Efficacy and Safety of Intranasal Dexmedetomidine Combined with Esketamine for Premedication in Children Undergoing Laser Treatment for Burn Scars: A Randomised Self-Controlled Crossover Trial

Children who have survived severe burns often face a difficult journey long after the initial injury has healed. Deep burns can leave behind thick, tight scars that itch, pull on the skin, and limit movement. To fix this, doctors use a special type of laser treatment that gently resurfaces the skin. However, for young children, this process is not just physically uncomfortable; it is also deeply frightening. Many of these children have already endured painful medical procedures, and the memory of that pain can make them terrified of returning to the hospital. When a child is scared, they may cry, pull away, or refuse to cooperate, which makes it hard for doctors to perform the delicate laser work safely. The challenge for medical teams is to find a way to calm these children down before the treatment begins, without using needles that might cause more fear or drugs that might stop them from breathing.

For decades, doctors have relied on sedatives to help children relax before medical procedures. One such drug, dexmedetomidine, works by quieting the brain's alarm system, making a child sleepy and calm without heavily depressing their breathing. Another drug, esketamine, acts on different parts of the brain to reduce pain and create a sense of detachment from the surroundings. While both drugs have been used separately, researchers wondered if combining them might offer a better solution. The idea was that using both together could provide a deeper level of calm and cooperation than using either one alone, potentially making the experience less traumatic for the child and easier for the medical team.

To test this idea, a team of researchers at Wuhan Third Hospital in China designed a careful study involving twenty-four children between the ages of two and six. These children were scheduled to receive laser treatment for their burn scars on two separate occasions, with a gap of about two months between the sessions. The researchers used a clever method called a crossover trial, where every child served as their own control. This means that each child received both treatment plans, just in a different order. Half of the children received a combination of the two drugs during their first session and the single drug during the second, while the other half received them in the reverse order. The medications were given through the nose, either as a spray or drops, which is a crucial detail because it avoids the need for an injection before the child is even sedated.

The combination treatment involved giving the child a specific dose of dexmedetomidine based on their weight, along with a dose of esketamine. The other treatment involved giving the child only the esketamine. The goal was to see which approach helped the children settle down faster and behave better when it was time to separate from their parents and put on the breathing mask for anesthesia. The researchers measured how sleepy the children were at regular intervals, how easily they let go of their parents, how well they accepted the mask, and how calm they remained as they woke up from the procedure. They also kept a close watch on the children's heart rates, blood pressure, and breathing to ensure safety.

The results showed that the combination of the two drugs worked better than esketamine alone. Children who received both medications became sleepy more quickly, taking about four minutes less to reach a state of calm sedation compared to those who received only esketamine. More importantly, the children in the combination group were significantly easier to manage during the most stressful moments of the procedure. They were less likely to cry when separated from their parents and were much more willing to accept the breathing mask without fear. When the children woke up, those who had received the combination drug were also calmer and less agitated.

Beyond behavior, the study found that the combination treatment had a tangible effect on the anesthesia required during the surgery itself. Because the children were already so calm and cooperative, the doctors needed to use less of the general anesthetic drug propofol to keep them asleep during the laser treatment. On average, the children required about six milligrams less propofol when they had received the combination premedication. This reduction suggests that the initial calming drugs made the rest of the anesthesia process more efficient.

Safety was a major focus of the study, and the results were reassuring. Throughout the procedures, the children's heart rates and blood pressure dropped slightly, which is a known effect of dexmedetomidine, but the levels never fell low enough to require medical intervention. No child needed help breathing, and none required treatment for a slow heart rate or low blood pressure. The oxygen levels in their blood remained stable and healthy throughout the entire process. The researchers noted that while the combination drug made the children very sleepy, it did not push them into a dangerous state of deep unconsciousness where they would lose their natural ability to breathe on their own.

This study provides strong evidence that adding a small dose of dexmedetomidine to an esketamine regimen can significantly improve the experience for young children undergoing painful laser treatments for burn scars. It offers a needle-free way to prepare a child for surgery, reducing the fear and distress that often accompany these necessary medical visits. By helping children separate from their parents more easily and accept the breathing mask without crying, the treatment addresses the emotional trauma of the procedure just as much as the physical pain. While the researchers caution that more studies are needed to confirm these findings across different settings and to determine the perfect dosage for every child, the current results suggest a promising path forward. The combination of these two drugs appears to be a safe and effective tool for turning a terrifying medical experience into a manageable one for some of the most vulnerable patients.