Pain management
in burn patients
R2 Surapa Klarod, MD.
Anesthesiology Department
TABLE OF CONTENTS
01
Pathophysiology &
mechanism of pain
in burns
03
Treatment of acute
burn pain
Non-pharmacological treatment
02
Treatment of acute
burn pain
Pharmacological
treatment
04
Treatment of chronic pain
following burn injury
1
2
3
4
Managing pain in a patient with burn
injury can be complex.
Pain that originates with burn injury is
generally classified temporally, first as
the pain in the acute process, then as
the pain in the chronic phase when
the bulk of tissue healing has
occurred.
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4
01.
Pathophysiology &
Mechanism of pain
in burn patient
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3
4
Mechanisms of burn pain
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast Surg. 2017;44(4):737-47.
Mechanisms of burn pain
•
•
•
•
•
Complex pathology both
peripheral & central process
Combines features of acute
nociceptive, inflammatory and
neuropathic pain.
Toxic inflammatory mediators
Protein denaturation, surrounding tissue
hypoperfusion, capillary vasoconstriction
Local & systemic responses
1
2
3
4
Morgan M, et al. Burn Pain. Pain Med. 2018;19(4):708-34.
Degree of pain
-Determined by depth of
burn injury, extent
involvement in TBSA
- Noxious heat stimuli are
conducted to the dorsal
horn of spinal cord via
nociceptive A d and C
fiber neuron.
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2
3
4
Morgan M, et al. Burn Pain. Pain Med. 2018;19(4):708-34.
Features of burn depth associated with pain
Burn depth
Appearance
Blistering
Sensation
Epidermal
Red
None
Painful
Superficial
Pink with wet appearance
Brisk cap-refill
+
Painful
Deep
Pale/fixed red staining
Poor cap-refill
+/-
Painful or painless
Full thickness
Leathery white or brown
None
None in burned area
+/- pain at edges
Partial
thickness
Morgan M, et al. Burn Pain. Pain Med. 2018;19(4):708-34.
Categories of acute burn pain
1. Evoked & Procedural
pain
•
•
•
Predictable events
With activities e.g., a
procedure, dressing, PT
Short-lived, high in
intensity
2. Background pain
•
•
•
•
1
2
Without provocation
Even at rest
Less intense, but constant
Able to have spontaneous
exacerbation, as well.
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast Surg. 2017;44(4):737-47.
3
4
02.
Treatment of acute
burn pain
Pharmocological treatment
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• Adequate pain management ¯morbidity &
mortality.
• Inadequate pain control is also associated with a
range of psychiatric conditions, including PTSD,
depression, anxiety, and sleep disorders.
Morgan M, et al. Burn Pain. Pain Med. 2018;19(4):708-34.
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn
Patient. J Burn Care Res. 2020;41(6):1129-51.
Pain assessment in adult burn patients
- Should be performed several times a day and during various phases of care (Level A).
-Should be protocolized and recorded by the physician and the nursing staff during the
various stages (Level B).
-Pain assessment tools should use patient-reported scales when able (Level C).
-The Burn Specific Pain Anxiety Scale (BSPAS) should be included as one of the
pain assessments in an acute burn hospitalization (Level C).
Km.
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn
Patient. J Burn Care Res. 2020;41(6):1129-51.
The Burn Specific Pain Anxiety Scale (BSPAS)
Inpatient pain management
ü
ü
ü
ü
Invidualized treatment
Continuous treatment
Reassessment
Analgesic dose adjustment
Opioids
q
q
q
q
q
q
Remain the mainstay of treatment, most effective medication in
perioperative moderate & severe pain management.
Should not be used in isolation but in conjunction with non-opioid & nonpharmacological treatment. (Level C)
No ceiling effect.
Side effects: constipation, nausea, itching, respiratory depression
Significant opioid dose escalation may be required for burn patients with
extended hospital stays, frequent procedure, prior opioid use.
Severe critically-ill à continuous IV infusion with ICU respiratory
monitoring
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast Surg. 2017;44(4):737-47.
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J Burn Care
Res. 2020;41(6):1129-51.
1
2
3
4
Opioids
q
q
q
q
Opioid analgesia is standard practice to manage procedural pain.
Fentanyl shows to be a safe and effective agent for pain control & burn
dressing changes in both adult and children.
TCI propofol + sufentanil/ remifentanil has been shown to be safe and
effective in burn dressing change analgesia
In pediatrics with no IV access à considered periprocedural intranasal
fentanyl
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American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J Burn
Care Res. 2020;41(6):1129-51.
Tolerance and Opioid-induced hyperalgesia
Opioid-induced
hyperalgesia (OIH)
Tolerance
•
•
•
•
Decrease in analgesic responsiveness
to opioid
Occur in hospitalization, even in
perioperative period– infusion of
short-acting opioid
Explain dose escalation for analgesic
effect
Not develop in certain S/E à
constipation, itching
•
•
•
•
Nociceptor become sensitized as a
result of opioid exposure.
Patients can experience increased pain
from painful & non painful stimuli
(hyperalgesia and allodynia)
Irrespective to duration of opioid
exposure or dose
Ultrashort-acting opioid may induce
the phenomenon & should be avoided
in burn patients.
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast
Surg. 2017;44(4):737-47.
Patient-controlled analgesia (PCA)
q
q
q
q
Common route of opioid IV administration to burn patients à flexible
administration, circumventing delays associated with nursing care.
Thought to be less likely associated with risk of RS depression
In most cases, no baseline infusion not recommended, except in opioidtolerant patients with high opioid consumption.
PCA dose should be individualized, considered patient health status &
comorbidities.
1
2
3
4
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast
Surg. 2017;44(4):737-47.
Non-opioid pain medication
Acetaminophen
NSAIDS
Gabapentin
1
2
Ketamine
Alpha-2 agonist
Lidocaine
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4
Acetaminophen
q
q
q
q
Has both analgesic and anti-pyretic properties, weakly inhibit prostaglandin
synthesis
Available in oral, IV and rectal form
To date, there are no studies investigated the efficacy of IV acetaminophen
in the burn population
should be utilized on all burn patients, with care taken to monitor maximal
daily dose. (Level D)
1
2
3
4
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J Burn
Care Res. 2020;41(6):1129-51.
Nonsteroidal anti-inflamatory drug (NSAIDS)
q
q
q
q
q
q
Analgesic and anti-pyretic properties
Reversibly inhibit cyclooxygenase by inhibiting prostaglandin production
Can reduce opioid consumption up to 20-30% (synergistic effect)
Ceiling effect
Weigh its use including baseline comorbidities, kidney function
Possible side effects– GI bleeding, renal dysfunction, risk of cardiovascular
event, platelet dysfunction
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American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J Burn
Care Res. 2020;41(6):1129-51.
Gabapentinioids
q
q
q
q
q
q
Should be considered as an adjunct to an opioid in patients who are having
neuropathic pain or who are refractory to standard therapy. (Level C)
Suppresses neurotransmission
Activates and enhances the efficacy and release of descending
noradrenergic neuronal activity
¯primary mechanical allodynia
¯ opioid consumption
Gabapentin 800 upto 2400 mg/day à reduce opioid consumption in burn
5-40% TBSA
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3
4
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J Burn
Care Res. 2020;41(6):1129-51.
Anti-depressants
q
q
q
q
TCA and SNRIs group
The analgesic action occurs at the level of the spinal cord through
bulbospinal pathway, by blocking uptake of serotonin and norepinephrine.
The analgesic effect of antidepressants does not correlate with the
treatment of depression. The analgesic benefit occurs before the
anticipated effect on mood (about 2 weeks for pain vs 6–8 weeks for mood)
Common side effects: antimuscarinic and antihistaminic effect.
1
2
3
4
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast
Surg. 2017;44(4):737-47.
Ketamine
q
q
q
q
q
q
q
Potential analgesic effects when administered at subanesthetic doses. (0.10.5 mg/kg IV or 0.1-0.5 mg/kg/hr IV infusion)
Fast onset of action (1-5 minutes) and relatively short duration of action
(10-30 minutes).
Provide effective analgesia for procedural pain in both adult and pediatric
burn patients.
¯ the area of secondary hyperalgesia
¯opioid consumption
No risk of developing tolerance, risk of withdrawal
Able to use as PCA for burn dressing, able to use as long-term sedation
&analgesia.
1
2
3
4
James DL, Jowza M. Principles of Burn Pain Management. Clin Plast
Surg. 2017;44(4):737-47.
Alpha-2 adrenagic agoinists
q
q
q
q
q
q
Decrease noradrenaline release at presynaptic receptor sites
Has sedative, sympatholytic, anxiolytic, and analgesic properties.
safe adjunct alternative to opioids and benzodiazepines for periprocedural
sedation
Improve macrophage function & anti-apoptotic activity
Dexmedetomidine: iv infusion at 0.2 to 1 mcg/kg/hr but may be bolused
intermittently in small doses of 4 to 8 mcg IV
Clonidine: 2 to 5 mcg/kg PO, 0.1 to 0.3 mg/24 hr TTD, or 30 mcg to 300 mcg IV
for procedural sedation in chronic opioid/chronic pain patients
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Local anesthesia
q
q
q
q
q
Improve periprocedural analgesia.
Treatment of neuropathic pain
¯primary and secondary hyperalgesia.
A study found a statistically significant reduction in pain score following IV
lidocaine. à reduced tissue response to thermal injury
Topical administration in burn patients remains controversial due to
concern of systemic toxicity.
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2
3
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American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient. J Burn
Care Res. 2020;41(6):1129-51.
Regional anesthesia
q
q
q
Peripheral regional nerve blockade/ Neuraxial block
Potential to provide improved pain relief, patient satisfaction, and opioid
use reduction without serious risks or complications (Level C)
Common regional nerve block
q Fascia iliaca block to provide anesthesia to the antero-lateral thigh, a
common site used to acquire donor skin
q Brachial plexus block, which provides anesthesia for procedures
involving the arm.
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Agents
Opioids
Examples
Fentanyl, morphine,
hydromorphone
Methadone
Mechanism of action
Administration
Mu-receptor agonist
IV,PO,IM,
Transdermal
Mu- R agonist, NMDA-R
antagonist, SN &NE receptor
antagonist
PO
NMDA antagonists
Ketamine,
Dextromethrophan
Non-competitive NMDA-R
antagonist
IV (Ketamine)
PO (dextrometrophan)
NSAIDS
Ketorolac,
Ibuprofen
Cyclooxygenase (COX-1 & COX-2
inhibition)
IV, PO, PR
Gabapentinoids
Gabapentin,
Pregabalin
Calcium channel blockage
PO
Local anesthetics
Lidocaine,
Bupivacaine,
Ropivacaine
Na channel blockage
IV (lidocaine)
Epidural/intrathecal
Perineural,
Transdermal
Alpha-2 adrenergic
agonists
Clonidine,
Dexmedetomidine
Central and peripheral a-2
adrenergic blockage/
IV (dexmed), PO
03.
Treatment of
acute burn pain
Non-Pharmocological treatment
1
2
3
4
Recommend that every patient be offered a nonpharmacological pain control technique, at least as an
adjunctive measure to their pain control regimen.
When the expertise and/or equipment is available,
cognitive-behavioral therapy, hypnosis and virtual
reality have the strongest evidence (Level A).
American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn
Patient. J Burn Care Res. 2020;41(6):1129-51.
Non-Pharmocological treatment
01
02
Cognitive behavioral
therapy
Hypnosis
03
Virtual reality
1
2
04
Relaxation technique
-Breathing therapy
-Music therapy
-Stress Inoculation
-Aromatherapy
-Massage
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4
Non-Pharmocological treatment
01
Cognitive behavioral therapy
Most effective when decatastrophizing and
reinterpreting signal were targeted.
03
04
Virtual reality
Relaxation technique
02
Hypnosis
-oldest intervention
Most effective when
-the affective component of pain was targeted
in posthypnotic suggestions
- Patients who had severe pain.
Success rate also depends on patient factorspast pain experience, memory of pain, cultural
conditioning, substance abuse, sensitivity to
hypnosis
Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review. Plast Reconstr Surg. 2022;149(5):985e-94e.
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Virtual Reality
q
q
q
Distraction-based intervention with most robust literature documenting its
use and efficacy.
Achieved by a sense of immersion and concept of “presence” described as
the experience of going “into” the virtual environment.
VR system includes a micro processing computer, a head-mounted, high
resolution, wide field display and body movement tracking sensor.
Bermo MS, et al. Virtual Reality to Relieve Pain in Burn Patients Undergoing Imaging and Treatment.
Top Magn Reson Imaging. 2020;29(4):203-8.
Bermo MS, et al. Virtual Reality to Relieve Pain in Burn Patients Undergoing Imaging and Treatment.
Top Magn Reson Imaging. 2020;29(4):203-8.
Virtual Reality Mechanism
q
q
q
q
Significant suppression of pain-related brain activity in anterior
cingulate cortex, insula, thalami and s1s2 cortex
Not completely understood.
Core concept = distraction attention
away from noxious stimuli
Limit pain signals passes through the
cortex esp. anterior cingulate
cortex.
Adjunctive VR Improves pain score
up to 30-50% reduction compared to
standard analgesia during burn
wound care
Bermo MS, et al. Virtual Reality to Relieve Pain in Burn Patients Undergoing Imaging and Treatment.
Top Magn Reson Imaging. 2020;29(4):203-8.
Gasteratos K, et al. Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain.Plast Reconstr Surg.
2022;149(5):985e-94e.
04.
Treatment of chronic
pain following
burn injury
1
2
3
4
1
“Debilitating impact”
•
•
Decreased patient function
and quality of life.
Effect 25-36% of burn
victims.
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3
4
Morgan M, et al. Burn Pain. Pain Med. 2018;19(4):708-34.
Chronic burn pain
q
q
q
q
No evidence that any intervention can reduce the incidence of
chronic pain in the burn-injured population.
General principle: multimodal analgesia in the setting of a
supportive interdisciplinary team with psychological intervention.
Adequate acute pain control is highest important in effort of
prevention progression
Due to concern for development of central sensitization, tolerance,
and OIH, use of opioid monotherapy should be avoided.
1
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Morgan M, et al. Burn Pain. Pain Med. 2018;19(4):708-34.
Key points
q Successfully managed acute pain improves trauma-related
morbidity & mortality, is associated with ¯ likelihood of
psychiatric comorbidities and chronic pain conditions.
q Opioids remain the cornerstone of acute pain management but
should not be used as monotherapy.
Take home messages
q
q
q
q
Burn pain consists of both nociceptive and neuropathic
components.
Understand the principles of analgesia and the importance of
delivering the right drugs at the right time.
Aggressive multimodal and multidisciplinary approach
Burn pain needs both pharmacologic and non-pharmacologic
modalities
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