Search

Burn injury in children can cause severe and chronic physical and mental sequelae. Opioids are a mainstay in burn pain management but increasing utilization in this country has led to concern for their continued use and potential for dependence. Methadone is a long-acting analgesic that targets the N-methyl-D-aspartate (NMDA) receptor in addition to the mu opioid receptor and has benefit in adult burn patients. However, its use in the pediatric burn population has been less robustly studied. This is a retrospective cohort study at a single Level 1 Burn Center whose primary aim is to compare opioid utilization 36 hours postoperatively between pediatric burn patients who received intraoperative, intravenous methadone and those who did not. Secondary aim was to describe differences in methadone-related complications between the cohorts. There was decreased opioid utilization measured by median morphine equivalents per kilogram (ME/kg) postoperatively in the methadone cohort compared to the control cohort (0.54 vs 0.77 mg/kg, P = .18). No adverse events were noted upon chart review. The data suggest that methadone use is beneficial in pediatric burn patients, but further prospective studies are warranted on a larger population., (© The Author(s) 2022. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population., Competing Interests: Disclosure The authors have no financial interests to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose of Review: The purpose of this article is to summarize literature in pediatric burn resuscitation and management that is relevant to the pediatric anesthesiologist. The scope of the literature is expanding as long-term survival in even the most critically ill, burn-injured children has increased., Recent Findings: Longstanding variations in the care of burn-injured children exist despite decades of experience in burn care management. There seems to be a discomfort outside major burn centers in the triage, evaluation, and assessment of burned children. This is evidenced by the prevalence of 'unnecessary intubations', continued overestimation of total body surface area injured, and subsequent fluid administration disproportionate to injury leading to over-resuscitation. Techniques, such as virtual reality and regional anesthesia are increasingly available and serve adjuncts to pharmacologic therapies for anxiolysis and analgesia. Such techniques reduce opioid utilization while maintaining patient comfort and satisfaction particularly during wound dressing changes. Questions about transfusion threshold and ratio of blood products remain topics of ongoing research., Summary: Literature review continues to reveal underpowered or retrospective analyses of these very important questions. Public health burden caused by burns warrants rigorous, prospective studies to take the best care of these patients and portend the best long-term outcomes. Collaboration amongst pediatric anesthesiologists who care for these children is necessary to develop and execute powered studies to answer important questions.

Opioids are the mainstay therapy in burned adults. Little data in the pediatric burn population exists that elucidates opioid prescribing practices. The primary purpose of this report is to quantify opioid and non-opioid analgesic use in pediatric burn patients admitted to a tertiary referral burn center. A retrospective audit of hospital charts and discharge records for patients <18 years old from March 2016 to March 2017 was performed. Opioid amounts were converted to either oral morphine miligram equivalents (MME) or oral MME per day and subsequently adjusted for age in kilograms (kg). Of the 226 patients, 223 (98.7%) were administered an opioid during admission. The median total opioid amount administered during admission was 0.4 (IQR: 0.3-0.6) mg oral MME per kilogram per day. Anecdotally, doses above 1 mg/kg/day are considered high risk for opioid tolerance. The median total opioid amount prescribed upon discharge was high at 3.9 (IQR: 2.3, 5.6) mg of oral MME per kilogram. Hydrocodone (96.0%) was the most common opioid administered, followed by morphine (88.1%). The most commonly prescribed discharge opioid was hydrocodone (95.4%). Non-opoioid analgesia during admission was used in 112 patients (49.6%). This study provides novel insight into the opioid practices at a tertiary burn center for pediatric patients, with our analysis showcasing high usage of opioids during admission and discharge for burn analgesia. It emphasizes the need to expand beyond opioids for burn analgesia and the importance of promoting non-opioid, multimodal analgesia in the pediatric burn population., (Copyright © 2019 Elsevier Ltd and ISBI. All rights reserved.)

The effects of injecting tumescence containing phenylephrine in pediatric burn patients are unknown, but anecdotally our clinicians note a high incidence of hypertension requiring treatment. This study sought to determine whether tumescence with phenylephrine was associated with hypertension requiring treatment in our pediatric burn patients. This was a retrospective cohort study of pediatric burn patients who underwent tangential excision with split-thickness autografting, excision alone, or autografting alone from 2013 to 2017. Records were reviewed for hypertensive episodes, defined as ≥2 consecutive blood pressure readings that were >2 SD above normal. Published intraoperative age- and sex-adjusted standards were used to define reference values. Parametric and nonparametric tests were used when appropriate. In total, 258 operations were evaluated. Mean patient age was 7.6 ± 5.2 years, and 64.7% were male. Patients were predominately white (69.8%). Overall, there was a 62.8% incidence of hypertension. On univariate logistic regression analysis, duration of operation, estimated blood loss, treated TBSA, and weight-adjusted volume of tumescence were significant predictors of intraoperative hypertension (P < .01). On multivariate analysis, weight-adjusted volume of tumescence alone was significantly associated with the presence of hypertension with an odds ratio of 2.0 (95% confidence interval: 1.33-3.04). Of the 162 operations which exhibited at least one episode of significant hypertension, 128 cases (79%) were treated. Intraoperative administration of phenylephrine-containing tumescence in pediatric burn patients is associated with clinically significant hypertension requiring treatment. This practice should be conducted with caution in pediatric burn operations until its clinical implications are defined., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Dandy-Walker syndrome is a rare congenital brain malformation that requires unique anesthetic considerations. We present a rare case of an 18-month-old boy with Dandy-Walker syndrome presenting with 17% total body surface area burns undergoing multiple general anesthetics for both operative and bedside procedures. Numerous lessons were learned during multiple anesthetics, which influenced and guided our subsequent anesthetic management. The preoperative assessment, risk for respiratory apnea, opioid management, risk for laryngospasm, and postoperative care of patients with Dandy-Walker syndrome were all lessons learned.