Cynthia Villarreal

Imipramine treatment in Pediatric burn patients with symptoms of acute stress disorder : A pilot study

OBJECTIVE Pediatric burn patients often exhibit acute stress disorder (ASD) symptoms. Information on psychopharmacological treatment of ASD symptoms in children is scarce. This pilot study used a prospective, randomized, double-blind design to test whether thermally injured children suffering ASD symptoms benefit from imipramine. METHOD Twenty-five children, aged 2 to 19 years, received either imipramine or chloral hydrate for 7 days. A structured interview (clinically useful, but validity and reliability not yet established) was used to assess the presence and frequency of ASD symptoms both before treatment and 3 times during the treatment period. RESULTS Eleven females and 14 males participated, with a mean total burn surface area of 45% (SD = 23%) and mean age of 8 years (SD = 6). Imipramine was more effective than chloral hydrate in treating ASD symptoms (chi 2 [1, N = 25] = 5.24, p < .02). Five of 13 were positive responders to chloral hydrate (38%). Ten of 12 were positive responders to low-dose imipramine (83%). CONCLUSIONS This pilot study suggests a place for cautious initial use of imipramine to reduce ASD symptoms in burned children. Care must be taken to minimize cardiovascular risks in an off-label application of imipramine in children, especially those receiving additional medications.

Effects of oxandrolone on outcome measures in the severely burned: a multicenter prospective randomized double-blind trial.

Severe burns induce pathophysiologic problems, among them catabolism of lean mass, leading to protracted hospitalization and prolonged recovery. Oxandrolone is an anabolic agent shown to decrease lean mass catabolism and improve wound healing in the severely burned patients. We enrolled 81 adult subjects with burns 20% to 60% TBSA in a multicenter trial testing the effects of oxandrolone on length of hospital stay. Subjects were randomized between oxandrolone 10 mg every 12 hours or placebo. The study was stopped halfway through projected enrollment because of a significant difference between groups found on planned interim analysis. We found that length of stay was shorter in the oxandrolone group (31.6 ± 3.1 days) than placebo (43.3 ± 5.3 days; P < .05). This difference strengthened when deaths were excluded and hospital stay was indexed to burn size (1.24 ± 0.15 days/% TBSA burned vs 0.87 ± 0.05 days/% TBSA burned, P < .05). We conclude that treatment using oxandrolone should be considered for use in the severely burned while hepatic transaminases are monitored.

Acetaminophen in the management of background pain in children post-burn

This retrospective review evaluated the pain management of 395 acutely burned pediatric patients who were treated by a pain management protocol emphasizing acetaminophen as the initial medication to control background pain. Pain was assessed by using standardized instruments based on observations by patients, nurses, and parents. Morphine was added when scheduled acetaminophen (10-15 mg/kg/4 hr) did not control background pain. Fifty percent of the children received only acetaminophen to control background pain. Younger children and children with the smallest burns, regardless of age, were likely to be managed with acetaminophen alone. Most peak serum concentrations of acetaminophen were less than 10 micrograms/mL. When needed, children also received medication for painful procedures, anxiety, and posttraumatic stress symptoms. These additional medications were not more frequently given to children receiving only acetaminophen for background pain. These data suggest that acetaminophen is a safe, useful medication for the control of post-burn background pain in some children.

Treating thermally injured children suffering symptoms of acute stress with imipramine and fluoxetine: A randomized, double-blind study

INTRODUCTION For pediatric burn patients with the symptoms of acute stress disorder (ASD) a first line medication is not widely agreed upon. A prospective, randomized, placebo controlled, double-blind design was used to test the efficacy of imipramine and fluoxetine. METHOD Patients 4-18 years of age with symptoms of ASD were randomized to 1 of 3 groups: imipramine, fluoxetine, or placebo for 1 week. Daily imipramine dose was 1mg/kg, with the maximum dose being 100mg. Daily fluoxetine dose was 5mg for children weighing >or=40 kg; 10mg for those weighing between 40 and 60 kg; 20mg for those weighing >60 kg. RESULTS Sixty participants, 16 females and 44 males, had an average body surface area burn of 53% (S.D.=18) and average age of 11 years (S.D.=4). Imipramine subjects received an average daily dose of 1.00+/-0.29 mg/kg. Fluoxetine subjects received an average daily dose of 0.29+/-0.16 mg/kg. Between group differences were not detected. Fifty-five percent responded positively to placebo; 60% responded positively to imipramine; and 72% responded positively to fluoxetine. CONCLUSION Within the parameters of this study design and sample, placebo was statistically as effective as either drug in treating symptoms of ASD.

A Double-Blind Study of the Analgesic Efficacy of Oral Transmucosal Fentanyl Citrate and Oral Morphine in Pediatric Patients Undergoing Burn Dressing Change and Tubbing

Burn wound care is extremely painful. The pain leads to added anxiety and therefore a distressing treatment that can negatively impact healing. Pain and anxiety management with oral transmucosal fentanyl citrate was compared with this institutions standard procedural pain medication, morphine. With a double-blinded, reverse crossover, time-randomized, and placebo-controlled design, the efficacy of morphine and fentanyl citrate was assessed with patients undergoing two consecutive days of tubbing. Pain and anxiety was assessed before, during, and after the tubbing procedure using the Faces Pain Rating Scale (Whaley and Wong, 1987) and the Fear Thermometer (Silverman and Kurtines, 1996). Data were analyzed with repeated measures analysis of variance. Pain and anxiety appeared better managed with fentanyl citrate. Generalization is limited by small sample size, yet findings warrant additional investigation.

An approach to the timely treatment of acute stress disorder

A convergent postburn psychopharmacologic treatment for children for acute stress disorder (ASD) symptoms has not been established. Both the application of what has been learned through treatment of similar symptoms experienced by adults with posttraumatic stress disorder and the examination of safe treatment options for children led to the clinical decision to use imipramine for 25 pediatric patients with acute burns. The treatment histories of these patients were retrospectively reviewed to see if further exploration into the efficacy of imipramine was warranted. Eighty percent of the children experienced remission of hyperarousal symptoms (eg, trouble staying asleep, trouble falling asleep) and intrusive reexperiencing symptoms (eg, nightmares). Twelve percent of the children experienced a decrease in the frequency or intensity of ASD symptoms. Eight percent had no relief of ASD symptoms. Initial findings suggest that imipramine assists children who have postburn ASD symptoms by decreasing the hyperarousal and intrusive reexperiencing symptoms of ASD.

Anxiety: current practices in assessment and treatment of anxiety of burn patients

Anxiety is an affective response commonly experienced by persons after emotional and physical trauma, as well as associated with aversive medical treatments. The scientific information related to the conceptualization, assessment, and treatment of anxiety is limited. In order to develop a pilot protocol for anxiety management, nursing directors at 64 burn centers were surveyed. At 89% of the centers, anxiety measures were not used. Most of the teams assess informally through observation of patient (n=21), dialogue with patient (n=12), or both observation and dialogue with patient (n=15). Assessors of anxiety range in breadth from nurse only to the entire burn team, including pastoral care representatives and family. The class of medication most frequently endorsed in treating anxiety is the benzodiazipine, most often lorazepam (Ativan). A number of non-pharmacologic techniques are used to manage anxiety, e.g., muscle relaxation, breathing, imagery. Consideration should be given to assessing anxiety systematically, so knowledge can be gleaned and applied to conceptualization of symptom presentation and application of treatment resources.

Early treatment of acute stress disorder in children with major burn injury

Objective: This study examines retrospectively the response rate of pediatric burn survivors with acute stress disorder to either imipramine or fluoxetine. Methods: On retrospective chart review, 128 intensive care unit patients (85 boys, 43 girls) with 52% ± 20% total body surface area burn, length of stay of 32.8 ± 25.2 days, mean age of 9.1 ± 4.7 yrs, and age range of 13 months to 19 yrs met criteria for acute stress disorder after ≥2 days of symptoms and were treated with either imipramine or fluoxetine. If significant improvement did not occur within 7 days, the medication was either increased or switched to the other class. Results: Initially, 104 patients were treated with imipramine and 24 with fluoxetine. A total of 84 patients responded to imipramine: seven of these patients required a higher dose. A total of 18 patients responded to initial fluoxetine treatment. Of 26 nonresponders to the initial medication, 13 imipramine failures and one fluoxetine failure refused further treatment. The other 12 responded to the second medication. Therefore, 114 of 128 treated patients (89%) responded to either fluoxetine (mean dose, 0.30 ± 0.14 mg/kg) or imipramine (mean dose, 1.30 ± 0.55 mg/kg). Response was independent of sex and age but was less for those with burns of >60% total body surface area. The side effects of each medication were not significant. Most patients continued treatment for ≥3 months; some required 6 months of treatment before successful discontinuation. Conclusions: Early treatment of acute stress disorder with either imipramine or fluoxetine is often able to reduce its symptoms. This is a review of a single hospital’s experience in managing psychiatric distress in this very high-risk group of burned children. Additional clinical studies are needed before generalizing these findings.

Much ado about nothing : Methicillin-resistant Staphylococcus aureus

The pathogenic methicillin-resistant Staphylococcus aureus (MRSA) has received a voluminous amount of notoriety. The four major reasons are its morbidity, mortality rate, cost of treatment, and constant appearance in intensive care units. Both Staphylococcus aureus and S. epidermidis (MRSE) account for 82% of our gram-positive wound isolates, whereas the gram-negative account for 34% of all isolates. Therefore we compared the morbidity, mortality rate, and cost factors related to MRSA-MRSE and gram-negative infections for a 4-year period, assessing more than 214 documented infections. Morbidity and mortality rates were minor for MRSA. Pseudomonas aeruginosa and Escherichia coli accounted for 57.5% of the total gram-negative isolates. Gram-negative antimicrobial therapy usually requires two therapeutic drugs, which increases morbidity and costs, whereas the staphylococci usually can be treated by one antimicrobial. During this period there were 47 gram-negative infections requiring 10 to 15 additional days of hospital stay, with a daily antibiotic cost of

The use of haloperidol and associated complications in the agitated, acutely ill pediatric burn patient.

293.40. Costs for MRSA or MRSE are 28% less. Therefore our preoccupation with MRSA or MRSE infections is unwarranted and unsubstantiated.