Elsevier

Burns

Volume 40, Issue 1, February 2014, Pages 48-53
Burns

A 2 year experience of nurse led conscious sedation in paediatric burns

https://doi.org/10.1016/j.burns.2013.08.021Get rights and content

Abstract

Introduction

Ketamine and midazolam have been used safely by anaesthetists in paediatric burns and have a good safety profile. We believed that this could be developed to a nurse led conscious sedation protocol, without direct anaesthetic attendance.

Methods

Two years experience of our technique was retrospectively reviewed. We recorded the age, weight, percentage burn, dose of oral ketamine and midazolam given, time for procedure whether an anaesthetist was called to the sedation room, and the reason for the call.

Results

Data were collected for a total of 45 children undergoing 131 procedures. The age (mean ± SD) was 9.5 ± 4.7 years, the weight (mean ± SD) 38.7 ± 19.8 kg and the percentage burn (mean ± SD) was 25.3 ± 22.9%. The dose of oral ketamine (mean ± SD) was 409.5 ± 252.3mg or 8.78 ± 3.27 mg/kg and the dose of oral midazolam (mean ± SD) was 17.6 ± 8.7 mg or 0.44 ± 0.14 mg/kg. The duration of procedure (mean ± SD) was 97.32 ± 32.90 min. The incidence of the anaesthetist required to administer further sedation was 29.8% of sedations. The decision to convert to general anaesthesia was taken in 2.3% of cases. An anaesthetist was called other than to top up sedation in 6.9% of sedations.

Conclusion

Our protocol for nurse-monitored conscious sedation using oral ketamine and midazolam in the burns patient provides a safe method of analgesic sedation for burn dressing changes.

Introduction

Procedural analgesia for burn wound management in the paediatric population presents a challenge to the burn team [1]. One bad pain experience can frighten children and emotionally sensitize them to subsequent procedures. The pharmacological agents used ideally should provide reliably effective analgesia to allow full wound therapy to be undertaken, yet must be safe, and have a low incidence of side effects. General anaesthesia requires a starvation period of six hours prior to the procedure and oral intake may be delayed for some hours following. Short acting drugs allow the child to resume oral intake as soon as possible, and achieve the increased calorie requirement that burn recovery demands.

Ketamine was introduced in the late 1960s and its suitability for use in burn care was soon recognized. It has now been used for many years for the provision of analgesia in this setting. Administered intravenously, or intramuscularly, it rapidly produces profound sedation and analgesia whilst maintaining spontaneous respiration and protective airway reflexes and hence it has earned an excellent safety record [2], [3], [4]. The drug also has amnesic properties. Notable side effects include laryngospasm, excessive tracheo-bronchial secretions, cardiovascular stimulation and emergence delirium, and the attending practitioner must be able to effectively trouble shoot these. The incidence of laryngospasm following intravenous use has been quoted as 0.4% [5] and a case controlled analysis of over 8000 sedations has failed to identify any predictors of this complication [6]. The drug is frequently combined with a benzodiazepine to reduce the incidence of emergence delirium.

Oral ketamine has a slower, less predictable onset of action than by parenteral routes, due to first pass metabolism, although peak levels are usually within 30 min [7]. The blood ketamine level required for an analgesic effect has been noted to be significantly lower following oral (40 ng/ml) compared to intramuscular administration (150 ng/ml) [7]. This has been attributed to increased levels, of the active metabolite nor-ketamine relative to ketamine following oral administration. Reports of complications and recognized side effects (in particular laryngospasm, and excessive secretions) following oral administration are less well defined, but anecdotally and in our experience they are lower. It is possible that nor-ketamine is less active in their causation than ketamine. In addition, an indwelling intravenous cannula, necessary for intravenous administration, carries a risk as an infection source, especially in the burns patient, and repeated cannulation may be poorly tolerated in paediatric burn patients.

Guidance on, and reports of the provision of safe sedation by non-anaesthetists and nursing staff have been published over the last 10 years and this includes the paediatric population [8], [9], [10], [11], [12], [13]. Oral ketamine has been successfully used for premedication of children both combined with midazolam and as a single agent [14], [15] without anaesthetic supervision. Humphries [16] has reported experience of oral ketamine as an effective analgesic for burns dressing changes in 19 children, yet this technique does not appear to have been popularized. We believed that appropriately trained burns nurses could safely supervise oral ketamine and midazolam induced conscious sedation [10] and analgesia for burns dressing changes in all age groups with the back-up support of an anaesthetic practitioner. We have written a protocol, with reference to published national guidance [8], [9], [10], [11] for use in our burns centre and here we report details of our protocol and two years of our experience in the paediatric population.

Section snippets

Materials and methods

Suitable procedures for this nurse-led technique include burns dressing changes, with or without showering, which are considered by the burns team as either too extensive for oral opiate use alone or healing well and no longer warranting of full general anaesthesia. The children are required to be physiologically stable and able to be cared for out of the critical care environment. The protocol is inappropriate for children with large raw areas of burn or donor site, poor baseline pain control

Data collection

The audit was registered with our local audit department and discussed with our Research and Development lead who decided that Local Research Ethics Committee approval was not necessary.

The first two years experience of this technique was retrospectively reviewed. Data were collected from the sedation room log book, and patient notes. We recorded the age, weight, percentage burn, dose of oral ketamine and midazolam given, whether an anaesthetist was called to the sedation room, and the reason

Results

During the 2 years studied, we treated around 600 children with burns, as inpatients. Demographics of the children are shown in Table 3. A total of 45 children required sedation for 131 procedures. The age (mean ± SD) was 9.8 ± 4.7 years, the weight (mean ± SD) was 38.7 ± 19.8 kg, and the mean percentage burn (mean ± SD) was 25.3 ± 22.9%.

The mean dose of oral ketamine required (mean ± SD) was 409.5 ± 252.3 mg or 8.78 ± 3.27 mg/kg and the mean dose of oral midazolam (mean ± SD) was 17.6 ± 8.7 mg or 0.44 ± 0.14 mg/kg. It is

Discussion

Our sedation protocol provides safe and effective sedation in paediatric burns patients and is well tolerated. We have described its use in patients rehabilitating from a mean burn size of 25.3%. The 131 procedures described obviated the need for general anaesthesia in children, who would have otherwise been placed on an elective theatre list. There has been less disruption to the hospital stay of these children, and more predictable planning of burns dressings, thereby reducing child and

Conclusions

Our protocol for nurse-monitored conscious sedation using oral ketamine and midazolam in the burns patient provides a safe method of analgesic sedation for burn dressing changes. It allows for sparing of theatre resources and is an efficient use of anaesthetic time. In 131 paediatric cases we have experienced no adverse events and notably no laryngospasm and we would postulate that the lower incidence of side effects compared with those reported for IV ketamine relate to the altered metabolism

Conflict of interest

The authors declare no conflicts of interest.

Acknowledgement

Thanks to Dr. T. Rampal for her help in data collection.

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