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Stanton E, Won P, Manasyan A, Gurram S, Gilllenwater TJ, Yenikomshian HA. Neuropathic pain in burn patients - A common problem with little literature: A systematic review. Burns 2024; 50:1053-1061. [PMID: 38472004 PMCID: PMC11216128 DOI: 10.1016/j.burns.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/27/2023] [Accepted: 02/21/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The prevalence of neuropathic pain (NP) in burn patients is reported in the literature to be as high as 80%1. Given the complexity of NP in burn patients and the wide range of treatments available, a systematic review of the literature is warranted to summarize our current understanding of management and treatment of NP in this population. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The following databases were queried to identify relevant articles: PubMed, Cochrane, Embase, Scopus, Ovid, and Web of Science. The main outcome measures were incidence and management of NP. Secondary outcomes included risk factors for NP. RESULTS Included articles presented findings from 11 different countries, capturing outcomes for 4366 patients. Risk factors for neuropathic pain in burn patients were identified, including older age, alcohol and substance abuse, current daily smoking, greater % total body surface area burns (TBSA), and longer hospitalizations. Pharmacologic treatments included gabapentin/pregabalin (n = 7), ascorbic acid (n = 1), and lidocaine (n = 1). Overall, the studies showed varied results regarding the efficacy of pharmacological treatments. While certain studies demonstrated gabapentanoids to be effective in reducing neuropathic symptoms, others found conflicting results. With regards to non-pharmacologic treatments, electroconvulsive therapy (n = 1), electropuncture (n = 1), nerve release/reconstruction (n = 2), and somatosensory feedback rehabilitation (n = 1) were used and demonstrated promise in reducing pain intensity and improving functionality. CONCLUSIONS Despite NP afflicting the majority of burn patients long after their injury, this systematic review demonstrates insufficient evidence on the pathophysiology, outcomes, and risk factors in NP, as well as the efficacy of various therapies. Future prospective and randomized studies evaluating the etiology of these factors can substantially improve our treatment strategies. This can allow for the development of well-delineated and evidence-based protocols in NP management in hopes of improving quality of life and both psychological and physical function in burn patients.
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Affiliation(s)
- Eloise Stanton
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA
| | - Paul Won
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA
| | | | | | - T Justin Gilllenwater
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA
| | - Haig A Yenikomshian
- Keck School of Medicine of USC, Los Angeles, CA, USA; Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA, USA.
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2
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Stanton E, McMullen K, Won P, Schneider JC, Ryan C, Carrougher G, Kowalske K, Yenikomshian HA. Neuropathic Pain After Burn Injury: A Severe and Common Problem in Recovery. Ann Surg 2024; 279:874-879. [PMID: 37916448 PMCID: PMC10997473 DOI: 10.1097/sla.0000000000006146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE The aim of this study was to address the limited understanding of neuropathic pain (NP) among burn survivors by comprehensively examining its prevalence and related factors on a national scale using the Burn Model System (BMS) National Database. BACKGROUND NP is a common but underexplored complaint among burn survivors, greatly affecting their quality of life and functionality well beyond the initial injury. Existing data on NP and its consequences in burn survivors are limited to select single-institution studies, lacking a comprehensive national perspective. METHODS The BMS National Database was queried to identify burn patients responding to NP-related questions at enrollment, 6 months, 12 months, 2 years, and 5 years postinjury. Descriptive statistics and regression analyses were used to explore associations between demographic/clinical characteristics and self-reported NP at different time points. RESULTS There were 915 patients included for analysis. At discharge, 66.5% of patients experienced NP in their burn scars. Those with NP had significantly higher Patient-Reported Outcomes Measurement Information System 29 (PROMIS-29) pain inference, itch, anxiety, depression, and sleep disturbance scores and were less able to partake in social roles. Multiple logistic regression revealed male sex, % total body surface area, and moderate-to-severe pain as predictors of NP at 6 months. At 12 months, % total body surface area and moderate-to-severe pain remained significant predictors, while ethnicity and employment status emerged as significant predictors at 24 months. CONCLUSIONS This study highlights the significant prevalence of NP in burn patients and its adverse impacts on their physical, psychological, and social well-being. The findings underscore the necessity of a comprehensive approach to NP treatment, addressing both physical symptoms and psychosocial factors.
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Affiliation(s)
- Eloise Stanton
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA
| | - Kara McMullen
- Burn Model Systems National Data and Statistical Center, University of Washington, Seattle, WA
| | - Paul Won
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA
| | - Jeffrey C Schneider
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
| | - Colleen Ryan
- Department of Surgery, Massachusetts General Hospital, Shriners Hospitals for Children®-Boston, Harvard Medical School, Boston, MA
| | - Gretchen Carrougher
- Department of Surgery, UW Medicine Regional Burn Center, University of Washington, Seattle, WA
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck Medicine of USC, Los Angeles, CA
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3
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Chiang LJ, Lai PC, Huang YT. Effectiveness and Adverse Events of Gabapentinoids as Analgesics for Patients with Burn Injuries: A Systematic Review with Meta-Analysis and Trial Sequential Analysis. J Clin Med 2023; 12:5042. [PMID: 37568444 PMCID: PMC10420087 DOI: 10.3390/jcm12155042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
(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.
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Affiliation(s)
- Liang-Jui Chiang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
| | - Pei-Chun Lai
- Education Centre, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
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4
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Pruskowski KA, Feth M, Hong L, Wiggins AR. Pharmacologic Management of Pain, Agitation, and Delirium in Burn Patients. Surg Clin North Am 2023; 103:495-504. [PMID: 37149385 DOI: 10.1016/j.suc.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
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.
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Affiliation(s)
- Kaitlin A Pruskowski
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Maximilian Feth
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA; Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Federal Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | - Linda Hong
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
| | - Amanda R Wiggins
- US Army Institute of Surgical Research, 3698 Chambers Pass, ATTN: FCMR-SRT, JBSA Fort Sam, Houston, TX 78234, USA
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5
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Roy TK, Uniyal A, Tiwari V. Multifactorial pathways in burn injury-induced chronic pain: novel targets and their pharmacological modulation. Mol Biol Rep 2022; 49:12121-12132. [PMID: 35842856 DOI: 10.1007/s11033-022-07748-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
Burn injuries are among the highly prevalent medical conditions worldwide that occur mainly in children, military veterans and victims of fire accidents. It is one of the leading causes of temporary as well as permanent disabilities in patients. Burn injuries are accompanied by pain that persists even after recovery from tissue damage which puts immense pressure on the healthcare system. The pathophysiology of burn pain is poorly understood due to its complex nature and lack of considerable preclinical and clinical shreds of evidence, that creates a substantial barrier to the development of new analgesics. Burns damage the skin layers supplied with nociceptors such as NAV1.7, TRPV1, and TRPA1. Burn injury-mediated co-localization and simultaneous activation of TRPA1 and TRPV1 in nociceptive primary afferent C-fibers which contributes to the development and maintenance of chronic pain. Burn injuries are accompanied by central sensitization, a key feature of pain pathophysiology mainly driven by a series of cascades involving aberrations in the glutamatergic system, microglial activation, release of neuropeptides, cytokines, and chemokines. Activation of p38 mitogen-activated protein kinase, altered endogenous opioid signaling, and distorted genomic expression are other pathophysiological factors responsible for the development and maintenance of burn pain. Here we discuss comprehensive literature on molecular mechanisms of burn pain and potential targets that could be translated into near future therapeutics.
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Affiliation(s)
- Tapas Kumar Roy
- Neuroscience & Pain Research Laboratory, Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University, 221005, Varanasi, U.P, India
| | - Ankit Uniyal
- Neuroscience & Pain Research Laboratory, Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University, 221005, Varanasi, U.P, India
| | - Vinod Tiwari
- Neuroscience & Pain Research Laboratory, Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology, Banaras Hindu University, 221005, Varanasi, U.P, India.
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6
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Polychronopoulou E, Kuo YF, Wilkes D, Raji MA. Prescribing of Gabapentinoids with or without opioids after burn injury in the US, 2012-2018. Burns 2022; 48:293-302. [PMID: 34991930 PMCID: PMC9007844 DOI: 10.1016/j.burns.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 12/14/2021] [Accepted: 12/17/2021] [Indexed: 12/14/2022]
Abstract
Burn injury pain manifests as a combination of inflammatory, nociceptive, and neuropathic features. While opioids are the mainstay of burn pain management, non-opioid medications, such as gabapentinoids, have also been considered as they target the central nervous system. Increased opioid adverse events and overdose deaths in the United States led to the 2014 and 2016 guidelines to reduce opioid prescribing and consider alternatives, such as gabapentinoids. In the context of burn, the rate of gabapentinoid prescribing at the national level is unknown and it is unclear whether any shift has occurred in prescribing practices over time. We conducted a population level cohort study of adult burn patients from 2012 to 2018 to evaluate the rates and determinants of gabapentinoid prescribing, with and without opioids. Of 98,001 patients with burn, 22,521 (22.98%) received opioids and/or gabapentinoids (GABA). GABA represented 2.4% of prescriptions in 2012, but increased to 7.2% by 2018, while GABA-opioid co-prescriptions increased from 2.3% to 5.1%. The rate of increase in GABA prescriptions was higher for those aged 50-65 years or residing in the South. After adjustment, GABA was 44% more likely to be prescribed in 2017 and 2018 compared to 2012 and 2013, opioids were 38% less likely, while co-prescribing did not show a statistically significant change. Our study showed a modest increase in gabapentinoids' outpatient prescribing for burn patients after the 2014 and 2016 guidelines, indicating more opportunities for prescribers to expand non-opioid pain management in this population.
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Affiliation(s)
- Efstathia Polychronopoulou
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch,Division of Rehabilitation Sciences, University of Texas Medical Branch
| | - Yong-Fang Kuo
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch,Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch,Sealy Center on Aging, University of Texas Medical Branch,Institute for Translational Sciences, University of Texas Medical Branch
| | - Denise Wilkes
- Department of Anesthesiology, The University of Texas Medical Branch
| | - Mukaila A. Raji
- Department of Preventive Medicine and Population Health, University of Texas Medical Branch,Department of Internal Medicine, Division of Geriatrics and Palliative Medicine, University of Texas Medical Branch,Sealy Center on Aging, University of Texas Medical Branch
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7
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Burn Wound Healing: Clinical Complications, Medical Care, Treatment, and Dressing Types: The Current State of Knowledge for Clinical Practice. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19031338. [PMID: 35162360 PMCID: PMC8834952 DOI: 10.3390/ijerph19031338] [Citation(s) in RCA: 76] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/13/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023]
Abstract
According to the World Health Organization (WHO), it is estimated that each year approximately 11 million people suffer from burn wounds, 180,000 of whom die because of such injuries. Regardless of the factors causing burns, these are complicated wounds that are difficult to heal and are associated with high mortality rates. Medical care of a burn patient requires a lot of commitment, experience, and multidirectional management, including surgical activities and widely understood pharmacological approaches. This paper aims to comprehensively review the current literature concerning burn wounds, including classification of burns, complications, medical care, and pharmacological treatment. We also overviewed the dressings (with an emphasis on the newest innovations in this field) that are currently used in medical practice to heal wounds.
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8
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McGovern C, Quasim T, Puxty K, Shaw M, Ng W, Gilhooly C, Arkoulis N, Basler M, Macfarlane A, Paton L. Neuropathic agents in the management of pruritus in burn injuries: a systematic review and meta-analysis. Trauma Surg Acute Care Open 2021; 6:e000810. [PMID: 34722931 PMCID: PMC8547510 DOI: 10.1136/tsaco-2021-000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 09/02/2021] [Indexed: 11/03/2022] Open
Abstract
Objectives Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury. Methods A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included. Results Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83). Conclusion This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce. Level of evidence Systematic review, level II.
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Affiliation(s)
- Christopher McGovern
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Tara Quasim
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Kathryn Puxty
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Martin Shaw
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Department of Clinical Physics and Bioengineering, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Wijnand Ng
- Medical Student, University of Glasgow, Glasgow, UK
| | - Charlotte Gilhooly
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
| | - Nikolaos Arkoulis
- Plastic and Burn Surgery, Glasgow Royal Infirmary, Glasgow, UK.,Honorary Clinical Senior Lecturer (Medicine), University of Glasgow, Glasgow, UK
| | - Michael Basler
- Anaesthesia and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Alan Macfarlane
- Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK.,Anaesthesia and Pain Medicine, Glasgow Royal Infirmary, Glasgow, UK
| | - Lia Paton
- Anaesthesia & Critical Care, Glasgow Royal Infirmary, Glasgow, UK
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9
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Chaghazardi S, Hedari M, Bazargan-Hejazi S, Mohammadi R, Ahmadi A. Comparing the Effect of Gabapentin, Ketamine, Dexmedetomidine, and Entonox on Pain Control in Burn Wound Dressing. J Burn Care Res 2021; 41:151-158. [PMID: 31630182 DOI: 10.1093/jbcr/irz142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Simin Chaghazardi
- Injury and Pain Management Research Center, Department of Anesthesiology Critical Care and Pain Management, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammadbagher Hedari
- Injury and Pain Management Research Center, Department of Anesthesiology Critical Care and Pain Management, Kermanshah University of Medical Sciences, Kermanshah, Iran.,Department of Surgery, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, College of Medicine, Charles Drew University of Medicine and Science & David Geffen School of Medicine at University of California, Los Angeles (UCLA), CA
| | - Reza Mohammadi
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Family Medicine and Primary Care, Karolinska Institutet, Huddinge, Sweden
| | - Alireza Ahmadi
- Department of Anesthesiology Critical Care and Pain Management, Kermanshah University of Medical Sciences, Kermanshah, Iran
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10
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Glucose Metabolism in Burns-What Happens? Int J Mol Sci 2021; 22:ijms22105159. [PMID: 34068151 PMCID: PMC8153015 DOI: 10.3390/ijms22105159] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 11/16/2022] Open
Abstract
Severe burns represent an important challenge for patients and medical teams. They lead to profound metabolic alterations, trigger a systemic inflammatory response, crush the immune defense, impair the function of the heart, lungs, kidneys, liver, etc. The metabolism is shifted towards a hypermetabolic state, and this situation might persist for years after the burn, having deleterious consequences for the patient's health. Severely burned patients lack energy substrates and react in order to produce and maintain augmented levels of glucose, which is the fuel "ready to use" by cells. In this paper, we discuss biological substances that induce a hyperglycemic response, concur to insulin resistance, and determine cell disturbance after a severe burn. We also focus on the most effective agents that provide pharmacological modulations of the changes in glucose metabolism.
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11
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Storey K, Kimble RM, Holbert MD. The Management of Burn Pain in a Pediatric Burns-Specialist Hospital. Paediatr Drugs 2021; 23:1-10. [PMID: 33447938 DOI: 10.1007/s40272-020-00434-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Appropriate pain management for children who have experienced an acute burn injury is critical to improve patient outcomes and reduce potential morbidities. With 60% of our patients being under the age of 4 years, pain management is crucial in reducing pain and anxiety in both patients and parents. It is imperative that appropriate pain relief is commenced from initial contact with healthcare workers as this will affect the success or failure of future wound procedures. Uncontrolled pain can negatively affect a patient, both short and long term. It may cause anticipatory anxiety for future medical procedures, increased pain and anxiety can decrease wound re-epithelialization which can lead to long-term consequences for growth and mobility, and increased pain can also influence the possibility of patients and families displaying signs of post-traumatic stress disorder. Pain management in the form of pharmaceuticals is imperative during burn wound treatment and should incorporate pain relief targeted at both background and procedural pain. It also requires a multimodal, individualized, and targeted approach combining both pharmaceutical and nonpharmaceutical techniques, including cold running water, multimodal distraction devices, hypnotherapy, and bubbles. We discuss the research and knowledge that our center has gained through treating pediatric patients with burns over the last 20 years.
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Affiliation(s)
- Kristen Storey
- Centre for Children's Burns and Trauma Research, Centre for Children's Health Research, South Brisbane, QLD, Australia. .,Pegg Leditschke Paediatric Burns Centre, The Queensland Children's Hospital, South Brisbane, QLD, Australia. .,Queensland University of Technology, Brisbane, QLD, Australia. .,Children's Health Queensland Hospital and Health Service, Queensland Children's Hospital, 501 Stanley Street, South Brisbane, QLD, 4101, Australia.
| | - Roy M Kimble
- Centre for Children's Burns and Trauma Research, Centre for Children's Health Research, South Brisbane, QLD, Australia.,Pegg Leditschke Paediatric Burns Centre, The Queensland Children's Hospital, South Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Queensland University of Technology, Brisbane, QLD, Australia
| | - Maleea D Holbert
- Centre for Children's Burns and Trauma Research, Centre for Children's Health Research, South Brisbane, QLD, Australia.,Pegg Leditschke Paediatric Burns Centre, The Queensland Children's Hospital, South Brisbane, QLD, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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12
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Romanowski KS, Carson J, Pape K, Bernal E, Sharar S, Wiechman S, Carter D, Liu YM, Nitzschke S, Bhalla P, Litt J, Przkora R, Friedman B, Popiak S, Jeng J, Ryan CM, Joe V. 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. J Burn Care Res 2020; 41:1129-1151. [PMID: 32885244 PMCID: PMC7703676 DOI: 10.1093/jbcr/iraa119] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kathleen S Romanowski
- University of California, Davis and Shriners Hospitals for Children Northern California, Sacramento, California
| | - Joshua Carson
- University of Florida Health Shands Burn Center, Gainesville, Florida
| | - Kate Pape
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Sam Sharar
- University of Washington School of Medicine, Harborview Medical Center, Seattle Washington
| | - Shelley Wiechman
- University of Washington School of Medicine, Harborview Medical Center, Seattle Washington
| | | | - Yuk Ming Liu
- Loyola University Medical Center, Maywood, Illinois
| | | | - Paul Bhalla
- University of Washington School of Medicine, Harborview Medical Center, Seattle Washington
| | - Jeffrey Litt
- University of Missouri School of Medicine, Columbia, Missouri
| | - Rene Przkora
- University of Florida Health, Anesthesiology and Pain Medicine, Gainesville, Florida
| | | | | | - James Jeng
- Nathan Speare Regional Burn Treatment Center Crozer Chester Medical Center, Upland, Pennsylvania
| | - Colleen M Ryan
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, and Shriners Hospitals for Children-Boston®, Boston, Massachusetts
| | - Victor Joe
- University of California Irvine Regional Burn Center, Orange, California
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Khammissa RAG, Ballyram R, Fourie J, Bouckaert M, Lemmer J, Feller L. Selected pathobiological features and principles of pharmacological pain management. J Int Med Res 2020; 48:300060520903653. [PMID: 32408839 PMCID: PMC7232056 DOI: 10.1177/0300060520903653] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/07/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Razia Abdool Gafaar Khammissa
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
- Department of Periodontics and Oral Medicine, University of
Pretoria, Pretoria, South Africa
| | - Raoul Ballyram
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
| | - Jeanine Fourie
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
| | - Michael Bouckaert
- Department of Maxillofacial and Oral Surgery, Sefako Makgatho
University, Pretoria, South Africa
| | - Johan Lemmer
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
| | - Liviu Feller
- Department of Periodontology and Oral Medicine, Sefako Makgatho
University, Pretoria, South Africa
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Kim DE, Pruskowski KA, Ainsworth CR, Linsenbardt HR, Rizzo JA, Cancio LC. A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis. J Burn Care Res 2019; 40:983-995. [DOI: 10.1093/jbcr/irz111] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Abstract
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.
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Affiliation(s)
- Daniel E Kim
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kaitlin A Pruskowski
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Craig R Ainsworth
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Julie A Rizzo
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas
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Najafi A, Zeinali Nejad H, Nikvarz N. Evaluation of the analgesic effects of duloxetine in burn patients: An open-label randomized controlled trial. Burns 2019; 45:598-609. [DOI: 10.1016/j.burns.2018.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/07/2018] [Accepted: 10/17/2018] [Indexed: 12/22/2022]
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16
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Morgan M, Deuis JR, Frøsig-Jørgensen M, Lewis RJ, Cabot PJ, Gray PD, Vetter I. Burn Pain: A Systematic and Critical Review of Epidemiology, Pathophysiology, and Treatment. PAIN MEDICINE 2019; 19:708-734. [PMID: 29036469 DOI: 10.1093/pm/pnx228] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective This review aims to examine the available literature on the epidemiology, pathophysiology, and treatment of burn-induced pain. Methods A search was conducted on the epidemiology of burn injury and treatment of burn pain utilizing the database Medline, and all relevant articles were systemically reviewed. In addition, a critical review was performed on the pathophysiology of burn pain and animal models of burn pain. Results The search on the epidemiology of burn injury yielded a total of 163 publications of interest, 72 of which fit the inclusion/exclusion criteria, with no publications providing epidemiological data on burn injury pain management outcomes. The search on the treatment of burn pain yielded a total of 213 publications, 14 of which fit the inclusion/exclusion criteria, highlighting the limited amount of evidence available on the treatment of burn-induced pain. Conclusions The pathophysiology of burn pain is poorly understood, with limited clinical trials available to assess the effectiveness of analgesics in burn patients. Further studies are needed to identify new pharmacological targets and treatments for the effective management of burn injury pain.
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Affiliation(s)
- Michael Morgan
- Centre for Pain Research, Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland, Australia
| | - Jennifer R Deuis
- Centre for Pain Research, Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland, Australia
| | - Majbrit Frøsig-Jørgensen
- Centre for Pain Research, Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland, Australia
| | - Richard J Lewis
- Centre for Pain Research, Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland, Australia
| | - Peter J Cabot
- School of Pharmacy, The University of Queensland, Wooloongabba, Queensland, Australia
| | - Paul D Gray
- Tess Cramond Multidisciplinary Pain Centre, Royal Brisbane & Women's Hospital, Metro North Health, Herston, Queensland, Australia.,School of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - Irina Vetter
- Centre for Pain Research, Institute for Molecular Bioscience, The University of Queensland, St Lucia, Queensland, Australia.,School of Pharmacy, The University of Queensland, Wooloongabba, Queensland, Australia
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17
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A novel double-layered polymeric nanofiber-based dressing with controlled drug delivery for pain management in burn wounds. Polym Bull (Berl) 2019. [DOI: 10.1007/s00289-019-02727-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Pain Management in Pediatric Burn Patients: Review of Recent Literature and Future Directions. J Burn Care Res 2018; 38:335-347. [PMID: 27893572 DOI: 10.1097/bcr.0000000000000470] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Childhood burns are a profoundly traumatic and painful experience. Despite recognition of the prevalence of burn injuries in children and the severity of the associated pain, burn pain remains undertreated. At the same time, more evidence is emerging to suggest that undertreated pain has serious long-term medical and psychiatric consequences, many of which can be ameliorated with improved pain control. Pain in burn patients is, however, notoriously difficult to treat, perhaps because there is a chronic pain aspect underlying the acute pain that accompanies wound care and procedures. This difficulty is compounded by the fact that there are little data to guide decision making in these patients. This article aims to identify the best strategies to guide clinical practice through a review of the past 10 years' development in pediatric burn pain management. However, because clinical investigations remain limited in burned children, we also aim to draw attention to those areas where the data do not identify an optimal approach and further work is needed. Overall, in addition to just the traditional pharmacological approaches to pain, such as acetaminophen, benzodiazepines, and opioids, there is growing evidence to support more widespread use of regional anesthesia and novel technologies such as virtual reality. Starting with an improved understanding of the current state of the literature, we can identify areas of research and important questions whose answers will ultimately improve care and reduce suffering for this unfortunate population of children.
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20
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Abstract
This article describes pathophysiology of burn injury-related pain and the basic principles of burn pain management. The focus is on concepts of perioperative and periprocedural pain management with extensive discussion of opioid-based analgesia, including patient-controlled analgesia, challenges of effective opioid therapy in opioid-tolerant patients, and opioid-induced hyperalgesia. The principles of multimodal pain management are discussed, including the importance of psychological counseling, perioperative interventional pain procedures, and alternative pain management options. A brief synopsis of the principles of outpatient pain management is provided.
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Affiliation(s)
- Dominika Lipowska James
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Maryam Jowza
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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21
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Boyle R, van Zundert AAJ. Professor Tess Cramond (1926–2015): Contributions to Anaesthesia and Pain Medicine. Anaesth Intensive Care 2017. [DOI: 10.1177/0310057x170450s102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Professor Tess Cramond joined the Queensland anaesthesia workforce in 1958, and contributed to high standards of clinical practice, pain management, training, scholarship and research. Evidence of her excellence, within the clinical, political and community spheres was recognised by multiple awards. Though deceased in 2015, she remains a role model for all physicians, using her expert knowledge, technical skills, clinical reasoning, emotions and values for the benefit of the individuals and community which she served.
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Affiliation(s)
- R. Boyle
- Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland
| | - A. A. J. van Zundert
- University of Queensland and Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland
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Abstract
Although pain management is a major challenge for clinicians, appropriate pain control is the foundation of efficacious burn care from initial injury to long-term recovery. The very treatments designed to treat burn wounds may inflict more pain than the initial injury itself, making it the clinician's duty to embrace a multimodal treatment approach to burn pain. Vigilant pain assessment, meaningful understanding of the pathophysiology and pharmacologic considerations across different phases of burn injury, and compassionate attention to anxiety and other psychosocial contributors to pain will enhance the clinician's ability to provide excellent pain management.
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Affiliation(s)
- Cornelia Griggs
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jeremy Goverman
- Division of Burn and Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Levi
- Division of Plastic Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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25
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Yin K, Deuis JR, Lewis RJ, Vetter I. Transcriptomic and behavioural characterisation of a mouse model of burn pain identify the cholecystokinin 2 receptor as an analgesic target. Mol Pain 2016; 12:12/0/1744806916665366. [PMID: 27573516 PMCID: PMC5007901 DOI: 10.1177/1744806916665366] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/22/2016] [Indexed: 12/23/2022] Open
Abstract
Burn injury is a cause of significant mortality and morbidity worldwide and is frequently associated with severe and long-lasting pain that remains difficult to manage throughout recovery. We characterised a mouse model of burn-induced pain using pharmacological and transcriptomic approaches. Mechanical allodynia elicited by burn injury was partially reversed by meloxicam (5 mg/kg), gabapentin (100 mg/kg) and oxycodone (3 and 10 mg/kg), while thermal allodynia and gait abnormalities were only significantly improved by amitriptyline (3 mg/kg) and oxycodone (10 mg/kg). The need for relatively high opioid doses to elicit analgesia suggested a degree of opioid resistance, similar to that shown clinically in burn patients. We thus assessed the gene expression changes in dorsal root ganglion neurons and pathophysiological mechanisms underpinning burn injury-induced pain using a transcriptomic approach. Burn injury was associated with significantly increased expression of genes associated with axon guidance, neuropeptide signalling, behavioural defence response and extracellular signalling, confirming a mixed neuropathic and inflammatory aetiology. Notably, among the pain-related genes that were upregulated post-injury was the cholecystokinin 2 receptor (Cckbr), a G protein-coupled receptor known as a pain target involved in reducing opioid effectiveness. Indeed, the clinically used cholecystokinin receptor antagonist proglumide (30 mg/kg) was effective at reversing mechanical allodynia, with additional analgesia evident in combination with low-dose oxycodone (1 mg/kg), including significant reversal of thermal allodynia. These findings highlight the complex pathophysiological mechanisms underpinning burn injury-induced pain and suggest that cholecystokinin-2 receptor antagonists may be useful clinically as adjuvants to decrease opioid requirements and improve analgesic management.
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Affiliation(s)
- Kathleen Yin
- Centre for Pain Research, Institute for Molecular Bioscience, University of Queensland, Queensland, Australia
| | - Jennifer R Deuis
- Centre for Pain Research, Institute for Molecular Bioscience, University of Queensland, Queensland, Australia
| | - Richard J Lewis
- Centre for Pain Research, Institute for Molecular Bioscience, University of Queensland, Queensland, Australia
| | - Irina Vetter
- Centre for Pain Research, Institute for Molecular Bioscience, University of Queensland, Queensland, Australia Pharmacy Australia Centre of Excellence, University of Queensland, Queensland, Australia
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McIntyre MK, Clifford JL, Maani CV, Burmeister DM. Progress of clinical practice on the management of burn-associated pain: Lessons from animal models. Burns 2016; 42:1161-72. [PMID: 26906668 DOI: 10.1016/j.burns.2016.01.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 01/05/2016] [Accepted: 01/21/2016] [Indexed: 02/08/2023]
Abstract
Opioid-based analgesics provide the mainstay for attenuating burn pain, but they have a myriad of side effects including respiratory depression, nausea, impaired gastrointestinal motility, sedation, dependence, physiologic tolerance, and opioid-induced hyperalgesia. To test and develop novel analgesics, validated burn-relevant animal models of pain are indispensable. Herein we review such animal models, which are mostly limited to rodent models of burn-induced, inflammatory, and neuropathic pain. The latter two are pain syndromes that provide insight into the pain caused by systemic pro-inflammatory cytokines and direct injury to nerves (e.g., after severe burn), respectively. To date, no single animal model optimally mimics the complex pathophysiology and pain that a human burn patient experiences. No currently available burn-pain model examines effects of pharmacological intervention on wound healing. As cornerstones of pain and wound healing, pro-inflammatory mediators may be utilized for insight into both processes. Moreover, common clinical concerns such as systemic inflammatory response syndrome and multiple organ dysfunction remain unaddressed. For development of analgesics, these aberrations can significantly alter the potential efficacy and/or adverse effects of a prescribed analgesic following burn trauma. We therefore suggest that a multi-model strategy would be the most clinically relevant when evaluating novel analgesics for use in burn patients.
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Affiliation(s)
- Matthew K McIntyre
- United States Army Institute of Surgical Research, 3650 Chambers Pass, BHT1:Bldg 3610, JBSA Fort Sam Houston, TX 78234-6315, United States.
| | - John L Clifford
- United States Army Institute of Surgical Research, 3650 Chambers Pass, BHT1:Bldg 3610, JBSA Fort Sam Houston, TX 78234-6315, United States.
| | - Christopher V Maani
- Brooke Army Medical Center, Department of Anesthesia and Operative Services, San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Anesthesia Residency Program, 3551 Roger Brooke Drive, JBSA Fort Sam Houston, TX 78234-6315, United States.
| | - David M Burmeister
- United States Army Institute of Surgical Research, 3650 Chambers Pass, BHT1:Bldg 3610, JBSA Fort Sam Houston, TX 78234-6315, United States.
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Abstract
Thermally injured patients experience tremendous pain from the moment of injury to months or years after their discharge from the hospital. Pain is therefore a critical component of proper management of burns. Although the importance of pain is well recognized, it is often undertreated. Acute uncontrolled pain has been shown to increase the incidence of mental health disorders and increase the incidence of suicide after discharge. Long-term poor pain control leads to an increase in the incidence of persistent pain. Most burn centers have used opioids as the mainstay analgesic, but recently, the significant side effects of opioids have led to the implementation of new and combined therapeutics. Pharmacological agents such as gabapentin, clonidine, dexmedetomidine, and ketamine have all been suggested as adjuncts to opioids in the treatment of burn pain. Nonpharmacological therapies such as hypnosis, virtual reality devices, and behavioral therapy are also essential adjuncts to current medications. This review aims at identifying the currently available pharmacological and nonpharmacological options for optimal pain management in the adult burn population.
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Abstract
Successful treatment of burn pain requires a multimodality approach. Although opioid agents are the mainstay, other nonopioid agents, such as anticonvulsants, are frequently employed for pain control, with unknown benefits. The authors sought to determine the efficacy of gabapentin in acute burn pain management. Patients admitted to the burn center with burns more than 5% total body surface area and expected length of stay more than 48 hours were randomized and prospectively enrolled in this double-blind, placebo-controlled study from February 2010 to September 2011. Drug escalation and titration were done by protocol. Pain was assessed by unit protocol with the Numeric Rating Scale. Neuropathic pain and anxiety were recorded at least biweekly. Psychosocial adjustment was assessed at follow-up. Opioid medications were converted to morphine equivalents. Differences between pain levels and opioid consumption were analyzed between groups with the Student's t-test and χ test, respectively. The study was designed to detect a difference of 22% in opioid use between the two study groups with an enrollment of 50 patients with α of 0.05 and β of 80%. P < .5 was considered significant. Fifty-three patients consented for the study and received the loading dose. Four patients withdrew. Both an intention-to-treat and actual treatment analysis were performed on all 53 patients. The placebo and drug populations were well matched for demographic variables, body surface area burned, and need for surgical intervention. The average length of stay was 11 ± 6.8 days and did not vary between groups. The study drug group received 10.8 ± 0.67 days of study drug, with eight patients receiving a dosage of 300 mg thrice daily (TID), 24 receiving 600 mg TID, 14 receiving 800 mg TID, and seven receiving 1200 mg TID. The incidence of neuropathic pain was 39% in the study drug arm and 38% in the placebo group. Neither pain scores (rest and procedural) nor opioid consumption differed between the groups. Forty-three patients (81.1%) were assessed at their first clinic visit. There was no difference in psychosocial functioning in either treatment group. In this randomized, double-blind, placebo-controlled study, the use of gabapentin in acute burn pain management did not decrease pain scores or lessen opioid requirements. Further research into nonopioid alternatives for burn pain analgesia is needed.
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Goldschneider KR, Good J, Harrop E, Liossi C, Lynch-Jordan A, Martinez AE, Maxwell LG, Stanko-Lopp D. Pain care for patients with epidermolysis bullosa: best care practice guidelines. BMC Med 2014; 12:178. [PMID: 25603875 PMCID: PMC4190576 DOI: 10.1186/s12916-014-0178-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 09/09/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Inherited epidermolysis bullosa (EB) comprises a group of rare disorders that have multi-system effects and patients present with a number of both acute and chronic pain care needs. Effects on quality of life are substantial. Pain and itching are burdensome daily problems. Experience with, and knowledge of, the best pain and itch care for these patients is minimal. Evidence-based best care practice guidelines are needed to establish a base of knowledge and practice for practitioners of many disciplines to improve the quality of life for both adult and pediatric patients with EB. METHODS The process was begun at the request of Dystrophic Epidermolysis Bullosa Research Association International (DEBRA International), an organization dedicated to improvement of care, research and dissemination of knowledge for EB patients worldwide. An international panel of experts in pain and palliative care who have extensive experience caring for patients with EB was assembled. Literature was reviewed and systematically evaluated. For areas of care without direct evidence, clinically relevant literature was assessed, and rounds of consensus building were conducted. The process involved a face-to-face consensus meeting that involved a family representative and methodologist, as well as the panel of clinical experts. During development, EB family input was obtained and the document was reviewed by a wide variety of experts representing several disciplines related to the care of patients with EB. RESULTS The first evidence-based care guidelines for the care of pain in EB were produced. The guidelines are clinically relevant for care of patients of all subtypes and ages, and apply to practitioners of all disciplines involved in the care of patients with EB. When the evidence suggests that the diagnosis or treatment of painful conditions differs between adults and children, it will be so noted. CONCLUSIONS Evidence-based care guidelines are a means of standardizing optimal care for EB patients, whose disease is often times horrific in its effects on quality of life, and whose care is resource-intensive and difficult. The guideline development process also highlighted areas for research in order to improve further the evidence base for future care.
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Affiliation(s)
- Kenneth R Goldschneider
- Pain Management Center, Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | - Julie Good
- Lucille Packard Children's Hospital, Department of Anesthesia (by courtesy, Pediatrics), Stanford University, Stanford, California, USA.
| | - Emily Harrop
- Helen and Douglas Hospices, Oxford and John Radcliffe Hospital, Oxford, USA.
| | - Christina Liossi
- University of Southampton, Southampton, UK.
- Great Ormond Street Hospital for Children NHS Trust, London, UK.
| | - Anne Lynch-Jordan
- Pain Management Center and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
| | - Anna E Martinez
- National Paediatric Epidermolysis Bullosa Centre, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Lynne G Maxwell
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Danette Stanko-Lopp
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Thomas JM, Bester K. Paediatric burns anaesthesia: the things that make a difference. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201181.2014.979630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Wolf SE, Tompkins RG, Herndon DN. On the horizon: research priorities in burns for the next decade. Surg Clin North Am 2014; 94:917-30. [PMID: 25085097 DOI: 10.1016/j.suc.2014.05.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This review demonstrates that many advances have been made in burn care that have made dramatic differences in mortality, clinical outcomes, and quality of life in burn survivors; however, much work remains. In reality, the current standard of care is insufficient and we cannot be satisfied with the status quo. We must strive for the following goals: no deaths due to burn, no scarring, and no pain. These particular goals have only begun to be confronted.
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Affiliation(s)
- Steven E Wolf
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines, Dallas, TX 75390-9158, USA.
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, 301 University, Galveston, TX 77550, USA
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Zachariah JR, Rao AL, Prabha R, Gupta AK, Paul MK, Lamba S. Post burn pruritus—A review of current treatment options. Burns 2012; 38:621-9. [DOI: 10.1016/j.burns.2011.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 11/01/2011] [Accepted: 12/10/2011] [Indexed: 11/29/2022]
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McClenaghan F. The concurrent use of gabapentin and opioid analgesia in burns patients. ARCHIVES OF TRAUMA RESEARCH 2012; 1:81-2. [PMID: 24396750 PMCID: PMC3876521 DOI: 10.5812/atr.6636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Revised: 06/17/2012] [Accepted: 06/21/2012] [Indexed: 11/23/2022]
Affiliation(s)
- Fiona McClenaghan
- Oral and Maxillofacial Department, Royal London Hospital, London, UK
- Corresponding author: Fiona McClenaghan, Oral and Maxillofacial Department, Royal London Hospital, London, UK. Tel.: +44-7880785300, Fax: +44-7880785300. E-mail:
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Dehkordi MA, Abolbashari S, Taheri R, Einolghozati S. Efficacy of gabapentin on subjective idiopathic tinnitus: a randomized, double-blind, placebo-controlled trial. EAR, NOSE & THROAT JOURNAL 2011; 90:150-8. [PMID: 21500166 DOI: 10.1177/014556131109000405] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tinnitus can cause extreme morbidity. Despite many attempts to find a treatment for idiopathic cases, they remain difficult to manage. Because nerve injury is one of the suspected etiologies of tinnitus and because gabapentin has been found to be effective in treating nerve injuries, some authors have attempted to determine if gabapentin has a role in treating tinnitus. Although gabapentin was found to be ineffective for tinnitus in these previous studies, to the best of our knowledge no studies have been performed that took into consideration the presence of various accompanying factors and concomitant diseases that might influence its effect. We conducted a prospective, randomized, double-blind, placebo-controlled clinical trial of gabapentin for idiopathic tinnitus. We treated 40 patients with gabapentin and measured its effectiveness by comparing differences between pre- and post-treatment Tinnitus Severity Index (TSI) values and tinnitus loudness scores. We also compared these outcomes with those of a group of 40 matched placebo controls. At study's end, we found no significant differences between the gabapentin and control groups in mean decreases in TSI value and loudness score (p=0.85 and p=0.12, respectively). However, we did find that patients with hypertension, diabetes, and/or dyslipidemia showed a better response to gabapentin than did those with tinnitus alone (p=0.01). We conclude that although there was no statistically significant difference between gabapentin and placebo in treating isolated tinnitus or tinnitus overall, patients with concomitant hypertension, diabetes, and/or dyslipidemia may benefit from gabapentin.
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Pregabalin in severe burn injury pain: A double-blind, randomised placebo-controlled trial. Pain 2011; 152:1279-1288. [DOI: 10.1016/j.pain.2011.01.055] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 01/31/2011] [Accepted: 01/31/2011] [Indexed: 11/23/2022]
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Davis MP. Opioid tolerance and hyperalgesia: basic mechanisms and management in review. PROGRESS IN PALLIATIVE CARE 2011. [DOI: 10.1179/174329111x13045147380537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Gandhi M, Thomson C, Lord D, Enoch S. Management of pain in children with burns. Int J Pediatr 2010; 2010:825657. [PMID: 20885937 PMCID: PMC2946605 DOI: 10.1155/2010/825657] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Accepted: 06/23/2010] [Indexed: 01/03/2023] Open
Abstract
Burn injuries are common in children under 10 years of age. Thermal injury is the most common mechanism of injury and scalds account for >60% of such injuries. All children with burns will experience pain, regardless of the cause, size, or burn depth. Undertreated pain can result in noncompliance with treatment and, consequently, prolonged healing. It is acknowledged that the monitoring and reporting of pain in children with burns has generally been poor. Due to the adverse physiological and emotional effects secondary to pain, adequate pain control is an integral and requisite component in the management of children with burns. A multidisciplinary approach is frequently necessary to achieve a robust pain relief. Key to successful treatment is the continuous and accurate assessment of pain and the response to therapy. This clinical review article discusses the essential aspects of the pathophysiology of burns in children provides an overview of pain assessment, the salient principles in managing pain, and the essential pharmacodynamics of commonly used drugs in children with burn injuries. Both pharmacological and nonpharmacological treatment options are discussed, although a detailed review of the latter is beyond the scope and remit of this article.
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Affiliation(s)
- M. Gandhi
- Central Manchester and Manchester University Children's Hospitals NHS Trust, Manchester, UK
| | - C. Thomson
- Central Manchester and Manchester University Children's Hospitals NHS Trust, Manchester, UK
| | - D. Lord
- Central Manchester and Manchester University Children's Hospitals NHS Trust, Manchester, UK
| | - S. Enoch
- University Hospitals of South and Central Manchester, Manchester, UK
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
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Treatment of post-burn neuropathic pain: Evaluation of pregablin. Burns 2010; 36:769-72. [DOI: 10.1016/j.burns.2009.05.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2008] [Revised: 05/04/2009] [Accepted: 05/29/2009] [Indexed: 11/18/2022]
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The management of pain in the burns unit. Burns 2009; 35:921-36. [DOI: 10.1016/j.burns.2009.03.003] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Revised: 02/10/2009] [Accepted: 03/16/2009] [Indexed: 01/17/2023]
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