Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft

Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. Procedural sedation and analgesia in the emergency department is a popular alternative to debridement in operating theatres under general anaesthesia. This study aims to evaluate the association between early (< 24 h post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements. Cohort study of children younger than 17 years who presented with burns of five percent total body surface area or greater. Data from January 2013 to December 2019 were extracted from a prospectively collected state-wide paediatric burns’ registry. Time to re-epithelialisation was tested using survival analysis, and binary logistic regression for odds of skin graft requirementto analyse effects of early non-excisional debridement in the operating theatre. Overall, 292 children met eligibility (males 55.5%). Early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (14 days versus 21 days, p = 0.029)) and the odds of requiring a skin graft in comparison to paediatric patients debrided in the emergency department under Ketamine sedation (OR: 6.97 (2.14–22.67), p < 0.001. This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.

Comparing the Role of Auditory Soothing Effect and Ketamine on Duration of Sedation and Recovery Time in Procedural Sedation and Analgesia (PSA) Among Pediatric Patients in Emergency Department. A Case-Control Comparative Study from a Tertiary Care Setting of LIC

Introduction: Pediatric pain, is a major concern of anxiety and fear during emergency procedures, to alleviate pediatric pain and distress different mode of sedation is required from local, nasal to parental. Appropriate pain relief with adequate sedation and analgesia different drugs are used, however, most have their side effects. Ketamine alone has been used for procedural sedation and analgesia (PSA), but a higher dose may be required to achieve adequate sedation and pain relief, leading to dose-dependent side effects. In this study, we hypothesize that cartoon music or parental/physicians soothing rhymes/sounds during PSA may reduce the dose and frequency of sedative medications, and reduce the duration of sedation and early recovery.Material and Methods: This is a prospective cross-sectional comparative hospital-based study, we used non-probability consecutive sampling from children below 16 years during 2018-2019, post ethical review board approval from Hospital Ethical Committee (3827-EM-ERC-15 (3827-EM-ERC-15{Emergency Medicine – Ethical Review Committee}), who need PSA in ED settings. The PSA was carried by ED physicians who were credentialed for PSA and advanced airway care, while the procedure will be dealt with by another physician from ED or another subspecialty. The study population was divided into two groups, one with Ketamine alone (control group) with 32 patients, while another (case group) with 60 children, who got a low dose of Ketamine along with either of the soothing auditory stimulus, like cartoon music via mobile, parental/physician rhymes during PSA. Data was entered and analyzed using SPSS version-21 Frequency and the percentage was calculated for qualitative variables. Shapiro-Wilk test was applied to check the hypothesis of normality for age (years), sedation, and recovery time, and descriptive statistics such as mean±SD, median (IQR), maximum and minimum were calculated appropriately. Effect modifiers like age, gender, sedation, and recovery time were addressed through stratification. The post-stratification chi-square test was applied by taking p ≤ 0.05 as significant.Results: Comparing the two major groups (case and control), there was no statistical difference among age, gender, types of procedures done, and recovery time, however LOS in ED (<60 minutes) and sedation time (<30 minutes) in the case group was statistically better than in control group (78% vs 87% and 85% and 78% respectively). Children with oxygen saturation ≤90% were slightly better in the case group 1.7% vs 3.1%, similarly 25% had tachycardia as compared to 28% in the ketamine-only group. Tachypnea was observed in 21.7% vs 28% among the case and control groups. Importantly ketamine repeat dose was observed in 34.4% among control (ketamine only) group and only 21.7 need repeated dose in the case group. Discussion: The goal of PSA was to relieve anxiety and fear of pain during the procedure in chaotic EDs. This will help in gaining child cooperation and parents' satisfaction along with reduced drug dose, minimizing LOS, speedy recovery time, and lessening the anticipated drug-related complications. The significant finding observed was the total sedation time and LOS in ED which was significantly better in the control group. Younger children were better soothed by parental voice (rhymes) as compared to other soothing methods examined, similarly lesser drop in oxygen saturation, minimal tachycardia or tachypnea were observed and fewer repeat doses of Ketamine was used as compared to the control group. Music during PSA demonstrates a reduction in patient anxiety, however, the dose and frequency of sedation required didn't show any such reduced medications.Conclusion: In conclusion, listening to cartoon music or parental sound/rhymes has no significant effect on the hemodynamic variables or the drug consumption among pediatric patients during PSA. By considering the reported beneficial results of previous studies, listening to music can be accepted as an adjunct non-pharmacological method for sedation.

Single-Shot Sub-Dissociative Dose Ketofol versus Ketamine Alone for Emergency Department Procedural Sedation and Analgesia in Adult

When compared with Ketamine alone for PSA in ED settings, the Ketofol with rapid onset of action, faster recovery time, cardio respiratory stability, less adverse events, and high patient satisfaction level make it a better option.

Review of the Physiology and Anesthetic Considerations for Pleuroscopy/Medical Thoracoscopy

Pleuroscopy or medical thoracoscopy is the second most common utilized procedure after bronchoscopy in the promising field of interventional pulmonology. Its main application is for the diagnosis and management of benign or malignant pleural effusions. Entry into the hemithorax is associated with pain and patient discomfort, whereas concurrently, notable pathophysiologic alterations occur. Therefore, frequently procedural sedation and analgesia is needed, not only to alleviate the patient’s emotional stress and discomfort by mitigating the anxiety and minimizing the pain but also for yielding better procedural conditions for the operator. The scope of this review is to present the physiologic derangements occurring in pleuroscopy and compare the various anesthetic techniques and sedative agents that are currently being used in this context.

Monitored Anesthesia Care with Dexmedetomidine Supplemented by Midazolam/Fentanyl versus Midazolam/Fentanyl Alone in Patients Undergoing Pleuroscopy: Effect on Oxygenation and Respiratory Function

Although pleuroscopy is considered a safe and well tolerated procedure with a low complication rate, it requires the administration of procedural sedation and analgesia. The purpose of this study was to assess the effects of dexmedetomidine administration on oxygenation and respiratory function in patients undergoing diagnostic or therapeutic pleuroscopy. Through a prospective, single center, cohort study, we studied 55 patients receiving either a dexmedetomidine intravenous infusion supplemented by midazolam/fentanyl (Group DEX + MZ/F) or a conventional sedation protocol with midazolam/fentanyl (Group MZ/F). Our primary outcome was the changes in lung gas exchange (PaO2/FiO2 ratio) obtained at baseline and at predetermined end points, while changes in respiratory mechanics (FEV1, FVC and the ratio FEV1/FVC) and PaCO2 levels, drug consumption, time to recover from sedation and adverse events were our secondary endpoints (NCT03597828). We found a lower postoperative decrease in FEV1 volumes in Group DEX + MZ/F compared to Group MZ/F (p = 0.039), while FVC, FEV1/FVC and gas exchange values did not differ between groups. We also found a significant reduction in midazolam (p < 0.001) and fentanyl consumption (p < 0.001), along with a more rapid recovery of alertness postprocedure in Group DEX + MZ/F compared to Group MZ/F (p = 0.003), while pain scores during the postoperative period, favored the Group DEX + MZ/F (p = 0.020). In conclusion, the use of intravenous dexmedetomidine during pleuroscopy is associated with a smaller decrease in FEV1, reduction of the consumption of supplementary sedatives and analgesics and quicker awakening of patients postoperatively, when compared to midazolam/fentanyl. Therefore, dexmedetomidine administration may provide clinically significant benefits in terms of lung mechanics and faster recovery of patients undergoing pleuroscopy.