Perioperative Multimodal Analgesia Reduces Opioid Use Following Skin Grafting in Nonintubated Burn Patients

The Role of Ketamine as a Component of Multimodal Analgesia in Burns: A Retrospective Observational Study

Background: Burn wound dressing and debridement are excruciatingly painful procedures that call for appropriate analgesia-typically multimodal. Better post-procedural pain management, less opioid use, and consequently fewer side effects, which could prolong recovery and increase morbidity, are all benefits of this type of analgesia. Intravenously administered ketamine can be effective as monotherapy or in combination with opioids, especially with procedural sedation such as in burn wound dressing. Methods: This observational study investigated the effect of ketamine administered in subanesthetic doses combined with opioids during burn wound dressing. The study was conducted from October 2018 to October 2021. A total of 165 patients met the inclusion criteria. A total of 82 patients were in the ketamine group, while 83 patients were dressed without ketamine. The main outcome was the effect of ketamine on intraprocedural opioid consumption. The secondary outcome included the effect of ketamine on postprocedural pain control. Results: Patients dressed with ketamine were significantly older (p = 0.001), while the mean doses of intraoperatively administered propofol and fentanyl were significantly lower than in patients dressed without ketamine (150 vs. 220 mg, p < 0.001; and 0.075 vs. 0.150 mg, p < 0.001; respectively). Conclusions: Ketamine was an independent predictor of lower intraoperative fentanyl consumption, according to the multivariate regression analysis (p = 0.015). Contrarily, both groups of patients required postoperative tramadol treatment, while intraoperative ketamine administration had no beneficial effects on postoperative pain management.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Impact of Opioid-Minimizing Pain Protocols after Burn Injury

In 2019, we implemented a pill-based, opioid-minimizing pain protocol and protocolized moderate sedation for dressing changes in order to decrease opioid exposure in burn patients. We hypothesized that these interventions would reduce inpatient opioid exposure without increasing acute pain scores. Two groups of consecutive patients admitted to the burn service were compared: Pre (01/01/2018 to 07/31/2019) and Post (01/01/2020 to 06/30/2020) implementation of the protocols (08/01/2019 to 12/31/2019). We abstracted patient demographics and burn injury characteristics from the burn registry. We obtained opioid exposure and pain scale scores from the electronic medical record. The primary outcome was total morphine milligram equivalents (MME). Secondary outcomes included MME/day, pain domain-specific MME, and pain scores. Pain was estimated by creating a normalized pain score (range 0-1), which incorporated 3 different pain scales (Numeric Rating Scale, Behavioral Pain Scale, and Behavioral Pain Assessment Scale). Groups were compared using Wilcoxon Rank Sum and Chi Square. Treatment effects were estimated using Bayesian generalized linear models.There were no differences in demographics or burn characteristics between the Pre (n=495) and Post groups (n=174). The Post group had significantly lower total MME (Post 110 MME [32, 325] versus Pre 230 [60, 840], p<0.001), MME/day (Post 33 MME/day [15, 54] versus Pre 52 [27, 80], p<0.001), and domain-specific total MME. No difference in average normalized pain scores was seen.Implementation of opioid-minimizing protocols for acute burn pain was associated with a significant reduction in inpatient opioid exposure without an increase in pain scores.