Principles of Burn Pain Management

Fascia Iliaca Catheters for Donor Site Pain After Split-Thickness Skin Grafting for Acute Burn Injury: A Retrospective Review

The management of acute burn pain poses significant challenges. Regional techniques have become increasingly popular in perioperative burn pain management. Continuous nerve block catheters are particularly useful for split-thickness skin grafts where donor site pain can exceed that of the burn-injured site. Donor skin is frequently harvested from the anterolateral thigh. The fascia iliaca (FI) compartment block provides blockade of both the lateral femoral cutaneous nerve and the femoral nerve, and thus, it is a useful modality for burn donor pain. Our institution initiated a protocol in which continuous FI catheters were placed in patients undergoing split-thickness skin grafting of the anterolateral thigh. This retrospective review seeks to assess the impact of this modality on postoperative pain scores and opioid requirements. Oral morphine equivalent (OME) administration was significantly lower in the FI group than the control group, starting with POD 0, which is the day of the FI catheter insertion (188 vs 327 mg, P < .001). Over the next 4 postoperative days (PODs), OME administration remained lower in the FI group compared to control patients, although not statistically significant on PODs 3-4. There was a significant difference in OME administered between the FI group and the control group on POD 5 (159.5 vs 209.2 mg, P < .05). Our retrospective study evaluating the role of FI catheters in burn patients undergoing split-thickness skin grafting surgery showed significantly lower opioid consumption on PODs 1-5 compared to patients without an FI catheter.

Esketamine use for primary intelligent analgesia in adults with severe burns: A double-blind randomized trial with effects on analgesic efficacy, gastrointestinal function and mental state

BACKGROUND

Opioid consumption for analgesia in burn patients is enormous. Non-opioid analgesics for burn pain management may result in opioid sparing, reducing opioid-related adverse reactions and drug tolerance or addiction.

METHODS

A dual-center, randomized controlled trial assessed Esketamine for the perioperative period in patients with severe [20-50 % total body surface area (TBSA)] and extensive (≥ 50 % TBSA) burns, comparing analgesia with standard anesthesia. Sixty patients were randomly allocated (1:1 ratio) to two arms. In the Treatment Arm, patients received intra-operative Esketamine and postoperative intravenous primary intelligent analgesia pump with Esketamine. Patients in the Control Arm received the same intervention as Treatment Arm without Esketamine. The primary endpoint was subjective analgesic efficacy (SAE) evaluated on Day 28 or the day before hospital discharge. Secondary outcomes included the postoperative Numeric Pain Rating (NPR) Scale at rest (NPRr) and during movement (NPRm) and opioid consumption. Gastrointestinal dysfunction Scores (GIDS) and serum markers of intestinal injury [intestinal fatty acid-binding protein 2 (iFabp2) and apolipoproteinA2 (ApoA2)] were measured in the 1st and 4th post-injury weeks. Depression and sleep quality were assessed by relevant questionnaires.

RESULTS

Fifty-five patients were included in the analysis. Esketamine-treated Arm recorded a better analgesic efficacy than the Control Arm (proportion of patients with Grade 1 or 2 SAE scores, 67.9 % vs. 40.7 %, p = 0.022). Esketamine-treated patients had lower NPRm values (p = 0.033) and lower daily opioid consumption (p = 0.033) when compared with Controls. Esketamine-treated patients showed comparable gastrointestinal recovery to those in the Control Arm. The overall sleep quality might be improved in the Treatment Arm.

CONCLUSIONS

Esketamine use is safe for perioperative primary intelligent analgesia of severe burns, resulting in improved resting pain control and lower opioid requirements.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry (www.chictr.org.cn/) (ChiCTR2000034069).

Subhypnotic Intravenous Ketamine Improves Patient Satisfaction With Burn Wound Care: A Quality Improvement Project

Despite advancements in pain management for burn injuries, analgesia often fails to meet our patients' needs. We hypothesized that low doses of intravenous (IV) ketamine as an adjunct to our current protocol would be safe, improving both nurse and patient satisfaction with analgesia during hydrotherapy. Burn patients admitted who underwent hydrotherapy from June 1, 2021, to June 30, 2023 were surveyed. Ketamine was administered with the standard opioid-midazolam regimen. Demographics, oral morphine equivalents, midazolam, ketamine doses and time of administration, and adverse events were collected. Patient and nurse satisfaction scores were collected. The ketamine and no-ketamine groups were compared. P < .05 was considered significant. Eighty-five hydrotherapies were surveyed, 47 without ketamine, and 38 with ketamine. Demographics, comorbidities, %TBSA, and hospital length of stay were not different. The median amount of ketamine given was 0.79 mg/kg [0.59-1.06]. Patients who received ketamine were more likely to receive midazolam (100% vs 61.7%; P < .001), and both oral and IV opioids (94.7% vs 68.1%; P = .002) prior to hydrotherapy and less likely to receive rescue opioids or midazolam during hydrotherapy. Two patients in the ketamine group had hypertension (defined as SBP > 180) that did not require treatment. Nurses tended to be more satisfied with patient pain control when ketamine was used (10 [8-10] vs 9 [7-10], P = .072). Patient satisfaction was higher in the ketamine group (10 [8.8-10] vs 9 [7-10], P = .006). Utilizing subhypnotic dose of IV ketamine for hydrotherapy is safe and associated with increased patient satisfaction.

Nitrous Oxide to Reduce Wound Care-Related Pain in Adults: A Systematic Review and Meta-Analysis

Significance: As an essential procedure, wound care comes with acute pain, which is short but high in intensity, causing patients to fear and affecting subsequent treatment. Nitrous oxide (N2O) is used to relieve pain related to wound care; however, evidence regarding its application is conflicting. Thus, this systematic review and meta-analysis was performed to evaluate the efficacy of N2O in wound care-related pain. Recent Advances: Randomized controlled trials that investigated the effect of N2O in adults undergoing wound care were systematically searched from PubMed, Embase, the Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov up to February 2023. The primary outcome was the pain score. Secondary outcomes included patients' satisfaction and side effects. Critical Issues: Through screening the 265 identified articles, seven and six studies were finally included in the systematic review and meta-analysis, respectively. Pooled analysis suggested that there was no significant difference in reducing wound care-related pain between the N2O group and the control group (mean difference [MD], -0.02, 95% confidence interval [CI], -1.46, 1.42; p = 0.98, I2 = 96%). Subgroup analyses indicated that there was a significant difference in favor of N2O for burns, not for ulcers, and N2O was superior to oxygen and similar to topical or intravenous anesthesia. There was no significant difference in patients' satisfaction or the incidence of side effects between groups. Future Directions: This review suggests that N2O might be effective for pain management in patients undergoing wound care. Caution must be taken when interpreting these results due to the high risk of biased methods in the included studies.

Optimizing burn wound procedural pain control, efficiency, and satisfaction through integrated nurse and physician education

Herein, we report the results of a quality improvement project (QI). Following a review of the burn unit practices, a nursing-led, physician supported educational intervention regarding optimal timing, dosage, and indication for medications used during hydrotherapy, including midazolam and opioids, was implemented. We hypothesized that such intervention would support improvement in both nurse and patient satisfaction with pain control management. Patients undergoing hydrotherapy were surveyed. Demographics, opioid dose prescribed (oral morphine equivalents), midazolam use, timing of administration, and adverse events were collected. Patient pain scores (1-10) before and after hydrotherapy and patient and nurse satisfaction scores (1-10) after hydrotherapy were collected. The pre- and post-education populations were compared. P < 0.05 was considered significant. Post-education, administration of opioids (59.1% v. 0%, p < 0.001) and midazolam (59.1% vs. 10.4%; p < 0.001) prior to hydrotherapy significantly improved, leading to fewer patients requiring rescue opioids during hydrotherapy (25% vs. 74%, p < 0.001). Hydrotherapy duration significantly decreased post-education (19 [13.3-30] min vs. 32 [18-43] min, p = 0.003). Nurses' ratings of their patient's pain control (9 [7.3-10] vs. 7.5 [6-9], p = 0.004) and ease of procedure (10 [9,10] vs. 9 [7.8-10], p = 0.037) significantly improved. Patients' pain management satisfaction rating did not change, but the number of subjects rating their pain management as excellent tended to increase (36.4% vs. 20%, p = 0.077). Nursing led, physician supported, education can improve medication administration prior to and during hydrotherapy, increasing the ease of the procedure as well as staff satisfaction.

The Efficacy of Whole-Body Vibration in Managing Postburn Victims' Complications: A Systematic Review

Burn injury is a complicated traumatic event with both systemic and local consequences. These complications include long periods of bed rest, pain, muscle weakness, vitamin D deficiency, and bone mineral density loss. Whole-body vibration demonstrated effectiveness in improving muscle power and bone mineral density in various musculoskeletal populations. This systematic review of randomized controlled trials aims to assess evidence for the effectiveness of using whole-body vibration on postburn survivors with at least 1% total body surface area on sensory and motor outcomes. A systematic search was conducted across six databases, which are, PubMed, Cochrane, PEDro, Scopus, Web of Science, and Google Scholar, from inception till March 2022. Retrieved studies were screened by title and abstract and full-text in two stages using Rayyan web-based. Included studies were assessed for risk of bias using the Cochrane risk of bias tool ROB 2.0. Six randomized controlled trials with 203 participants were included. Five of the included studies demonstrated an overall high risk of bias. Compared to conventional physiotherapy programs, whole-body vibration demonstrated improvement in functional mobility and balance using timed up and go and Biodex balance assessment, respectively. However, there were no differences between whole-body vibration and conventional physiotherapy program alone in bone mineral density and muscle power. Although the current evidence of whole-body vibration is limited, whole-body vibration combined with traditional physical therapy programs may improve functional mobility and balance in postburn survivors compared to physical therapy programs alone.

Comparing novel virtual reality and nursing standard care on burn wound care pain in adolescents: A randomized controlled trial

PURPOSE

This study compared the effectiveness of age-appropriate, high technology, interactive virtual reality (VR) distraction with standard care (SC) provided by the nurse on adolescents' acute procedural pain intensity perception during burn wound care treatment in the ambulatory clinic setting.

DESIGN

This randomized controlled trial included 43 adolescents ages 10-21 from the ambulatory burn clinic of a large children's hospital.

METHODS

Blinded study participants were randomly assigned to either VR or SC (non-significantly different, current mean burn surface area, 1.3 and 1.7, respectively) during the first burn wound care procedure in the burn clinic. Blinded research staff collected pre-procedure data including Spielberger's State-Trait Anxiety Inventory and postprocedure wound care pain intensity using the Adolescent Pediatric Pain Tool. A total of 41 participants completed all study procedures.

RESULTS

No statistically significant difference in burn wound care procedural pain was noted between the VR and SC groups after adjusting for several factors. Pre-procedure state and trait anxiety correlated with reported pre-procedure pain. Wound care pain was found to be significantly associated with pre-wound care pain score, time from original burn to clinic burn care treatment, and length of wound care treatment. These factors accounted for approximately 45% of the variation in pain scores during wound care treatment.

PRACTICE IMPLICATIONS

VR distraction can be a useful pain management strategy but may not take the place of the unique nurse-patient relationship that occurs during clinical encounters. Tailoring pain management during burn wound care requires consideration of anxiety, time from the burn injury to the wound care procedure, length of time of the wound care procedure, and pretreatment pain level. Knowing patients' needs, desires, and temperaments along with the specifics about the healthcare procedures are critical to formulating individualized care plans that may or may not include VR. Newer technology, such as easier-to-use, less expensive VR, may assist with translation into practice making its clinical use more routine.

Reconceptualizing Acute Pain Management in the 21st Century

Acute pain can have many etiologies that include surgical procedures, trauma (motor vehicle accident), musculoskeletal injuries (rib fracture) and, burns among others. Valuable components of a multimodal approach to acute pain management include both opioid and non-opioid medications, procedure specific regional anesthesia techniques (peripheral nerve blocks and neuraxial approaches), and interventional approaches (eg, peripheral nerve stimulation and cryo-neurolysis). Overall, successful acute perioperative pain management requires a multimodal, multidisciplinary approach that involves a coordinated effort between the surgical team, the anesthesia team, nursing, and pharmacy staff using Enhanced Recovery After Surgery (ERAS) protocols.

Burn Injury Complications Impacting Rehabilitation

Successful post-burn rehabilitation requires an understanding of a wide range of complications to maximize functional recovery. This article reviews a range of potential challenges including burn scar contracture, amputation, peripheral nerve injury, heterotopic ossification, dysphagia, altered skin physiology, pain, and pruritis. The overall focus is to serve as a guide for post-injury therapy and rehabilitation spanning the phases of care and considering evidence-based approaches, prevention, and treatment with an ultimate goal of aiding in the functional recovery and long-term quality of life for burn survivors.

Effectiveness and Adverse Events of Gabapentinoids as Analgesics for Patients with Burn Injuries: A Systematic Review with Meta-Analysis and Trial Sequential Analysis

(1) Background: Pain after a burn injury is difficult to endure, and emerging studies aim to ascertain the effects of gabapentin and pregabalin as non-opioid treatment options. (2) Methods: We searched for randomised controlled trials (RCTs) in six databases. The risk of bias was assessed using the RoB 2.0 tool. We performed meta-analysis and trial sequential analysis and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology for judging the certainty of evidence (CoE). (3) Results: Five RCTs were included. Compared with placebo, gabapentinoids significantly decreased the pain intensity within 24 h (mean difference (MD) = -1.06, 95% confidence interval (CI): -1.47--0.65) and from 72 h to 9 days (MD = -0.82, 95% CI: -1.16--0.48), but not after 3 weeks (MD = -0.44, 95% CI: -1.31-0.42). Opioid consumption (mg/day) was reduced within 24 h (MD = -13.34, 95% CI: -22.16--4.52) and from 72 h to 9 days (MD = -7.87, 95% CI: -14.82--0.91). Increased risks of drowsiness (risk ratio (RR) = 3.255, 95% CI: 1.135-9.335) and dizziness (RR = 3.034, 95% CI: 1.006-9.147) were observed, but sensitivity analysis using the Bayesian method showed no increased risk. All endpoints were judged as low to very low CoE. (4) Conclusions: Gabapentinoids offer modest analgesic benefits as a component of multimodal pain management for burn injuries of less than 3 weeks. The adverse effects should be carefully monitored. Large-scale RCTs are warranted for the reinforcement of CoE in clinical use.

Supramolecular hybrid hydrogels as rapidly on-demand dissoluble, self-healing, and biocompatible burn dressings

Despite decades of efforts, state-of-the-art synthetic burn dressings to treat partial-thickness burns are still far from ideal. Current dressings adhere to the wound and necessitate debridement. This work describes the first "supramolecular hybrid hydrogel (SHH)" burn dressing that is biocompatible, self-healable, and on-demand dissoluble for easy and trauma-free removal, prepared by a simple, fast, and scalable method. These SHHs leverage the interactions of a custom-designed cationic copolymer via host-guest chemistry with cucurbit[7]uril and electrostatic interactions with clay nanosheets coated with an anionic polymer to achieve enhanced mechanical properties and fast on-demand dissolution. The SHHs show high mechanical strength (>50 kPa), self-heal rapidly in ∼1 min, and dissolve quickly (4-6 min) using an amantadine hydrochloride (AH) solution that breaks the supramolecular interactions in the SHHs. Neither the SHHs nor the AH solution has any adverse effects on human dermal fibroblasts or epidermal keratinocytes in vitro. The SHHs also do not elicit any significant cytokine response in vitro. Furthermore, in vivo murine experiments show no immune or inflammatory cell infiltration in the subcutaneous tissue and no change in circulatory cytokines compared to sham controls. Thus, these SHHs present excellent burn dressing candidates to reduce the time of pain and time associated with dressing changes.

Ultrasound Guidance Pulsed Radiofrequency Ablation of the Medial Antebrachial Cutaneous Nerve for Palliation of Chronic Pain after Burn Injury: A Case Report

Chronic burn pain persists for 6 months or longer after the wound has healed, affecting the patient's quality of life and daily activities. Pharmacological treatments are essential in the treatment of chronic pain after burns, but interventional methods come to the fore in cases where there is no response to pharmacological treatments. Radiofrequency ablation is known as a safe, effective, and minimally invasive treatment for patients with intractable chronic pain. Various pain syndromes can be successfully treated with radiofrequency ablation however, there is no publication of chronic pain management associated with burn injury. Here, we first describe the successful management of chronic burn pain using radiofrequency ablation of the medial antebrachial cutaneous nerve.

A Multimodal Pain Management Strategy for Burn Patients

BACKGROUND

Acute burn pain is difficult to manage, and poorly managed pain can lead to deleterious consequences such as post-traumatic stress disorder, prolonged recovery, chronic pain and long-term dependence on opioids. Understanding the role of nursing in promoting self-efficacy and minimizing opioid use is valuable. It is unknown whether strategic efforts aimed at enhancing patient self-efficacy will improve pain managment and lessen opioid requirements in the adult burn population.

AIM

The aim of this study was to examine the effect of a multi-modal, interdisciplinary pain management strategy on coping self-efficacy, pain scores, and opioid use in adult burn patients in the acute care setting.

METHOD

A quasi-experimental pre-test/post-test design was employed in an American Burn Association (ABA) verified burn center in the Pacific Northwestern United States. Data were collected prospectively for a 6-month period on 44 burn patients. The comparison group received usual care (n = 28), and the intervention received a pain management protocol (n = 16). Coping self-efficacy was measured on admission and at discharge in both groups using the Coping Self-Efficacy Scale. Numeric pain scores and opioid use in morphine milligram equivalents were averaged for each participant. Burn nurse perceptions were gathered via an anonymous electronic survey post data collection in February 2021.

RESULTS

There were no significant differences in measured coping self-efficacy, pain scores, or opioid use between the intervention and comparison groups. A significant positive correlation was found between length of stay, size of burn, and coping self-efficacy and problem focused self-efficacy. Burn nurses reported increased use of nonpharmacologic adjuncts since protocol implementation.

CONCLUSION

Nonpharmacologic adjuncts are more likely to be used consistently when protocolized. There is also evidence to support that certain aspects of self-efficacy may be enhanced during acute phase of burn care.

Risk factors for opioid use disorder after severe burns in adults

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.

Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain

Patients with severe burn injuries often require split-thickness skin grafting to expedite wound healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Peripheral nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. The purpose of this case series is to assess the safety, feasibility, and clinical efficacy of a recently demonstrated novel continuous LAM (lateral, anterior, medial) femoral cutaneous block technique in a larger cohort. The study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 and May 2021 who had the continuous LAM block performed for donor site pain by the acute pain service team. Demographics were reported with descriptive statistics and morphine milligram equivalents (MME) were analyzed via Friedman analysis of variance. Forty-seven patients had a total of 53 blocks placed, where 2 patients received the LAM block on two separate occasions and 4 patients had bilateral LAM blocks placed. Most were African-American males, but mechanism of injury varied. Over half had a neurologic (17%) or psychiatric history (34%) outside of substance use. Almost three-quarters had a history of substance use with 17% being opioids, and a quarter had a history of polysubstance use. Median day from admission to LAM was 7 (2.5, 11.5) with a median duration of 4 (3, 5) days. Temperature and pressure sensation were reduced at the donor site. Quadricep strength remained intact, and median day until first ambulation after LAM placement was 2 (1, 3) days. Pain was adequately controlled, and there were no significant adverse events associated with the block. There was a significant reduction in MME after block placement (p < .001). Continuous peripheral nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids or multimodal regimens. The novel LAM technique reduced sensation and pain without inhibiting early ambulation, and patients were able to fully participate in their rehabilitation.

Efficacy of dexmedetomidine versus midazolam when combined with butorphanol for sedation and analgesia during burn dressing changes: A randomized clinical trial

Objective: The aim of this study was to compare dexmedetomidine-butorphanol (DB) and midazolam-butorphanol (MB) combinations for sedation, and analgesia in burn patients undergoing dressing changes.

Methods: A total of 56 ASA I–II burn patients were included in this single-center randomized clinical trial. The ages of these patients were between 20 and 60 years. TBSA ranged from 10% to 50%. They were randomized to group DB and group MB during dressing change. In the DB group, each patient received a bolus dose of dexmedetomidine (0.5 μg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). In the MB group, each patient received a bolus dose of midazolam (0.05 mg kg−1) and intermittent boluses of butorphanol (20 μg kg−1). The primary outcomes were sedation scores and pain scores. The second outcomes were vital signs, side effects, and butorphanol consumption.

Results: The sedation scores of these two groups did not differ significantly (p &gt; 0.05), and the pain scores of these groups were not significantly different (p &gt; 0.05). More patients had hypotension in the DB group than in the MB group (6 versus 0, p = 0.01), but the number of patients who had respiratory depression was higher in the MB group compared with the DB group (4 versus 0, p = 0.038). Butorphanol consumption in the MB group was higher than in the DB group (p = 0.025).

Conclusion: Dexmedetomidine is comparable to midazolam when combined with butorphanol in burn patients during dressing change. Compared with midazolam, it has the advantage of opioid-sparing effect.

Clinical Trial Registration: [http://www.chictr.org.cn/showproj.aspx&amp;proj=130622], identifier [ChiCTR2100049325].

Perioperative Management of Calciphylaxis: Literature Review and Treatment Recommendations

Calciphylaxis is a serious and rare medical condition that leads to substantial clinical manifestations including pain, creating perioperative and treatment challenges. No standard treatment protocol exists nor are comprehensive guidelines available for perioperative management of patients with calciphylaxis. In this review, we evaluate existing literature (January 2000 to May 2021) with the aim to offer guidance for treating patients with this challenging disease through the perioperative period. Although no therapies are currently considered standard for treating calciphylaxis, multiple interventions are available for improving symptoms. Preoperative and intraoperative management involves monitoring and optimizing patient comorbid conditions and any possible electrolyte imbalances. Postoperative management can be challenging when potential calciphylaxis triggers are indicated, such as warfarin and corticosteroids. In addition, poor wound healing and difficult pain control are common. Therefore, a multifactorial approach to controlling postoperative pain is recommended that includes the use of nerve blocks, renal-sparing opioids, benzodiazepines, and/or ketamine. We present preoperative, intraoperative, and postoperative recommendations for treating calciphylaxis with levels of evidence when appropriate.

Choosing wisely in burn care

BACKGROUND

The Choosing Wisely Campaign was launched in 2012 and has been applied to a broad spectrum of disciplines in almost thirty countries, with the objective of reducing unnecessary or potentially harmful investigations and procedures, thus limiting costs and improving outcomes. In Canada, patients with burn injuries are usually initially assessed by primary care and emergency providers, while plastic or general surgeons provide ongoing management. We sought to develop a series of Choosing Wisely statements for burn care to guide these practitioners and inform suitable, cost-effective investigations and treatment choices.

METHODS

The Choosing Wisely Canada list for Burns was developed by members of the Canadian Special Interest Group of the American Burn Association. Eleven recommendations were generated from an initial list of 29 statements using a modified Delphi process and SurveyMonkey™.

RESULTS

Recommendations included statements on avoidance of prophylactic antibiotics, restriction of blood products, use of adjunctive analgesic medications, monitoring and titration of opioid analgesics, and minimizing 'routine' bloodwork, microbiology or radiological investigations.

CONCLUSIONS

The Choosing Wisely recommendations aim to encourage greater discussion between those involved in burn care, other health care professionals, and their patients, with a view to reduce the cost and adverse effects associated with unnecessary therapeutic and diagnostic procedures, while still maintaining high standards of evidence-based burn care.

Comparing Auditory and Visual Distractions for Reducing Pain Severity and Pain Anxiety in Older Outpatients with Burn: A Randomized Controlled Trial

Pain and anxiety are major issues among older patients with burn injuries. Complementary medicine and non-pharmacological methods can relieve pain and anxiety in older people, but comparison of the effects of these methods needs further research. This study aimed to compare the effects of auditory and visual distractions on pain severity and pain anxiety in older outpatients referred to a burn clinic for dressing change. In this randomized controlled clinical trial, older men were randomly assigned to three groups as auditory distraction, visual distraction, and control (n = 45 in each group). The Visual Analogue Scale (VAS) and the Burn Specific Pain Anxiety Scale (BSPAS) were used to asses pain severity and pain anxiety before and immediately after the interventions, and after wound dressing. Reduction in pain severity and pain anxiety after visual distraction was reported. Auditory distraction only reduced pain anxiety. Therefore, visual distraction had a better effect on alleviating pain anxiety compared with auditory distraction. Visual distraction is suggested to be used during dressing changes for older outpatients with burn injuries in outpatient clinics in order to reduce their burn-related suffering and improve their collaboration with the therapeutic regimen.

Novel use of methadone intraoperatively in pediatric burn patients

Burn injury in children can cause severe and chronic physical and mental sequelae. Opioids are a mainstay in burn pain management but increasing utilization in this country has led to concern for their continued use and potential for dependence. Methadone is a long-acting analgesic that targets the N-methyl-D-aspartate (NMDA) receptor in addition to the mu opioid receptor and has benefit in adult burn patients. However, its use in the pediatric burn population has been less robustly studied. This is a retrospective cohort study at a single Level 1 Burn Center whose primary aim is to compare opioid utilization 36 hours postoperatively between pediatric burn patients who received intraoperative, intravenous methadone and those who did not. Secondary aim was to describe differences in methadone-related complications between the cohorts. There was decreased opioid utilization measured by median morphine equivalents per kilogram (ME/kg) postoperatively in the methadone cohort compared to the control cohort (0.54mg/kg v. 0.77mg/kg, p = 0.18). No adverse events were noted upon chart review. The data suggests methadone use is beneficial in pediatric burn patients, but further prospective studies are warranted on a larger population.

Pain Management for Pediatric Burns in the Outpatient Setting: A Changing Paradigm?

Childhood burns are common and distressing for children and their parents. Pain is the most common complaint and often thought to be undertreated, which can negatively influence the child's care and increase the risk of posttraumatic stress disorder. There is limited literature on the role of opioids and multimodal therapy in the treatment of pediatric outpatient burns. We sought to evaluate the current use of opioids (including the use of multimodal therapies), storage, and disposal of opioids in this patient population. Parents of burn-injured children 8 months to 18 years old, who were seen in an outpatient setting within 2 weeks of their burn injury, were queried from April to December 2019 regarding their child's pain control, opioid medication use, over-the-counter pain medication use, opioid storage, and disposal. A total of 142 parents of burn-injured children and their parents were surveyed. The median age of the burn-injured children was 2.7 years old and the majority (54.2%; 77/142) were male. The mean total body surface area (TBSA) was 1.8% and half sustained burn injuries to one or both hands. The most frequently used regimens for constant and/or breakthrough pain control were acetaminophen (62.7%) and nonsteroidal anti-inflammatory drugs (NSAIDs; 68.3%). Less than one fifth (26/142;18%) of patients were prescribed opioids and 88% filled their prescription. The median number of doses of opioids prescribed was eight doses, with a median of four doses of opioids unused. Only three patients used all of their prescribed opioids and no patient ≥12 years old used their entire prescription. Burns greater than 3% TBSA, irrespective of burn injury location, were associated with opioid prescription (P = .003). Approximately 40% (10/26) of parents who filled their child's opioid prescription stored the opioid in a locked area. Fewer than one third (7/26) of patients were educated on how to dispose of excess opioid pain medication. Overall, most pediatric outpatient burn injuries can be successfully managed with over-the-counter medications. Providers, who care for burn-injured children ≤ 12 years old with burns that cover ≥3% TBSA in the outpatient setting, should consider no more than four opioid doses for initial pain control. This guideline, coupled with family and provider-centered education on multimodal therapy at the time of initial presentation and safe use of opioids, are important first steps to minimizing the use of opioids in the management of small area burns in children.

Efficacy of opioids and non-opioid analgesics in the treatment of post procedure pain of burned patients: a narrative review

Introduction

Burns are a common trauma that cause acute severe pain in up to 80% of patients. The objective of this narrative review is to evaluate the efficacy of opioids, non-steroidal anti-inflammatory drugs, paracetamol, gabapentinoids, ketamine, and lidocaine in the treatment of acute pain in burn victims.

Methodology

The databases explored were PubMed, Embase, ClinicalTrials, and OpenGrey. The included randomized, controlled clinical trials assessed the analgesic efficacy of these drugs on hospitalized patients, had no age limit, patients were in the acute phase of the burn injury and were compared to placebo or other analgesic drugs. Studies describing deep sedation, chronic opioid use, chronic pain, and patients taken to reconstructive surgeries were excluded. The Jadad scale was used to evaluate quality.

Results

Six randomized controlled clinical trials (397 patients) that evaluated the analgesic efficacy of fentanyl (n = 2), nalbuphine (n = 1), ketamine (n = 1), gabapentin (n = 1), and lidocaine (n = 1) to treat post-procedural pain were included. Fentanyl, nalbuphine, and ketamine were effective, while lidocaine was associated with a slight increase in reported pain and gabapentin showed no significant differences. Two studies were of high quality, one was of medium high quality, and three were of low quality. No studies on the efficacy of NSAIDs or paracetamol were found.

Conclusion

Evidence of efficacy is very limited. Fentanyl, nalbuphine, and ketamine seem to be effective for controlling acute pain in burn patients, whereas gabapentin and lidocaine did not show any efficacy.

Techniques and strategies for regional anesthesia in acute burn care-a narrative review

Burn injuries and their treatments result in severe pain. Unlike traumatic injuries that are characterized by a discrete episode of pain followed by recovery, burn-injured patients endure pain for a prolonged period that lasts through wound closure (e.g. background pain, procedural pain, breakthrough pain, neuropathic pain and itch). Regional anesthesia, including peripheral nerve blocks and neuraxial/epidural anesthesia, offers significant benefits to a multimodal approach in pain treatment. A 'regional-first' approach to pain management can be incorporated into the workflow of burn centers through engaging regional anesthesiologists and pain medicine practitioners in the care of burn patients. A detailed understanding of peripheral nerve anatomy frames the burn clinician's perspective when considering a peripheral nerve block/catheter. The infra/supraclavicular nerve block provides excellent coverage for the upper extremity, while the trunk can be covered with a variety of blocks including erector spinae plane and quadratus lumborum plane blocks. The lower extremity is targeted with fascia iliaca plane and sciatic nerve blocks for both donor and recipient sites. Burn centers that adopt regional anesthesia should be aware of potential complications and contraindications to prevent adverse events, including management of local anesthetic toxicity and epidural infections. Management of anticoagulation around regional anesthesia placement is crucial to prevent hematoma and nerve damage. Ultimately, regional anesthesia can facilitate a better patient experience and allow for early therapy and mobility goals that are hallmarks of burn care and rehabilitation.

Comparing the Effect of Gabapentin, Ketamine, Dexmedetomidine, and Entonox on Pain Control in Burn Wound Dressing

This study aimed to evaluate differences in the experience of pain, nausea, and vomiting, as well as the hemodynamic parameters including heart rate (HR) and blood pressure (BP) in burn patients across four pain treatment groups-i.e., gabapentin, ketamine, dexmedetomidine, and entonox. In a single blinded randomized comparative study, 25 burn patients with second- or third-degree burns between 20% and 50% of their body surface were assigned to different treatment groups by using block randomization, while keeping the investigator blind to the size of the block. We recorded demographics, the hemodynamics, adverse effects, and pain levels before the treatment and again 5, 10, 15, 30, 60, 120, 240, and 360 minutes postadministration of pain medication (after-treatment). Gabapentin ketamine, dexmedetomidine, and entonox had significant effects in treatment of pain in burn patients. Entonox had the best analgesic effect with the least adverse effects and hemodynamic changes. Gabapentin also had good pain management effects; however, it showed less desirable effects on hemodynamic variables. Entonox caused the least amount of hemodynamic changes and the least adverse reactions, but since the medication is delivered by a facemask it limited its application with our patients. Gabapentin offered good benefits but caused a gradual drop in BP and HR and had some unfavorable reactions. However, since it is administered orally and often is cheaper, it could be considered as the drug of choice.

Autologous platelet-rich plasma repairs burn wound and reduces burn pain in rats

OBJECTIVE

To investigate the effects of autologous platelet-rich plasma (PRP) on burn wound and burn pain in rats.

METHODS

Rats were treated with high-temperature copper rod to induce skin burn. During treatment, the wound area of rats was recorded on days 0, 3, 7, 10, 14 and healing rates were calculated. After 14-day treatment, the paw withdrawal mechanical threshold (PWMT) as well as paw withdrawal thermal latency (PWTL) were measured. In addition, CD31 expression in burn wound was detected by Immunohistochemistry. The contents of TNF-α and IL-1β in wound tissues were detected by ELISA. Moreover, the mRNA and protein expression levels of VEGF, MMP-9 and TGF-β1 in wound tissues were detected by RT-qPCR together with Western blot.

RESULTS

Burn wound of rats in the PRP group gradually got better with a decreased wound area. Compared with the NS group, the wound area of the PRP group was significantly reduced and the healing rate was significantly increased. Meanwhile, PWMT of the rats in the PRP group was obviously increased compared with the NS group. Compared with the NS group, the rate of CD31-positive cells in the wound tissue of burned rats was increased; while the contents of TNF-α and IL-1β were significantly decreased after a subcutaneous injection of PRP. In addition, the mRNA and protein expression levels of VEGF, MMP-9 and TGF-β1 in the wound tissue of rats from PRP group were evidently increased.

CONCLUSION

Autologous platelet-rich plasma not only shortened the healing time, but also relieved the burn pain.

A review of burn symptoms and potential novel neural targets for non-invasive brain stimulation for treatment of burn sequelae

Burn survivors experience myriad associated symptoms such as pain, pruritus, fatigue, impaired motor strength, post-traumatic stress, depression, anxiety, and sleep disturbance. Many of these symptoms are common and remain chronic, despite current standard of care. One potential novel intervention to target these post burn symptoms is transcranial direct current stimulation (tDCS). tDCS is a non-invasive brain stimulation (NIBS) technique that modulates neural excitability of a specific target or neural network. The aim of this work is to review the neural circuits of the aforementioned clinical sequelae associated with burn injuries and to provide a scientific rationale for specific NIBS targets that can potentially treat these conditions. We ran a systematic review, following the PRISMA statement, of tDCS effects on burn symptoms. Only three studies matched our criteria. One was a feasibility study assessing cortical plasticity in chronic neuropathic pain following burn injury, one looked at the effects of tDCS to reduce pain anxiety during burn wound care, and one assessed the effects of tDCS to manage pain and pruritus in burn survivors. Current literature on NIBS in burn remains limited, only a few trials have been conducted. Based on our review and results in other populations suffering from similar symptoms as patients with burn injuries, three main areas were selected: the prefrontal region, the parietal area and the motor cortex. Based on the importance of the prefrontal cortex in the emotional component of pain and its implication in various psychosocial symptoms, targeting this region may represent the most promising target. Our review of the neural circuitry involved in post burn symptoms and suggested targeted areas for stimulation provide a spring board for future study initiatives.

"More than Scabs and Stitches": An Interview Study of Burn Survivors' Perspectives on Treatment and Recovery

Sustaining a burn injury often results in a life-long recovery process. Survivors are impacted by changes in their mobility, appearance, and ability to carry out activities of daily living. In this study, we examined survivors' accounts of their treatment and recovery in order to identify specific factors that have had significant impacts on their well-being. With this knowledge, we may be better equipped to optimize the care of burn patients. We conducted inductive, thematic analysis on transcripts of in-depth, semi-structured interviews with 11 burn survivors. Participants were purposefully selected for variability in age, gender, injury size and mechanism, participation in peer support, and rurality. Survivors reported varied perceptions of care quality and provider relationships. Ongoing issues with skin and mobility continued to impact their activities of daily living. Many survivors reported that they did not have a clear understanding or realistic expectations of the recovery process. Wound care was often described as overwhelming and provoked fear for many. Even years later, trauma from burn injury can continue to evolve, creating fears and impediments to daily living for survivors. To help patients understand the realistic course of recovery, providers should focus on communicating the nature of injury and anticipated recovery, developing protocols to better identify survivors facing barriers to care, and referring survivors for further support.

In Silico Simulation of the Systemic Drug Exposure Following the Topical Application of Opioid Analgesics in Patients with Cutaneous Lesions

The use of opioid analgesics in treating severe pain is frequently associated with putative adverse effects in humans. Topical agents that are shown to have high efficacy with a favorable safety profile in clinical settings are great alternatives for pain management of multimodal analgesia. However, the risk of side effects induced by transdermal absorption and systemic exposure is of great concern as they are challenging to predict. The present study aimed to use "BIOiSIM" an artificial intelligence-integrated biosimulation platform to predict the transdermal disposition of opioid analgesics. The model successfully predicted their exposure following the topical application of central opioid agonist buprenorphine and peripheral agonist oxycodone in healthy human subjects with simulation of intra-skin exposure in subjects with burns and pressure wounds. The predicted plasma levels of analgesics were used to evaluate the safety of the therapeutic pain control in patients with the dermal structural impairments caused by acute (burns) or chronic cutaneous lesions (pressure wounds) with topical opioid analgesics.

Driving improved burns care and patient outcomes through clinical registry data: A review of quality indicators in the Burns Registry of Australia and New Zealand

BACKGROUND

In 2009, the Burns Registry of Australia and New Zealand (BRANZ) published a set of clinical quality indicators (QIs) to monitor performance, improve quality of care, and inform and change policy. With several years of data collected since the initial development of the indicators for burns, the BRANZ QI Working Party reviewed the clinical QIs for relevance and meaning, and considered new QIs that had not been collected previously.

METHOD

Using published literature and expert opinion, the QI Working Party, consisting of multidisciplinary burn clinicians, reviewed the QIs for burn care to be included as routine data items in the BRANZ.

RESULTS

In July 2016, the list of clinical QIs in the BRANZ was updated to 23 QIs/data items, covering structure, process, and outcome measures. Four QIs were removed as they were not found to be useful, nine QIs/data items were revised, and eight new QIs/data items were added as they were considered to be clinically useful.

CONCLUSION

This review outlines the changes made to the QIs collected by the BRANZ four years since their development and implementation. Ongoing refinement of the BRANZ QIs will ensure that high quality data is collected to drive improvements in clinical and patient outcomes.

Assessing opioid administration in pediatric burn patients with nonsurgical management

BACKGROUND

Despite the vast literature studying the opioid crisis, sparse data describe this in the pediatric burn population. This study sought to assess patient-level characteristics and their potential effects on opioid administration in nonsurgical pediatric burn inpatients.

METHODS

Admitted burn patients from 2013 to 2018 with nonsurgical management at an American Burn Association (ABA) verified pediatric burn center were retrospectively identified. Morphine milligram equivalents by weight (MME/kg) per admission were evaluated through a multiple loglinear regression with race, sex, age, total body surface area burned (TBSA), and burn depth as predictors. Simple linear regression was used to evaluate the temporal trend of median opioid utilization.

RESULTS

A total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10-18 years; p<0.0001) and larger burns (>5% TBSA burned; p<0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p=0.0103).

CONCLUSIONS

Nonsurgical burn patients who were older and presented with larger TBSA experienced marked increases in opioid utilization. Overall, opioid administration decreased over time.

Risk factors associated with higher pain levels among pediatric burn patients: a retrospective cohort study

INTRODUCTION

There is an absence of evidence regarding predictors of moderate to severe pain in children undergoing acute burn treatment. This investigation aimed to determine if relationships existed between patient and clinical characteristics, and pain at first dressing change for children with acute burn injuries.

METHODS

A retrospective cohort investigation was conducted using clinical data from pediatric burn patients treated at the Queensland Children's Hospital, Brisbane, Australia. Data extracted included patient and burn characteristics, first aid, and follow-up care. Observational pain scores were categorized into three groups (mild, moderate, and severe pain), and bivariate and multivariable relationships were examined using proportional odds ordinal logistic regression. Data from 2013 pediatric burns patients were extracted from the database.

RESULTS

Factors associated with increased odds of procedural pain included: hand burns (OR 1.7, 95% CI 1.3 to 2.1, p<0.001), foot burns (OR 1.5, 95% CI 1.1 to 2.1, p<0.01), baseline pain (OR 5.5, 95% CI 2.8 to 10.8, p<0.001), deep dermal partial-thickness injuries (OR 7.9, 95% CI 4.0 to 15.6, p<0.001), increased burn size (OR 1.1, 95% CI 1.0 to 1.2, p<0.01), four or more anatomical regions burned (OR 3.6, 95% CI 1.5 to 8.6, p<0.01), initial treatment at a non-burns center (OR 1.8, 95% CI 1.4 to 2.3, p<0.001), and time to hospital presentation (OR 0.9, 95% CI 0.8 to 0.9, p<0.001). These burn characteristics are associated with increased odds of moderate to severe procedural pain during a child's first dressings change.

DISCUSSION

It is recommended that patients presenting with one or more of the aforementioned factors are identified before their first dressing change, so additional pain control methods can be implemented.

Pain assessment following burn injury in Australia and New Zealand: Variation in practice and its association on in-hospital outcomes

BACKGROUND

Pain is common following burn injury. Pain assessments are required to ensure appropriate pain management is provided. This study aimed to describe the prevalence and potential variation in practice of validated and documented pain assessment following burn injury in Australian and New Zealand burn units, identify clinical characteristics of patients who receive a pain assessment, and explore the associations between receiving a pain assessment and in-hospital outcomes.

METHODS

Burns Registry of Australia and New Zealand (BRANZ) admissions data were extracted. Responses to the pain assessment field were presented by contributing burns unit using frequencies and percentages. Demographic, injury severity and event, and in-hospital outcomes data were assessed.

RESULTS

There were 3009 admissions over the study period; 2481 of these received an assessment. The rate of pain assessment varied considerably between units. Women and adult patients more commonly received a pain assessment. Receiving a pain assessment was associated with a 53% adjusted increase in LOS.

CONCLUSIONS

There are differences in the profile of patients who receive a pain assessment after burn injury. The findings of this study will be reported back to designated burns units to improve pain assessment rates and patient care.

Selected pathobiological features and principles of pharmacological pain management

Pain induced by inflammation and nerve injury arises from abnormal neural activity of primary afferent nociceptors in response to tissue damage, which causes long-term elevation of the sensitivity and responsiveness of spinal cord neurons. Inflammatory pain typically resolves following resolution of inflammation; however, nerve injury-either peripheral or central-may cause persistent neuropathic pain, which frequently manifests as hyperalgesia or allodynia. Neuralgias, malignant metastatic bone disease, and diabetic neuropathy are some of the conditions associated with severe, often unremitting chronic pain that is both physically and psychologically debilitating or disabling. Therefore, optimal pain management for patients with chronic neuropathic pain requires a multimodal approach that comprises pharmacological and psychological interventions. Non-opioid analgesics (e.g., paracetamol, aspirin, or other non-steroidal anti-inflammatory drugs) are first-line agents used in the treatment of mild-to-moderate acute pain, while opioids of increasing potency are indicated for the treatment of persistent, moderate-to-severe inflammatory pain. N-methyl D-aspartate receptor antagonists, antidepressants, anticonvulsants, or a combination of these should be considered for the treatment of chronic neuropathic pain. This review discusses the various neural signals that mediate acute and chronic pain, as well as the general principles of pain management.

Analgesic use in contemporary burn practice: Applications to burn mass casualty incident planning

BACKGROUND

Determining the amount of analgesics required will help burn centers improve their ability to plan for a burn mass casualty incident (BMCI). We sought to quantify the amount of analgesics needed in an inpatient burn population. We hoped that assessing the analgesic use in daily burn care practice will potentially help estimate opioid needs in a burn mass casualty incident (BMCI).

METHODS

We included patients with burns covering equal to or less than 30% total body surface area (TBSA), admitted from spring 2013 to spring 2015. Patient records were reviewed for analgesics and adjuncts, pain scores, age and TBSA. The doses of the different opioids administered were converted into morphine equivalent doses (MED).

RESULTS

We enrolled 141 acute burn survivors with a mean TBSA of 8.2±0.6%. The lowest daily average MED per person was 24.6±2.0mg MED, recorded on the day of injury. The daily average MED per person increased until it peaked at 52.5±5.6mg MED at day 8 post-burn. Then, it declined to 24.6±3.4mg MED by day 14. Bivariate regression analysis of average MED by TBSA showed a significant positive correlation (p<0.001). The analysis of average MED by age showed a significant negative correlation (p<0001).

CONCLUSION

Our study quantified opioid requirements in an inpatient burn population and identified TBSA (positively) and age (negatively) as significant predictors.

Comparison of analgesic and anxiolytic effects of nitrous oxide in burn wound treatment: A single-blind prospective randomized controlled trial

AIM

We compared the effects of 50% N2O and N2O titration in burn management to alleviate pain and anxiety associated with burn dressing.

METHODS

In this single-blind prospective randomized controlled trial, 70 stable adult burn patients were randomized to 2 groups during May 2015 to January 2016. The experimental group was titrated with N2O ranging from 30% to the ideal sedation concentration before dressing change until the end. The control group was treated with 50% N2O 2 minutes before dressing change until the end. Pain, anxiety, vital signs, and the highest concentrations of N2O inhaled were recorded at 1 minute before N2O inhalation (T0), dismantling of outer (T1), inner dressings (T2), debridement (T3), drug-smearing (T4), bandaging (T5), and 10 minutes after completion of the procedure (T6).

RESULTS

The pain and anxiety scores in the experimental group performed significantly less than the control group during T2-T6. The systolic blood pressure in T2 and the heart rate at T2 and T3 varied significantly between the 2 groups. The highest N2O concentrations of the experimental group were mainly 60% to 70% at T2 (87.9%), T3 (87.9%), and T4 (81.8%).

CONCLUSION

N2O titration significantly reduced pain and anxiety in burn patients, with minimal side effects.

Longitudinal Clinical Trial Recruitment and Retention Challenges in the Burn Population: Lessons Learned From a Trial Examining a Novel Intervention for Chronic Neuropathic Symptoms

Long-term trials are key to understanding chronic symptoms such as pain and itch. However, challenges such as high attrition rates and poor recruitment are common when conducting research. The aim of this work was to explore these issues within a long-term randomized control trial using transcranial direct current stimulation to treat pain and itch. This parallel double blinded, placebo-controlled randomized trial was comprised of 15 transcranial direct current stimulation visits and 7 follow-up visits. Participants were over the age of 18, had a burn injury that occurred at least 3 weeks before enrollment, and reported having pain and/or itch that was moderate to severe in intensity. A total of 31 subjects were randomized into either an active or sham transcranial direct current stimulation groups. There were no significant differences between the groups in terms of age, race, education, baseline depression, or anxiety. The median dropout time was at visit 19 (visit 16 [SE = 1.98] for the sham group and visit 19 [SE = 1.98] for the active group). Analysis showed no differences in the dropout rate between groups [χ2(1) = 0.003, P = .954]. The dropout rate was 46.7% for the sham group and 43.8% for the active group. Overall, 45.2% of the subjects dropped out of the trial. Long-term clinical trials are an essential part of evaluating interventions for symptoms such as chronic pain and itch. However, as seen in this trial, long-term studies in the burn population often face recruitment and adherence challenges.