Analgo-sedation of patients with burns outside the operating room.

Following the initial resuscitation of burn patients, the pain experienced may be divided into a 'background' pain and a 'breakthrough' pain associated with painful procedures. While background pain may be treated with intravenous opioids via continuous infusion or patient-controlled analgesia (PCA) and/or less potent oral opioids, breakthrough pain may be treated with a variety of interventions. The aim is to reduce patient anxiety, improve analgesia and ensure immobilization when required. Untreated pain and improper sedation may result in psychological distress such as post-traumatic stress disorder, major depression or delirium. This review summarizes recent developments and current techniques in sedation and analgesia in non-intubated adult burn patients during painful procedures performed outside the operating room (e.g. staple removal, wound-dressing, bathing). Current techniques of sedation and analgesia include different approaches, from a slight increase in background pain therapy (e.g. morphine PCA) to PCA with rapid-onset opioids, to multimodal drug combinations, nitrous oxide, regional blocks, or non-pharmacological approaches such as hypnosis and virtual reality. The most reliable way to administer drugs is intravenously. Fast-acting opioids can be combined with ketamine, propofol or benzodiazepines. Adjuvant drugs such as clonidine or NSAIDs and paracetamol (acetaminophen) have also been used. Patients receiving ketamine will usually maintain spontaneous breathing. This is an important feature in patients who are continuously turned during wound dressing procedures and where analgo-sedation is often performed by practitioners who are not specialists in anaesthesiology. Drugs are given in small boluses or by patient-controlled sedation, which is titrated to effect, according to sedation and pain scales. Patient-controlled infusion with propofol has also been used. However, we must bear in mind that burn patients often show an altered pharmacokinetic and pharmacodynamic response to drugs as a result of altered haemodynamics, protein binding and/or increased extracellular fluid volume, and possible changes in glomerular filtration. Because sedation and analgesia can range from minimal sedation (anxiolysis) to general anaesthesia, sedative and analgesic agents should always be administered by designated trained practitioners and not by the person performing the procedure. At least one individual who is capable of establishing a patent airway and positive pressure ventilation, as well as someone who can call for additional assistance, should always be present whenever analgo-sedation is administered. Oxygen should be routinely delivered during sedation. Blood pressure and continuous ECG monitoring should be carried out whenever possible, even if a patient is undergoing bathing or other procedures that may limit monitoring of vital pulse-oximetry parameters.

A treatment protocol for abdomino-pelvic injuries.

BACKGROUND: Abdomino-pelvic injuries often present a challenge for the emergency department. Although literature reports several protocols on the treatment of abdomino-pelvic injuries aiming at defining the most advisable treatment line, optimal treatment is still controversial. This paper describes a protocol that has been used to treat abdomino-pelvic injuries in our hospital since 2002. MATERIALS AND METHODS: In literature different protocol of abdomino-pelvic injuries are described and comparing them most of the difference are the timing of CT scan, the angiography and the laparotomy when treating a lesion of pelvic ring. If patient is haemodynamically instable and presents a lesion of pelvic ring our protocol suggest the simplest and fastest stabilization (pelvic external fixator) in emergency room and delay exam such as CT scan as second level exam. In the presence of an abdominal injury, with a positive focused assessment with sonography for trauma test, the first step should be a pelvic ring stabilization, as laparotomy decreases the abdominal pressure and reduces the tamponade effect on the retroperitoneum. According to presented protocol the angiography is not be a first choice treatment. This protocol was applied to 58 cases of abdomino-pelvic injury with unstable pelvic lesions from October 2002 to December 2005. Mean injury severity score was 27.2 (CI 24.1-30.3). RESULTS: Five patients (8%) died, three due to haemorrhagic shock and two due to pulmonary embolization. Four patients (6.9%) had a partial or complete cauda equina syndrome, four patients (6.9%) complained of mild incontinence, whilst 1 (1.7%) complained of urinary retention with multiple cystitis. Two patients (3.4%) with retention and multiple cystitis, had a malunion and a painful non-union of the fracture. Seven patients (12.3%) had neurological impairment: 5 (8.6%) sciatic nerve palsy, 1 (1.7%) lumbosacral root lesions in a C2-type fracture and there was one case (1.7%) of inconstant lumbago with sciatic pain. Twelve patients reported different levels of sexual dysfunction (20.7%). CONCLUSIONS: Although validation with a larger cohort is required, our preliminary clinical data are similar to, or better than, those reported in the most recent publications on this question, suggesting that this protocol could well reduce both the mortality rate and the long term complications of abdominopelvic injuries.

High tidal volume is associated with the development of acute lung injury after severe brain injury: an international observational study.

OBJECTIVE: Although a significant number of patients with severe brain injury develop acute lung injury, only intracranial risk factors have previously been studied. We investigated the role of extracranial predisposing factors, including hemodynamic and ventilatory management, as independent predictors of acute lung injury in brain-injured patients. DESIGN: Prospective multicenter observational study. SETTING: Four European intensive care units in university-affiliated hospitals. PATIENTS: Eighty-six severely brain-injured patients enrolled in 13 months. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All patients with severe brain injury (Glasgow Coma Scale score <9) were studied for 8 days from admission. Ventilatory pattern, respiratory system compliance, blood gas analysis, and hemodynamic profile were recorded and entered in a stepwise regression model. Length of stay in the intensive care unit, ventilator-free days, and mortality were collected. Eighteen patients (22%) developed acute lung injury on day 2.8 +/- 1. They were initially ventilated with significantly higher tidal volume per predicted body weight (9.5 +/- 1 vs. 10.4 +/- 1.1), respiratory rate, and minute ventilation and more often required vasoactive drugs (p < .05). In addition to a lower Pao2/Fio2 (odds ratio 0.98, 95% confidence interval 0.98-0.99), the use of high tidal volume (odds ratio 5.4, 95% confidence interval 1.54-19.24) and relatively high respiratory rate (odds ratio 1.8, 95% confidence interval 1.13-2.86) were independent predictors of acute lung injury (p < .01). After the onset of acute lung injury, patients remained ventilated with similar tidal volumes to maintain mild hypocapnia and had a longer length of stay in the intensive care unit and fewer ventilator-free days (p < .05). CONCLUSIONS: In addition to a lower Pao2/Fio2, the use of high tidal volume and high respiratory rate are independent predictors of acute lung injury in patients with severe brain injury. In this patient population, alternative ventilator strategies should be considered to protect the lung and guarantee a tight CO2 control.

Regional anesthesia in trauma patients.

Medical and surgical treatment of the trauma patient has evolved in the last decade. Treatment of pain from multiple fractures or injured organs and surgical anesthesia with regional anesthesia techniques have been used to reduce post-traumatic stress disorder and reduce the adverse effects of general anesthesia. Neuraxial blocks and peripheral nerve block techniques should be practiced by trained emergency and operatory room staff. This article reviews recent publications related to the role of regional anesthesia in trauma patients in the prehospital, emergency, and operatory room settings. It also describes indications, limitations, and practical aspects of regional anesthesia.