Focal Adhesion Kinase Inhibition Ameliorates Burn Injury-Induced Chronic Pain in Rats

Burn injury-induced pain (BIP) is a significant global health concern, affecting diverse populations including children, military veterans, and accident victims. Current pharmacotherapeutics for the management of BIP are associated with severe side effects including drug addiction, respiratory depression, sedation, and constipation posing significant barrier to their clinical utility. In the present study, we have investigated the potential role of focal adhesion kinase (p-FAK) for the very first time in BIP and elucidated the associated underlying mechanisms. Defactinib (DFT), a potent p-FAK inhibitor, administered at doses of 5, 10, and 20 mg/kg via intraperitoneal injection, demonstrates significant efficacy in reducing both evoked and spontaneous pain without causing addiction or other central nervous system toxicities. Burn injury triggers p-FAK-mediated phosphorylation of Erk1/2 and NR2B signaling in the DRG, resulting in heightened hypersensitivity through microglial activation, neuropeptide release, and elevated proinflammatory cytokines. Defactinib (DFT) counteracts these effects by reducing NR2B upregulation, lowering substance P levels, inhibiting microglial activation, and restoring IL-10 levels while leaving CGRP levels unchanged. These findings provide valuable insights into the pivotal role of p-FAK in regulating BIP and highlight the potential for developing novel therapeutics for burn injury-induced pain with minimal side effects.

Acceptability and Usability of Smileyscope Virtual Reality for Paediatric Pain Management During Burn Procedures: Perspectives of Patients, Carers and Clinicians

AIM

To explore clinician, child and parent acceptability and usability of the Smileyscope VR device in the context of addressing the unique pain and distress needs of young burn patients.

DESIGN

A survey comprising closed and open-ended questions.

METHOD

Descriptive statistics analysed participant characteristics, pain and analgesia. Qualitative content was collected from April 2022-August 2022 and analysed to identify barriers and enablers. Categories were then mapped onto the Capabilities, Opportunities and Motivation-Behaviour Wheel (COM-B) framework.

RESULTS

Smileyscope was found to be effective for reducing pain and anxiety during dressing changes by both patients (n = 39) and parents (n = 37). Clinicians (n = 35) reported high self-efficacy and willingness to reuse the device. However, concerns arose regarding the device's fit and the need for age-appropriate programmes.

CONCLUSION

Smileyscope demonstrated promise in reducing procedural pain and distress. The device is well accepted by all participants implying ease of implementation. Feedback suggests further program development and fitting optimisation is required.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Improved procedural pain has proven to decrease wound healing times, decreasing possible need for further scar management and long-term consequences after sustaining a burn injury. Smileyscope use in rural hospitals presents valuable opportunities for optimising early paediatric burn pain.

IMPACT

Increased burn pain can delay wound healing and have long term physical and psychological impact on patients. Smileyscope was well received within this cohort; however, improvements in device design and programmes were suggested. This study shows the potential for use of Smileyscope as a non-pharmacological approach to improving paediatric burn pain and distress.

PATIENT OR PUBLIC CONTRIBUTION

While our study included patients, parents and clinicians as research participants, there was no patient or public contribution in the design or conduct of the study, analysis or interpretation of the data.

Chronic Use of Prescription Pain Medication and Outcomes in Patients With Burn Injury: A Burn Model System National Database Study

OBJECTIVE

This study attempts to examine long-term pain medication usage after burn injury and its association with functional and psychosocial outcomes.

DESIGN

This is a multicenter retrospective cohort study utilizing the Burn Model System National Longitudinal Database. Participants injured from 2015 to 2021 were divided into two groups, those taking and not taking prescription pain medication at 12 mos after injury. Regression analyses examined associations between pain medication use and outcomes at 12 mos, adjusting for demographics, burn size, length of hospital stay, and preinjury pain medication use and employment status. Outcomes included VR-12 Physical and Mental Component Summary scores Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores, Satisfaction with Life Scale, and employment status.

RESULTS

Of 358 participants analyzed, prescription pain medication use was associated with worse outcomes at 12 mos: Physical Component Summary (β = -7.11, P < 0.001), Mental Component Summary (β = -6.01, P < 0.001), and Patient-Reported Outcomes Measurement Information System Depression (β = 4.88, P < 0.001) and Anxiety (β = 6.16, P < 0.001). Satisfaction with Life Scale was not significantly associated with pain medication use ( P = 0.069) and those taking pain medication were 52% less likely to be employed at 12 mos ( P = 0.035).

CONCLUSIONS

There is a significant association between prescription pain medication use and worse physical, mental, and employment outcomes at 12 mos after burn injury.

Morphine (10, 20 mg) in a Postoperative Dressing Used with Patients After Surgical Debridement of Burn Wounds: A Prospective, Double-Blinded, Randomized Controlled Trial

Objective: This is the first clinical trial to evaluate the analgesic effect of 10 and 20 mg of morphine used in a postoperative dressing with patients after surgical debridement of burn wounds. Approach: In this randomized controlled trial, 20 adult patients with third-degree flame burns, who had undergone surgical debridement under general anesthesia, were randomly assigned to either group A, whose members were treated with a burn dressing that contained 10 mg of morphine, or group B, whose members were treated with a burn dressing that contained 20 mg of morphine; the dressing was also soaked with octenidine and phenoxyethanol in the case of both groups. The plasma morphine concentrations were measured 1, 2, 3, and 6 h after surgery, while the level of pain intensity was determined on the Numeric Pain Rating Scale (NRS), and the occurrence of side effects was observed. Results: The serum morphine concentration levels were very low, but statistically different between the two groups at all time points. The NRS value was similar in both groups at all time points (p > 0.05). Despite this, in group B, the NRS value was 0 in all patients in postoperative hours 1, 2, and 3. No adverse effect of morphine sulfate was observed in any patient. Innovation: This project is the first clinical study to have demonstrated that morphine administered in dressings in concentrations of 0.02-0.08 mg/mL significantly reduces the occurrence of pain. Conclusion: The use of morphine in dressings after surgical treatment of burn wounds is very effective when it comes to pain management and is safe for the patient.

Opioid prescription and opioid disorders in burns: A large database analysis from 1990 to 2019

BACKGROUND

Opioids remain crucial in the management of burn pain. A comprehensive analysis of opioid use in burns and their complications has not been investigated.

METHODS

Data were collected from TriNetX, a large multicenter database with de-identified patient information. The population included patients prescribed opioids on or following burn injury from January 1st, 1990, to December 31st, 2019. Opioid prescription use was analyzed after cohort stratification by decades: 1990-1999, 2000-2009, and 2010-2019. Outcomes for opioid-related disorders, opioid dependence, opioid abuse, intentional self-harm, and mental and behavioral disorders from psychoactive substance use were investigated.

RESULTS

Hydrocodone was the most frequently prescribed opioid in 1990-1999 and 2000-2009, with oxycodone taking the lead in 2010-2019 (p < 0.0001). During 1990-1999, patients had a decreased risk of recorded opioid-related disorders (RR=0.52), opioid dependence (RR=0.46), opioid abuse (RR=0.55), mental and behavioral disorders (RR=0.88), and intentional self-harm (RR=0.37) when compared to 2000-2009. A comparison of the 2000-2009-2010-2019 cohorts showed an increased risk of recorded opioid-related disorders (RR= 1.91), opioid dependence (RR=1.56), opioid abuse (RR=1.67), mental and behavioral disorders (RR =1.73), and intentional self-harm (RR=2.02).

CONCLUSIONS

The risk of opioid-related disorders has nearly doubled since the year 2000 warranting precautions when prescribing pain medications to burn patients.

Rehabilitation Management of the Burned Hand

Burns to the hands constitute a small total surface area burn, but can result in significant functional challenges and disability. The complexity of multiple anatomical structures and intricate interplay of bones, muscles, and connective tissues requires specialized knowledge of how burns of the hand can affect function and independence. This article will provide an evidence-based overview of rehabilitation of the burned hand across the burn care continuum including a focus on evaluation, pain management, treatment interventions, and outcome assessment. Additionally, various deficits that can put the hand at significant risk for loss of function will be discussed. Finally, the authors will address the special considerations and treatment caveats of addressing the pediatric hand burn.

Pharmacologic Management of Pain, Agitation, and Delirium in Burn Patients

The majority of hospitalized burn patients experience pain, agitation, and delirium. The development of each one of these conditions can also lead to, or worsen, the others. Providers, therefore, need to thoroughly assess the underlying issue to determine the most effective treatment. Multimodal pharmacologic regimens are often used in conjunction with non-pharmacologic strategies to manage pain, agitation, and delirium. This review focuses on the pharmacologic management of these complicated patients in a critical-care setting.

Critical Care of the Burn Patient

Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.

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.

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.

The effects of Rosa damascene aromatherapy on anxiety and sleep quality in burn patients: A randomized clinical trial

INTRODUCTION AND OBJECTIVE

Sleep disorders and anxiety are common problems in burn patients, and aromatherapy is a common complementary treatment in medicine. The aim of this study was to determine the effects of aromatherapy with the inhalation of rose essential oil on anxiety and sleep quality in burn patients.

MATERIALS AND METHODS

This randomized controlled clinical trial was performed on 60 patients admitted to the Valiasr Hospital B in Arak from March 2021 to the end of July 2021. The patients were chosen by the convenience sampling method and then randomly divided into the intervention and control groups based on the block randomization method (six blocks). Aromatherapy along with the routine care was provided to the participants of the intervention group for three consecutive nights. These participants inhaled five drops of 40 % rose essential oil. The members of the control group also inhaled five drops of distilled water as a placebo. In both groups, anxiety and sleep quality were assessed using the St. Mary's Hospital Sleep Quality Questionnaire (SMHSQ) and the Spielberger State-Trait Anxiety Inventory (STAI), respectively, before and after the intervention.

RESULTS

The sleep quality scores of the intervention and control groups after the intervention were 17.88 ± 2.04 and 26.11. 3.31, respectively, showing a statistically significant difference (P < 0.05). Our results also showed a statistically significant difference in the anxiety score between the intervention and control groups after aromatherapy (P < 0.05).

RESULTS

Rose essential oil aromatherapy reduced anxiety and improved sleep quality in burn patients, suggesting this approach as a useful complementary method along with other therapeutic measures in these patients.

Adverse childhood experiences and burn pain: a review of biopsychosocial mechanisms that may influence healing

Adverse childhood experiences (ACEs) affect over half of the adults in the United States and are known to contribute to the development of a wide variety of negative health and behavioral outcomes. The consequences of ACE exposure have been studied in patient populations that include individuals with gynecologic, orthopedic, metabolic, autoimmune, cardiovascular, and gastrointestinal conditions among others. Findings indicate that ACEs not only increase risks for chronic pain but also influence emotional responses to pain in many of these individuals. A growing body of research suggests that these effects may be the result of long-lasting changes induced by ACEs in neurobiological systems during early development. However, one area that is still largely unexplored concerns the effects of ACEs on burn patients, who account for almost 450,000 hospitalizations in the United States annually. Patients with severe burns frequently suffer from persistent pain that affects their well-being long after the acute injury, but considerable variability has been observed in the experience of pain across individuals. A literature search was conducted in CINAHL and PubMed to evaluate the possibility that previously documented ACE-induced changes in biological, psychological, and social processes might contribute to these differences. Findings suggest that better understanding of the role that ACEs play in burn outcomes could lead to improved treatment strategies, but further empirical research is needed to identify the predictors and mechanisms that dictate individual differences in pain outcomes in patients with ACE exposure and to clarify the role that ACE-related alterations play in early healing and recovery from burn injuries.

Music therapy and music medicine interventions with adult burn patients: A systematic review and meta-analysis

BACKGROUND

Pain is one of the most common and most difficult symptoms to manage in adult burn patients in the Intensive Care Unit (ICU). Insufficient or unsuccessful pain management can negatively affect physiological, psychological, and social health in burn patients, both during and after hospitalization. Music therapy and music medicine interventions have been shown to positively affect pain and mental health in this population. This systematic review and meta-analysis provide an update of Randomized Controlled Trials (RCTs) using music therapy or music medicine interventions in adult burn patients.

METHODS

A variety of databases were searched from their beginning to June 2020, including PsycINFO and PsycArticles (via APAsycNET), PubMed and MEDLINE (via OvidSP), Scopus, Web of Science, and the Cochrane Library. Data of all articles meeting the inclusion criteria were extracted, organized, and processed according to the PRISMA guidelines. Statistical analysis was performed using Q-test and I2 statistics.

RESULTS

10 RCTs with a total of 1061 participants were included. The results of the meta-analysis showed a statistically significant reduction of pain (I² = 96.03%, P < 0.001), anxiety (I² = 98.85%, P < 0.002), and improved relaxation (I² = 87.19%, P < 0.001) favoring music interventions compared to control groups.

CONCLUSIONS

This review provides preliminary evidence for the effectiveness of music interventions for adult burn patients. However, more high-quality RCTs are needed to safely establish guidelines for music therapists and other health care professionals in using music for health purposes with this population.

Adjunctive Nonpharmacologic Interventions for the Management of Burn Pain: A Systematic Review

BACKGROUND

The conventional way of treating burn victims with mainstream pain control modalities is costly and has many negative side effects. In this study, the authors aim to present the findings from the major clinical trials on three nonpharmacologic interventions-hypnosis, virtual/augmented reality, and yoga-as supplements to conventional pain regimens for burn management.

METHODS

A computerized literature search was conducted of the PubMed and ClinicalTrials.gov databases in April of 2020. The online screening process was performed by two independent reviewers with the Covidence tool. The protocol was reported using the Preferred Reporting Items for Systematic Review and Meta-Analyses, and it was registered at the International Prospective Register of Systematic Reviews of the National Institute for Health Research.

RESULTS

The search yielded 254 articles from 1955 to 2020. Fifty-eight studies met the authors' inclusion criteria. Yoga reduced cognitive and somatic anxiety in burn survivors, and improved body image. Virtual reality is effective in pain reduction in both the pediatric and the adult burn population, and in faster burn wound reepithelialization. Hypnosis has similar results regarding reducing pain quality and anxiety in burn patients undergoing burn wound care and dressing changes but was not found to significantly accelerate the healing process.

CONCLUSIONS

Nonpharmacologic interventions are not a substitute for conventional analgesics; however, they could help patients have better control over their pain, greater self-esteem, and less postburn traumatic experiences. Burn care centers should consider nonpharmacologic interventions to improve patient satisfaction and their participation in the treatment and rehabilitation process.

US national trends in prescription opioid use after burn injury, 2007 to 2017

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.

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.

American Burn Association Guidelines on the Management of Acute Pain in the Adult Burn Patient: A Review of the Literature, a Compilation of Expert Opinion, and Next Steps

The ABA pain guidelines were developed 14 years ago and have not been revised despite evolution in the practice of burn care. A sub-committee of the American Burn Association's Committee on the Organization and Delivery of Burn Care was created to revise the adult pain guidelines. A MEDLINE search of English-language publications from 1968 to 2018 was conducted using the keywords "burn pain," "treatment," and "assessment." Selected references were also used from the greater pain literature. Studies were graded by two members of the committee using Oxford Centre for Evidence-based Medicine-Levels of Evidence. We then met as a group to determine expert consensus on a variety of topics related to treating pain in burn patients. Finally, we assessed gaps in the current knowledge and determined research questions that would aid in providing better recommendations for optimal pain management of the burn patient. The literature search produced 189 papers, 95 were found to be relevant to the assessment and treatment of burn pain. From the greater pain literature 151 references were included, totaling 246 papers being analyzed. Following this literature review, a meeting to establish expert consensus was held and 20 guidelines established in the areas of pain assessment, opioid medications, nonopioid medications, regional anesthesia, and nonpharmacologic treatments. There is increasing research on pain management modalities, but available studies are inadequate to create a true standard of care. We call for more burn specific research into modalities for burn pain control as well as research on multimodal pain control.

Effect of lycopene on pain facilitation and the SIRT1/mTOR pathway in the dorsal horn of burn injury rats

To explore the effect of intrathecal injection of lycopene on pain facilitation, glial activation, and the SIRT1/mTOR pathway in the dorsal horn of rats with burn injury pain (BIP). Here we found that the mechanical pain threshold increased in the lycopene group compared with that of the control group, (P < 0.05). Compared with expression in the sham group, mTOR, pS6, p4EBP, GFAP, and Iba-1 decreased and SIRT1 increased in the lycopene group (P < 0.01). Glial activation in the spinal dorsal horn of BIP rats was alleviated by lycopene (P < 0.01). The SIRT1 and mTOR were mainly distributed in neurons in the spinal dorsal horn in the BIP model. Intrathecal injection of 3-MA (a mTOR agonist) or EX-527 (an inhibitor of Sirt1) partially antagonized lycopene-induced analgesia. Intrathecal injection of rapamycin (an mTOR inhibitor) or SRT1720 (an agonist of Sirt1) induced analgesia in BIP rats. 3-MA abrogated the SRT1720-induced analgesic effects. The present data indicated that the SIRT1/mTOR pathway changed in the spinal dorsal horn of BIP rats; Lycopene alleviated the pain sensitization of BIP rats by regulating the SIRT1/mTOR pathway and glial activation in the spinal dorsal horn.

Pediatric burn care: new techniques and outcomes

PURPOSE OF REVIEW

Thermal injury is a leading cause of morbidity and mortality in children. This review highlights the current management of thermal injury and its complications.

RECENT FINDINGS

Many recent advances in burn care have improved the outcomes of patients with thermal injury; however, variability does exist, and there are many opportunities for improvement. This review will highlight the complexity of issues encountered along the continuum of care for thermal injury patients. Accurate estimation of total burn surface area (TBSA) of a burn continues to be a challenge in pediatric patients. Variability continues to exist surrounding the management of burn resuscitation and complex wounds. Children with extensive burns have profound immune and metabolic changes that can lead to multiple complications, including infections, growth arrest, and loss of lean body mass. Standardization in measurements related to quality of life and psychological stress following pediatric thermal injury is much needed.

SUMMARY

The care of pediatric patients with thermal injury is complex and multifaceted. This review highlights the most recent advances in pediatric burn care.

Challenges in anaesthesia and pain management for burn injuries

Burn-injured patients provide unique challenges to those providing anaesthesia and pain management. This review aims to update both the regular burn anaesthetist and the anaesthetist only occasionally involved with burn patients in emergency settings. It addresses some aspects of care that are perhaps contentious in terms of airway management, fluid resuscitation, transfusion practices and pharmacology. Recognition of pain management failures and the lack of mechanism-specific analgesics are discussed along with the opioid crisis as it relates to burns and nonpharmacological methods in the management of distressed patients.

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

Hundreds of patients are treated for burn injuries each year at University of Wisconsin School of Medicine and Public Health. Pain management is particularly challenging during dressing changes and following skin grafting procedures. We performed a retrospective chart review from January 2011 through June 2018 to evaluate the effect of nonopioid analgesic medications on opioid use in nonintubated patients. Our primary outcome was the change in opioid use following the procedure. We found that most patients (69%) report severe pain (Numeric Rating Scale ≥7) immediately after autologous skin grafting. On average, patients required an additional 52 mg of oral morphine equivalents (ME) in the 24 h after the procedure compared with the 24 h before. The use of perioperative nonopioid analgesia varied between patients (acetaminophen 29%, gabapentin 29%, ketamine 35%, and all three 8%). Patients who received either gabapentin or a combination of acetaminophen, gabapentin, and ketamine had a smaller increase in their opioid use than patients who did not receive the medications (-25 ME, 95% confidence interval [-46, -4]; P = .018 and -47 ME, [-81, -11]; P = .010, respectively). These results support using a combination of acetaminophen, gabapentin, and ketamine for perioperative analgesia in burn patients undergoing autologous skin grafting.