Analgesia and sedation for children undergoing burn wound care

Abstract

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.

Ketamine versus alfentanil combined with propofol for sedation in colonoscopy procedures: A randomized prospective study

“…Ketamine is often used for sedation and analgesia as a sole agent or adjuvant (13). It is a dissociative anesthetic, providing amnesia and analgesia, and maintains spontaneous respiration by protecting upper airway reflexes and muscle tone (4).…”

Pediatric burn injuries

“…This contributes to a loss of muscle protein, bone mineral density, and overall bone mineral content. [1] In addition, thermoregulatory responses are impaired, with resetting of the patient's core temperature in proportion to the total burn area. [12] Burned skin is unable to retain heat and water, with the potential consequence of massive evaporative fluid losses and metabolic responses much more severe than thought previously.…”

“…Nearly a fourth of all burn injuries occur in children under the age of 16, of whom the majority are under the age of five. [1] Most burn injuries are minor and do not necessitate hospital admission. [2] A minority of burn injuries are serious and meet criteria for transfer to a burn center; the care of these critically ill children requires a coordinated effort and expertise in the management of the burned patient.…”

A randomized trial of a distraction‐type intervention to assist in managing dressing changes for children experienced burns

“…As an auxiliary therapy, non‐pharmacological pain treatment has an apparent curative effect in relieving pain for children with burns and is safer than pharmacological treatment (Bayat, Ramaiah, & Bhananker, ; Lee, McTavish, & Sorkin, ; Yang et al, ). Distraction is a common non‐pharmacological pain treatment method that is commonly used in children.…”