centers had adult (22%), pediatric (12%), or pediatric and adult (66%) patients. Eighty percentage of centers had >200 patients/year. Sixty-eight percentage always used a premedication. Oxycodone and morphine or fentanyl was the most frequently used per oral (PO) and intravenous (IV) opioid premedication, respectively. The most common IV premedication anxiolytic were benzodiazepines. Sixty-eight percentage always used a long-acting opioid. Anesthetic regimen was decided case-by-case (47%) or specific protocol (24%). Protocol was followed always (18%) or mostly (55%). Patients' procedural pain could be better controlled 20% of the time. Pain regimen was altered most of the time (25%). Providers differed rarely (39%) and sometimes (44%) regarding preferred regimen. Ketamine was the most common deep sedative. A dedicated anesthesiologist was rarely (33%) consulted, determined case-by-case (33%) or prior failure/excess pain (19%). Acute pain service was never (51%) or rarely (35%) consulted. Pain and sedation management for burn dressing change is difficult and variations in approach exist among burn centers. Such management needs individualized care. Providers must be responsive to pain alterations. Consultation with anesthesia providers may be needed in specific cases. Further studies need to be completed to demonstrate the most effective means of controlling burn pain and evaluating patient outcomes.

Sevoflurane for procedural sedation in critically ill patients: A pharmacokinetic comparative study between burn and non-burn patients

BACKGROUND

Sevoflurane has anti-inflammatory proprieties and short lasting effects making it of interest for procedural sedation in critically ill patients. We evaluated the pharmacokinetics of sevoflurane and metabolites in severely ill burn patients and controls. The secondary objective was to assess potential kidney injury.

METHODS

Prospective interventional study in a burn and a surgical intensive care unit; 24 mechanically ventilated critically ill patients (12 burns, 12 controls) were included. The sevoflurane was administered with an expired fraction target of 2% during short-term procedural sedation. Plasma concentrations of sevoflurane, hexafluoroisopropanolol (HFIP) and free fluoride ions were recorded at different times. Kinetic Pro (Wgroupe, France) was used for pharmacokinetic analysis. Kidney injury was assessed with neutrophil gelatinase-associated lipocalin (NGAL).

RESULTS

The mean total burn surface area was 36±11%. The average plasma concentration of sevoflurane was 70.4±37.5mg·L^-1 in burns and 57.2±28.1mg·L^-1 in controls at the end of the procedure (P=0.58). The volume of distribution was higher (46.8±7.2 vs 22.2±2.50L, P<0.001), and the drug half-life longer in burns (1.19±0.28h vs 0.65±0.04h, P<0.0001). Free metabolite HFIP was higher in burns. Plasma fluoride was not different between burns and controls. NGAL did not rise after procedures.

CONCLUSION

We observed an increased volume of distribution, slower elimination rate, and altered metabolism of sevoflurane in burn patients compared to controls. Repeated use for procedural sedation in burn patients needs further evaluation. No renal toxicity was detected.

TRIAL REGISTRY NUMBER

ClinicalTrials.gov Identifier NCT02048683.

Pain and the thermally injured patient-a review of current therapies

Thermally injured patients experience tremendous pain from the moment of injury to months or years after their discharge from the hospital. Pain is therefore a critical component of proper management of burns. Although the importance of pain is well recognized, it is often undertreated. Acute uncontrolled pain has been shown to increase the incidence of mental health disorders and increase the incidence of suicide after discharge. Long-term poor pain control leads to an increase in the incidence of persistent pain. Most burn centers have used opioids as the mainstay analgesic, but recently, the significant side effects of opioids have led to the implementation of new and combined therapeutics. Pharmacological agents such as gabapentin, clonidine, dexmedetomidine, and ketamine have all been suggested as adjuncts to opioids in the treatment of burn pain. Nonpharmacological therapies such as hypnosis, virtual reality devices, and behavioral therapy are also essential adjuncts to current medications. This review aims at identifying the currently available pharmacological and nonpharmacological options for optimal pain management in the adult burn population.

Virtual restorative environment therapy as an adjunct to pain control during burn dressing changes: study protocol for a randomised controlled trial

BACKGROUND

The pain of a severe burn injury is often characterised by intense background pain, coupled with severe exacerbations associated with essential procedures such as dressing changes. The experience of pain is affected by patients' psychological state and can be enhanced by the anxiety, fear and distress caused by environmental and visual inputs. Virtual Reality (VR) distraction has been used with success in areas such as burns, paediatrics and oncology. The underlying principle of VR is that attention is diverted from the painful stimulus by the use of engaging, dynamic 3D visual content and associated auditory stimuli. Functional magnetic resonance imaging (fMRI) studies undertaken during VR distraction from experimental pain have demonstrated enhancement of the descending cortical pain-control system.

METHODS/DESIGN

The present study will evaluate the feasibility of introducing a novel VR system to the Burns Unit at the Queen Elizabeth Hospital Birmingham for dressing changes: virtual restorative environment therapy (VRET). The study will also explore the system's impact on pain during and after the dressing changes compared to conventional analgesia for ward-based burn dressing changes. A within-subject crossover design will be used to compare the following three conditions: 1. Interactive VRET plus conventional analgesics. 2. Passive VRET with conventional analgesics. 3. Conventional analgesics alone. Using the Monte Carlo method, and on the basis of previous local audit data, a sample size of 25 will detect a clinically significant 33 % reduction in worst pain scores experienced during dressing changes.

DISCUSSION

The study accrual rate is currently slower than predicted by previous audits of admission data. A review of the screening log has found that recruitment has been limited by the nature of burn care, the ability of burn inpatients to provide informed consent and the ability of patients to use the VR equipment. Prior to the introduction of novel interactive technologies for patient use, the characteristics and capabilities of the target population needs to be evaluated, to ensure that the interface devices and simulations are usable.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN23330756 . Date of Registration 25 February 2014.

"Burn catatonia": a case report and literature review

Thermal injuries have been recognized to cause significant neuropsychiatric symptoms and disability in their sufferers since the middle of the 20th century, when Drs. Stanley Cobb and Erich Lindemann of the Massachusetts General Hospital (Boston, MA) studied survivors of the Cocoanut Grove nightclub fire in Boston. Although "burn encephalopathy" or burn-induced delirium is a common occurrence in the acute phase, catatonia in burn patients is not often reported. This report describes a case of malignant catatonia occurring in a 51-year-old male patient acutely suffering from burns acquired in a chemical explosion, effectively treated with reinstitution of a selective serotonin reuptake inhibitor. The literature on burn encephalopathy and catatonia in burns is reviewed. Few examples of burn catatonia exist. Burn encephalopathy is common, and may occur in patients with low TBSA burns such as described in the case above. Descriptions of burn encephalopathy are numerous, but have not included catatonia as a possible etiology. Catatonia in burn patients as an etiology of burn encephalopathy is likely underrecognized. Clinicians should be aware of the possibility of catatonia when a patient's confusional state after a burn does not respond to usual care.

Ventilation strategies in burn intensive care: A retrospective observational study

Consensus regarding optimal burns intensive care (BICU) patient management is lacking. This study aimed to assess whether ventilation strategies, cardiovascular support and sedation in BICU patients have changed over time, and whether this affects outcome. A retrospective observational study comparing two 12-patient BICU cohorts (2005/06 and 2010/11) was undertaken. Demographic and admission characteristics, ventilation parameters, sedation, fluid resuscitation, cardiovascular support and outcome (length of stay, mortality) data were collected from patient notes. Data was analysed using T-tests, Fisher's exact and Mann-Whitney U tests. In our study cohort groups were equivalent in demographic and admission parameters. There were equal ventilator-free days in the two cohorts 10 ± 12.7 vs. 13.3 ± 12.2 ventilator free days; P = 0.447). The 2005/06 cohort were mechanically ventilated more often than in 2010/11 cohort (568 ventilator days/1000 patient BICU days vs. 206 ventilator days/1000 patient BICU days; P = 0.001). The 2005/06 cohort were ventilated less commonly in tracheostomy group/endotracheal tube spontaneous (17.8% vs. 26%; P = 0.001) and volume-controlled modes (34.4% vs. 40.8%; P = 0.001). Patients in 2010/11 cohort were more heavily sedated (P = 0.001) with more long-acting sedative drug use (P = 0.001) than the 2005/06 cohort, fluid administration was equivalent. Patient outcome did not vary. Inhalational injury patients were ventilated in volume-controlled (44.5% vs. 28.1%; P = 0.001) and pressure-controlled modes (18.2% vs. 9.5%; P = 0.001) more frequently than those without. Outcome did not vary. This study showed there has been shift away from mechanical ventilation, with increased use of tracheostomy/tracheal tube airway spontaneous ventilation. Inhalation injury patients require more ventilatory support though patient outcomes do not differ. Prospective trials are required to establish which strategies confer benefit.

Pediatric burn injuries

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

Impact of respiratory pattern on lung mechanics and interstitial proteoglycans in spontaneously breathing anaesthetized healthy rats

AIM

The aim of this study was to investigate the effect of different pattern of spontaneous breathing on the respiratory mechanics and on the integrity of the pulmonary extracellular matrix.

METHODS

Experiments were performed on adult healthy rats in which different spontaneously breathing pattern was elicited through administration of two commonly used anaesthetic mixtures: pentobarbital/urethane (P/U) and ketamine/medetomidine (K/M). The animals (five per group) were randomized and left to spontaneously breath for 10 min (P/U-sham; K/M-sham) or for 4h (P/U-4h; K/M-4h), targeting the anaesthesia level to obtain a tidal volume of about 8 mL kg(-1) body wt. At the end of the experiment, lung matrix integrity was assessed through determination of the glycosaminoglycans (GAGs) content in the lung parenchyma.

RESULTS

Compared with K/M, anaesthesia with P/U cocktail induced: (1) a higher respiratory rate and minute ventilation attained with lower P(a) CO(2) ; (2) a higher pressure-time-product and work of breathing per minute; (3) a lower static lung compliance; (4) an increased activation of lung tissue metalloproteases; and (5) greater extraction of pulmonary interstitial GAGs.

CONCLUSIONS

This study suggests that the breathing pattern induced by the different anaesthetic regimen may damage the pulmonary interstitium even during spontaneous breathing at physiological tidal volumes.

Analgesia and sedation for children undergoing burn wound care

Standard care of burn wounds consists of cleaning and debridement (removing devitalized tissue), followed by daily dressing changes. Children with burns undergo multiple, painful and anxiety-provoking procedures during wound care and rehabilitation. The goal of procedural sedation is safe and efficacious management of pain and emotional distress, requiring a careful and systematic approach. Achieving the best results needs understanding of the mechanisms of pain and the physiologic changes in burn patients, frequent evaluation and assessment of pain and anxiety, and administration of suitable pharmacological and nonpharmacological therapies. Pharmacological therapies provide the backbone of analgesia and sedation for procedural pain management. Opioids provide excellent pain control, but they must be administered judiciously due to their side effects. Sedative drugs, such as benzodiazepines and propofol, provide excellent sedation, but they must not be used as a substitute for analgesic drugs. Ketamine is increasingly used for analgesia and sedation in children as a single agent or an adjuvant. Nonpharmacological therapies such as virtual reality, relaxation, cartoon viewing, music, massage and hypnosis are necessary components of procedural sedation and analgesia for children. These can be combined with pharmacological techniques and are used to limit the use of drugs (and hence side effects), as well as to improve patient participation and satisfaction. In this article, we review the pathophysiologic changes associated with major thermal injury in children, the options available for sedation and analgesia for wound care procedures in these children and our institutional guidelines for procedural sedation.

Analgesia and Sedation in the Intensive Care of Burn Patients

Objective: A variety of agents and techniques are employed in different countries, settings, and medical specialities in order to provide analgesia and sedation in intensive care. Several national guidelines have been published in recent years regarding sedation and analgesia in a general intensive care patient population; however, to date no data exist for patients with burn injuries. The aim of the study was to evaluate analgesia and sedation practice in the intensive care of burn patients in Europe. Design: A postal survey was sent to 188 burn centers in Europe. The addresses were provided by the European Burn Association. The heads of the intensive care units were asked to fill in a structured questionnaire concerning the use of analgesia and sedation in their units. Results: The overall response rate was 27.04%; 63% of European burn centers reported standard operating procedures for sedation and analgesia. A regular score-based assessment of sedation, analgesia, and delirium is carried out by 58%, 60%, and 5%, respectively, of the units. Propofol is the sedative most frequently used for short-term sedation and the weaning phase, whereas benzodiazepines are the preferred substances for medium- and long-term sedation. α2-agonists are widely used during weaning. Opioids are the analgesics of choice for approximately two thirds of the patients. Ketamine is preferred for analgesia in 12% and for sedation in 13% of all substances used. For painful procedures (eg, dressing changes), a large variety of different combinations of analgesics and sedatives are used. Half of the responding intensive care units use neuromuscular blocking agents and supportive nonpharmacological techniques. Two thirds of the European burn centers perceive the need for change in their concepts of analgesia and sedation. Conclusion: A wide variety of drugs are used for analgesia and sedation in European burn centers. This would appear to be due to lack of guidelines or scientific evidence. The implementation of regular assessment of sedation, analgesia, and delirium must be improved. The widespread use of neuromuscular blocking agents should be restricted or even abandoned. Two thirds of the units identify a need for change in their concepts. Valid scientific data are needed to develop guidelines for sedation and analgesia of burn patients.

European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care

The European Association for Palliative Care (EAPC) considers sedation to be an important and necessary therapy in the care of selected palliative care patients with otherwise refractory distress. Prudent application of this approach requires due caution and good clinical practice. Inattention to potential risks and problematic practices can lead to harmful and unethical practice which may undermine the credibility and reputation of responsible clinicians and institutions as well as the discipline of palliative medicine more generally. Procedural guidelines are helpful to educate medical providers, set standards for best practice, promote optimal care and convey the important message to staff, patients and families that palliative sedation is an accepted, ethical practice when used in appropriate situations. EAPC aims to facilitate the development of such guidelines by presenting a 10-point framework that is based on the pre-existing guidelines and literature and extensive peer review.

[Burn trauma--Part 2. Anesthesiological, surgical and intensive care management]

After initial stabilization of burn victims at the scene and in the trauma room, a tight cooperation and communication between anesthesiologists, plastic surgeons and intensive care specialists is needed for further therapy. Interdisciplinary communication about preoperative planning, timing of necrectomy and intensive care therapy is vital regarding functional and aesthetic outcome and survival rate. During burn surgery attention has to be paid to excessive blood loss and the danger of hypothermia. The main problems of intensive care therapy involve the evaluation of volume status, high demands for analgesia and sedation, high incidence of septic multiorgan failure and therapy and prophylaxis of the effects of hypermetabolism.