Introduction:
What is Effective Analgesia and Sedation in Burn wound care? Depending on who is asked the Answer varies. From the Burn center’s goals, it should minimize unnecessary suffering, enable efficient burn care for providers, and maximize patient safety. There are many obstacles to optimum delivery of effective analgesia and sedation in Burn wound care. Recently changes to legal regulations on nursing physicians, pharmacists, and hospitals, concerns for opioid safety/drug dependence has made it difficult to balance effective comfort with safety. The challenge with effective delivery of analgesia and sedation in burn wound care is finding the balance between comfort and safety. This balance is so challenging because it is not an exact science and can be fluid and change suddenly. Delivery of higher levels of sedation requires increased training and staffing. With fewer and fewer burn physicians available this may put a large strain on burn provider’s time limiting reliable delivery. At UAB medical center we have found our solution by collaboration with Anesthesia. We present our process of partnering with our Anesthesia Department to set up a dedicated biweekly monitored Anesthesia Care (“MAC”) refers to a specific service performed by a qualified anesthesia provider for a diagnostic or therapeutic procedure. This allows the proceduralist to focus on successful completion of the procedure, while the anesthesia provider(s) can focus on hemodynamics and the ongoing pathophysiologic effects of medications, the procedure, and position changes.

Methods:
Partnership with Anesthesia was accomplished by the need to find a medium between medicating patients properly for hydrotherapy dressing changes and the legalities of what the bedside RNs could administer for pain to a patient in 4-5 to 1 ratio outside of ICU. Discussion took place through the moderate sedation committee meetings along with senior hospital leadership on options offered to aid in hydrotherapy. The hydrotherapy suite is a treatment area housed on the combination trauma/burn step-down unit. It includes an anesthesia station equipped for varying levels of sedation, oxygen delivery and ventilation, and hemodynamic support. The anesthesia station lies at the head of a water-compatible procedure table positioned beneath irrigation tubing which allows for thorough wound cleansing. Patients were chosen based on wound complexity, pain tolerance, and medical stability. These patients were discussed with the Trauma team (who medically manages them) or other primary team to ensure clear communication. The patients were then posted, consented, and marked per the facility’s preoperative guidelines. A pre-anesthesia evaluation was performed per the pre-operative anesthesia team in the time prior to the procedure. Immediately pre-procedure, the intraprocedural plan was reviewed with the Burn Dressing Team (“BDT”) and a basic report was given to the anesthesia provider which may include the patient’s respiratory status, cardiovascular status, any concerns brought forth by the primary team, how patient is tolerating pain control, any drug history the patient may have, how long the procedure is expected to last, and the anticipated patient positions. In the hydrotherapy suite, the patients underwent a wound evaluation, sharp debridement, washout, and dressing change under MAC. Afterward, they recovered in the post-anesthesia care unit (PACU) until stable to return to a non-ICU bed. Recovery in PACU was omitted if the patient was to return to the ICU.

Results:
The Partnership with Anesthesiology to provide monitored Anesthesia Care (“MAC”) has improved patient analgesia and sedation, safety, patient and staff satisfaction, efficiency, operating room utilization, and quality and effectiveness of burn wound care.

Conclusions:
We at UAB would like to share our journey of the logistics of setting up our collaboration, the challenges and speed bumps, as well as the unexpected benefits of our partnership. The same situation we faced are shared nationwide by other centers who could likely benefit from our road map.