A Prospective, Multicenter, Randomized, Double-Blind Trial of IV Ibuprofen for Treatment of Fever and Pain in Burn Patients:

Fever therapy in febrile adults: systematic review with meta-analyses and trial sequential analyses

OBJECTIVE

To investigate the effects of fever therapy compared with no fever therapy in a wide population of febrile adults.

DESIGN

Systematic review with meta-analyses and trial sequential analyses of randomised clinical trials.

DATA SOURCES

CENTRAL, BIOSIS, CINAHL, MEDLINE, Embase, LILACS, Scopus, and Web of Science Core Collection, searched from their inception to 2 July 2021.

ELIGIBILITY CRITERIA

Randomised clinical trials in adults diagnosed as having fever of any origin. Included experimental interventions were any fever therapy, and the control intervention had to be no fever therapy (with or without placebo/sham).

DATA EXTRACTION AND SYNTHESIS

Two authors independently selected studies, extracted data, and assessed the risk of bias. Primary outcomes were all cause mortality and serious adverse events. Secondary outcomes were quality of life and non-serious adverse events. Aggregate data were synthesised with meta-analyses, subgroup analyses, and trial sequential analyses, and the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Forty two trials assessing 5140 participants were included. Twenty three trials assessed 11 different antipyretic drugs, 11 trials assessed physical cooling, and eight trials assessed a combination of antipyretic drugs and physical cooling. Of the participants, 3007 were critically ill, 1892 were non-critically ill, 3277 had infectious fever, and 1139 had non-infectious fever. All trials were assessed as being at high risk of bias. Meta-analysis and trial sequential analysis showed that the hypothesis that fever therapy reduces the risk of death (risk ratio 1.04, 95% confidence interval 0.90 to 1.19; I²=0%; P=0.62; 16 trials; high certainty evidence) and the risk of serious adverse events (risk ratio 1.02, 0.89 to 1.17; I²=0%; P=0.78; 16 trials; high certainty evidence) could be rejected. One trial assessing quality of life was included, showing no difference between fever therapy and control. Meta-analysis and trial sequential analysis showed that the hypothesis that fever therapy reduces the risk of non-serious adverse events could be neither confirmed nor rejected (risk ratio 0.92, 0.67 to 1.25; I²=66.5%; P=0.58; four trials; very low certainty evidence).

CONCLUSIONS

Fever therapy does not seem to affect the risk of death and serious adverse events.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019134006.

Comparison of intravenous ibuprofen and paracetamol in the treatment of fever: A randomized double-blind study

OBJECTIVE

Fever is one of the frequent reasons for admission to the emergency department. Studies comparing oral forms of non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol with intravenous (IV) forms for fever are common in the literature. Our study is the first emergency department study comparing IV forms of ibuprofen and paracetamol in the treatment of febrile patients.

METHODS

A randomized, double-blind study was conducted in a tertiary university emergency department for a six-month period. Patients aged 18-65 years who had a fever of ≥38.0 °C were included. Patients were administered 400 mg of IV ibuprofen and 1000 mg of IV paracetamol. The primary aim of the study was to determine whether there was a difference in the effect of the two drugs on fever. The secondary aim was to investigate whether there was a difference in terms of numeric rating scale (NRS) measurements and the need for additional antipyretic therapy.

RESULTS

A total of 200 people, 100 of whom were female, were included in the study. The mean age was 30.77 ± 10.61 years. The mean initial temperature for ibuprofen and paracetamol was 38.79 ± 0.470 °C and 38.70 ± 0.520 °C, respectively, with no difference noted between the groups (p = 0.380). It was found that both drugs significantly provided fever control in the first 30 min (p < 0.001), with no difference between them in terms of fever reduction (p = 0.980). Both drugs significantly improved in accompanying symptoms, although both drugs did not show superiority to each other (p = 0.0226). When evaluated in terms of a need for rescue medication, no significant difference was found between the two drugs (p = 0.404). No side effects were encountered during the study.

CONCLUSION

In adult age group patients admitted to the emergency department with high fever, the IV forms of 1000 mg paracetamol and 400 mg ibuprofen effectively and equally reduce complaints, such as fever and accompanying pain. They can be effectively used as each other's rescue medicine and as an alternative to each other in patients with comorbid diseases.

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.

Narrative Summary of Recently Published Literature on Intravenous Ibuprofen

PURPOSE

This is a narrative review of the published literature on IV ibuprofen (IVIB) as one of the drugs used in multimodal pain management in inpatients and outpatients pre- and postoperatively and for nonsurgical pain or fever.

METHODS

The efficacy, concurrent opioid use, pharmacokinetic properties, tolerability, stress response, and postoperative recovery with IVIB, which were investigated in 9 clinical studies, are presented in this narrative review. In total, 1062 adult patients and healthy volunteers were included in these 9 studies; 757 of these subjects received IVIB, and the remaining 305 received either placebo or a comparator medication.

FINDINGS

The plasma ibuprofen level with IVIB was twice that with oral ibuprofen, and patients experienced less postoperative pain, decreased opioid use, improved quality of recovery, and reduced postsurgical fatigue and surgical stress response, and used less over-the-counter medication.

IMPLICATIONS

Overall, preemptive IVIB should be considered in the analgesic regimen for the management of pre- and postoperative pain, as it has a favorable safety profile, with fewer associated adverse events and serious adverse events, significantly lower levels of perioperative cytokines and catecholamines, and improved peri- and postoperative pain control with a decreased use of opioid medications.

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.

A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis

Opioids are the mainstay of pain management after burn injury. The United States currently faces an epidemic of opioid overuse and abuse, while simultaneously experiencing a nationwide shortage of intravenous narcotics. Adjunctive pain management therapies must be sought and utilized to reduce the use of opioids in burn care to prevent the long-term negative effects of these medications and to minimize the dependence on opioids for analgesia. The purpose of this review was to identify literature on adjunctive pain management therapies that have been demonstrated to reduce pain severity or opioid consumption in adult burn patients. Three databases were searched for prospective studies, randomized controlled trials, and systematic reviews that evaluated adjunctive pain management strategies published between 2008 and 2019 in adult burn patients. Forty-six studies were analyzed, including 24 randomized controlled trials, six crossover trials, and 10 systematic reviews. Various adjunctive pain management therapies showed statistically significant reduction in pain severity. Only one randomized controlled trial on music therapy for acute background pain showed a reduction in opioid use. One cohort study on hypnosis demonstrated reduced opioid use compared with historical controls. We recommend the development of individualized analgesic regimens with the incorporation of adjunctive therapies in order to improve burn pain management in the midst of an abuse crisis and concomitant national opioid shortage.

Burns management in ICU: Quality of the evidence: A systematic review

BACKGROUND

The objective of this study was to assess the quality of readily available evidence regarding critical care aspects of the management of patients with severe burn injuries.

METHOD

PUBMED, EMBASE, Cochrane Databases and bibliographies of included studies and burns review articles were searched from inception of databases to end of February 2015. We included systematic reviews, randomised controlled trials (RCTs) and cohort studies with concurrent controls on the topics of (a) fluid resuscitation (b) analgesia (c) haemodynamic monitoring and targets (d) ventilation (e) blood transfusion. The quality of the studies was assessed using validated tools.

RESULTS

Fifty six studies fulfilled the inclusion criteria. Twenty three on fluid resuscitation, 22 on analgesia, nine on haemodynamic monitoring and two on ventilation. No studies were found on blood transfusion practice. There were ten systematic reviews, 38 RCTs and eight cohort studies with concurrent controls. The majority of studies were single centre trials with small numbers of patients, surrogate outcomes and high risk of bias.

CONCLUSIONS

There is very little high quality evidence to guide clinical practice in early management of the severely burnt patient. Eleven of 56 studies found in our search of critical care topics were of good methodological quality with low risk of bias.

An integrated safety analysis of intravenous ibuprofen (Caldolor(®)) in adults

Intravenous (IV) nonsteroidal anti-inflammatory drugs such as IV ibuprofen are increasingly used as a component of multimodal pain management in the inpatient and outpatient settings. The safety of IV ibuprofen as assessed in ten sponsored clinical studies is presented in this analysis. Overall, 1,752 adult patients have been included in safety and efficacy trials over 11 years; 1,220 of these patients have received IV ibuprofen and 532 received either placebo or comparator medication. The incidence of adverse events (AEs), serious AEs, and changes in vital signs and clinically significant laboratory parameters have been summarized and compared to patients receiving placebo or active comparator drug. Overall, IV ibuprofen has been well tolerated by hospitalized and outpatient patients when administered both prior to surgery and postoperatively as well as for nonsurgical pain or fever. The overall incidence of AEs is lower in patients receiving IV ibuprofen as compared to those receiving placebo in this integrated analysis. Specific analysis of hematological and renal effects showed no increased risk for patients receiving IV ibuprofen. A subset analysis of elderly patients suggests that no dose adjustment is needed in this higher risk population. This integrated safety analysis demonstrates that IV ibuprofen can be safely administered prior to surgery and continued in the postoperative period as a component of multimodal pain management.

Intravenous non-opioid analgesia for peri- and postoperative pain management: a scientific review of intravenous acetaminophen and ibuprofen

Pain is a predictable consequence following operations, but the management of postoperative pain is another challenge for anesthesiologists and inappropriately controlled pain may lead to unwanted outcomes in the postoperative period. Opioids are indeed still at the mainstream of postoperative pain control, but solely using only opioids for postoperative pain management may be connected with risks of complications and adverse effects. As a consequence, the concept of multimodal analgesia has been proposed and is recommended whenever possible. Acetaminophen is one of the most commonly used analgesic and antipyretic drug for its good tolerance and high safety profiles. The introduction of intravenous form of acetaminophen has led to a wider flexibility of its use during peri- and postoperative periods, allowing the early initiation of multimodal analgesia. Many studies have revealed the efficacy, safety and opioid sparing effects of intravenous acetaminophen. Intravenous ibuprofen has also shown to be well tolerated and demonstrated to have significant opioid sparing effects during the postoperative period. However, the number of randomized controlled trials confirming the efficacy and safety is small and should be used in caution in certain group of patients. Intravenous acetaminophen and ibuprofen are important options for multimodal postoperative analgesia, improving pain and patient satisfaction.

Frequency and use of pain assessment tools implemented in randomized controlled trials in the adult burns population: a systematic review

INTRODUCTION

Pain continues to be an ongoing issue of concern in adult burn patients. Inadequate pain assessment hinders meaningful research, and prevents the optimal management of burn pain. The objective of this study was to examine the content of existing research in burn pain with the frequency and context of pain assessment tool use in randomized clinical trials in order to further inform their use for future researchers and clinicians.

METHODS

Electronic searches of MEDLINE, CINAHL, EMBASE and The Cochrane Library databases from 1966 onwards were used to identify English articles related to clinical trials utilising pain assessment in adult burns patients.

RESULTS

The systematic literature search identified 25 randomized clinical trials utilising pain assessment tools. Unidimensional pain assessment tools were most frequently used pain assessment tools, with multidimensional tools used less often, despite the multifaceted and complex nature of burn pain.

CONCLUSION

The review highlights the lack of consistency of pain assessment tool use in randomized clinical trials with respect to managing burn pain. We recommend a broader but consistent use of multidimensional pain assessment tools for researchers undertaking clinical trials in this field. The review supports the need for an international expert consensus to identify the necessary critical outcomes and domains for clinicians and researchers undertaking further research into burn pain.