The synergistic effect of dexmedetomidine on propofol for paediatric deep sedation: A randomised trial.

BACKGROUND: Propofol and dexmedetomidine are used separately, and sometimes together, for paediatric deep sedation. Although their combination has been described in adults, the effect of dexmedetomidine as a potential synergist in children has not been studied before. OBJECTIVES: The primary objective was to compare the propofol requirements of children who receive propofol alone with those who receive it in combination with dexmedetomidine for deep sedation for upper and lower endoscopic gastrointestinal procedures. DESIGN: This was a prospective, open-label, randomised study comparing patients who received propofol alone (group P) with those who received dexmedetomidine and propofol (group DP). The depth of sedation was titrated to a target bispectral (BIS) index. SETTING: A Gastroenterology Procedure Unit at a single, tertiary care academic medical centre from April 2018 until December 2019. PATIENTS: Eligible patients were scheduled for upper endoscopy, lower endoscopy or both. A total of 39 patients were enrolled (20 DP) and (19 P). INTERVENTIONS: Patients in Group DP received dexmedetomidine 0.5 µg kg-1 administered over 1 min followed by an infusion of 0.15 µg kg-1 h-1. In both groups, intravenous propofol was given in bolus increments titrated to a BIS index of 40 to 50 and then a continuous infusion of propofol to maintain BIS at 40 to 50. MAIN OUTCOME MEASURES: The primary outcome measure was propofol requirement in each group. Secondary outcome measures were time to achieve the targeted sedation depth, time to achieve an Aldrete recovery score of 9, duration of sedation, mean BIS values, adverse events, 'PAED' scores and time to discharge from the postanaesthesia care unit (PACU). RESULTS: The median (range) total dose of propofol was 0.23 (0.10 to 0.50) mg kg-1 min-1 in group DP and 0.40 (0.20 to 0.50) mg kg-1 min-1 in group P (P = 0.0004). Time of discharge from the PACU was 60 (20 to 121) min in group DP and 63 (46 to 91) min in group P (P = 0.0409). CONCLUSION: The combination of dexmedetomidine and propofol for paediatric procedural sedation achieved a significant reduction in median propofol dose and a slightly shorter median time to discharge from PACU. Large-scale studies may determine whether this reduction decreases the risk of significant adverse events. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02952222.

Future of paediatric sedation: towards a unified goal of improving practice.

This review offers a perspective on the future of paediatric sedation. This future will require continued evaluation of adverse events, their risk factors, and predictors. As the introduction of new sedatives with paediatric applications will remain limited, the potential role of mainstay sedatives administered by new routes, for new indications, and with new delivery techniques, should be considered. The role of non-pharmacological strategies for anxiolysis, along with the application of non-mainstay physiologic monitoring, may aid in the improvement of targeted sedation delivery. Understanding the mechanism and location of action of the different sedatives will remain an important focus. Important developments in paediatric sedation will require that large scale studies with global data contribution be conducted in order to support changes in sedation practice, improve the patient experience, and make sedation safer.

Efficacy Outcome Measures for Pediatric Procedural Sedation Clinical Trials: An ACTTION Systematic Review.

Objective evaluations comparing different techniques and approaches to pediatric procedural sedation studies have been limited by a lack of consistency among the outcome measures used in assessment. This study reviewed those existing measures, which have undergone psychometric analysis in a pediatric procedural sedation setting, to determine to what extent and in what circumstances their use is justified across the spectrum of procedures, age groups, and techniques. The results of our study suggest that a wide range of measures has been used to assess the efficacy and effectiveness of pediatric procedural sedation. Most lack the evidence of validity and reliability that is necessary to facilitate rigorous clinical trial design, as well as the evaluation of new drugs and devices. A set of core pediatric sedation outcome domains and outcome measures can be developed on the basis of our findings. We believe that consensus among all stakeholders regarding appropriate domains and measures to evaluate pediatric procedural sedation is possible and that widespread implementation of such recommendations should be pursued.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations.

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations.

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the US Food and Drug Administration, convened a meeting of sedation experts from a variety of clinical specialties and research backgrounds with the objective of developing recommendations for procedural sedation research. Four core outcome domains were recommended for consideration in sedation clinical trials: (1) safety, (2) efficacy, (3) patient-centered and/or family-centered outcomes, and (4) efficiency. This meeting identified core outcome measures within the efficacy and patient-centered and/or family-centered domains. Safety will be addressed in a subsequent meeting, and efficiency will not be addressed at this time. These measures encompass depth and levels of sedation, proceduralist and patient satisfaction, patient recall, and degree of pain experienced. Consistent use of the recommended outcome measures will facilitate the comprehensive reporting across sedation trials, along with meaningful comparisons among studies and interventions in systematic reviews and meta-analyses.

Dexmedetomidine versus morphine infusion following laparoscopic bariatric surgery: effect on supplemental narcotic requirement during the first 24 h.

INTRODUCTION: The primary aim of this pilot study was to determine whether the dexmedetomidine infusion initiated immediately after laparoscopic bariatric surgery, offers an advantage over a morphine infusion with respect to rescue morphine and paracetamol requirements over the first 24 post-operative hours. METHODS: Sixty morbidly obese adult patients scheduled for laparoscopic bariatric surgery were randomly assigned to receive an infusion of either 0.3 mcg/kg/h dexmedetomidine (Group D) or 3 mg/h Morphine (Group M) for 24 h immediately post-operatively. All patients received standardized general anesthesia and were evaluated and treated for pain in the intensive care unit by providers who were blinded to their treatment group. The primary outcome was the need for supplemental, "rescue" paracetamol (Dolargan. Hikma, Jordan) and morphine titrated to achieve visual analog scales (VAS) of <40 and <70, respectively. RESULTS: A total of 60 patients (77 % female, mean age 33.5 years ± 9.5 and body mass index (BMI) 43.0 ± 4.5) were randomized to Group M and 30 to Group D. There were no significant differences in mean rescue paracetamol and morphine requirements. Mean total morphine requirements in Group D were 6.1 ± 3.1 mg, whereas 72.9 ± 2.2 mg in Group M (p < 0.0001). CONCLUSIONS: An intravenous infusion of dexmedetomidine, initiated and continued for 24 h following laparoscopic bariatric surgery, can decrease the overall morphine requirements during this period. This pilot study demonstrated that the post-operative initiation of dexmedetomidine can be morphine sparing following laparoscopic bariatric surgery.

A forecast of relevant pediatric sedation trends.

PURPOSE OF REVIEW: Over the past decade, the field of pediatric sedation has benefited from contributions which include the introduction and update of policies, procedures, and guidelines regarding training, physiologic monitoring and delivery, the approval of new sedatives, the multispecialty collaborations intended to advance the field and the development of sedatives, and delivery systems. This review will explore new drug innovations as well as evolved formulations of already approved agents, unique sedative delivery systems, the clinical application of pharmacogenetics and will conclude with a reflection on the current and future trends and focus of pediatric sedation research. RECENT FINDINGS: In recent years, the number of diagnostic and therapeutic procedures performed on children in nonoperating room anesthetizing locations has exploded at a rate which has in many instances, outpaced the availability of anesthesiologists. Over the past decade, the search for safe and effective sedatives and delivery systems has been embraced by all sedation providers. Dexmedetomidine and fospropofol were recently introduced, along with a computer-assisted personalized sedation delivery system which empowers the patient to assist in his own sedation. The evolution of target-controlled infusion systems with both open and closed-loop design are intended to more precisely deliver sedation using pharmacokinetic models specific for each sedative. New formulations of propofol, ketamine, etomidate, and benzodiazepines are in development, all striving to improve predictability, safety, and recovery profile. Pharmacogenetics is being explored for its role in the effects of analgesics, sedatives, and local anesthetics. SUMMARY: As the demand for procedural sedation continues to expand, the sedation providers must continue to be creative in their search for novel, safe, effective, and efficient methods to deliver care. Approaching the field of sedation as a science is essential for the clinicians and researchers who strive to tailor the sedation to the patient and the procedure.

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

PURPOSE OF REVIEW: From an understanding of human psychology and the reliability of high-technology systems, this review considers critical threats to the safety of patients undergoing sedation outside of the operating room, and will stratify these threats along what we define as the 'Patient Risk Continuum'. We then consider interventions suitable for addressing identified risks. RECENT FINDINGS: The technology, organization and delivery of healthcare continue to become more complex, highlighting the importance of maintaining the safety of patients. Sedation outside of the operating room is known to be associated with higher rates of adverse events. However, a number of recent safety initiatives have shown benefit in improving patient safety. SUMMARY: The following threats to patients undergoing sedation, in increasing order of risk, are discussed: equipment and environmental factors, known patient risks, poor team performance, combinatorial problems and egregious violations. To address these threats, we discuss a number of approaches consistent with the systems approach to safety, namely: encouraging functions, forcing functions, cognitive safety nets, information sharing, recovery strategies and regulatory change. Demonstrating improvement with any safety initiative relies critically on quality data collected on the problem area in question.

Intranasal dexmedetomidine for sedation for pediatric computed tomography imaging.

UNLABELLED: This prospective observational pilot study evaluated the aerosolized intranasal route for dexmedetomidine as a safe, effective, and efficient option for infant and pediatric sedation for computed tomography imaging. The mean time to sedation was 13.4 minutes, with excellent image quality, no failed sedations, or significant adverse events. TRIAL REGISTRATION: Registered with ClinicalTrials.gov: NCT01900405.

Bradycardia in perspective-not all reductions in heart rate need immediate intervention.

According to Wikipedia, the word 'bradycardia' stems from the Greek ßραδύς, bradys, 'slow', and καρδία, kardia, 'heart'. Thus, the meaning of bradycardia is slow heart rate but not necessarily too slow heart rate. If looking at top endurance athletes they may have a resting heart rate in the very low thirties without needing emergent intervention with anticholinergics, isoprenaline, epinephrine, chest compressions or the insertion of an emergency pacemaker (Figure 1). In fact, they withstand these episodes without incident, accommodating with a compensatory increase in stroke volume to preserve and maintain cardiac output. With this in mind, it is difficult for the authors to fully understand and agree with the general sentiment amongst many pediatric anesthesiologists that all isolated bradycardia portends impending doom and must be immediately treated with resuscitative measures.

Hemodynamic response to fluid management in children undergoing dexmedetomidine sedation for MRI.

OBJECTIVE: Dexmedetomidine is administered for pediatric sedation for MRI studies. It has the advantage of preserving respiratory function and producing a sedation state identical to that of natural sleep. It can, however, cause a dose-dependent decrease in systemic blood pressure in children. The purpose of this study was to investigate whether i.v. fluid loading with normal saline solution before the initiation of dexmedetomidine administration would affect the frequency of hypotension. MATERIALS AND METHODS: Quality assurance data on consecutively registered children who were sedated with dexmedetomidine for MRI were reviewed. All children received a bolus of 3 µg/kg dexmedetomidine followed by a continuous infusion of 2 mg/ kg/h. A normal saline fluid bolus consisting of 0, 10, or 20 mL/kg was administered to each child within 1 hour before initiation of dexmedetomidine administration. Hypotension was defined as a greater than 20% decrease in mean arterial blood pressure from baseline. RESULTS: Sedation was administered to 1692 children. Data on fluid administration were missing in three cases. In the other cases, 252 (14.9%) children received 0 mL/kg of normal saline solution, 598 (35.3%) received 10 mL/kg, and 839 (49.6%) received 20 mL/kg. In a multiple logistic regression model controlled for confounding variables, the odds of development of hypotension with 10 mL/kg of fluid decreased 53% (odds ratio, 0.47; 95% CI, 0.28-0.79; p = 0.004) compared with 0 mL/kg. CONCLUSION: Administration of 10 mL/kg of normal saline solution before the initiation of dexmedetomidine administration for pediatric MRI sedation is effective in decreasing the incidence of observed hypotension.

Presenting clinical symptoms of post-COVID-19 breakthrough infection: Predictors of mortality in a Middle Eastern population.

Objective: Breakthrough COVID-19 infections are common following immunisation with various types of vaccines. The patterns of infections have not been well established. We aimed to analyse the signs and symptoms of post vaccination infections in addition to the need for hospital admission, ER visit and supplemental oxygen in relation to age and gender. Methods: A cross-sectional cohort study was conducted in JUH from March 2021 to August 2022, we interviewed 1479 individuals who are >15 years of age and got a breakthrough infection. The statistical analysis was performed using STATA statistical software. Results: Out of the 1479 cases, 50.2 % and 69.4 % were females and less than 45 years of age respectively. Symptoms of cough, fever and headache were reported by nearly 50 % of the patients, while one-third complained of dyspnoea. We found that participants older than 45 years had worse clinical outcomes (P-value < 0.001). 13 deaths were identified in this study due to breakthrough infection, 92.3 % of them were older than 45 years (P-value < 0.001). Participants ≥45 years who experienced a breakthrough infection of COVID-19 were 0.7 times less likely to be females using adjusted logistic regression. Conclusion: This study indicates that despite more severe symptoms reported in younger patients, the major clinical outcomes were worse among older patients, which makes age a major risk for poor outcomes regardless of symptoms. Thus, older people should be evaluated carefully when presenting with mild symptoms of COVID-19 breakthrough infection. The study also confirms that there is no difference in the incidence of COVID-19 breakthrough infections between males and females. Prospective studies are needed to risk stratify COVID-19 breakthrough infections, which should take into account variants of the virus and comorbidities.

Dexmedetomidine offers an option for safe and effective sedation for nuclear medicine imaging in children.

PURPOSE: To determine the safety, efficacy, and outcomes of bradycardia, hypotension, and hypertension with dexmedetomidine (DEX), a recently approved sedative used for procedural sedation that has not been described previously for pediatric nuclear medicine imaging. MATERIALS AND METHODS: Between March 2005 and August 2011, 669 patients (mean age, 5.7 years ± 4.5 [standard deviation]; median age, 4.5 years; age range, 0.1-22.5 years) received DEX in this HIPAA-compliant study. Sedation was administered with DEX, an α-2 adrenergic agonist, as an intravenous bolus (2 µg per kilogram of body weight) over a 10-minute period; this was followed by continuous infusion at a rate of 1 µg/kg/h until imaging was complete. The bolus could be repeated up to two times, if needed, to achieve the targeted level of a Ramsay sedation score of 4. After institutional review board approval, collected quality assurance data were reviewed. RESULTS: Adequate sedation was achieved within 8.6 minutes ± 4.6 (median, 8.0 minutes; range, 1.0-40.0 minutes) on average in studies that averaged 41.3 minutes ± 25.5 (median, 31.5 minutes; range, 9.0-183.0 minutes). Of 669 studies, 667 (99.7%) were completed successfully. Six children (0.9%) had brief periods of oxygen desaturation below 95%, none of which required airway intervention. Hypotension, hypertension, and bradycardia (all defined as deviations of more than 20% from age-adjusted awake norms), occurred in 58.7% (n = 393), 2.1% (n = 14), and 4.3% (n = 29) of patients, respectively. Both hypotension and bradycardia were related to age (P = .033 and P = .002, respectively); older children tended to experience more of these events. None of these fluctuations required pharmacologic therapy. Discharge criteria (modified Aldrete score ≥ 9) were met, on average, within 41.4 minutes ± 27.9 (median, 36.0 minutes; range, 1.0-220.0 minutes). CONCLUSION: DEX offers advantages for pediatric sedation for nuclear medicine imaging. DEX produces a condition similar to natural sleep, with no detrimental effect on respiration. The hemodynamic variability anticipated with DEX did not require pharmacologic treatment, and the drug was well tolerated.

Aerosolized intranasal midazolam for safe and effective sedation for quality computed tomography imaging in infants and children.

This pilot study introduces the aerosolized route for midazolam as an option for infant and pediatric sedation for computed tomography imaging. This technique produced predictable and effective sedation for quality computed tomography imaging studies with minimal artifact and no significant adverse events.

Image quality of thoracic 64-MDCT angiography: imaging of infants and young children with or without general anesthesia.

OBJECTIVE: The purpose of this study was to compare the image quality of thoracic CT angiography (CTA) studies performed with two techniques--with general anesthesia and without general anesthesia--for infants and for children younger than 5 years. MATERIALS AND METHODS: All consecutively registered infants and young children (age, ≤ 5 years) who underwent contrast-enhanced thoracic CTA from November 2005 to October 2010 were categorized into two groups: general anesthesia and awake (i.e., no general anesthesia). Two radiologists independently evaluated image quality by quantifying the degree of motion artifact at three anatomic levels (upper, middle, and lower lung zones). Motion artifacts were graded on an ordinal scale (0, no motion; 1, mild; 2, moderate; 3, severe), and the Pearson chi-square test was used to assess whether the degree of motion artifact differed between the general anesthesia and awake groups in the upper, middle, and lower lung zones. Logistic regression analysis was performed to determine whether image quality based on the presence or absence of motion artifact in any lobe was related to general anesthesia versus the awake state; age and sex were covariates. Interobserver agreement between two reviewers was evaluated with kappa statistics. RESULTS: There were a total of 135 patients (mean age 1.0 year), 95 in the awake group (70%) and 40 in the general anesthesia group (30%). No significant difference was found between the two groups in percentage of studies with motion artifact detected in each lung zone and the total motion artifact score. Results of multivariable logistic regression analysis indicated that image quality was not influenced by age (p = 0.52) or sex (p = 0.20). There was excellent interobserver kappa agreement between reviewers for detecting motion artifact in the upper, middle, and lower lung zones (all κ > 0.90, p < 0.001). CONCLUSION: There is no significant difference in image quality of thoracic CTA with 64-MDCT assessed by degree of motion artifact with and without general anesthesia. The results of this study support use of thoracic CTA without general anesthesia in the care of young pediatric patients who meet screening criteria for awake imaging studies.

Remimazolam as an Adjunct to General Anesthesia in Children: Adverse Events and Outcomes in a Large Cohort of 418 Cases.

Remimazolam was first approved in 2020 as a general anesthetic for adults and still does not have pediatric labeling. Our study will be the first pilot program that administers remimazolam as an adjunct to a general endotracheal anesthetic in children. Between August 2020 and December 2022, electronic medical records were collected for all children who received remimazolam during anesthesia. The remimazolam dosing regimen was extrapolated from the adult package insert, with intravenous induction doses of 12 mg/kg/h administered until the desired effect was achieved. Subsequent infusions were given at a rate of 1-2 mg/kg/h, accompanied by intermittent boluses of 0.2 mg/kg, with all dosing adjustments made according to the anesthesiologist's clinical discretion. A total of 418 children (mean 4.6 yrs, 68.7% ASA 1 and 2) underwent surgeries which averaged 81.2 min. A total of 75.2% of patients had greater than a 20% change (increase or decrease) in MAP (lowest or highest) from baseline, and 203 (49.3%) patients had greater than a 30% change (increase or decrease) in MAP (lowest or highest) from baseline. A total of 5% received ephedrine to treat unanticipated hemodynamic variability. Discharge criteria were met within an average of 13.8 min after arrival at the post-anesthesia care unit. Remimazolam may offer the benefits of rapid recovery following general endotracheal anesthesia. The risk of hemodynamic variability which necessitates and responds to ephedrine should be anticipated.

Remimazolam Pilot for Office-Based Dental Sedation: Adverse Events, Awareness and Outcomes.

In recent years, remimazolam has gained approval for use in adult procedural sedation in both the United Kingdom and the United States, potentially offering an alternative to conventional sedatives like propofol and midazolam for procedural sedation. However, there is a limited body of literature that systematically reviews the outcomes of a remimazolam-alfentanil combination protocol for routine office-based dental procedures. The primary objective of this pilot study was to assess the occurrence of significant adverse events associated with the use of a remimazolam-alfentanil sedation protocol for adult dental procedures. Secondary outcomes included evaluating physiological responses, sedation effectiveness, patient and clinician satisfaction and the incidence of intraprocedural awareness. Notably, no significant adverse events were reported among the 25 adult subjects who received remimazolam and alfentanil, and all dental procedures were successfully completed. Patients and clinicians expressed high levels of satisfaction, and patients did not report any distressing memories associated with the dental procedure. These findings suggest that in a limited cohort, the remimazolam-alfentanil regimen appears to be well tolerated and effective for office-based dental procedures in adult patients, with a low risk of adverse events, acceptable hemodynamic effects, rapid onset and recovery and minimal intraoperative awareness. This study provides valuable insights into the potential use of the remimazolam-alfentanil combination in dental sedation practice.

Remimazolam for Pediatric Procedural Sedation: Results of an Institutional Pilot Program.

Remimazolam, an ultra-short-acting benzodiazepine sedative, was first approved in 2020 in Japan as a general anesthetic for adults. However, its utilization in pediatric settings remains unexplored and, to date, is confined to isolated case reports due to a lack of specific pediatric labeling. The primary objective of our study was to evaluate the safety profile of remimazolam when used for procedural sedation in children following dosages established in adult protocols. Additional parameters, including dosage per kg of body weight, duration of the procedure, efficacy (measured as successful completion of the procedure), the necessity for supplemental medications, and changes in physiological parameters, such as the heart rate (HR) and mean arterial blood pressure (MAP), were assessed. Our study encompassed 48 children with an average age of 7.0 years. The objective Tracking and Reporting Outcomes of Procedural Sedation tool indicated no adverse events. In our cohort, propofol and ketamine were used as adjunctive treatments in 8 and 39 patients, respectively, with successful completion of all procedures. Notable hemodynamic variability was observed, with 88.4% of patients experiencing a ≥20% change (increase or decrease) and 62.8% experiencing a ≥30% change in MAP. Additionally, a ≥20% change in HR was observed in 54.3% of patients, and a ≥30% change was observed in 34.8% of patients. Nevertheless, none of the patients required pharmacological intervention to manage these hemodynamic fluctuations. Our findings suggest that remimazolam, when supplemented with propofol or ketamine, could offer a safe and effective pathway for administering procedural sedation in pediatric populations.

The Emerging Role of Virtual Reality as an Adjunct to Procedural Sedation and Anesthesia: A Narrative Review.

Over the past 20 years, there has been a significant reduction in the incidence of adverse events associated with sedation outside of the operating room. Non-pharmacologic techniques are increasingly being used as peri-operative adjuncts to facilitate and promote anxiolysis, analgesia and sedation, and to reduce adverse events. This narrative review will briefly explore the emerging role of immersive reality in the peri-procedural care of surgical patients. Immersive virtual reality (VR) is intended to distract patients with the illusion of "being present" inside the computer-generated world, drawing attention away from their anxiety, pain, and discomfort. VR has been described for a variety of procedures that include colonoscopies, venipuncture, dental procedures, and burn wound care. As VR technology develops and the production costs decrease, the role and application of VR in clinical practice will expand. It is important for medical professionals to understand that VR is now available for prime-time use and to be aware of the growing body in the literature that supports VR.

Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study.

Although most scald burn injuries involve children under six, because of the challenges of using head mounted displays with young children there is very little research exploring the use of VR in children under six. The current clinical pilot study measured the analgesic effectiveness of our new desktop VR system (with no VR helmet) in children under six during burn wound care (a within-subjects design with randomized treatment order). Between December 2021-April 2022, nine children with burn injuries (10 months to 5 years age, mean = 18 months) participated. The mean burn size was 10% Total Body Surface Area, range 2-22%. Using nurse's ratings, VR significantly reduced children's pain during burn wound care by 40% on the observational Faces, Legs, Activity, Crying, and Consolability (FLACC) pain scale. Specifically, non-parametric within-subject sign tests compared nurse's ratings of the young patients' pain during burn wound care using usual pain medications with no VR = 6.67, (SD = 2.45) vs. adjunctive Animal Rescue World VR (VR = 4.00, SD = 2.24, p < 0.01). The observational Procedure-Behavior Checklist (PBCL) nurse's scale measured a 34% reduction in anxiety with VR as compared to pharmacologic treatment alone (p < 0.005). Similarly, when using single graphic rating scales the patients' parents reported a significant 36% decrease in their child's pain during VR (p < 0.05), a 38% (p < 0.005) decrease in their child's anxiety during VR, and a significant increase in patients' joy during VR. It can be concluded that during burn wound care with no distraction (traditional pain medications), children under 6 years old experienced severe pain during a 10 min burn wound cleaning session. During burn wound care combining desktop virtual reality and traditional pain medications, the same pediatric patients experienced only mild pain during burn wound cleaning/debridement. VR significantly reduced the children's pain and anxiety during burn wound care.