Paradigm-based treatment approaches for burn pain control
- Shelley Wiechman, PhD
Shelley Wiechman, PhD
- Associate Professor, Department of Rehabilitation Medicine
- University of Washington
- Sam R Sharar, MD
Sam R Sharar, MD
- Professor, Department of Anesthesiology
- University of Washington
Pain management is a central component of the treatment of patients with burns. Despite advances in burn care, control of burn pain is often inadequate during the acute and chronic rehabilitation phases of burn care . Pain is among the most common causes of distress during the first year after recovery and, hence, should be aggressively managed [2,3]. Burn pain management is typically based upon clinical experience and physician and/or institutional preference, since available evidence is insufficient to clearly support one approach .
The approach to the management of patients with acute, background, procedural, and chronic pain secondary to burns will be discussed here. An overview of the pharmacologic and nonpharmacologic treatment options for managing burn pain is reviewed elsewhere. (See "Burn pain: Principles of pharmacologic and nonpharmacologic management".)
BURN PAIN PARADIGM
A burn pain paradigm guides the use of analgesics for management of the different phases and variability of burn pain . This paradigm is based upon five phases of burn pain occurrence and includes:
●Background pain ─ Pain that is present while the patient is at rest, results from the thermal tissue injury itself, and is typically of low to moderate intensity and long duration.
●Procedural pain ─ Brief but intense pain that is generated by wound debridement and dressing changes and/or rehabilitation activities (eg, physical therapy and occupational therapy).
- Retrouvey H, Shahrokhi S. Pain and the thermally injured patient-a review of current therapies. J Burn Care Res 2015; 36:315.
- Askay SW, Stricklin M, Carrougher GJ, et al. Using QMethodology to identify reasons for distress in burn survivors postdischarge. J Burn Care Res 2009; 30:83.
- Wiechman Askay S, Patterson DR, Sharar SR, et al. Pain management in patients with burn injuries. Int Rev Psychiatry 2009; 21:522.
- Burn Pain: A Unique Challenge. Pain Clinical Updates. International Association for the Study of Pain. Vol IX, Issue 1. March 2001. www.iasp-pain.org.
- Patterson DR, Sharar SR. Burn pain. In: Bonica's Management of Pain, 4th edition, Fishman SM, Ballantyne JC, Rathmell JP (Eds), Lippincott Williams and Wilkins, Philadelphia 2010. p.754.
- Kealey GP. Pharmacologic management of background pain in burn victims. J Burn Care Rehabil 1995; 16:358.
- Furman WR, Munster AM, Cone EJ. Morphine pharmacokinetics during anesthesia and surgery in patients with burns. J Burn Care Rehabil 1990; 11:391.
- Richardson P, Mustard L. The management of pain in the burns unit. Burns 2009; 35:921.
- Faucher L, Furukawa K. Practice guidelines for the management of pain. J Burn Care Res 2006; 27:659.
- Sheridan RL, Hinson M, Nackel A, et al. Development of a pediatric burn pain and anxiety management program. J Burn Care Rehabil 1997; 18:455.
- Gibbons J, Honari SR, Sharar SR, et al. Opiate-induced respiratory depression in young pediatric burn patients. J Burn Care Rehabil 1998; 19:225.
- Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med 1998; 152:147.
- Thurber CA, Martin-Herz SP, Patterson DR. Psychological principles of burn wound pain in children. I: theoretical framework. J Burn Care Rehabil 2000; 21:376.
- Myers R, Lozenski J, Wyatt M, et al. Sedation and Analgesia for Dressing Change: A Survey of American Burn Association Burn Centers. J Burn Care Res 2017; 38:e48.
- American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96:1004.
- Joint Commission Resources. Approaches to Pain Management, Second Edition. PDF book. www.jcrinc.com/e-books/EBAPM10/2213/ (Accessed on February 28, 2011).
- Dimick P, Helvig E, Heimbach D, et al. Anesthesia-assisted procedures in a burn intensive care unit procedure room: benefits and complications. J Burn Care Rehabil 1993; 14:446.
- Powers PS, Cruse CW, Daniels S, Stevens BA. Safety and efficacy of debridement under anesthesia in patients with burns. J Burn Care Rehabil 1993; 14:176.
- Humphries Y, Melson M, Gore D. Superiority of oral ketamine as an analgesic and sedative for wound care procedures in the pediatric patient with burns. J Burn Care Rehabil 1997; 18:34.
- Sharar SR, Bratton SL, Carrougher GJ, et al. A comparison of oral transmucosal fentanyl citrate and oral hydromorphone for inpatient pediatric burn wound care analgesia. J Burn Care Rehabil 1998; 19:516.
- Sharar SR, Carrougher GJ, Selzer K, et al. A comparison of oral transmucosal fentanyl citrate and oral oxycodone for pediatric outpatient wound care. J Burn Care Rehabil 2002; 23:27.
- Prakash S, Fatima T, Pawar M. Patient-controlled analgesia with fentanyl for burn dressing changes. Anesth Analg 2004; 99:552.
- Choiniere M, Grenier R, Paquette C. Patient-controlled analgesia: a double-blind study in burn patients. Anaesthesia 1992; 47:467.
- Owens VF, Palmieri TL, Comroe CM, et al. Ketamine: a safe and effective agent for painful procedures in the pediatric burn patient. J Burn Care Res 2006; 27:211.
- Demling RH, Ellerbe S, Jarrett F. Ketamine anesthesia for tangenital excision of burn eschar: a burn unit procedure. J Trauma 1978; 18:269.
- Ward CM, Diamond AW. An appraisal of ketamine in the dressing of burns. Postgrad Med J 1976; 52:222.
- Chen L, Wang M, Xiang H, et al. Prediction of effect-site concentration of sufentanil by dose-response target controlled infusion of sufentanil and propofol for analgesic and sedation maintenance in burn dressing changes. Burns 2014; 40:455.
- Coimbra C, Choinière M, Hemmerling TM. Patient-controlled sedation using propofol for dressing changes in burn patients: a dose-finding study. Anesth Analg 2003; 97:839.
- Yamashita S, Kaneda K, Han TH. Population pharmacokinetics of a propofol bolus administered in patients with major burns. Burns 2010; 36:1215.
- Han TH, Greenblatt DJ, Martyn JA. Propofol clearance and volume of distribution are increased in patients with major burns. J Clin Pharmacol 2009; 49:768.
- Carrougher GJ, Ptacek JT, Sharar SR, et al. Comparison of patient satisfaction and self-reports of pain in adult burn-injured patients. J Burn Care Rehabil 2003; 24:1.
- Cuignet O, Mbuyamba J, Pirson J. The long-term analgesic efficacy of a single-shot fascia iliaca compartment block in burn patients undergoing skin-grafting procedures. J Burn Care Rehabil 2005; 26:409.
- Choinière M, Melzack R, Papillon J. Pain and paresthesia in patients with healed burns: an exploratory study. J Pain Symptom Manage 1991; 6:437.
- Malenfant A, Forget R, Amsel R, et al. Tactile, thermal and pain sensibility in burned patients with and without chronic pain and paresthesia problems. Pain 1998; 77:241.
- Dauber A, Osgood PF, Breslau AJ, et al. Chronic persistent pain after severe burns: a survey of 358 burn survivors. Pain Med 2002; 3:6.
- Gray P, Kirby J, Smith MT, et al. Pregabalin in severe burn injury pain: a double-blind, randomised placebo-controlled trial. Pain 2011; 152:1279.
- Gray P, Williams B, Cramond T. Successful use of gabapentin in acute pain management following burn injury: a case series. Pain Med 2008; 9:371.
- Ahuja RB, Gupta R, Gupta G, Shrivastava P. A comparative analysis of cetirizine, gabapentin and their combination in the relief of post-burn pruritus. Burns 2011; 37:203.
- Naraynsingh V, Hariharan S, Dan D, et al. Conservative management for idiopathic granulomatous mastitis mimicking carcinoma: case reports and literature review. Breast Dis 2010; 31:57.