Enzymatic Debridement (ED) at Bedside: Role of Dexmetomidine during its application in Pediatrics with Burn–Induced Compartimental Syndrome: Case Report.
R. Villani, A. Lanza, M. Sasso, Bicoku I*, Cataldo C*, Mataro I°., Pagnozzi E.°, D’AlessioR°
Burn Intensive Care Unit / °Burn Unit “A. Cardarelli” Hospital - Naples, Italy
*University  “L. Vanvitelli”- Naples, Italy
Email addresses: annalanz@tiscali.it; villaniromolo@gmail.com 
Avoiding pain  and discomfort  should be a  primary gold standard  in  management of all  burned patients: in Our Centres  application / removal of mixture for Enzymatic Debridement (ED) in Adult ones follows our procedural pain relief schedule by ketamine/fentanyl-low-dose/midazolam compound usually used for dressing change/wound debridement, measuring  Richmond Agitation-Sedation Scale ( RASS), Aldrete Score and VAS in order to set Comfort, Clinical status and Analgesia. Although off-label in Pediatrics , after Informed Consent , mixture for ED was apply  in a 20 % TBSA 13 y.o. boy with left forearm burn induced compartment syndrome,  measured by ICP monitoring;  added to drugs using dexemetomidine, α2- adrenergic agonist allowed  comfort in lapsetime of 4 hours  between application/removal procedures.
Patient , Methods and Results: 13 yo boy, 38 Kg, admitted in Burn Intensive Care Unit after primary survey , with 20% TBSA Alcool induced burns, history of low mental delay, no allergies. At bedside , in spontaneous breathing, monitoring Vital Parameters (HR, SpO2%,RR, NIBP)  and in left circumferential burned forearm measuring of intracompartimental pressure ( ICP) that shows high level of 45 mm Hg.  Infusion of dexmetomidine  0.5-0.9 γ/k/h  was started to avoid discomfort and prior to application of ED mixture in ketamine/ fentanyl /midazolam ( K: 1,5-2 mg/k; F: 0,5-1 mcg/kg; M 0.15mg/kg). Application of debridement mixture  was  applied on 15% TBSA included on circumferential burned  left forearm  that shows even after 2,5 h ICP of 10 mmHg. In lapsetime comfort of patient was obtained by  increasing  dexmetomidine at high level of infusion admitted in patient in spontaneous breathing . Removal of Enzymatic Debridement was implemented at same  way of application.
Conclusion: Aldrete Score, RASS score and VAS score  showed  a good comfort  and analgesia, showing a gold standard tailored patient therapy for a  less invasive surgical technique at bedside .





In young
Burn-induced compartment syndrome is a severe sequela after circumferential burns of the extremities: as the interstitial pressure rises there is initially impairment of venous outflow followed by diminution of arterial inflow exacerbated by tissue edema developed during the acute phase of burn resuscitation in the first 48h after injury. Although the current gold standard is operative escharotomy, this procedure is traumatic, may cause considerable blood loss, and entails possible morbidity and complications. Enzymatic debridement (ED) is considered one promising alternative of non-surgical option for eschar removal and results suggested that the use of this technique reduces need for surgery and escharotomy.
The early application of ED can release tissue pressure by timely removing the constrictive eschar, reduce inflammation-associated edema and thus may prevent patients from the need for surgical escharotomy and its possible complications and invasiveness.

5 - Enzymatic Debridement (ED) at Bedside: Role of Dexmetomidine during its application in Pediatrics with Burn–Induced Compartimental Syndrome: Case Report.