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PATIENT CONTROLLED SEDATION (PCS) IN BURN PATIENTS

¹ Université de Montréal, Department of Anesthesiology and
² Centre des Grands Brûlés, Hôtel-Dieu, 3840 Rue St-Urbain, Montreal, H2Y 1T8, Montreal

INTRODUCTION

The first postoperative change of wound dressings after skin grafting, however, creates not only significant pain but also substantial anxiety. Propofol PCS seems a good alternative to routine intermittent nurse-controlled sedation using benzodiazepines or propofol.

METHODS
In all 12 (preliminary results of 20) patients, the procedure was the first change of wound dressings after skin grafting surgery, performed 5 days after surgery. All patients were familiarized with the propofol PCS. They were asked to press the control button whenever they felt uncomfortable or anxious. In part I (N=10), the PCS was set to administer a bolus of 0.3 mg/kg propofol with a lockout time of 5 min. The amount of attempts and the actual propofol boli were recorded. After analysis of the results of part I, PCS was set to determine the propofol bolus by initial doctor-controlled application to reduce BIS by at least 15 % (Part II). Before the procedure, all patients received either 3 times the hourly dose of a continuous morphine infusion or 0.1 mg/kg morphine + 10 % of the total oral morphine intake during the last 24 hours, but at least 0.15 mg/kg. BIS - monitoring was applied to all patients and recorded every 2 minutes. Pulse oximetry, ECG, noninvasive blood pressure and the respiratory rate (RR) were recorded every 2 min. Satisfaction scores (1=very unsatisfied, 6 very satisfied) were determined 1 hour after the procedure as well as mean pain during the procedure (0= no pain, 10=maximal pain). Data are presented as mean (SD).

RESULTS
From our first series of patients (N=10, 9 m, 1 f; age: 38 ± 16 y, burn surface: 14 ± 3 %), results show that PCS is feasible and safe for burn patients (RR 14 (2), no change in blood pressure, Sat O₂more than 93 %). Satisfaction and pain scores were 5.4 (0,8) and 3.4 (2), respectively. The number of demands (6 vs 3 deliveries) and BIS values between 71 and 98 with a mean of 94 (8) showed an insufficient bolus and lockout period which was set too long. First results of part II (N=2) show a mean 0.35 mg/kg of propofol as an effective bolus (BIS reduced by 15 %). BIS during the procedure ranged between 62 and 98 with saturations of more than 94 % and 5 (2) demands during a period of 20 (2) min.

DISCUSSION
Our preliminary results suggest that propofol PCS is a good method to reduce anxiety and discomfort in burn patients during their first dressing change after skin grafting. BIS monitoring provides an objective method to determine an individualized bolus setting and seems superior to a fixed bolus of 0.3 mg/kg. No lockout period seems necessary for PCS and still provide safe respiratory conditions.

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