An optimized procedure for paediatric facial laceration

Diversified applications of paediatric sedation have gained widespread attention among clinical practitioners as they help ensure favourable therapeutic effects in various medical scenarios. We were particularly interested in a case report by Patel et al1 where nocturnal sedation was introduced to achieve an adequate interval for healing a striking facial ulceration secondary to herpes zoster in a 3-year-old girl suffering from trigeminal trophic syndrome. The patient's repetitive involuntary excoriation worsened the wound, leading to a trophic ulceration and rendering varied topical measures ineffective. To address this issue, the author administered chloral hydrate as a nocturnal sedative and successfully achieved decent wound closure. We appreciated the ingenious application of sedation in this case. However, several issues require further discussion. First, the details of the sedation medication, including the dosage and method of administration, need to be explained. According to generally accepted knowledge, the administration dose of chloral hydrate ranges from 50 to 100 mg/kg, and the action duration varies between 2 and 8 h.2 We are interested in the specific dose of sedative that was used to ensure a peaceful nocturnal sleep. Furthermore, since the rate of sedation failure rises with increasing age,3 we wonder whether this method is applicable to older children. We anticipate more experience with nocturnal sedation in this context. Meanwhile, chloral hydrate can be administered rectally or orally, and it would be meaningful if the authors could provide some suggestions on the preferred administration method. Second, the residual effects of chloral hydrate should be considering, which may occur up to 24 h after administration. Hangover performance caused by residual sedation, such as headache, disorientation, ataxia, and paradoxical excitement, has been reported in previous literature.2 Although nocturnal sedation improved wound healing in this case, continuous use of chloral hydrate per night increases the risk of potential resedation. Hence, developing a rational medication plan that balances the efficacy and safety of the sedation is crucial, and subsequently monitoring pulse oximetry along with baseline vital signs during sedation could be meaningful. Third, apart from the topical methods mentioned in the case, the combined use of low-level laser therapy could also be an effective option to promote wound healing. This noninvasive strategy is widely used in dermatology for the treatment of postherpetic neuralgia and the enhancement of skin regeneration via red or infrared light radiation.4 Nocturnal sedation provides a favourable occasion when the introduction of low-level laser therapy is feasible, which could help shorten the treatment course while reducing the sedation sessions. The introduction of chloral hydrate sedation in the case is impressive and has ignited our interest in exploring multiple medical settings for the utilisation of this conventional sedative. Chloral hydrate is commonly used as a paediatric sedative before diagnostic procedures.5 However, its application in paediatric surgery has rarely been reported, especially in emergency settings. Considering this, we would like to share our own clinical experience of using chloral hydrate in the treatment of paediatric facial lacerations in our department. When a child presents with a minor facial laceration in an emergency setting, families often refuse general anaesthesia operations due to the risks associated with anaesthesia, psychological stress, and significant cost. Likewise, children's agitation and lack of cooperation make surgical sutures under local anaesthesia less feasible. Therefore, chloral hydrate-assisted local anaesthesia surgery could become a favourable choice. We have developed an optimised procedure for facial laceration repair specifically designed for children under 3 years old and weighing less than 20 kg, which we would like to introduce as follows.3 To start with, pre-anaesthesia preparation is necessary. Parents are advised to engage their child in activities that will use up their remaining energy. Once the child is fatigued but not yet asleep, they should return to the treatment room. Then, four steps are performed: First, a local anaesthetic (lidocaine) is injected around the laceration with parental accompaniment. Second, the child is given physical reassurance and psychological comfort by cuddling and patting to calm their temperament. Third, chloral hydrate is administered rectally (at a dosage of 50 mg/kg) through a delivery tube, and at least 20 min of sleep is allowed before adequate sedation for surgery is achieved. Fourth, the child's body is swaddled with cloth sheets to enhance fixation. The debridement and cosmetic suture are then performed sequentially (see Figure 1). Successful sedation provides 1–2 h sufficient for a minor operation, during which the child will be relaxed and feel no pain. This allows for an effective and prompt cosmetic suture for facial lacerations with minimal risk, and adverse effects are rare after surgery. It should be noted that chloral hydrate sedation is not suitable for children with neurodevelopmental disorders or certain genetic syndromes. A 30-month-old child presented to our department with a 1.2 cm × 0.5 cm laceration on the outside of her eyebrow after falling on the stairs. After a simple antiseptic dressing, we performed the treatment procedure described above. As the child weighed 17 kg, 850 mg of chloral hydrate was diluted in 5 mL of saline and administered rectally. Once the child was asleep, we swaddled her to prevent any unconscious movement from contaminating the operating area (see Figure 2A). The wound was documented before and after suturing in the letter (see Figure 2B,C). The whole operation took 20 min and went smoothly without an awakening halfway. The usage of chloral hydrate for paediatric sedation in various medical conditions requires more specific guidelines. We commend the original author for their inspiring application of sedation, and hope that our strategy for facial laceration repair can also benefit children in need. The authors declare no conflicts of interest. Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.