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Yessaillian A, Reese M, Clark RC, Becker M, Lopes K, Alving-Trinh A, Llaneras J, McPherson M, Gosman A, Reid CM. A systematic review of morphine equivalent conversions in plastic surgery: Current methods and future directions. J Plast Reconstr Aesthet Surg 2024; 95:142-151. [PMID: 38909598 DOI: 10.1016/j.bjps.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/16/2024] [Accepted: 06/01/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Protocols surrounding opioid reduction have become commonplace in plastic surgery to improve peri-operative outcomes. Within such protocols, opioid requirement is a frequently analyzed outcome. Though often examined, there is no literature standard conversion for morphine milligram equivalents (MME) at present, leading to questionable external validity. We hypothesized significant heterogeneity in MME reporting would exist within plastic surgery literature. METHODS Following the PRISMA guidelines, the authors conducted a systematic review of 16 journals. Clinical studies focused on opioid reduction within plastic surgery were identified. Primary outcomes included reporting of morphine equivalents (ME) delivery (IV/oral), operative ME, inpatient ME, outpatient ME, timeline, and method of calculation. RESULTS Among the 101 studies analyzed, 73% reported opioid requirements in the form of ME. Among those that used ME, 3% reported IV ME, 41% reported oral, 32% reported both, and 25% gave no indication of either. Operative ME were reported in 19% of studies. Furthermore, 54% of studies reported inpatient ME whereas 32% of studies reported outpatient ME. Only 19% reported the number of days opioids were consumed postoperatively. Moreover, 27% of the studies reported the actual method of ME conversion, with 17 unique methods described. Only 8 studies (8%) reported using the Center for Disease Control and Prevention guidelines for ME conversion. CONCLUSION There is significant variability among the reported ME conversion methodology within plastic surgery literature. Highlighting these discrepancies is an essential step in creating and implementing a single, standard method to mitigate opioid morbidity in plastic surgery and to optimize enhanced recovery protocols.
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Affiliation(s)
- Andrea Yessaillian
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - McKay Reese
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Robert Craig Clark
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Miriam Becker
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Kelli Lopes
- UC San Diego School of Medicine, 9500 Gilman Dr, San Diego, CA, United States
| | - Alexandra Alving-Trinh
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Jason Llaneras
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Mary McPherson
- University of Maryland School of Pharmacy, 20 N Pine St, Baltimore, MD 21201, United States
| | - Amanda Gosman
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States
| | - Chris M Reid
- UC San Diego Division of Plastic Surgery, 200 W. Arbor Drive M/C 8890, San Diego, CA 92013, United States.
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Stanton E, Won P, Manasyan A, Gurram S, Gilllenwater TJ, Yenikomshian HA. Neuropathic pain in burn patients - A common problem with little literature: A systematic review. Burns 2024; 50:1053-1061. [PMID: 38472004 PMCID: PMC11216128 DOI: 10.1016/j.burns.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/27/2023] [Accepted: 02/21/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The prevalence of neuropathic pain (NP) in burn patients is reported in the literature to be as high as 80%1. Given the complexity of NP in burn patients and the wide range of treatments available, a systematic review of the literature is warranted to summarize our current understanding of management and treatment of NP in this population. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The following databases were queried to identify relevant articles: PubMed, Cochrane, Embase, Scopus, Ovid, and Web of Science. The main outcome measures were incidence and management of NP. Secondary outcomes included risk factors for NP. RESULTS Included articles presented findings from 11 different countries, capturing outcomes for 4366 patients. Risk factors for neuropathic pain in burn patients were identified, including older age, alcohol and substance abuse, current daily smoking, greater % total body surface area burns (TBSA), and longer hospitalizations. Pharmacologic treatments included gabapentin/pregabalin (n = 7), ascorbic acid (n = 1), and lidocaine (n = 1). Overall, the studies showed varied results regarding the efficacy of pharmacological treatments. While certain studies demonstrated gabapentanoids to be effective in reducing neuropathic symptoms, others found conflicting results. With regards to non-pharmacologic treatments, electroconvulsive therapy (n = 1), electropuncture (n = 1), nerve release/reconstruction (n = 2), and somatosensory feedback rehabilitation (n = 1) were used and demonstrated promise in reducing pain intensity and improving functionality. CONCLUSIONS Despite NP afflicting the majority of burn patients long after their injury, this systematic review demonstrates insufficient evidence on the pathophysiology, outcomes, and risk factors in NP, as well as the efficacy of various therapies. Future prospective and randomized studies evaluating the etiology of these factors can substantially improve our treatment strategies. This can allow for the development of well-delineated and evidence-based protocols in NP management in hopes of improving quality of life and both psychological and physical function in burn patients.
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Affiliation(s)
- Eloise Stanton
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA
| | - Paul Won
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA
| | | | | | - T Justin Gilllenwater
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA
| | - Haig A Yenikomshian
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA.
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Stanton E, McMullen K, Won P, Schneider JC, Ryan C, Carrougher G, Kowalske K, Yenikomshian HA. Neuropathic Pain After Burn Injury: A Severe and Common Problem in Recovery. Ann Surg 2024; 279:874-879. [PMID: 37916448 PMCID: PMC10997473 DOI: 10.1097/sla.0000000000006146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The aim of this study was to address the limited understanding of neuropathic pain (NP) among burn survivors by comprehensively examining its prevalence and related factors on a national scale using the Burn Model System (BMS) National Database. BACKGROUND NP is a common but underexplored complaint among burn survivors, greatly affecting their quality of life and functionality well beyond the initial injury. Existing data on NP and its consequences in burn survivors are limited to select single-institution studies, lacking a comprehensive national perspective. METHODS The BMS National Database was queried to identify burn patients responding to NP-related questions at enrollment, 6 months, 12 months, 2 years, and 5 years postinjury. Descriptive statistics and regression analyses were used to explore associations between demographic/clinical characteristics and self-reported NP at different time points. RESULTS There were 915 patients included for analysis. At discharge, 66.5% of patients experienced NP in their burn scars. Those with NP had significantly higher Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) pain inference, itch, anxiety, depression, and sleep disturbance scores and were less able to partake in social roles. Multiple logistic regression revealed male sex, % total body surface area, and moderate-to-severe pain as predictors of NP at 6 months. At 12 months, % total body surface area and moderate-to-severe pain remained significant predictors, while ethnicity and employment status emerged as significant predictors at 24 months. CONCLUSIONS This study highlights the significant prevalence of NP in burn patients and its adverse impacts on their physical, psychological, and social well-being. The findings underscore the necessity of a comprehensive approach to NP treatment, addressing both physical symptoms and psychosocial factors.
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Affiliation(s)
- Eloise Stanton
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA
| | - Kara McMullen
- Burn Model Systems National Data and Statistical Center, University of Washington, Seattle, WA
| | - Paul Won
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
| | - Colleen Ryan
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children®-Boston, Harvard Medical School, Boston, MA
| | - Gretchen Carrougher
- Department of Surgery, UW Medicine Regional Burn Center, University of Washington, Seattle, WA
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA
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Jamal S, Shaw M, Quasim T, Puxty K, McGovern C. Long term opioid use after burn injury: a retrospective cohort study. Br J Anaesth 2024; 132:599-606. [PMID: 38216388 PMCID: PMC10870133 DOI: 10.1016/j.bja.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/30/2023] [Accepted: 12/04/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Patients who have survive a burn injury might be at risk of opioid dependence after discharge. This study examined the use of opioids in patients who suffer burn injury and explored factors associated with persistent opioid use after hospital discharge. METHODS This retrospective cohort study compared adults admitted with a burn injury from 2009 to 2019 with two matched comparison cohorts from the general population and adults with a diagnosis of acute pancreatitis. Pre-admission prescription opioid use was determined, and a multivariable negative binomial regression analysis used to explore post-discharge opioid use. RESULTS A total of 7147 burn patients were matched with 6810 pancreatitis patients and with 28 184 individuals from the general population. Pre-admission opioid use was higher in the burn and pancreatitis cohorts (29% and 40%, respectively) compared with the general population (17%). Opioid use increased in both burn and pancreatitis cohorts after discharge (41% and 53%, respectively), although patients with pancreatitis were at even higher risk of increased opioid use in an adjusted analysis (incidence rate ratio 1.43). Female sex, lower socioeconomic status, ICU admission, pre-injury opioid use, and a history of excess alcohol use were all associated with an increase in opioid prescriptions after discharge. CONCLUSIONS Opioid use is high in those admitted with a burn injury or acute pancreatitis when compared with the general population, increasing further after hospital discharge. Female sex and socioeconomic deprivation are among factors that make increased opioid use more likely, although this phenomenon seems even more pronounced in those with acute pancreatitis compared with burn injuries.
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Affiliation(s)
- Sherzah Jamal
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
| | - Martin Shaw
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Tara Quasim
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Kathryn Puxty
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Mauck MC, Zhao Y, Goetzinger AM, Tungate AS, Spencer AB, Lal A, Barton CE, Beaudoin F, McLean SA. Incidence of persistent opioid use following traumatic injury. Reg Anesth Pain Med 2024; 49:79-86. [PMID: 37364919 DOI: 10.1136/rapm-2022-103662] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/11/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION Major traumatic injuries are a known risk factor for persistent opioid use, but data describing the relationship between specific traumatic injuries and opioid use is lacking. METHODS We used insurance claims data from January 1, 2001 to December 31, 2020 to estimate the incidence of new persistent opioid use in three hospitalized trauma populations: individuals hospitalized after burn injury (3809, 1504 of whom required tissue grafting), individuals hospitalized after motor vehicle collision (MVC; 9041), and individuals hospitalized after orthopedic injury (47, 637). New persistent opioid use was defined as receipt of ≥1 opioid prescriptions 90-180 days following injury in an individual with no opioid prescriptions during the year prior to injury. RESULTS New persistent opioid use was observed in 12% (267/2305) of individuals hospitalized after burn injury with no grafting, and 12% (176/1504) of burn injury patients requiring tissue grafting. In addition, new persistent opioid use was observed in 16% (1454/9041) of individuals hospitalized after MVC, and 20% (9455/47, 637) of individuals hospitalized after orthopedic trauma. In comparison, rates of persistent opioid use in all trauma cohorts (19%, 11, 352/60, 487) were greater than the rates of persistent opioid use in both non-traumatic major surgery (13%) and non-traumatic minor surgery (9%). CONCLUSIONS These data demonstrate that new persistent opioid use frequently occurs in these common hospitalized trauma populations. Improved interventions to reduce persistent pain and opioid use in patients hospitalized after these and other traumas are needed.
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Affiliation(s)
- Matthew C Mauck
- Institute for Trauma Recovery, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Ying Zhao
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Amy M Goetzinger
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Andrew S Tungate
- Institute for Trauma Recovery, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Alex B Spencer
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Asim Lal
- Institute for Trauma Recovery, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Chloe E Barton
- Institute for Trauma Recovery, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Anesthesiology, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Francesca Beaudoin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Samuel A McLean
- Institute for Trauma Recovery, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
- Emergency Medicine, The University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Carrougher GJ, Bamer AM, Mason S, Stewart BT, Gibran NS. Defining numerical cut points for mild, moderate, and severe pain in adult burn survivors: A northwest regional burn model system investigation. Burns 2023; 49:310-316. [PMID: 36566097 PMCID: PMC11164406 DOI: 10.1016/j.burns.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/13/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Pain is a common and often debilitating sequela of burn injury. Burn pain develops following damage to peripheral sensory nerves and the release of inflammatory mediators from injury. Burn pain is complex and can include background and procedural pain that result from the injury itself, wound care, stretching, and surgery. Clinicians and researchers need valid and reliable pain measures to guide screening, treatment, and research protocols. Unlike other conditions, visual analog, or numeric pain rating scale (VAS/NRS) scores that represent mild, moderate, and severe pain among people with burn injury have not been established. The aim of this study was to identify the most suitable average pain intensity rating scores for mild, moderate, and severe pain in adult burn survivors using a PROMIS Pain Interference (PROMIS-PI) short form. METHODS An average pain intensity VAS/NRS score (0-10) and customized PROMIS-PI short form were administered to adults with burn injury treated at a regional burn center at hospital discharge (baseline) and at 6, 12, and 24-months after injury. To identify pain intensity scores that represent mild, moderate, and severe pain, we computed F values and Bayesian Information Criterion (BIC) statistics associated with multiple ANOVA comparisons for mean pain interference scores by various pain intensity cut points. Six possible cut points (CP) were compared: CP 3,6; 3,7; 4,6; 4,7; 2,5; and 3,5. Optimal cut points were considered those with the highest ANOVA F statistics. Models with similar F statistics were also compared with BIC. RESULTS Data from a sample of 253 participants (83% white, 66% male, mean age 47 years) with VAS/NRS pain intensity and PROMIS-PI scores at one or more timepoints were analyzed. The optimal classification for mild, moderate, and severe pain was CP 2,5 at baseline and 12-months. Although CP 3,6 had the highest F value at 6-months, there was not strong evidence to support CP 3,6 over CP 2,5 (BIC difference: 2.9); similarly, CP 3,7 had the highest value at 24-months, but the BIC difference over CP 2,5 was only 2.2. CONCLUSIONS VAS/NRS scores for pain among adults with burn injury can be categorized as mild (0-2), moderate (3-5), and severe (6-10). These findings advance our understanding regarding the meaning of pain intensity ratings after burn injury, and provide an objective definition for clinical management, quality improvement, and pain research.
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Affiliation(s)
| | - Alyssa M Bamer
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Stephanie Mason
- Ross Tilley Burn Centre, University of Toronto, Toronto, Canada
| | - Barclay T Stewart
- UW Medicine Regional Burn Center, University of Washington, Seattle, WA, USA; Harborview Injury Prevention and Research Center, Seattle, WA, USA
| | - Nicole S Gibran
- UW Medicine Regional Burn Center, University of Washington, Seattle, WA, USA
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DeJesus J, Shah NR, Franco-Mesa C, Walters ET, Palackic A, Wolf SE. Risk factors for opioid use disorder after severe burns in adults. Am J Surg 2023; 225:400-407. [PMID: 36184330 DOI: 10.1016/j.amjsurg.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/09/2022] [Accepted: 09/18/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Risk factors for opioid dependence amongst burn patients have not been well-explored compared to other surgical fields. METHODS The TrinetX database was queried for patients diagnosed with opioid use disorder (OUD) after thermal or chemical burn. Propensity score matching was performed. Opioid and non-opioid analgesia use, ICU care, surgery, and comparative risks among common opiates were examined using descriptive and univariate regression models, including odds ratios. Subgroup analysis evaluated the impact of multimodal analgesia. RESULTS Odds of receiving IV opioids for acute analgesia (p = <0.0001, OR = 1.80, CI = 1.45-2.25), undergoing surgery (p = <0.0001, OR = 1.58, CI = 1.26-1.98), and ICU care (p = <0.0001, OR = 3.60, CI = 2.00-3.83) after burn injury were higher in patients who developed OUD. Patients receiving multimodal therapy within 24 hours of admission had lower odds of developing OUD (OR = 0.74, CI = 2.76-4.68, p = 0.0001) and chronic pain (OR = 0.89, CI = 0.78-1.00, p = 0.05) regardless of TBSA. CONCLUSION Patients who developed opioid use disorder following burn injury had higher odds of receiving opioid exclusive pain management, more frequent surgery, ICU care.
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Affiliation(s)
- Jana DeJesus
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Nikhil R Shah
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Camila Franco-Mesa
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Elliot T Walters
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
| | - Alen Palackic
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA; Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, 8036, Austria.
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, 301 University Blvd., Galveston, TX, 77555, USA.
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Opioid use disorder in adult burn patients: Implications for future mental health, behavioral and substance use patterns. Burns 2022:S0305-4179(22)00209-1. [DOI: 10.1016/j.burns.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/13/2022] [Accepted: 08/10/2022] [Indexed: 11/02/2022]
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Froutan R, Tavousi SH, Sedaghat A, Sadeghnia HR, Layegh M, Mazlom SR. The Effect of Inhalation Aromatherapy on Sedation Level, Analgesic Dosage, and Bispectral Index Values during Donor Site Dressing in Patients with Burns: A Randomized Clinical Trial. Adv Skin Wound Care 2022; 35:1-9. [PMID: 34935724 DOI: 10.1097/01.asw.0000801544.79621.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the effect of inhalation aromatherapy on sedation level, analgesic dosage, and bispectral index (BIS) values during donor site dressing in patients with burns. METHODS This trial was conducted on 62 patients with burns requiring donor site dressing who were admitted to the Burn Center of Imam Reza Hospital, Mashhad, Iran. In the intervention group, the patients inhaled damask rose 40% and lavender 10% essential oils during donor site dressing change, whereas in the control group, the site was dressed using routine protocol. Sedatives and analgesics were prescribed until the levels of brain activity achieved light sedation. The brain activity and sedation levels were measured before and after the donor site dressings using the BIS. Data were analyzed using the analysis of covariance and the two-way analysis of variance with repeated measures. RESULTS All 62 patients completed the study. The required doses of ketamine (P < .001), fentanyl (P = .003), morphine (P < .001), and propofol (P < .001) were significantly lower in the intervention group. The BIS was also significantly lower in the intervention group (P < .001). Heart rate decreased significantly during the aromatherapy, as well as after analgesic and sedative consumption (P < .001). CONCLUSIONS The inhalation of damask rose and lavender essential oils is an effective intervention to reduce the doses of sedative and analgesic drugs administered as well as BIS during donor site dressing change in patients with burns.
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Affiliation(s)
- Razieh Froutan
- At the Mashhad University of Medicine Sciences (MUMS), Iran, Razieh Froutan, PhD, is Assistant Professor, School of Nursing and Midwifery; Seyed Hassan Tavousi, MD, is Associate Professor, Burn Surgery, Surgical Oncology Research Center; Alireza Sedaghat, MD, is Assistant Professor of Anesthesiology, Lung Disease Research Center; Hamid Reza Sadeghnia, PhD, is Associate Professor of Pharmacology, Pharmacological Research Center of Medicinal Plants; Mohaddeseh Layegh, BSc, is Nurse, Burn Center, Imam Reza Hospital; and Seyed Reza Mazlom, MSc, is Nursing Instructor, Department of Medical-Surgical Nursing, School of Nursing and Midwifery. Acknowledgments: This study was excerpted from a research project (code: 970394) at MUMS. The authors thank the Deputy of Research of MUMS and the study participants. The authors have disclosed no other financial relationships related to this article. Submitted May 17, 2021; accepted in revised form July 23, 2021
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Gibran NS, Shipper E, Phuong J, Braverman M, Bixby P, Price MA, Bulger EM. Developing a national trauma research action plan: Results from the Burn Research Gap Delphi Survey. J Trauma Acute Care Surg 2022; 92:201-212. [PMID: 34554139 DOI: 10.1097/ta.0000000000003409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The 2016 National Academies of Science, Engineering and Medicine call for a national integrated, military-civilian trauma action plan to achieve zero preventable deaths and disability after injury included a proposal to establish a National Trauma Research Action Plan to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma/burn care from prehospital to rehabilitation. The Burn/Reconstructive Surgery group represents one focus area for this research agenda development. METHODS Experts in burn and reconstructive surgery research identified gaps in knowledge, generated research questions and prioritized questions using a consensus driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability with military and civilian representatives. Literature reviews informed the panel. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population; Intervention; Compare/Control; Outcome. Participants ranked the priority of each question on a nine-point Likert scale, which was categorized to represent low, medium, and high priority items. Consensus was defined based on ≥60% panelist agreement. RESULTS Subject matter experts generated 949 research questions in 29 Burn & 26 Reconstruction topics. Five hundred ninety-seven questions reached consensus. Of these, 338 (57%) were high-priority, 180 (30%), medium-priority, and 78 (13%) low-priority questions. CONCLUSION Many high-priority questions translate to complex wound management and outcomes. Panel recognition that significant gaps in knowledge exist in understanding functional outcomes after injury underscores the importance of long-term recovery metrics even when studying acute injury or interventions such as resuscitation or inhalation injury. Funding agencies and burn/reconstructive surgery researchers should consider these gaps when they prioritize future research. LEVEL OF EVIDENCE Expert consensus, Level IV.
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Affiliation(s)
- Nicole S Gibran
- From the Harborview Medical Center UW Department of Surgery (N.S.G., E.B.), Seattle WA; UW Department of Biomedical Informatics and Medical Education (J.P.), Seattle WA; Coalition for National Trauma Research (E.S., M.B., P.B., M.P.), San Antonio, Texas
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11
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Hill DM, Boyd AN, Zavala S, Adams B, Reger M, Maynard KM, Adams TR, Drabick Z, Carter K, Johnson HA, Alexander KM, Smith L, Frye J, Gayed RM, Quan AN, Walroth TA. A review of the most impactful published pharmacotherapy-pertinent literature of 2019 and 2020 for clinicians caring for patients with thermal or inhalation injury. J Burn Care Res 2021; 43:912-920. [PMID: 34788823 DOI: 10.1093/jbcr/irab220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Keeping abreast with current literature can be challenging, especially for practitioners caring for patients sustaining thermal or inhalation injury. Practitioners caring for patients with thermal injuries publish in a wide variety of journals, which further increases the complexity for those with resource limitations. Pharmacotherapy research continues to be a minority focus in primary literature. This review is a renewal of previous years' work to facilitate extraction and review of the most recent pharmacotherapy-centric studies in patients with thermal and inhalation injury. Sixteen geographically dispersed, board-certified pharmacists participated in the review. A MeSH-based, filtered search returned 1,536 manuscripts over the previous 2-year period. After manual review and exclusions, only 98 (6.4%) manuscripts were determined to have a potential impact on current pharmacotherapy practices and included in the review. A summary of the 10 articles that scored highest are included in the review. Nearly half of the reviewed manuscripts were assessed to lack a significant impact on current practice. Despite an increase in published literature over the previous 2-year review, the focus and quality remain unchanged. There remains a need for investment in well-designed, high impact, pharmacotherapy-pertinent research for patients sustaining thermal or inhalation injuries.
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Affiliation(s)
- David M Hill
- Department of Pharmacy, Regional One Health, Memphis, TN
| | - Allison N Boyd
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN
| | - Sarah Zavala
- Department of Pharmacy, Community Hospital, Munster, IN
| | - Beatrice Adams
- Department of Pharmacy, Tampa General Hospital, Tampa, FL
| | - Melissa Reger
- Department of Pharmacy, Community Regional Medical Center, Fresno, CA
| | - Kaylee M Maynard
- Department of Pharmacy, University of Rochester Medical Center, Rochester, NY
| | - Tori R Adams
- Department of Pharmaceutical Care, University of Iowa Health Care, Iowa City, IA
| | - Zachary Drabick
- Department of Pharmacy, University of Florida Health Shands Hospital, Gainesville, FL
| | - Kristen Carter
- Department of Pharmacy, UC Health University of Cincinnati Medical Center, Cincinnati, OH
| | - Heather A Johnson
- Department of Pharmacy, Methodist Hospital and Methodist Children's Hospital, San Antonio, TX
| | - Kaitlin M Alexander
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL
| | - Lisa Smith
- Department of Pharmacy, Doctors Hospital, Augusta, GA
| | - Jared Frye
- Department of Pharmaceutical Care, University of Iowa Health Care, Iowa City, IA
| | - Rita M Gayed
- Department of Pharmacy and Clinical Nutrition, Grady Health System, Atlanta, GA
| | - Asia N Quan
- Department of Pharmacy, The Arizona Burn Center Valleywise Health, Phoenix, AZ
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, IN
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12
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Polychronopoulou E, Raji MA, Wolf SE, Kuo YF. US national trends in prescription opioid use after burn injury, 2007 to 2017. Surgery 2021; 170:952-961. [PMID: 33472746 PMCID: PMC8285464 DOI: 10.1016/j.surg.2020.12.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Opioid misuse and overdose in the United States remain a public health emergency. Overprescribing has been recognized as a significant contributor to the epidemic. Opioids are the mainstay for pain management after burn; however, to date, no large-scale nationally representative study has evaluated outpatient opioid prescribing practices in this population. METHODS A retrospective study was conducted of patients up to 65 years old with burn injuries between 2007 and 2017 using national commercial insurance data. The primary outcome was initial opioid prescribing after burn injury. Secondary outcomes were total days' supply, oral daily morphine milligram equivalents, and number of refills. RESULTS Of the 140,753 patients with burns, 34,685 (24.6%) received an opioid prescription. The odds of prescription opioid use were lower in 2015, 2016, and 2017 compared with 2007. Interactions with age, severity (P < .0001), and region (P = .003) showed significant variation in rates of decline from 2007 to 2017, with the steepest decline in those aged <20 and in residents of Northeast United States. Prescribing rates remained stable over time among those with more severe burn injuries. The significant decline in daily opioid morphine milligram equivalents after 2013 was paralleled by an increase in days of supply (P values <.005). The odds of refill declined in 2016 and 2017. CONCLUSION While opioid prescribing after burn has declined in the past decade, significant variation remains among regions and age groups, suggesting a need to develop uniform guidelines to improve the quality of opioid prescribing and pain management protocols in burn patients.
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Affiliation(s)
- Efstathia Polychronopoulou
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Mukaila A Raji
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - Steven E Wolf
- Division of Burn and Trauma Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch, Galveston, TX; Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX.
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Lin M, Deng K, Li Y, Wan J. Morphine enhances LPS-induced macrophage apoptosis through a PPARγ-dependent mechanism. Exp Ther Med 2021; 22:714. [PMID: 34007323 PMCID: PMC8120503 DOI: 10.3892/etm.2021.10146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/29/2021] [Indexed: 12/17/2022] Open
Abstract
Morphine has been widely used for the treatment of pain and extensive studies have revealed a regulatory role for morphine in cell apoptosis. However, the molecular mechanisms underlying morphine-mediated apoptosis remain to be fully elucidated. The present study aimed to investigate the effects of morphine on lipopolysaccharide (LPS)-induced bone marrow-derived macrophage (BMDM) apoptosis and to determine the role of the peroxisome proliferator-activated receptor (PPAR)γ signaling pathway in this process. BMDMs were isolated from BALB/c mice and stimulated with LPS. Hoechst 33342 staining and flow cytometric analysis were performed to evaluate the effects of morphine on LPS-induced apoptosis of BMDMs. Caspase activity assays were used to determine the involvement of the apoptosis pathway. The expression levels of caspase-3, caspase-8, caspase-9 and PPARγ were analyzed using western blotting. Finally, GW9662, a specific PPARγ antagonist, was used to determine whether the regulatory effects of morphine on LPS-induced BMDM apoptosis were PPARγ-dependent. The results of the present study revealed that morphine increased the apoptosis of LPS-stimulated BMDMs. Morphine upregulated the expression levels and activity of caspase-3 in LPS-stimulated BMDMs, but downregulated the expression levels and activity of caspase-8. Morphine treatment also upregulated LPS-induced PPARγ expression levels in BMDMs. Finally, the stimulatory effects of morphine on LPS-induced apoptosis and caspase-3/9 activation were markedly reduced by GW9662. In conclusion, the findings of the present study indicated that morphine significantly promoted LPS-induced BMDM apoptosis and caspase-3/9 activation. These results suggested that the intrinsic pathway of apoptosis may be involved in the proapoptotic effects of morphine on LPS-stimulated BMDMs, which may be dependent, at least partially, on PPARγ activation.
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Affiliation(s)
- Mingying Lin
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Keqiong Deng
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Ya Li
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Jing Wan
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
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Sibbett SH, Carrougher GJ, Pham TN, Mandell SP, Arbabi S, Stewart BT, Gibran NS. Burn survivors' perception of recovery after injury: A Northwest Regional Burn Model System investigation. Burns 2020; 46:1768-1774. [PMID: 33268159 DOI: 10.1016/j.burns.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 09/10/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Previous reports suggest that many factors impact recovery from burn injury. To improve our understanding of these factors, we queried adult burn survivors using a mixed method design during the first year after injury. METHODS An anonymous, 2-page survey was developed and administered to adult burn survivors during routine outpatient clinic follow-up visits at a regional burn center. Participants rated issues of concern and their impacts on return to pre-burn activity levels. Both quantitative and qualitative data were obtained. Descriptive statistics were used to analyze quantitative data and thematic analysis was used to identify, analyze and report patterns from open-ended responses. RESULTS Over seven months in 2016, 187 patients completed the anonymous survey. Study participants were predominantly male, white, and non-Hispanic. Participants who had not yet returned to pre-burn function reported worse outcomes for all issues queried compared to those who had. Burn survivors from racial and ethnic minority groups reported greater difficulty with accessing medical care and information about their injury as well as higher levels of self-identified posttraumatic stress, issues related to appearance and concerns for loss of strength. Several themes and sub-themes were identified that had both negative and positive impact on early recovery. Such themes included: healing process, psychological recovery and emotional health, and community reintegration/employment. CONCLUSIONS Several themes from responses provided insight into challenges as well as key support systems during the first year of recovery after injury. Collectively, these findings can be used to direct clinical outpatient care, patient education and psychosocial support services.
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Affiliation(s)
- Stephen H Sibbett
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States.
| | - Gretchen J Carrougher
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States
| | - Tam N Pham
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States
| | - Samuel P Mandell
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States
| | - Saman Arbabi
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States
| | - Barclay T Stewart
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States
| | - Nicole S Gibran
- UW Medicine Regional Burn Center, Department of Surgery, University of Washington, 325 9th Avenue, Seattle, WA, 98104, United States
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Yeung C, Kiss A, Rehou S, Shahrokhi S. Prescribing patterns of opioids and adjunctive analgesics for patients with burn injuries. Burns 2020; 47:776-784. [PMID: 33131947 DOI: 10.1016/j.burns.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/10/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Large quantities of analgesics are prescribed to control pain among patients with burn injuries and may lead to chronic use and dependency. This study aimed to determine whether patients are overprescribed analgesics at discharge and to identify factors that influence prescribing patterns. MATERIAL AND METHODS A retrospective review of patient charts (n = 199) between July 1, 2015-2018 were reviewed from a registry at a single burn center. Opioid, neuropathic pain agent, acetaminophen, and ibuprofen quantities given before and at discharge were compared. Linear mixed regression models were used to identify factors that increased the amount of analgesics prescribed. RESULTS On average, patients were prescribed significantly more analgesics at discharge compared to what was consumed pre-discharge (p < 0.0001). Specifically, on average, providers did not overprescribe the daily dose, but overprescribed the duration of pain medications required. For every increase in percent TBSA, 14 MEQ more opioids, 203 mg more neuropathic pain agents, 843 mg more acetaminophen, and 126 mg more ibuprofen were prescribed (p < 0.05). Surgery was a predictor for higher opioid and neuropathic pain agent prescriptions (p = 0.03), while length of stay was associated with fewer neuropathic pain agents prescribed (p = 0.04). Fewer ibuprofen were given to patients with a history of substance misuse (p = 0.01). CONCLUSIONS The quantity of analgesics prescribed at discharge varied widely and often prescribed for long durations of time. Standardized prescribing guidelines should be developed to optimize how analgesics are prescribed at discharge.
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Affiliation(s)
- Celine Yeung
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Sarah Rehou
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shahriar Shahrokhi
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Carrougher GJ, Bamer AM, Mandell SP, Brych S, Schneider JC, Ryan CM, Kowalske K, Esselman PC, Gibran NS. Factors Affecting Employment After Burn Injury in the United States: A Burn Model System National Database Investigation. Arch Phys Med Rehabil 2020; 101:S71-S85. [DOI: 10.1016/j.apmr.2019.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 07/17/2019] [Accepted: 09/04/2019] [Indexed: 10/25/2022]
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