Burn Pain - Principles of Pharmacologic and Nonpharmacologic Management

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Burn pain: Principles of pharmacologic and nonpharmacologic management
Official reprint from UpToDate www.uptodate.com 2013 UpToDate
Burn pain: Principles of pharmacologic and nonpharmacologic management Authors Shelley Wiechman, PhD Sam R Sharar, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Dec 2012. | This topic last updated: ago 9, 2012. INTRODUCTION Burns can be extremely painful. Pain management, which includes pharmacologic and nonpharmacologic approaches, is a central component of the complex issues involved in treating patients with burns. Despite advances in burn care, inadequate burn pain management still exists during both the acute and rehabilitation phases of care [1]. Burn pain is among the most common causes of distress during the first year after discharge [2,3]. Burn pain management is based upon tradition, personal bias, and/or institutional preference rather than based upon scientific approaches [4]. An overview of pharmacologic and nonpharmacologic options for the management of burn pain is reviewed here. Emergency care and local management of burns and pain are discussed elsewhere. (See "Emergency care of moderate and severe thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children" and "Local treatment of burns: Topical antimicrobial agents and dressings" and "Paradigm-based treatment approaches for burn pain control".) CHARACTERISTICS OF BURN PAIN All burns are painful initially [5]. Burn pain varies greatly from patient to patient, shows substantial fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of anatomic, physiologic, psychosocial, and premorbid behavior issues [6]. Burn patients typically report pain as being severe or excruciating, despite receiving opioid analgesics [7]. Burn pain also varies depending upon depth of burn (figure 1) (see "Classification of burns"): Superficial partial thickness burns result in hyperalgesia and mild to moderate pain. They are the most painful burns immediately following the injury. These burns damage only the outer layers of the skin. Moderate partial thickness burns are associated with marked hyperalgesia, and produce moderate to severe pain. Burns at this depth injure and/or inflame sensory receptors in the dermis. Deep partial thickness to full thickness burns are typically characterized by an absence of pain. Hyperalgesia to cutaneous stimulation is uncommon. Acute pain is typically minimal, but can be variable, and is universally present with respect to the transition zone between burned and unburned skin. The dermis is completely destroyed, including its sensory and vascular structures. There is little to no response to sharp stimuli, yet patients complain of a deep aching pain related to the inflammatory response. BURN PAIN ASSESSMENT TECHNIQUES Pain assessment tools must be practical, reliable, and valid, and must be able to assess three dimensions of pain: pain intensity, behavioral reactions, and physiologic reactions. A variety of pain measurement tools have been used with adult and pediatric burn patients. However, there are no randomized trials that have identified an optimal assessment technique for burn patients. The key is to choose an instrument and use it consistently. The most common tools used for adults and children with burn pain include verbal adjective scales, numeric written or visual analog scales, pain assessment in dementia scales, FACES, and FLACC (Face, Legs, Activity, Cry, Consolability) [8-13]. Adults The more common tools for assessing post burn pain in adults are the adjective scales, which allow a patient to describe the severity of pain in words, such as none, mild, moderate, or severe or no pain, mild, discomforting, distressing, horrible, or excruciating pain (figure 2) [11]. An alternative to the verbal description of pain is the numeric scale, which allows a patient to describe the pain on a scale of increasing severity typically from 0 to 10 (figure 3) [10]. The numeric scale is administered to the patient verbally or written as a visual analog scale (figure 4). Pain assessment can be challenging in the burned and demented patient. The Pain Assessment in Advanced Dementia Scale, an observational scoring instrument, is a simple to administer valid and reliable instrument (table 1) [12]. (See "Pain control in the critically ill adult patient", section on 'Assessment and monitoring'.) Children The measurement of children's pain is much more complex than it is for adults, especially for preverbal
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children. Typical physiologic indicators, such as heart rate, respiratory rate, and blood pressure are unreliable in measuring a childs pain since all are affected by a variety of stressors related to the burn injury [13,14]. (See "Evaluation and management of pain in children", section on 'Assessment of pain severity and cognition'.) Behavior scales have been devised to measure pain by providing standardized instructions and guidelines for observing behaviors thought to be specific to pain. Facial expression may be the most consistent infant indicator of pain [13]. Observational scales have been developed that are multidimensional and include length of cry, facial expressions, and behavioral states [3]. These scales are easier to use and allow an observer to assess pain as either present or absent without further quantification. The FLACC (Faces Legs Activity Cry Consolability scale) is the most widely used observer rating scale in preverbal children (table 2) [8]. Simple self-report pain scales can be used with preschool children. There is no evidence that any one of these scales is more reliable than the other, hence, it is best to select one that the evaluator prefers and it should be used consistently. When self-report scales are used in conjunction with observational scales, a practitioner may develop a better appreciation of the intensity of the child's response to burn pain and the effectiveness of pain management. The following are examples of pain scales that are commonly used with children: The Wong-Baker FACES Pain Scale is designed for children three years and older (figure 5) [9]. This pain scale uses drawings of faces displaying varying degrees of pain and discomfort. Each face communicates a level of pain intensity and the child is asked to choose the face that most accurately describes their pain level. The OUCHER scale includes a picture scale for very young children and a numerical scale that can be used in children over five years old [15]. There are different versions that can be used for children of various races, and an example is shown for a Caucasian boy (picture 1). PHARMACOLOGIC TREATMENT OPTIONS Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the anticipated duration of pain, and intravenous (IV) access. These medications have variable durations of action, particularly in burn patients, and should be titrated to meet the needs of the patient in each clinical setting. Pharmacologic techniques should provide near-constant plasma levels of analgesics through regularly scheduled administration of long-acting opioids (eg, methadone), or continuous IV opioid infusion (eg, morphine) in patients unable to take oral medications. Regularly schedule benzodiazepines (eg, lorazepam) may have added value in patients with significant anxiety that contributes to their pain experience. A severe burn injury results in physiologic changes that may alter the pharmacokinetic and pharmacodynamic response to drugs in inconsistent ways, hence deviation from the usual doses may be necessary to avoid toxicity or decreased efficacy [16]. The tables linked to this topic provide dosages of opioids and nonopioid analgesias as recommended for patients without serious pathophysiologic and metabolic changes without altered drug clearance. These dosages serve as a reference point for administering pharmacologic agents to burned patients. Medications may be more potent and have a prolonged effect in the burn patient. Monitoring of the airway, breathing, and circulation is necessary, particularly when intravenous drugs are administered. (See "Hypermetabolic response to severe burn injury: Recognition and treatment".) Opioid analgesics Opioid analgesics, the most common type of medication used for acute pain relief, are potent and provide a dose dependent degree of sedation important during burn wound care procedures (table 3 and table 4) [3]. Burn pain should be treated aggressively and there is no clear evidence that the use of opioids during acute burn pain management increases the likelihood of opioid dependency [17]. A review of intravenous opioid analgesia for adults and children is discussed in detail elsewhere. (See "Pain control in the critically ill adult patient", section on 'Intravenous analgesia' and "Procedural sedation in adults", section on 'Medications' and "Evaluation and management of pain in children", section on 'Opioids'.) Opioids can be administered intravenously or orally, depending on IV access, gastrointestinal function, and the patients ability to cooperate. For severe pain, the optimal route of administration is IV, which provides faster pain relief and can be titrated to meet the individual needs of the patient. Patient-controlled analgesia (PCA) with IV opioids offers the burn patient a safe and efficient method of achieving more flexible analgesia, provided the patient is alert and competent to use the device (table 5) [18]. (See "Management of postoperative pain", section on 'Patient controlled analgesia'.) Studies comparing PCA opioid use to other routes of administration in the burn population have shown positive, but limited benefits of PCA. Oral or gastrointestinal administration of opioids via an enteral tube provides potent pain relief with rapid onset and short duration of action, and requires minimal monitoring. Oral transmucosal administration is particularly helpful for performing
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burn dressing changes in children [19,20]. Intramuscular opioid administration is not recommended for use in burn patients. The injections are painful, they need to be repeated frequently, and the absorption is variable due to compartmental fluid shifts. (See "Emergency care of moderate and severe thermal burns in adults", section on 'Fluid resuscitation' and "Emergency care of moderate and severe thermal burns in children", section on 'Fluid resuscitation'.) Nonopioid analgesics Nonopioid analgesics, such as dexmedetomidine and ketamine, provide short-term effective analgesia and sedation that may be helpful for limited burn debridement and/or dressing changes in adults and children. Dexmedetomidine provides sedation, anxiolysis, and analgesia for burned children, with less respiratory depression than other sedatives [21,22]. In case study reports, ketamine used in conjunction with clonidine has been effective in providing analgesia and sedation in children with severe burn pain, particularly during dressing changes [23,24]. (See "Sedativeanalgesic medications in critically ill patients: Properties, dosage regimens, and adverse effects", section on 'Dexmedetomidine' and "Procedural sedation in adults", section on 'Ketamine' and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Dexmedetomidine' and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Ketamine' and "Pharmacologic agents for pediatric procedural sedation outside of the operating room", section on 'Introduction'.) Other nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), provide mild analgesia and are best suited to treat minor burn pain in the outpatient setting (table 6). Oral NSAIDs and acetaminophen exhibit a ceiling effect in their dose-response relationship, rendering them unsuitable for the treatment of severe burn pain. There are no high quality data from randomized trials that have determined the optimal nonopioid analgesic for burn patients. The mechanism of action and therapeutic use of NSAIDS is discussed in detail elsewhere. (See "NSAIDs: Mechanism of action" and "NSAIDs: Therapeutic use and variability of response in adults".) Anxiolytics Anxiety is a common consequence of burns, due to the need for aggressive surgical treatment and debridement of the wounds, and the persistent and repetitive qualities of background and procedural burn pain. The recognition that anxiety can exacerbate acute pain has led to the common practice of using anxiolytic drugs in combination with opioid analgesics, a practice that has become more widespread in burn centers in the past two decades [25,26]. This practice is particularly useful in premedicating patients for wound care, due to the anticipatory anxiety experienced by these patients prior to and during such procedures. Benzodiazepine therapy improved postprocedure pain scores in burn patients (table 7). A trial that randomly assigned 79 burn patients to receive lorazepam 1 mg or placebo in addition to their standard opioid analgesics found no difference between groups in pain score, except in patients with high baseline pain [27]. In high baseline pain patients, lorazepam significantly reduced VAS pain score ratings (54.3 versus 69.1). (See "Sedatives and hypnotics abuse and dependence: Pharmacology and epidemiology".) Antipsychotic medications are also an option for management of anxiety and agitation associated with burn pain and treatment [28]. First generation antipsychotics (eg, haloperidol) are used adjunctively for treatment or prevention of hyperactive delirium and agitation in critically ill patients. (See "Sedative-analgesic medications in critically ill patients: Properties, dosage regimens, and adverse effects", section on 'Neuroleptics'.) Second generation antipsychotics (eg, quetiapine) are increasingly used for treating various anxiety disorders and may be useful in combination with a benzodiazepine for managing anxiety and improving sleep in burn patients. (See "Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects".) Anesthetics General, neuraxial, targeted nonneuraxial, and regional anesthetics are useful in managing burn pain in various clinical settings. The specific types and administration of anesthesia are discussed in detail elsewhere. (See "Overview of anesthesia and anesthetic choices".) General or deep sedation A general anesthetic or deep sedation provides relief of relatively brief, intense pain that would be experienced during a procedure, such as skin grafting, extensive wound debridement, or dressing changes that occur outside of the operating room. While the risks of complications following a general anesthetic are typically low in healthy individuals, burn patients have metabolic, physiologic, and thermoregulatory abnormalities as well as possible inhalation injuries that are associated with increased risk of complications of perioperative hypothermia, hypoxemia, and abnormal responses to both depolarizing and non-depolarizing muscle relaxants [29]. Inhaled nitrous oxide is an anesthetic agent that can be safely administered and provides effective analgesia without loss of consciousness (ie, moderate sedation) for moderately painful procedures. It can be used for the treatment of burn pain, typically as a 50 percent mixture in 50 percent oxygen, and self-administered by an awake, cooperative, and spontaneously
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breathing patient via a mouthpiece or mask [30,31]. Full anesthetic care capabilities have been extended outside the operating room into specialized, high volume burn center intensive care units [32,33]. Drugs, such as intravenously administered propofol and remifentanil and inhaled sevoflurane, with rapid onset and short duration of action, rapid recovery, and few side effects have facilitated burn care and pain management in the patients hospital bed without transporting the patient to the operating room. The occasional provision of brief, dense analgesia/anesthesia (eg, general anesthesia or deep sedation) should be administered in a comprehensively monitored setting by medical professionals specifically trained to provide the service. When administered in a controlled environment, a general anesthesia or deep sedation is safe and efficient, both in terms of allowing wound care (eg, debridement of facial burns in children) to proceed rapidly, and in terms of cost-effective use of the operating room only for true surgical burn care procedures [30,31]. Regional Regional anesthesia is achieved by injecting a local anesthetic agent (eg, bupivacaine, lidocaine) around a nerve to block the sensory stimulation from that area innervated by the nerve. A regional anesthesia is particularly useful for procedures and burn pain relief involving the extremities. The most common nerve groups accessible for a nerve block include the brachial plexus (interscalene block, infraclavicular block, axillary block), the sciatic nerve, and the femoral nerve. (See "Peripheral nerve block: Techniques".) Neuraxial Neuraxial anesthesia is the administration of an anesthetic agent (eg, bupivacaine, lidocaine) and/or opioid analgesics via a spinal or epidural catheter with the goal of providing background, procedural, and postoperative pain relief. This procedure has only been anecdotally used in burn patients but theoretically has the advantage of providing an autonomic sympathectomy and peripheral dilatation [34]. A major drawback to the use of neuraxial anesthesia is the potential colonization of the indwelling catheter, particularly if inserted through burned skin, and the associated risks of meningitis and epidural abscess formation [35]. Targeted non-neuraxial blockade In contrast to neuraxial anesthesia, targeted non-neuraxial regional blockade is relatively easy to perform and carries minimal risks [36,37]. An example of a non-neuraxial nerve block is the fascia iliaca compartment blockade (FICB), which can be used for lower extremity analgesia following skin graft harvesting [36,37]. NONPHARMACOLOGIC TREATMENT OPTIONS Nonpharmacologic treatments should be complementary to pharmacologic approaches when treating pain and anxiety in the burn patient. Empirical evidence for the efficacy of nonpharmacologic treatments has been reported with burn pain, particularly when used as an adjunct to opioid analgesics [3]. A number of nonpharmacologic approaches are available. In choosing the most effective approach, the team should be guided by the manner in which the patient typically responded to prior stressful medical procedures, if possible. Such responses lie on a continuum ranging from giving up control to the health care professional and desiring little information, to seeking out as much information as possible and actively participating in care [38]. The following examples illustrate the types of coping styles to burn and procedural pain: Avoidance Those burn patients who wish to give up control to the health care professional have a tendency toward cognitive avoidance, or an avoidance style of coping mechanism. They will likely use various types of distraction techniques to avoid the painful stimuli. Approach Those burn patients who seek out information about the procedure and attempt to participate and not relinquish control have an approach style of coping mechanism. These patients often find distraction techniques distressing as trying to ignore a procedure may serve to relinquish too much control. It is important to note that both coping styles can be adaptive and it is best for the burn care team to support an individuals coping style rather than try to change the natural response. Patients may also change their coping style depending on the procedure. As an example, a patient may find it is easier to use distraction techniques for short procedures such as receiving injections, whereas they are more comfortable attending to details of their long wound care sessions and participating when possible. Patients may also change their coping style as they become more familiar and comfortable with the environment. Avoidance techniques Avoidance interventions are designed to psychologically distract or distance the patient from the pain. The Multiple Resource Theory of Attention suggests that diverting attention towards a nonpainful stimulus may lessen the intensity of perceived pain [39]. The four interventions in the avoidance category include distraction, guided imagery, hypnotic analgesia, and virtual reality [3]. The nonpharmacological techniques are described in order of those more appropriate for avoidance coping styles towards those more appropriate for the approach coping styles. However, randomized trials have not been performed to determine the optimal diversion approach as an adjunct for managing pain in burn patients.
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Distraction Distraction is the most common intervention activated by patients or the provider as an adjunct for pain management in burned children [40].The types of distraction techniques available to reduce burn pain are limited only by the creativity of patients and health care professionals. Common distraction techniques used with children include bubble blowing, singing songs, reading a story, and counting. Generating distraction strategies for adults may require a bit more creativity, and include engaging in enjoyable conversation during the procedure, listening to music, or playing a video game [41]. Guided imagery Imagery is an integrative therapy that incorporates imagined pictures, sounds, or sensations for specific therapeutic goals, such as the reduction of burn pain. While the patient is engaged in the imagery scene, less attention is available for the painful stimuli. It is the patient that selects the imagery. A related discussion on imagery and pain control in cancer patients can be found using the following link. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Imagery'.) Patients using imagery simply create or recreate an image in their mind, presumably one that they find pleasant and engaging. Prior to a painful procedure, we often have the patient elicit a safe or favorite place to go. This can be a place where they have been before (eg, a favorite vacation spot) or simply a place that they imagine to be relaxing and safe. The clinician then simply cues the patient with the details that they have provided and we encourage them to imagine this place during their subsequent wound care. Limited evidence suggests that guided imagery is effective in reducing the sensory and emotional components of pain [42]. The Agency for Health Care Policy and Research advocates the use of imagery for reduction of pain intensity and distress for cancer pain and for the management of mild to severe acute pain [43]. Hypnotic analgesia Hypnosis is an altered state of consciousness characterized by an increased receptivity to suggestion, ability to alter perceptions and sensations, and an increased capacity for dissociation [44]. It is believed that the dramatic shift in consciousness that occurs with hypnosis is the cornerstone of an individuals ability to change their awareness of pain [45]. Hypnotic analgesia should only be used by trained clinicians who can assess the risks and benefits of this powerful technique [44,46]. Although hypnosis involves much more than just avoidance or distraction, the end result is often similar, the patients focus is diverted from the pain or painful procedure. Several features make hypnotic analgesia a unique method of pain control that differs markedly from imagery or relaxation. Hypnosis may or may not lead to relaxation depending on the nature of the suggestions. In turn, it is not necessary for a patient to be relaxed or even in a deep hypnotic state in order for suggestions to be useful [47]. A related discussion on hypnotic analgesia and pain control in cancer patients can be found using the following link. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Hypnotic analgesia'.) Hypnosis involves several stages, including building clinician-patient rapport, enhancing relaxation through deep breathing, suggestions for deepening the hypnotic state, and narrowing their attention, providing posthypnotic suggestions, and alerting stage [48]. Burn patients are good candidates for hypnotic analgesia because [49-51]: The intense nature and severity of burn pain motivates patients to engage in hypnosis. The behavioral regression that often occurs after a traumatic injury makes patients more willing to be taken care of by others. Patients with burn injuries often experience a dissociative response as a means of coping that may moderate hypnotizability. Procedures, which cause the most intense pain, can be scheduled and thus allow hypnosis to be performed in advance of the painful stimulus. Several studies have shown the positive effect of hypnosis when used in conjunction with prescribed analgesia [49,52-55]. Patients with higher baseline pain levels have a greater decrease in pain after hypnosis than patients with lower baseline pain levels [49]. However, these studies are limited by methodological differences, lack of uniform assessment of hypnotizability and severity of pain, and small series of burn patients. Virtual reality Virtual reality diverts attention away from the painful sensations by immersing patients in a computer generated environment [3,56]. Burn patients can interact with the computer while painful procedures, such as dressing changes, are performed. Observational and small controlled studies indicate that virtual reality is effective in reducing pain and may have utility when used in conjunction with hypnosis [56-59]. Approach technique The most commonly used approach technique is information provision. Information provision Information provision, a technique that actively involves patient input, is an essential element of managing burn pain by providing treatment information in a timely and targeted manner. Information provision assists
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patients understanding of the issues, alternatives, and solutions. This process provides information on how their input will affect the end result, and sharing information can build trust and mutual understanding [60]. Relaxation techniques Relaxation techniques are used to lower arousal, including unnecessary muscle tension that can increase pain [3,61]. The techniques include deep breathing exercises, progressive muscle relaxation exercises, and cognitive behavioral techniques. There are no randomized trials to determine the optimal relaxation technique to be used as an adjunct for burn pain management. Deep breathing Deep breathing, or diaphragmatic breathing, is one of the least time consuming techniques to employ and easiest for adults and children to learn. When a person becomes anxious and/or experiences pain, breathing can become shallow and irregular due to the increased muscle tension in our chest wall. Such shallow breathing, known as thoracic breathing, leads to an increase in muscle tension and subsequent heightened pain [61]. Deep breathing techniques allow patients to become aware of shallow irregular breathing and leads to relaxation that may alleviate some pain. Children can be taught bubble blowing or blowing on a pinwheel to encourage deep breathing. Adults can be taught to place a hand on their stomach and to take a breath deep enough that it passes through their chest and fills their stomach (shallow breathing is more in the chest and will not cause as much hand movement on the stomach). Their hand should rise and fall with the stomach. Exhalation is the most important part of deep breathing exercises and should not be rushed. Diaphragmatic breathing is central to all forms of relaxation and is simple and time efficient. Progressive muscle relaxation Muscle tension increases as patients experience stress and pain, hence the focused effort on relaxing and tensing muscles in a controlled manner diverts the attention away from the pain. Progressive muscle relaxation is a technique used to reduce anxiety associated with painful stimuli, such as burn dressing changes, by alternately tensing then relaxing muscles [62]. Muscles are sequentially tensed (10 seconds) and relaxed (20 seconds) through various parts of the body and can be performed during dressing changes. Observational studies suggest that progressive muscle relaxation can decrease recuperation time for hospitalized patients [62]. If a person is unable to actively tense a muscle group due to pain or injury, he or she can still imagine each muscle becoming progressively warm, heavy, and relaxed or listen to a tape, a process known as autogenic training [44]. Cognitive behavioral techniques Cognitive-behavioral therapy (CBT) is used to treat multiple conditions by changing thoughts and behaviors. For treatment of burn patients, CBT includes diversion, information provision, coping skills, and relaxation techniques to modify the patients thought process about the painful experience [3]. (See "Overview of psychotherapy", section on 'Cognitive and behavioral therapies'.) Expectations of a bad outcome, such as intense pain, are associated with higher levels of perceived pain [63]. CBT can be used adjunctively to manage these expectations and associated pain in the following manner [64]: Recognize that the procedure will cause pain (anticipatory pain or distress). Stop the thought that the procedure will cause pain by active efforts to block the thought process. Distract from the pain by diverting attention to another thought. SUMMARY AND RECOMMENDATIONS The control of burn pain is a challenge that demands creativity and continued staff training on pain assessment, traditional pharmacologic analgesic approaches, and adjunctive nonpharmacologic techniques. Pharmacologic analgesics should be administered by trained and experienced staff in monitored conditions. Pain, which is present at least initially in all burn patients, varies greatly from patient to patient, shows substantial fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of anatomic, physiologic, psychosocial, and premorbid behavior. (See 'Characteristics of burn pain' above.) Pain assessment instruments use visual and/or numeric scales to assess pain intensity, behavioral reactions, and physiologic reactions. There is no one optimal assessment technique for burn patients. The key is to choose an instrument and use it consistently. (See 'Burn pain assessment techniques' above.) Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the anticipated duration of pain, and intravenous (IV) access. (See 'Pharmacologic treatment options' above.) Opioid analgesics (eg, morphine, fentanyl), the most common type of medication used for acute pain relief, are potent and provide a dose dependent degree of sedation important during burn wound care procedures. (See 'Opioid analgesics' above.) Nonopioid analgesics (eg, dexmedetomidine, ketamine, NSAIDs), provide short-term effective analgesia and sedation
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that may be helpful for limited burn debridement and/or dressing changes in adults and children. (See 'Nonopioid analgesics' above.) Anxiolytic drugs (eg, benzodiazepines) are useful in premedicating patients for wound care, due to the anticipatory anxiety experienced by these patients prior to and during such procedures. (See 'Anxiolytics' above.) Nonpharmacologic treatments should be adjunctive to pharmacologic approaches when treating pain and anxiety in the burn patient. These approaches include cognitive distraction, information provision, relaxation, coping skills, and cognitive behavioral techniques. (See 'Nonpharmacologic treatment options' above.)
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24. Lyons B, Casey W, Doherty P, et al. Pain relief with low-dose intravenous clonidine in a child with severe burns. Intensive Care Med 1996; 22:249. 25. Martin-Herz SP, Patterson DR, Honari S, et al. Pediatric pain control practices of North American Burn Centers. J Burn Care Rehabil 2003; 24:26. 26. Perry S, Heidrich G. Management of pain during debridement: a survey of U.S. burn units. Pain 1982; 13:267. 27. Patterson DR, Ptacek JT, Carrougher GJ, Sharar SR. Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain 1997; 72:367. 28. Vulink NC, Figee M, Denys D. Review of atypical antipsychotics in anxiety. Eur Neuropsychopharmacol 2011; 21:429. 29. MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology 1998; 89:749. 30. Filkins SA, Cosgrav P, Marvin JA. Self-administered anesthesia: A method of pain control. J Burn Care Rehabil 1981; 2:33. 31. Baskett PJ, Hyland J, Deane M, Wray G. Analgesia for burns dressing in children. A dose-finding study for phenoperidine and droperidol with and without 50 per cent nitrous oxide and oxygen. Br J Anaesth 1969; 41:684. 32. 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. 33. 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. 34. Punja K, Graham M, Cartotto R. Continuous infusion of epidural morphine in frostbite. J Burn Care Rehabil 1998; 19:142. 35. Still JM, Abramson R, Law EJ. Development of an epidural abscess following staphylococcal septicemia in an acutely burned patient: case report. J Trauma 1995; 38:958. 36. Cuignet O, Pirson J, Boughrouph J, Duville D. The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures. Anesth Analg 2004; 98:1077. 37. 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. 38. Martin-Herz SP, Thurber CA, Patterson DR. Psychological principles of burn wound pain in children. II: Treatment applications. J Burn Care Rehabil 2000; 21:458. 39. Wickens CD, Helleberg J, Xu X. Pilot maneuver choice and workload in free flight. Hum Factors 2002; 44:171. 40. Hanson MD, Gauld M, Wathen CN, Macmillan HL. Nonpharmacological interventions for acute wound care distress in pediatric patients with burn injury: a systematic review. J Burn Care Res 2008; 29:730. 41. Landolt MA, Marti D, Widmer J, Meuli M. Does cartoon movie distraction decrease burned children's pain behavior? J Burn Care Rehabil 2002; 23:61. 42. Eller LS. Guided imagery interventions for symptom management. Annu Rev Nurs Res 1999; 17:57. 43. Acute pain management: operative or medical procedures and trauma, Part 2. Agency for Health Care Policy and Research. Clin Pharm 1992; 11:391. 44. Patterson DR. Clinical hypnosis for pain control. American Psychological Association: Washington, DC, US. 2010. page 37.doi: 10.1037/12128-002. psycnet.apa.org/books/12128/ (Accessed on June 13, 2011). 45. Barber J. A brief introduction to hypnotic analgesia. In: Hypnosis and Suggestion in the Treatment of Pain, Barber J (Ed), WW Norton & Company, New York 1996. p.3. 46. Barber J. Rapid induction analgesia: a clinical report. Am J Clin Hypn 1977; 19:138. 47. Wark DM. Alert hypnosis: a review and case report. Am J Clin Hypn 2006; 48:291. 48. Patterson DR. Burn Pain. In: Hypnosis and Suggestion in the Treatment of Pain, Barber J (Ed), WW Norton & Company, New York 1996. p.267. 49. Patterson DR, Everett JJ, Burns GL, Marvin JA. Hypnosis for the treatment of burn pain. J Consult Clin Psychol 1992; 60:713. 50. Patterson DR, Adcock RJ, Bombardier CH. Factors predicting hypnotic analgesia in clinical burn pain. Int J Clin Exp Hypn 1997; 45:377. 51. Patterson DR, Ptacek JT. Baseline pain as a moderator of hypnotic analgesia for burn injury treatment. J Consult Clin Psychol 1997; 65:60. 52. Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of hypnotically induced analgesia: how effective is hypnosis? Int J Clin Exp Hypn 2000; 48:138. 53. Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychol Bull 2003; 129:495. 54. Patterson DR, Questad KA, Boltwood MD, et al. Patient self-reports three months after sustaining a major burn. J Burn Care Rehabil 1987; 8:274.
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55. Wakeman JR, Kaplan JZ. An experimental study of hypnosis in painful burns. Am J Clin Hypn 1978; 21:3. 56. Patterson DR, Tininenko JR, Schmidt AE, Sharar SR. Virtual reality hypnosis: a case report. Int J Clin Exp Hypn 2004; 52:27. 57. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual reality for adjunctive treatment of adult burn pain during physical therapy: a controlled study. Clin J Pain 2000; 16:244. 58. Patterson DR, Wiechman SA, Jensen M, Sharar SR. Hypnosis delivered through immersive virtual reality for burn pain: A clinical case series. Int J Clin Exp Hypn 2006; 54:130. 59. Sharar SR, Miller W, Teeley A, et al. Applications of virtual reality for pain management in burn-injured patients. Expert Rev Neurother 2008; 8:1667. 60. Burn pain: Nonpharmacologic approaches. Pain ladder treating pain painladder.com/index.php/acute-pain/burn-painnonpharmacologic-approaches (Accessed on June 22, 2011). 61. Greenberg JS. Part 3. General applications: Relaxation techniques. Chapter 10. Autogenic training, imagery, and progressive relaxation. In: Comprehensive Stress Management, 12th, Greenberg JS (Ed), McGraw-Hill Higher Education, New York 2011. p.203. 62. Jacobson E. Progressive Relaxation, University of Chicago Press, Chicago 1938. 63. Edwards RR, Haythornthwaite JA, Sullivan MJ, Fillingim RB. Catastrophizing as a mediator of sex differences in pain: differential effects for daily pain versus laboratory-induced pain. Pain 2004; 111:335. 64. 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. Topic 14989 Version 3.0
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GRAPHICS
Burn classification
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Adjective Rating Scale for pain assessment
The Adjective Rating Scale allows patients to use descriptive terms to describe the severity of their pain. Scoring can be modified for conversion to a numeric scale.
Original figure modified for this publication. Melzack R. The short-form McGill Pain Questionnaire. Pain 1987; 30:191. Illustration used with the permission of Elsevier Inc. All rights reserved.
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Numeric Pain Scale
The Numeric Pain Scale allows patients to rate the pain on a scale of 0 to 10, with 10 as the worst possible pain.
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Visual analog scale
Visual Analog Scale (VAS) (10 cm line). [Score = 0 - 100 mm] - measuring in millimeters from the left hand end of the line to the point that the patient marks.
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PAINAD - Pain Assessment in Advanced Dementia scale

Items*
Breathing independent of vocalization Negative vocalization
0
Normal.
1
Occasional labored breathing. Short period of hyperventilation. Occasional moan or groan. Low-level speech with a negative or disapproving quality. Sad. Frightened. Frown. Tense. Distressed pacing. Fidgeting. Distracted or reassured by voice or touch.
2
Noisy labored breathing. Long period of hyperventilation. CheyneStokes respirations. Repeated troubled calling out. Loud moaning or groaning. Crying. Facial grimacing. Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out. Unable to console, distract or reassure. Total:
Score
None.
Facial expression Body language Consolability
Smiling or inexpressive. Relaxed.
No need to console.
This pain assessment score can be used to assess pain in demented patients. Patients should be observed for five minutes prior to performing the assessment. Total scores range from 0 to 10, with 10 representing severe pain.
* Five-item observational tool. Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0 = "no pain" to 10 = "severe pain"). Original figure modified for this publication. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4:9. Illustration used with the permission of Elsevier Inc. All rights reserved.
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Revised FLACC pain score

Categories
F Face
Scoring
0 No particular expression or smile Normal position or relaxed Lying quietly, normal position, moves easily No cry (awake or asleep) Content, relaxed 1 Occasional grimace or frown, withdrawn, disinterested; appears sad or worried Uneasy, restless, tense; occasional tremors 2 Frequent to constant frown, clenched jaw, quivering chin; distressed-looking face: expression of fright or panic Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking Arched, rigid, or jerking; severe agitation, head banging; shivering (not rigors); breath-holding, gasping or sharp intake of breath; severe splinting Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures
L Legs
A Activity
Squirming, shifting back and forth, tense; mildly agitated (eg, head back and forth, aggression); shallow and splinting respirations, intermittent sighs Moans or whimpers, occasional complaint; occasional verbal outburst or grunt Reassured by occasional touching, hugging, or being talked to, distractable
C Cry
C Consolability
This pain score can be used to assess pain from burns and other etiologies for preverbal children. Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten. Patients who are awake: Observe for at least 1-2 minutes. Observe legs and body uncovered. Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling interventions if needed. Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If possible reposition the patient. Touch the body and assess for tenseness and tone. The revised FLACC can be used for children with cognitive disability. The additional descriptors (in italics) are included with the original FLACC. The nurse can review the descriptors within each category with parents. Ask them if there are additional behaviors that are better indicators of pain in their child. Add these behaviors to the tool in the appropriate category.
Reproduced with permission. Copyright 2002 The Regents of the University of Michigan.
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Wong-Baker FACES pain rating scale
Explain to the child that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the child to choose the face that best describes how he is feeling. Rating scale is recommended for persons age three years and older. Point to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes own pain and record the appropriate number.
Reproduced with permission from: Wong DL, Hockenberry-Eaton M, Wilson D, et al. Wong's Essentials of Pediatric Nursing, 6th ed. Mosby, St. Louis, 2001. p.301. Copyright 2001 Elsevier.
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OUCHER pain scale
The OUCHER pain scale uses both pictures and numbers. The pictures can be used for preschool children, while older children can also use the numerical scale. The scales include pictures of Caucasian, African-American, Hispanic, Asian, and First Nation children. The example here depicts a Caucasian child.
The Caucasian version of the Oucher was developed and copyrighted in 1983 by Judith E Beyer, Ph.D., RN, (University of Missouri-Kansas City School of Nursing, Retired), USA. For more information, please visit http://www.oucher.org. Reproduced with permission.
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Sedative dosage regimens

Duration of intermittent dose (minutes)
30-60+
Drug
Loading dose
Maintenance dose range
Onset (minutes)
Characteristics and role
Opioid analgesics* Fentanyl 1 to 2 mcg/kg (50-200 mcg) 0.7 to 10 mcg/kg/hour infusion <0.5 Advantages: Potent analgesicsedative with immediate onset, minimal venodilation, relative cardiovascular stability, less hypotension, and relative lack of histamine release. Hepatically metabolized by cytochrome P4503A4 to inactive metabolites. Disadvantages: Highly lipophilic parent drug accumulates with repeated or prolonged administration. As with all opioids, tolerance may require dose escalation and withdrawal syndrome may be precipitated upon abrupt discontinuation. Chest wall rigidity may occur with higher dosing. Role: A good choice for analgesia and sedation for most critically ill patients. Hydromorphone 7 to 15 mcg/kg/hour infusion 5-10 240-300
10 to 30 mcg/kg (1-4 mg)
Advantages: No consistent advantage over fentanyl. Disadvantages: Hepatically metabolized to inactive and active metabolites which can accumulate in organ failure and prolong effects. Some metabolites linked to neurotoxicity based on preliminary evidence.
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Morphine sulfate
0.05 to 0.2 mg/kg (2-10 mg)
0.07 to 0.5 mg/kg/hour infusion
5-10
240
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Histamine release and vagallymediated venodilation and bradycardia can be significant. Histamine release may precipitate bronchospasm. Role: Limited to analgesia and sedation in critically ill patients where preload reduction and myocardial depressive effects are desirable or tolerable.
Remifentanil
None
0.6 to 15 mcg/kg/hour infusion
1-3
5-10 (after cessation of infusion)
Advantages: Ultra short acting. Cleared by nonspecific plasma esterases to inactive metabolites. Does not accumulate in renal or hepatic insufficiency. Prompt reversal of analgesia and sedation upon discontinuation. Disadvantages: Anticipate pain and discomfort upon abrupt cessation. Glycine excipient may accumulate in renal insufficiency. Role: An alternate to fentanyl for patients requiring frequent neurological assessments or with multi-organ failure.
Benzodiazepines* Lorazepam 0.02-0.06 mg/kg (1 to 4 mg) 0.02-0.06 mg/kg every 26 hours AND/OR 0.01-0.1 mg/kg/hour infusion (0.5-10 mg/hour) 5-20 360-480+ Advantages: Sedative, amnestic, potent anxiolysis with anti-convulsant properties. Hepatically metabolized to inactive metabolites. Relatively low risk of drug interactions and safety in mild to moderate hepatic and renal insufficiency. Disadvantages:
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Relatively slow onset. Risk of over-sedation when titrating due to delayed response and accumulation in peripheral tissues. IV incompatibilities and risk of line precipitate. Propylene glycol solvent may accumulate with high dosing causing metabolic acidosis and endorgan dysfunction. See text. Role: A good choice for sedation and anxiolysis for most patients, including those who may require long-term ongoing sedation. Although intermittent bolus dosing may be preferred, a continuous infusion may be initiated for patients requiring frequently repeated higher dosing. Midazolam 1-5 30
0.02 to 0.08 mg/kg (1 to 5 mg)
0.02 to 0.04 mg/kg (1 to 2 mg) intermittent OR 0.04 to 0.2 mg/kg/hour infusion (2 to 8 mg/hour)
Advantages: A potent amnestic and anxiolytic agent with an immediate onset of action and a short duration of effect when administered short-term (<48 hours). It is the only intravenous benzodiazepine that is not delivered in propylene glycol. Disadvantages: Metabolized to active metabolites that may accumulate and cause prolonged sedation if delivered longterm. Also, it interacts with numerous common ICU drugs. Role: A good choice for shortterm anxiolysis and treatment of acute agitation.
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Diazepam
0.1 to 0.2 mg/kg (5 to 20 mg)
0.03 to 0.1 mg/kg every 0.5 to 6 hours Continuous infusion is not recommended
20-60 (prolonged with repeated dosing)
Advantages: Rapid onset with potent sedative and musclerelaxant effects. Disadvantages: Hepatically metabolized to active metabolites that may accumulate and cause prolonged sedation if delivered longterm. Also, it interacts with numerous common ICU drugs. Injection solution contains propylene glycol solvent and cannot be delivered as a continuous infusion. Injection site pain and risk of phlebitis limits usefulness of intravenous injections. Role: Seldom used for sedation of critically ill patients. May be useful for critically ill patient at risk of alcohol withdrawal or seizures due to drug overdose or poisoning.
Anesthetic-sedative Propofol Loading dose is not recommended 5 to 80 mcg/kg/minute Initiate at 5 mcg/kg/minute and titrate every 5-10 minutes in increments of 5-10 mcg/kg/minute <1 3-10+ Advantages: Potent sedative hypnotic with an immediate onset and rapid awakening upon discontinuation when delivered for short term use. Metabolism is reportedly unaltered in hepatic or renal insufficiency and subject to few significant drug interactions. Infusion is readily titratable to desired depth of sedation minimizing risk of over-sedation. Propofol effectively decreases intracranial
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pressure, lowers cerebral metabolism, controls intractable seizures and may reduce shivering in rewarming phase of induced hypothermia following resuscitation from cardiac arrest. Disadvantages: With long term use propofol has no advantage over lorazepam or midazolam regarding the duration of vent weaning. Adverse effects include hypotension, decreased myocardial contractility, elevated triglycerides, peripheral injection site pain, and propofol infusion syndrome. See text. Specific product presentations may include potential allergens (egg, soy, peanut, others). Consult product label information. Role: A good choice for short term sedation for patients in whom rapid awakening is advantageous such as neurosurgical patients requiring frequent neurologic assessments. Also a good choice to decrease elevated intracranial pressure or for short-term sedation in a general critical care population that is likely to be ready soon for ventilator weaning trials. Central alpha-2 agonist Dexmedetomidine Loading dose is not recommended 0.2 to 1.4 mcg/kg/hour >5-10 60-120 Advantages: Effective sedative sympatholytic
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Initiate at 0.2 mcg/kg/hour and titrate every 30 minutes
(central alpha-2 agonist) with moderate anxiolysis and analgesia, yet no clinically significant effect on respiratory drive. Character and depth of sedation may permit critically ill mechanically ventilated patients to be interactive or easily awakened, yet comfortable. Reduces shivering in rewarming phase of induced hypothermia following resuscitation from cardiac arrest. May be less likely to cause delirium than other sedative choices. Disadvantages: Potentially significant hypotension and bradycardia or hypertension that do not resolve quickly upon abrupt discontinuation. Hepatically metabolized by glucuronidation and cytochrome P450-2A6. Dose reduction recommended with renal and/or hepatic insufficiency. Rapid administration of loading dose may be associated with cardiovascular instability, tachycardia, bradycardia, or heart-block. Limited data support higher dose and longer term use (>24 hours) than in the US FDA approved information. Does not induce deep sedation needed for neuromuscular blockade. Role: An alternate choice for short and long-term sedation in critically ill
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patients without relevant cardiac conditions. May be useful for sedation of patients with or at high risk of developing delirium, although this has not been well established. Neuroleptics Haloperidol 0.03-0.15 mg/kg (2-10 mg) 0.03 to 0.15 mg/kg every 30 minutes to 6 hours Various regimens; see text 30-60 minutes 30-360+ CAUTION: Not recommended as a first or second line of treatment for burn patients. Advantages: Sedating dopamine 2 antagonist for control of positive symptoms of delirium and ICU psychoses. Minimal cardiorespiratory effects in euvolemic hemodynamically stable patients. Disadvantages: Complex hepatic metabolism includes cytochrome P4503A4 and cytochrome P4502D6 transformations. Some experts consider certain metabolites to be active or potentially neurotoxic. Halflife becomes prolonged with repeated administration. Adverse effects include dose dependent QT interval prolongation and hypotension. Interacts with some common ICU drugs by interference with metabolism and/or additive QT prolongation. Extrapyramidal symptoms and neuroleptic malignant syndrome rare in critical care use. Role: A commonly used treatment
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for delirium in critically ill patients or for prevention of delirium while tapering sedation in preparation for ventilator weaning. Use with extreme caution in burn patients. Quetiapine None Initially 50 mg orally every 12 hours; increase every 24 hours as needed up to 400 mg per day 24 hours --
Advantages: Relatively lower risk of extrapyramidal symptoms and less QT prolongation than haloperidol. Disadvantages: Requires enteral route of administration and scheduled dosing due to slow onset of action and relatively gradual titration schedule. Adverse effects may include sedation or orthostatic hypotension. Hepatically metabolized by cytochrome P4503A4 to active and inactive metabolites. Dose reduction in hepatic insufficiency needed. Role: A potential choice as adjunct to as-needed intravenous haloperidol for treatment or prevention of delirium. The precise role of quetiapine in treating or preventing ICU delirium is not yet well established.
Doses shown are for adult patients, intravenous administration, unless stated otherwise. Data on drug metabolism and activity of metabolite(s) are for assessment of potential for drug interactions and risk of accumulation.
+: Duration of action shown for initial dose. Duration becomes significantly prolonged after repeated dosing or with administration as a continuous infusion due to accumulation of drug in non-lean tissue. * For patients with significant obesity, standard initial dosing (shown in parentheses based on ideal body weight) is preferred. For additional information see "Management of the critically ill obese patient". One or more loading doses may be needed. See onset of action data for minimum time between redosing. Loading dose should be reduced or omitted in patients that are older, hypovolemic, having increasing vasopressor requirements or at-risk of hemodynamic compromise. Quetiapine recommendations and data based on limited experience and small trial results (CCM 2010; 38:419).
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Data from: 1. Lexicomp Online. Copyright 1978-2013 Lexicomp, Inc. All Rights Reserved. 2. Brunton BL, et al. (Eds). Goodman & Gilman's The Pharmacological Basis of Therapeutics 11th ed. McGraw-Hill, NY. Copyright 2006. 3. Wynn GH, et al. (Eds). Clinical Manual of Drug Interaction Principles for Medical Practice APA publishing, Washington, DC. Copyright 2009.
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Opioid analgesics for use in children with burns

Equianalgesic dose*
Oral (mg) Morphine Hydromorphone Oxycodone Fentanyl Methadone 30 7.5 20 N/A IV (mg) 10 1.5 N/A 0.1 (100 mcg)
Drug
Oral dose and frequency

0.3 mg/kg every three to four hours 0.04 to 0.08 mg/kg every three to four hours 0.1 to 0.2 mg/kg every three to four hours N/A 0.1 mg/kg every eight to twelve hours
IV dose and frequency
0.1 mg/kg every two to four hours 0.015 mg/kg every two to four hours N/A 0.5 to 1 mcg/kg every one to two hours 0.5 to 0.1 mg/kg every eight to twelve hours
N/A: not available. Approximate equianalgesic dose for estimation when changing opioid agents. * Doses are for individuals over 6 months of age with a maximum weight of 50 kg. Oral doses refer to immediate release products. Dose adjustment for renal insufficiency may be required. Not recommended in severe renal insufficiency. Oral transmucosal fentanyl is commonly used in pediatric burn patients for procedural pain, due to its acceptance by children, its relatively fast onset of action, and its relatively short duration of action, at a dose of 10-20 mcg/kg. Due to gradual drug accumulation at tissue sites, the dose and frequency of methadone differ for initial compared with repeated use; dose and interval given is usual after repeated use; methadone should be initiated and titrated by a clinician experienced with its use. Data from: Gutstein HB, Akil H. Opioid analgesics. In: Goodman & Gilmans pharmacological basis of therapeutics, 11th ed, McGraw-Hill, New York 2006.
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PCA dosing
Drug
Morphine General PCA dosing* Standard Concentration PCA Dose Lockout Interval 4 Hour Dose Limit 1 mg/ml 1.5 mg 7 30 mg 1 mg/ml 0.2 mg 7 3 mg 10 mcg/ml 20 mcg 7 300 mcg Dilaudid Fentanyl
Continuous infusion dosing should be avoided (0 mg/hr) Typical PCA Dose Change Rescue Doses Notes High Risk PCA dosing Standard Concentration PCA Dose Lockout Interval 4 Hour Dose Limit 1 mg/ml 1 mg 7 30 mg 1 mg/ml 0.1 mg 7 3 mg 10 mcg/ml 15 mcg 7 300 mcg 0.5 mg 3 mg IV q 5 min x3 0.1 mg 0.3 mg IV q 5 min x3 Preferred in renal dysfunction over morphine 5 mcg 25 mcg IV q 5 min x3 Shorter clinical effect
Continuous infusion dosing should be avoided (0 mg/hr) Typical PCA Dose Change Rescue Doses Notes 0.5 mg 2 mg q15 min, may repeat x1 prn 0.1 mg 0.2 mg q 15 min, may repeat x1 prn Preferred in renal dysfunction over morphine 5 mcg 25 mcg I q 15 min, may repeat x1 prn Shorter clinical effect
IV: intravenous; q: every; prn: as needed; PCA: patient controlled analgesia; mg: milligrams; mcg: micrograms; ml: milliliters. * May be recorded as: PCA dose/lockout interval/4 hour limit/infusion rate). May be recorded as: PCA dose/lockout interval/4 hour limit/infusion rate). Indications for High Risk are: Patients identified as elderly (age 70 or above), morbidly obese, history of sleep apnea, or patients who have received more than 25 mg morphine sulfate IV (or its equivalent). Reproduced with permission from: Pain Management Tables and Guidelines. Dana Farber Cancer Institute/Brigham and Women's Hospital Pain and Pallitative Care Program. Copyright 2004.
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Selected nonopioid analgesic and nonsteroidal antiinflammatory drugs (NSAIDs): Usual dosing for adults with pain or inflammation
Initial dose per day (mg)
<2600
Drug
Usual analgesic dose and interval

325 to 1000 mg every 4 to 6 hours
Maximum dose per day (mg)
Role in therapy
Para-aminophenol derivative Acetaminophen* (paracetamol) 4000 Treatment of mild pain and minor febrile conditions. Lacks significant antiinflammatory effect. Useful adjunct to opioid analgesics and NSAIDs. Lacks antiplatelet effect and gastrointestinal (GI) toxicity. Can cause hepatotoxicity in chronic or acute overdosage. Avoid, or use a lower daily dose, in older adults and patients at risk for hepatoxicity (eg, heavy alcohol use or malnourished). Interacts with warfarin (prolongation of INR) and CYP-450 inducing drugs (elevated risk of hepatic inflammation). Short term treatment of mild to moderate acute pain and febrile conditions when oral administration is not available and as an adjunct to opiate analgesics for the treatment of moderate to severe pain. Patient should be well hydrated and dose reduced for hepatic or renal impairment. Not indicated for treatment of chronic cancer pain.
Acetaminophen intravenous
<2600
650 mg every 4 hours or 1000 mg ever 6 hours, or 15 mg/kg every six hours for patients weighing <50 kg
4000; maximal daily dose 75 mg/kg if <50 kg
Non-selective nonsteroidal antiinflammatory (NSAID) agents

Salicylate (acetylated)
Aspirin*
2600
4000
Standard for comparison but now used infrequently for treatment of chronic pain and inflammation due to its association with severe gastropathy. Unlike other NSAIDs, irreversibly inhibits platelet function for platelet life (7 to 10 days) and salicylism may occur with high doses or chronic use at analgesic doses.
Salicylates (non-acetylated)
Diflunisal
1000 once 1500 once 1500
500 mg every 8 to 12 hours 750 mg every 8 to 12 hours 750 to 1000 mg every 8 to 12 hours
1500
Choline magnesium trisalicylate Salsalate
3000
3000
All agents: Treatment of mild to moderate pain and acute or chronic inflammatory conditions. Relatively lower risk of gastropathy compared to aspirin and possibly other NSAIDs. Generally tolerated by patients with asthma. Slower onset and possibly longer duration of action than aspirin or acetaminophen. Do not inhibit platelet function.
Propionic acids
Ibuprofen*
1600
400 mg every 4 to 6 hours
3200 acute, 2400 chronic
Treatment of mild to moderate pain, minor fever and acute or chronic inflammatory conditions. A 200 to 400 mg dose is comparable in analgesic effect to 650 mg acetaminophen or aspirin. Reversibly
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inhibits platelet function and increases bleeding time. Can alter cardioprotective effect of low dose aspirin . Minimal risk of severe gastropathy with daily dose 2400 mg. Ibuprofen (intravenous) 1600 400 to 800 mg every 6 hours 3200 (acute) Short term treatment of mild to moderate acute pain and febrile conditions when oral administration is not available and as an adjunct to other analgesics for the treatment of moderate to severe postoperative pain. Patients should be well hydrated and without significant kidney disease. Not indicated for treatment of chronic cancer pain. Treatment of mild to moderate pain, minor fever and acute and chronic inflammatory conditions. 250 mg dose (base) comparable in analgesic effect to 650 mg aspirin. In the treatment of rheumatologic disorders, total daily dose may be increased to a maximum of 1500 mg base (1650 mg naproxen sodium) when needed for added effect. Reversibly inhibits platelet function and increases bleeding time. Can alter cardioprotective effect of low dose aspirin . Appears to have the greatest relative cardiovascular safety profile among nonselective COX-2 inhibitors. Ketoprofen* 100 25 to 50 mg every 6 to 8 hours 300 mg For treatment of mild to moderate pain and acute or chronic inflammation. 25 mg dose comparable to analgesic effect of 400 mg ibuprofen. For treatment of mild to moderate pain and acute or chronic inflammation. In some countries it is available as a lozenge for throat pain and as an intravenous injection. For treatment of chronic pain and inflammation, osteo- and rheumatoid arthritis. Once daily dosing may be useful.
Naproxen*
500 once (naproxen base)
250 mg every 8 hours or 500 mg every 12 hours (naproxen base) 275 every 8 hours or 550 mg every 12 hours (naproxen sodium)
1250 acute, 1000 chronic (naproxen base)
550 once (naproxen sodium)
1375 acute, 1100 chronic (naproxen sodium)
Flurbiprofen
100
300 mg
Oxaprozin
600
1200
26 mg/kg up to 1800 mg
Acetic acids
Diclofenac
75 or 100 mg once
50 mg every 8 hours
150 mg
For treatment of mild to moderate pain and acute or chronic inflammation. Also available as a topical patch for pain due to trauma and as a gel for treatment of painful joints. For treatment of mild to moderate pain and acute or chronic inflammation. 200 mg dose has a comparable analgesic effect to 400 mg of ibuprofen. For treatment of chronic pain and inflammation, osteo- and rheumatoid arthritis. For treatment of acute and chronic
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Etodolac
600
1200 mg
Tolmetin
600
400 to 600 mg every 8 hours 150 to 200
1800
Sulindac
300
400
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mg every 12 hours
pain and inflammatory conditions. More frequently implicated in hepatotoxicity than other NSAIDs. Parent drug and metabolites can accumulate with hepatic insufficiency. Drug and metabolites have been identified in renal calculi. 150 An alternate, non first-line option for treatment of mild to moderate pain and acute or chronic inflammatory conditions. GI and central nervous system adverse effects may be more frequent or severe than with other NSAIDs. Intravenous formulation not indicated for pain. Short term treatment of moderate acute pain when oral administration of an NSAID is not available and as an adjunct to other analgesics for the treatment of moderate to severe postoperative pain. Not indicated for treatment of chronic cancer pain. Risk of gastropathy is increased when use exceeds five days. An oral preparation of ketorolac is available but offers no advantage over other oral NSAIDs.
Indomethacin (indometacin)
75
25 to 50 mg every 8 to 12 hours Controlled release: 75 mg every 12 hours
Ketorolac (intravenous and intramuscular)
<65 yrs 60 mg IV or IM once 65 yrs 30 mg IV or IM once
15 to 30 mg every 6 hours 15 mg every 6 hours
120
60
Oxicams (enolic acids)
Meloxicam
7.5
7.5 to 15 mg every 24 hours
15
For treatment of chronic pain and inflammation, osteo- and rheumatoid arthritis. Once daily dosing may be useful. While reported to be selective for COX-2 at lower dose of 7.5 mg, overall adverse effects are similar to other NSAIDs. An alternate, non first-line option for treatment of chronic pain and inflammation poorly responsive to other NSAIDs. Comparatively high incidence of gastropathy in daily dose above 20 mg and in older adults. Concurrent pharmacologic gastroprotection is suggested.
Piroxicam
10
10 to 20 mg every 24 hours
20
Fenamates (anthranilic acids)
Meclofenamate (meclofenamic acid) Mefenamic acid
150
50 mg every 4 to 6 hours 250 mg every 6 hours
400
For treatment of acute or chronic pain and inflammation, osteo- and rheumatoid arthritis, dysmenorrhea. For acute pain and dysmenorrhea. Anti-inflammatory efficacy is comparatively low. Not indicated for treatment of chronic cancer pain.
500 once
1000
Non-acidic (naphthylalkanone)
Nabumetone
1000 once
500 to 750 mg every 8 to 12 hours or 1000 to 1500 mg once daily
2000
For treatment of chronic pain and inflammation, osteo- and rheumatoid arthritis. While reported to be comparatively selective for COX-2 at the lower dose of 500 mg twice daily, the overall adverse effects when dosed in the usual range are similar to the other NSAIDs. Once daily dosing may be useful.
Selective COX-2 inhibitors Celecoxib 400 once 200 mg daily or 100 mg every 400 An option for patients requiring chronic NSAID treatment who may be at risk for gastropathy.
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12 hours
Demonstrated efficacy and relative reduction in GI toxicity compared to non-selective NSAIDs. No effect on platelet function. Dosage above 200 mg daily associated with increased cardiovascular risk. 120 For treatment of acute and chronic pain and inflammation, osteo- and rheumatoid arthritis. For short-term treatment of postoperative pain where oral route of administration is not available. Not indicated for treatment of chronic cancer pain.
Etoricoxib
30
30 to 90 mg once daily 20 to 40 mg every 6 to 12 hours
Parecoxib (intravenous and intramuscular)
40 once
80
NSAID: nonsteroidal antiinflammatory drug. Available without a prescription in US. * NSAIDs may interact with aspirin, warfarin, methotrexate, anti-hypertensives, highly protein bound agents and other drugs. See "NSAIDs: Therapeutic use and variability of response in adults", section 'Drug interactions'. See Lexi-Interact for information on interaction of specific combinations of drugs. Optional initial loading dose for pain or inflammation. See "Nonselective NSAIDs: Cardiovascular effects", section on 'Interference with beneficial effects of aspirin'. For additional information on gastroprotective strategies including selective COX-2 inhibitors and other options, see "Overview of selective COX-2 inhibitors" and "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity". Not available in US.
Doses are for adults, oral administration, except where noted otherwise.
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Pharmacology of benzodiazepines
Adult oral dose (mg)*
0.5-4 0.5-6 once daily
Drug
Comparative potency (mg)
Onset after oral dose
Metabolism
Elimination half-life (hours)
Used primarily to treat anxiety disorders Alprazolam Alprazolam extended release Clonazepam 0.5 Intermediate Hepatic by CYP3A4 oxidation. One metabolite possesses partial activity. Hepatic by CYP3A4 oxidation. No active metabolite. Hepatic by glucuronidation (rapid). No active metabolite. Hepatic by glucuronidation (rapid). No active metabolite. Hepatic by CYP3A4 oxidation to active metabolites. Hepatic by CYP2C19 and 3A4 oxidation. Multiple active metabolites. Hepatic by CYP3A4 oxidation to active metabolite. Requires acidity for activation of parent compound. Hepatic by CYP3A4 oxidation. Multiple active metabolites. Extensive firstpass metabolism. 12-15
0.5-4
0.25-0.5
Intermediate
18-50
Lorazepam
0.5-6 0.5-4 (hypnotic)
Intermediate
10-14
Oxazepam
30-120 15-30 (hypnotic)
15-30
Intermediate
5-15
Chlordiazepoxide
5-100
10
Intermediate
30-100
Diazepam
4-40
Rapid
50-100
Clorazepate
7.5-60
7.5
Rapid
36-200
Prazepam
10-60
15
Slow
30-200
Used primarily to treat insomnia Triazolam 0.1250.25 0.1 Rapid Hepatic by rapid CYP3A4 hydroxylation. No active metabolite. Hepatic by CYP3A4 2-5
Estazolam
1-2
0.3
Intermediate
10-24
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oxidation. No active metabolite. Temazepam 15-30 5 Intermediate Hepatic by UGT2B7, 2C19, 3A4 glucuronidation. No active metabolite. Hepatic by CYP3A4 oxidation to active metabolites. Hepatic by CYP3A4 (major) and 2C19 (minor) oxidation to active metabolites. 10-40
Flurazepam
15-30
Intermediate
40-114
Quazepam
15
Intermediate
28-114
* Range of usual effective total daily dose for adults. Dosages usually given in divided doses two to four times daily for anxiety or panic. Important: data shown are for comparing potencies and are NOT recommendations for initation of therapy or for conversion between agents. Half-life of parent drug and active metabolite(s), if any. Give once daily in am; do not crush, break, or chew. Duration of effect longer than predicted by half-life due to extended release. Not available in US or Canada. Range of usual effective hypnotic dose for adults, given once daily at bedtime.
Data on drug metabolism and activity of metabolite(s) are for assessment of potential for drug interactions and risk of accumulation. Risk of accumulation is greater, and dose reduction necessary, for older or debilitated adults and for patients with renal or hepatic insufficiency.
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Burn Pain - Principles of Pharmacologic and Nonpharmacologic Management

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Burn Pain - Principles of Pharmacologic and Nonpharmacologic Management

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28/01/13

Burn pain: Principles of pharmacologic and nonpharmacologic management

Official reprint from UpToDate www.uptodate.com 2013 UpToDate

Section Editor Marc G Jeschke, MD, PhD

Deputy Editor Rosemary B Duda, MD, MPH, FACS

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Adjective Rating Scale for pain assessment

Burn pain: Principles of pharmacologic and nonpharmacologic management

Numeric Pain Scale

Burn pain: Principles of pharmacologic and nonpharmacologic management

Visual analog scale

Burn pain: Principles of pharmacologic and nonpharmacologic management

PAINAD - Pain Assessment in Advanced Dementia scale

Facial expression Body language Consolability

Smiling or inexpressive. Relaxed.

Burn pain: Principles of pharmacologic and nonpharmacologic management

Revised FLACC pain score

Burn pain: Principles of pharmacologic and nonpharmacologic management

Wong-Baker FACES pain rating scale

Burn pain: Principles of pharmacologic and nonpharmacologic management

OUCHER pain scale

Burn pain: Principles of pharmacologic and nonpharmacologic management

Sedative dosage regimens

Maintenance dose range

Characteristics and role

10 to 30 mcg/kg (1-4 mg)

0.05 to 0.2 mg/kg (2-10 mg)

0.07 to 0.5 mg/kg/hour infusion

Burn pain: Principles of pharmacologic and nonpharmacologic management

0.6 to 15 mcg/kg/hour infusion

5-10 (after cessation of infusion)

Burn pain: Principles of pharmacologic and nonpharmacologic management

0.02 to 0.08 mg/kg (1 to 5 mg)

Burn pain: Principles of pharmacologic and nonpharmacologic management

0.1 to 0.2 mg/kg (5 to 20 mg)

20-60 (prolonged with repeated dosing)

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Initiate at 0.2 mcg/kg/hour and titrate every 30 minutes

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Opioid analgesics for use in children with burns

Oral dose and frequency

IV dose and frequency

Burn pain: Principles of pharmacologic and nonpharmacologic management

Burn pain: Principles of pharmacologic and nonpharmacologic management

Usual analgesic dose and interval

Maximum dose per day (mg)

4000; maximal daily dose 75 mg/kg if <50 kg

Non-selective nonsteroidal antiinflammatory (NSAID) agents

325 to 650 mg every 4 to 6 hours