Introduction and objectives
One of the fundamental pillars in the treatment of patients with acute burns is effective pain management, which also requires indirect early management of short-term complications derived from ineffectual management, including venous thrombosis, hypertension with target organ, tachycardia, coronary event, hyperglycemia, immunosuppression, as well as of the long-term complications such as neuropathic pain, depression, anxiety, and joint contractures.1–6
In the current literature, pain management approaches in patients with burn injuries focus on controlling the somatic component reflecting the traumatic insult. However, pain in burn injuries is much more complex, involving multiple areas (physical, emotional, psychological) and involving pathophysiological mechanisms that mean much more than just a phenomenon that can be addressed with the administration of opioids. Consequently, pain management must be based on the best available evidence and performed by a multidisciplinary team using pharmacological and nonpharmacological interventions5,6 in order to break the vicious circle of pain and prevent the previously mentioned complications that may be triggered after a burn injury.
All of the above created the need to conduct a nonsystematic review of the literature on the comprehensive management of acute pain in patients with severe burn injury, summarizing the most relevant findings, so as to apply them at Hospital Universitario de Santander, one of the few medical centers with a care unit for burn patients. This document was developed by Universidad Industrial de Santander and it is designed to provide guidelines for acute pain management in this patient population that can be applied at any point in the acute care process. Its application is not limited just to Level III or Level IV care institutions in our country.
A nonsystematic review of the literature between 2000 and 2016, from databases such as MEDLINE/PUBMED, Embase, Science Direct, SciELO, LILACS, and Google scholar databases, as well as in academic texts, institutional management guidelines or regulatory documents, using the following search terms in English and Spanish: acute pain, burns, analgesics, therapy, pathophysiology of burns, nonpharmacologic analgesic for acute burn pain, management of pain in burned children, virtual reality in burn pain, opioid withdrawal, opioid overdose, management of pruritus in burns, acute pain in burn patients, burn, analgesia, perioperative management in burn patients, pain management in the pediatric burn patient, opioid overdosing, opioid weaning, management of pruritus in burns. Meta-analyses, clinical trials, observational studies, review articles, case series, management guidelines, and books were considered, excluding those that did not contribute relevant information about acute management and those that were outside the search dates (Figure 1). The authors read the retrieved articles and selected those cited in the references. The results of this review, from the perspective of the authors, are presented as follows.
Pain assessment must be performed before, during, and after a painful procedure, and also 30 minutes after an analgesic intervention, and it must be objective and performed regularly using a validated tool6,7 such as the following: Visual Analogue Scale (VAS), in patients over 8 years of age8; Verbal Numeric Scale (VNS), in patients over 12 years of age and in settings where there is limited understanding of the VAS8; Verbal Global Scale (VGS), in patients over 12 and in settings where there is limited understanding of the VAS and the VNS8; Smiles Pain Rating Scale (SRPS), in patients 5 to 12 years of age8; FLACC (pain facies, lower limb movements, agitation, consolabilty, and crying), in children under 5 years of age.8
Pharmacological management: general
Potent opioid drugs are the cornerstone in the management of acute pain due to burn injuries.8–11 It is suggested to initiate management with potent opioid drugs and then taper down, instead of scaling up in potency.9,12 Every service in which these drugs are used routinely must have access to oxygen sources, devices, and trained staff for cardiopulmonary cerebral (CPCR) resuscitation, and naloxone.8–10 In addition, side effects from opioid administration must be anticipated and treated aggressively.9–11,13 Extremely painful procedures or procedures that cannot be tolerated by the patient must be performed under general anaesthesia.9,10,12,14
Underlying pain management: paracetamol and nonsteoridal anti-inflammatory agents (NSAIDs)
It is advisable to give all patients a scheduled around-the-clock (ATC) prescription of paracetamol 500 mg p.o. every 6 hours in adults, and 10 to 15 mg/kg every 6 hours in children8,10,11,14 as part of underlying pain management, unless contraindicated.10,11 Adding an ATC short-cycle (maximum 3 days) prescription of nonsteoridal anti-inflammatory agents (NSAIDs) may be considered12,13 (ibuprofen 400 mg Per Os (PO) every 8 hours, 10 mg/kg every 8 hours in children over 6 months of age, or diclofenac 50 mg PO every 12 hours, 75 mg IV every 12 hours in adults, 1 to 2 mg/kg every 12 hours in children over 5 years of age), and ATC paracetamol in noncritically ill patients with preserved oral route during the acute burn phase.9
Underlying pain management: opioids
Should pain control not be achieved with the administration of paracetamol or a short cycle of NSAIDs, a weak opioid agonist should be added ATC to the pharmacological regimen, including tramadol 1 mg/kg/dose every 6 to 8 hours in children or 50 to 100 mg Intravenous (IV) every 6 to 8 hours maximum 400 mg/day in adults, or codeine 1 mg/kg/dose every 6 to 8 hours in children, or 30 to 60 mg PO every 6 hours in adults, maximum 240 mg/day.6,7,9,15
If these measures are not sufficient to achieve adequate pain control, pharmacological management with a scheduled strong opioid agonist should be initiated, making sure that the weak opioid administration is discontinued first, as follows: low-dose intravenous morphine titration (1–2 mg in adults, 0.01 mg/kg in children) every 5 to 10 minutes until pain control is achieved or until the patient is drowsy, titrating the whole dose every 4 to 6 hours if persistence of the cause of pain is anticipated.9,16,17
If no strong opioid is available, ATC administration of an agonist-antagonist opioid-like nalbuphine 0.4 mg/kg/dose every 4 to 6 hours may be prescribed instead of the weak opioid.17
Incident pain management
Another management option for acute pain is patient--controlled analgesia (PCA), which is mainly useful for incident pain management. PCA with fentanyl is recommended using 1 initial bolus of 1 μg/kg, 30 μg on demand, with 5-minute closure interval, or intravenous morphine 0.05 to 0.2 mg/kg/dose every 4 to 6 hours.7 Also useful in the management of incident pain is meperidine 1 mg/kg/dose (maximum 4 doses in total).16
Management of procedure-associated pain
There are several options with high-quality evidence for the management of pain caused by procedures in this population. The first is the application of a strong opioid before the procedure (morphine 0.05–0.2 mg/kg 10 minutes before, or fentanyl 1 μg/kg 5 minutes before) or the use of PCA associated with a benzodiazepine before the procedure (midazolam 0.05 mg/kg 30 minutes–1 hour before).6,7,12,14,18,19 The association with ketamine has been used widely for more than 40 years in burn patients, but its use has diminished because of the side effects, which can be avoided when used together with a benzodiazepine. Ketamine at a dose of 1 mg/kg associated with a benzodiazepine (midazolam 0.05 mg/kg) and an antisialagogue (atropine 0.01 mg/kg) is an excellent analgesic option, provided it is administered in centers where the anesthetist is present.6,8,14,15,19–21
Another combination of drugs that offers excellent analgesic effect for procedure-associated pain is dexmedetomidine in a 1 μg/kg bolus, associated with a bolus dose of ketamine 2 mg/kg and tramadol 1 mg/kg, in intermediate care facilities, with presence of staff trained in CPCR or of the anaesthetist.10,20,22,23
On the contrary, nonpharmacological interventions in adolescents include the association of virtual reality, performed in facilities with the appropriate infrastructure and duly trained personnel,6,13,18,24–29 as well as the use of transcutaneous electrical stimulation (TENS), before, during, and after the procedure. These interventions need to be explained to the patient and used in association with pharmacological regimens.19,30
Postoperative pain management
The plastic surgery anesthesia service should think about using preventive systemic analgesia with NSAIDs or systemic paracetamol before the procedure,16,19 and tumescent anaesthesia,6 regional blocks,6,13,14,18,21 or topical lidocaine for dressing changes6,8,15 in an attempt at providing residual analgesic effect after the surgical-anesthetic procedure. In stable patients who tolerate well the oral route, the use of weak opioids can be considered, including codeine at a dose of 30 to 60 mg every 6 hours and a maximum dose of 240 mg/day, maintaining active vigilance on side effects in order to treat them promptly. The use of conventional oxycodone at a dose of 5 to 10 mg every 8 hours or with an extended release formula every 12 to 24 hours, methadone 2.5 to 5 mg every 6 hours, or hydrocodone 5 to 10 mg every 4 to 6 hours may also be considered. It is important to try not to use oral opioids for more than 10 days in order to avoid physical dependence.6,8,18,19,31
Neuropathic pain management
Given the characteristics of the injuries in burn patients, neuropathic pain is common in this population. Consequently, the early association of pregabalin is recommended on the basis of proven clinical effectiveness in reducing peripheral and central neuropathic pain at a starting titration of 37.5 mg with oral opioid.19,32–34 In situations where there is no access to pregabalin, the use of gabapentin should be considered, at an initial titration of 300 mg PO per day.33,35,36
Pruritus must be treated with pharmacological measures such as gabapentin in incremental doses, from 300 mg up to 1500 mg/day PO37–42 and also with nonpharmacological measures proven to be effective,37,40 bearing in mind that the oral route may be used for administering medications in cases of mild burns,11,43 and that the intramuscular and subcutaneous routes should not be used in the acute phase of the burn injury.6,43
Nonpharmacological options should be offered together with pharmacological ones.9,10,21,31 In services with the adequate facilities and trained personnel, nonpharmacological strategies may include music therapy, hypnosis, nonimmersive virtual reality (images, videos, video games) or immersive virtual reality, and psychotherapy before and after any procedure, and throughout the treatment period.10,24–28,44
Management of complications secondary to the use of medications for analgesic management in burn patients
Opioid-related respiratory depression
The use of opioids in high doses in patients with burn injuries entails the risk of secondary adverse events. The most serious of those adverse events is respiratory depression. Recognizing or suspecting this condition early on is mandatory when faced with a patient with a confirmed history of receiving high-dose opioids, a respiratory rate lower than 8/minute, myosis, pulse oximetry below 90%, and drowsiness or stupor. Response must be immediate, priority alert must be sent to the anesthesia and emergency services, and tactile and auditory stimulation of the patient must be initiated. Naloxone must also be titrated at a dose of 1 μg/kg IV every 3 to 5 minutes until bradypnea resolves or the patient shows signs of recovering consciousness and an arterial oxygen saturation of 91% or higher. The attending physician must determine if the patient needs basic and/or advanced airway management and ventilation in accordance with the CPCR guidelines, in which he/she must be trained. Attention must be paid to the possibility of renarcotization, depending on the opioid that caused the depression and the form of use.9,13,22,45–47
Benzodiazepine-related respiratory depression
In case respiratory depression secondary to the use of benzodiazepines is suspected, the administration of flumazenil 0.2 mg IV every minute is recommended until the patient regains consciousness, followed by the steps described above under the heading on management of opioid-related respiratory depression.8,22,48,49
Ketamine-related psychotomimetic crisis
In the event of altered sensory perception (hallucinations, delusions) or behavior (agitation, inattention) suspected to be related to the use of ketamine, the emergency anesthesia service should be notified immediately while simultaneously initiating midazolam at a dose of 0.05 mg/kg.22,49,50
Weaning from potent parenteral opioids in the step-down unit and the intensive care unit
Whenever an opioid withdrawal syndrome is suspected, active support from the Pain Clinic and the psychology and psychiatry services of the institution must be requested.
Withdrawal syndrome in patients managed with strong opioids in the Burn Unit (step-down unit) or the Intensive Care Unit must be suspected in the presence of suggestive symptoms such as tachycardia, diaphoresis, hypertension, mydriasis, piloerection, muscle cramps, abdominal cramps, or diarrhea. Weaning from potent opioids is suggested if they have been used for more than 5 days, tapering the dose initially by 20% to 40%, followed by subsequent 10% reductions every 12 to 24 hours.51–54
In the presence of physical findings of opioid withdrawal when strong opioids have been used for more than 10 days, the initiation of substitution therapy with methadone at a fractionated equianalgesic dose every 6 to 8 hours can be considered, tapering it down by 20% every week until complete discontinuation is achieved towards the fifth week.51,55
The concomitant use of nonsubstitution therapy (benzodiazepines, clonidine) is suggested.54–56
Pain management in burn patients is a challenge given that, ideally, it requires a multidisciplinary approach. Understanding the pathophysiology of burn injuries is critical in order to understand the type and the severity of the pain that these patients may experience. Acute pain management should not focus only on the somatic components of pain but must also encompass the emotional and psychosocial components, in order to provide comprehensive management, both pharmacological and nonpharmacological.
Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.
Confidentiality of data. The authors declare that they have followed the protocols of their work center on the publication of patient data.
Right to privacy and informed consent. The authors declare that no patient data appear in this article.
The authors declare not having received external funding
Conflicts of interest
The authors declare having no conflict of interest to disclose.
1. Browne A, Andrews R, Schug S, et al. Persistent pain
outcomes and patient satisfaction with pain management
after burn injuries. Clin J Pain
2. Ramírez C, Ramírez C, González L, et al. Fisiopatología del paciente quemado. Rev Salud UIS
3. Dauber A, Osgood P, Breslau A, et al. Chronic persistent pain
after severe burns
: a survey of 358 burn survivors. Pain Med
4. Dyster-Aas J, Willebrand M, Wikehult B, et al. Major depression and posttraumatic stress disorder symptoms following severe burn injury in relation to lifetime psychiatric morbidity. J Trauma
5. Patterson D, Tininenko J, Ptacek J. Pain
during burn hospitalization predicts long term outcome. J Burn Care Res
6. Faucher L, Furukawa K. Practice guidelines for the management of pain
. J Burn Care Res
7. European Burns
Association. Practice Guidelines for Burn Care, 2nd ed. Vienna; 2013.
8. Larrea B, Avila M, Raddatz C. Manejo de dolor
en pacientes quemados. Rev Chil Anest
9. Midlands Burn Care Network, Guidelines For Pain
and Itch Management For Patients Within The Midland Burn Care Network, Birmingham (England). 1 Ed. 2011.
10. Alencar R, Cunha P, Kimiko R. Tratamiento del dolor
en quemados. Rev Bras Anestesiol
11. Aguilera F. Anestesia y manejo perioperatorio del paciente quemado. Rev Salud Bosque
12. Macintyre P, Schug S, Scott D, et al. APM: SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain
Medicine. Acute Pain
Management: Scientific Evidence 3er ed. Melbourne: ANZCA & FPM; 2010.
13. Guidelines for Pain Management
For patients within the Midland Burn Operational Delivery Network. Birmingham: Review date 2016.
14. Cordero I, Rodriguez R, Miquet L, et al. Conducta perioperatoria del paciente quemado. Rev Cub Anest Rean
15. Ministerio de Salud de Chile Guía Clínica gran Quemado. Santiago: Minsal. 2007.
16. Marret E, Kurdi O, Zufferey P, et al. Effects of nonsteroidal, antiinflammatory drugs on patient-controlled analgesia morphine side effects: meta-analysis of randomized, controlled trials. Anesthesiology
17. Ramírez C, Ramírez C, Ramírez M, Ramírez N. Manejo del paciente quemado. Rev Univ Ind Santander Salud 2007:73–86.
18. Richardson P, Mustard L. The management of pain
in the burns
19. Ministerio de Salud de Chile Guías clínicas AUGE gran quemado. Santiago: Minsal 2016.
20. Zor F, Ozturk S, Bilgin F, et al. Pain
relief during dressing changes of major adult burns
: ideal analgesic combination with ketamine. Burns
21. Larrea B. Dolor
en trauma térmico. Boletín el dolor
22. Mc Graw Hill, Morgan Ge. Morgan GE. Coadyuvantes de la Anestesia. Anestesiología Clínica
4 ed.2009. 277–279.
23. Walker J, MacCallum M, Fischer C, et al. Sedation using dexmedetomidine in pediatric burn patients. J Burn Care Res
24. Kipping B, Rodger S, Miller K, et al. Virtual reality for acute pain
reduction in adolescents undergoing burn wound care: a prospective randomized controlled trial. Burns
25. Mott J, Bucolo S, Cuttle L, et al. The efficacy of an augmented virual reality system to alleviate pain
in children undergoing burns
dressing changes: a randomised controlled trial. Burns
26. Hoffman H, Chambers G, Meyer W, et al. Virtual reality as an adjunctive non-pharmacologic analgesic for acute burn pain
during medical procedures. Ann Behav Med
27. Jonhson S, Coxon M. Sound can enhance the analgesic effect of virtual reality. R Soc Open Sci
28. Hoffman H, Sharar S, Coda B, et al. Manipulating presence influences the magnitude of virtual reality analgesia. Pain
29. Morris L, Louw Q, Grimmer-Somers K. The effectiveness of virtual reality on reducing pain
and anxiety in burn injury patients: a systematic review. Clin J Pain
30. Vásquez K, García R, Cruz M, et al. Electroterapia como manejo alternativo del dolor
en quemaduras. Rev San Milit Mex
31. Gandhi M, Thomson C, Lord D, et al. Management of pain
in children with burns
. Int J Pediatr
32. Grey P, Kirby J, Smith M, et al. Pregabalin in severe burn injury pain
: a double-blind, randomized placebo-controlled trial. Pain
33. Grey P. Acute neuropathic pain
, diagnosis and treatment. Curr Opin Anaesthesiol
34. Wong L, Turner L. Treatment of postburn neuropathic pain
: evaluation of pregrabalin. Burns
35. Cuignet O, Pirson J, Soudon O, et al. Effects of gabapentin on morphine consumption and pain
in severely burned patients. Burns
36. Grey P, Williams B, Cramond T. Successful use of gabapentin in acute pain
management following burn injury: a case series. Pain Med
37. Ahuja R, Chatterjee P. Postburn pruritus: a practical review. Indian J Burns
38. Ahuja R, Gupta G. A four arm, double blind, randomized and placebo controlled study of pregabalin in the management of postburn pruritus. Burns
39. Goutos I, Eldardiri M, Khan A, et al. Comparative evaluation of antipruritic protocols in acute burns
. The emerging value of gabapentin in the treatment of burn pruritus. J Burn Care Res
40. Goutos I. Review of therapeutic agents for burns
pruritus and protocols for management in adult and pediatric patients using the grade classification. Indian J Plast Surg
41. Orellana M, Yañez, Gutiérrez J, et al. Prurito neuropático. Revista el dolor
42. Goutos I. Neuropathic mechanisms in the pathophysiology of burns
pruritus: redefining directions for therapy and research. J Burn Care Res
43. Connolly S. Clinical Practice Guidelines: Burn Patient Management. Sydney: Agency for Clinical Innovation; 2011.
44. Moix J. La hipnosis en el tratamiento del dolor
. Rev Soc Esp Dolor
45. Boyer E. Management of opiod analgesic overdose. N Engl J Med
46. Mugabure B, González S, Uría A, et al. Actualizaciones en el manejo clínico de los opioides espinales en el dolor agudo
postoperatorio. Rev Soc Esp Dolor
47. Cadavid A. Analgesia opioide en el postoperatorio, en: Opiodes en la práctica médica. 2009; Bogotá (Colombia): Asociación colombiana para el estudio del dolor
48. Acuña J. Intoxicación grave por psicofármacos. Rev Med Clin Condes
49. Oses I, Burillo-Putze G, Munne P, et al. Intoxcaciones medicamentosas, psicofármacos y antiarrítmicos. ANALES Sis San Navarra
50. Eslava S. Aguilera F. Anestésicos endovenosos. Anestesiología y Medicina Perioperatoria
4th ed.Celsus: Bogotá; 2010. 158–164.
51. Zapantis A, Leung S. Tolerance and withdrawal issues with sedation. Crit Care Nurs Clin North Am
52. Rivera R. Sedación y analgesia: una revisión. Acta Pediátr Costarricense
53. Galinkin J, Lee J. Recognition and management of iatrogenically-induced opioid dependence and withdrawal in children. Pediatrics
54. Suttner J, White A, Vernachio K. Best practices in tapering methods in patients undergoing opioid therapy. Adv Pharmacol Pharm
55. Celis E, Besso J, Birchenall C, et al. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva
56. Baltieri D, Strain E, Dias J, et al. Brazilian guideline for the treatment of patients with opioids dependence syndrome. Rev Bras Psiquiatr