Effectiveness of Hypnoanalgesia in Paediatric Dermatological Surgery

Background and objective. Stress in surgical settings has subtle psychological and physiological repercussions in children. The objective is to evaluate whether hypnosedation is effective in reducing the doses of sedation and analgesia required during the periprocedural period in children undergoing dermatological surgery, without negatively affecting pain and satisfaction. Patients and methods: A prospective, longitudinal, observational study where paediatric patients (aged 5–16 years) scheduled for dermatological surgery were analysed according to whether they received hypnosis or distraction during surgery (both common procedures at the centre). As outcome measurements we used sedation doses (propofol) during surgery and the need for analgesia; pain assessment post-surgery and at 24 h using a visual analogue scale (VAS) or revised face pain scale (FPS-r) (both 0–10) depending on age, as well as patient and guardian satisfaction (on a scale of 0–10). Results: Of the 68 patients eligible during the follow-up period, 65 were included. Of these, 33 were treated with hypnosis and 32 with distraction. Children who underwent hypnosis required less total propofol (45.5 ± 11.8 mg vs. 69.3 ± 16.8 mg; p < 0.001) and metamizole in the immediate postoperative period (34.4% vs. 65.6%; p = 0.018). After 24 h, they required less ibuprofen (9.1% vs. 28.1%; p = 0.048) and paracetamol (48.5% vs. 75.0%; p = 0.028). Mean pain according to VAS or FPS-r at 24 h was 3.1 with hypnosis vs. 4.3 with distraction (p < 0.001). Overall satisfaction was higher in the hypnosis group (8.7 ± 0.1 vs. 8.1 ± 0.2; p = 0.009). Conclusions: Hypnoanalgesia in children undergoing dermatological outpatient surgery could not only reduce sedation and analgesia requirements, but also improve child and guardian(s) satisfaction.

Sedative and Analgesic Effects of Intravenous Midazolam and Ketamine Combination in Bone Marrow Aspiration and Biopsy of Childhood Cancer

Background: Various drugs, including ketamine and midazolam, are used for sedation in children. Objectives: This study aimed to evaluate the effectiveness of intravenous midazolam and ketamine combination in bone marrow aspiration and biopsy in children with cancer. Methods: This descriptive cross-sectional study was conducted on 100 children aged six months to 17 years candidates for bone marrow aspiration or biopsy. Sampling was easy, accessible, and sequential. Children were injected with 0.05 mg/kg midazolam and 1 mg/kg ketamine for sedation and analgesia. Then, sedation rate, restlessness, nausea, vomiting, laryngospasm, and decreased oxygen saturation were assessed. Data were analyzed using SPSS version 18 software. Results: The mean age of children was 6.8 ± 4.3 years. The mean degree of sedation based on the modified Ramsey score was 5.2 ± 0.74. Nausea and vomiting were observed in nine (9%) children. Six (6%) children had arterial saturation of less than 90%. Twelve (12%) children showed restlessness when waking up. There were no cases of laryngeal spasms. Conclusions: The present study showed that the intravenous midazolam and ketamine combination provides suitable sedation and analgesia to children, with low and negligible side effects.

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.

Effects of different sedatives/analgesics on stress responses in patients undergoing craniotomy and bone flap decompression

Objective To explore the effects of sedation and analgesia with dexmedetomidine and other drugs on the stress response in patients with cerebral hemorrhage after craniotomy hematoma removal and bone flap decompression and insertion of an indwelling endotracheal catheter. Methods A total of 180 patients with cerebral hemorrhage with consciousness disturbance who underwent emergency surgery were included in this study. They were divided into six groups treated with propofol, dexmedetomidine, lidocaine, sufentanil, dezocine, and remifentanil, respectively. Intravenous medication was given after recovery of spontaneous respiration, and stress responses were compared among the group. Results Serum concentrations of norepinephrine, epinephrine, and cortisol and systolic blood pressure were significantly correlated with drug treatment. Serum norepinephrine concentrations differed significantly among the groups, except between the sufentanil and propofol groups. There were significant differences in serum epinephrine concentrations among all groups, and significant differences in serum cortisol concentrations among all groups, except the propofol, dexmedetomidine, and lidocaine groups. Conclusion Dexmedetomidine can reduce the stress response in patients with intracerebral hemorrhage undergoing emergency craniotomy and bone flap decompression, and can reduce adverse events from an indwelling endotracheal catheter 3 hours post-operation.

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.