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Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No.5 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 14

Perioperative Dexmedetomidine for Analgesia During Burn Excision and Grafting
Amy Ybarra, BSN, RN
Affiliation:
Texas Christian University

Funding/Conflict of Interest Disclosure: 
None

KEYWORDS:  burn anesthesia; burn analgesia; dexmedetomidine

Abstract
Patients with superficial burns normally do not require surgical intervention, however, burns that are deep and large, 
require numerous procedures for excision and skin grafting (EG).1 One of the challenges with these patients lies in 
their multi-faceted, but common theme of pain, which is confounded not only by high inter-patient variability and 
unpredictability1, 2 , but by pain from the initial injury, by wound care pain and by the new, postoperative pain from EG 
procedures.1  This case report details the utilization of dexmedetomidine as an adjunct for analgesia during EG for a 
severely burned patient. Findings are consistent with the evidence and reveal on the day dexmedetomidine was used, 
the patient had lower post-operative pain scores, lower postoperative Richmond Agitation Sedation Scores (RASS), 
and it was the only day the patient did not require any postoperative PRN pain medication administration. Although 
limited evidence exists specifically related to the use of intraoperative dexmedetomidine for EG of severe burns, this case 
report suggests a promising role for the addition of this a2 agonist as a multi-modal approach to caring for this complex 
population. 

AEJ



Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No.5 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 15

PowerPoint Template ©2009 Texas Christian University, Center for Instructional Services. For Educational Use Only. Content is the property of the presenter and their resources.

Introduction
• Pain is a common factor among burn patients1

• Burn pain is multifaceted; includes initial injury 
pain, wound care pain, new pain from excision 
and grafting (EG)1

• Burn pain produces both hyperalgesia and 
allodynia2

• Increasing narcotic doses and tolerance is 
common but may fail to provide adequate relief 
and may result in opioid-induced 
hyperalgesia1,2,3

Research
• There is limited research. One study details 

dexmedetomidine intraoperatively for EG, 4 
others detail its use for burn wound care 
sedation or non-burn care.

• Provided enhanced analgesia, decreased 
surgical stress response, reduction of total 
opioid consumption in non-burn surgical 
patients.4

• Produced positive patient perception, decreased 
post-operative pain and opioid requirements in 
moderately burned patient study.4

• Produced improved sedation and thus better 
tolerated burn wound care in pediatric burn 
patients.5

Dexmedetomidine
• Alpha-2 adrenergic agonist6

• Acts on preganglionic sympathetic neurons 
resulting in inhibition of norepinephrine release.6

• Highly selective for α2 receptors, numerous in 
locus ceruleus which plays major role in 
regulation of memory, arousal, analgesia.4,6

• Produces sympatholysis, analgesia, sedation.6

• Side effects include bradycardia and 
hypotension, worse with hypovolemia.2,6

• Decreases MAC requirements, opioid 
requirements, surgical stress response, plasma 
catecholamine concentrations during 
anesthesia.4,6

Discussion and Conclusions

• The excision and grafting detailed for this 
case report (red outline) was the most 
extensive EG in this series, including the 
entirety of bilateral buttocks, lower back, as 
well as circumferential excision and grafting of 
bilateral lower extremities from below the 
ankles to upper thighs.

• In order to minimize data skew from 
physiologic changes, compared cases were 
limited to a 20-day timeframe, 9 days prior to 
and 11 days after the detailed case report 
procedure. EG sites compared in table. 

• Anesthesia and post-operative records were 
compared from time of initial preoperative 
medication with midazolam through midnight 
on same operative day.

• 1 of 5 excision and grafting procedures 
compared incorporated dexmedetomidine.  

• Patient exhibited signs of stimulation only one 
time during the 5-hour procedure, and was 
medicated with dexmedetomidine 5 mcg and 
dilaudid 0.5 mg.

• Postoperative pain scores and Richmond 
Agitation-Sedation Scale (RASS) were lower 
with dexmedetomidine.

• No additional postoperative analgesia was 
required through midnight on operative day 
when intraoperative dexmedetomidine was 
used.

Mechanism of Action

Case Report
Patient Information
• 26-year-old female with a 1-month history of 2nd and 3rd degree burns over 95% of her total body surface area
• ASA 3, 70kg 
• Patient had undergone approximately 14 escharotomies and/or excision and grafting procedures in the 6 weeks 

between her admission and the last compared surgical procedure.
• Each surgical procedure compared in the case report involved excision and grafting of different but similar sites, 

detailed in the table above. Procedure for case report (red outline) was the most extensive.

Anesthetic Management
• Balanced anesthetic included preoperative midazolam, maintenance sevoflurane, and rocuronium.
• Dexmedetomidine infusion of 0.3mcg/kg/hr was started immediately after induction and discontinued 

approximately 2 minutes prior to end of procedure. Patient received a total of 175 mcg per infusion. 
• Additional intraoperative analgesics included ketamine 10 mg every hour for a total of 30 mg, 50 mcg fentanyl 

prior to each major surgical stimulation for a total of 100mcg, and a one-time dose of dilaudid 0.5 mg with 
dexmedetomidine 5 mcg for signs of stimulation.

• Total surgery time was approximately 5 hours.

Procedure Comparison

Perioperative Dexmedetomidine for Analgesia 
During Burn Excision and Grafting

Amy Ybarra, BSN, RN, Texas Christian University

References
1. Ray DE, Karlekar MB, Crouse DL, et al. Care of the critically ill burn patient. Ann Am Thorac Soc. 

2017;12(7):1094-1102. DOI: 10.1513/AnnalsATS.201607-577PS

2. Bittner E, Shank E, Woodson L, Martyn J. Acute and perioperative care of the burn-injured patient. 
Anesthesiology. 2015;122(2):448-464. DOI: 10.1097/ALN.0000000000000559

3. Retrouvey H, Shahrokhi S. Pain and the thermally injured patient—A review of current therapies. 
Journal of Burn Care & Research. 2015;36(2):315-323. DOI: 10.1097/BCR.0000000000000073

4. Jiang, M, Sun Q, Liu G, Qu H, Ma J. Efficacy of dexmedetomidine in reducing post-operative pain and 
improving the quality of recovery in patients with burn wounds undergoing tangential excision skin 
grafting. Experimental and Therapeutic Medicine.2019;17:1776-1782. DOI:10.3892/etm.2019.7155

5. Pardesi O, Fuzaylov G. Pain management in pediatric burn patients: Review of recent literature and 
future directions. Journal of Burn Care & Research. 2017;38(6): 335-347. DOI: 
10.1097/BCR.0000000000000470

6. Flood P, Rathmell J, Shafer S. Stoelting’s pharmacology and physiology in anesthetic practice. 
Philadelphia, PA: Wolters Kluwer Health; 2015.

7. Sanders RD, Maze M. Alpha2-agonists and other sedatives and amnestics. In: Evers AS, Maze M, 
Kharasch ED, eds. Anesthetic Pharmoacolgy: Basic Principles and Clinical Practice. 2nd ed. Cambridge: 
Cambridge University Press; 2011:478-492. Doi:10.1017/CBO9780511781933.031

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