ABA releases guideline on management of acute pain in burn patients
The American Burn Association (ABA) has released a guideline on the management of acute pain in adult burn patients. The guideline is published in the Journal of Burn Care & Research.
Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures. Burn pain is especially complicated; it is multifaceted and frequently changes over time as the patient undergoes repeated procedures and treatments that require manipulation of their painful burn sites.
Despite an understanding of the importance of pain management in recovery from burn wounds, numerous reports are discussing the inadequacy of treatment of burn pain. Furthermore, inconsistency in practice standards has been well documented for almost three decades.
In this guideline, the researchers reviewed the principles of acute pain management in adult burn patients and presented a reasonable approach to the management of the complex pain associated with burn injury based on a review of the literature and expert opinion.
- Pain assessments should be performed several times a day and during various phases of care.
- Pain assessments should be protocolized and recorded by the physician and the nursing staff during the various stages of care to ensure consistent language when discussing pain evaluation.
- Pain assessment tools should use patient-reported scales when able.
- The Burn Specific Pain Anxiety Scale (BSPAS) should be included as one of the pain assessments used during an acute burn hospitalization as it is a validated tool for the burn patient population and includes evaluation of anxiety.
- Critical Care Pain Observation Tool (CPOT) can be used when a patient is not able to interact or communicate their individual assessment of pain.
Opioid Pain Medications
- When choosing opioid pain medications, decisions about choice of agent should be based on physiology, pharmacology, and physician experience given the limited amount of high-quality data available.
- Opioid therapy should be individualized to each patient and continuously adjusted throughout their care due to the heterogeneity of individual responses, adverse effects, and the narrow therapeutic window of opioids.
- Attempts should be made to use as few opiate equivalents as needed to achieve the desired level of pain control.
- Opioid pain medications should not be used in isolation but in conjunction with nonopioid and nonpharmacological measures.
- Patients should be educated about the role of opioids and other pain medications in their recovery from burn injury.
Nonopioid Pain Medication
- Acetaminophen should be utilized on all burn patients, with care taken to monitor the maximal daily dose.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in all patients due to their safety profile and efficacy in other settings; however, the patient's clinical picture including baseline comorbidities and kidney function as well as surgeon preference should be included in this decision.
- Agents for the treatment of neuropathic pain (eg, gabapentin or pregabalin) should be considered as an adjunct to an opioid in patients who are having neuropathic pain or who are refractory to standard therapy.
- Ketamine should be considered for procedural sedation, with appropriate training and monitoring for the physician and nursing staff who are administering.
- Low-dose ketamine should be considered as an adjunct to opioid therapy in patients who could benefit from reduced opioid consumption, particularly in the postoperative period.
- Dexmedetomidine and clonidine are recommended as pain management adjuncts, particularly in patients showing signs of withdrawal or prominent anxiety symptoms and dexmedetomidine as a first-line sedative in the intubated burn patient.
- The use of IV lidocaine for burn pain management cannot be recommended at this time as a first-line agent, but it is a reasonable second- or third-line adjuvant agent.
- Given the lack of evidence and the potential legal and political obstacles, we are unable to make a recommendation for the use of cannabinoids in the treatment of
- acute burn pain.
- Regional anesthesia for burn pain management has the potential to provide improved pain relief, patient satisfaction, and opioid use reduction without serious risks or complications.
- Every patient should be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen. When the expertise and/or equipment is available, cognitive-behavioral therapy, hypnosis and virtual reality have the strongest evidence.
"We call for more burn specific research into all modalities for burn pain control as well as research on multimodal pain control. Additionally, we call for the use of common data elements in burn pain research studies so studies and protocols created can be reliably compared, concluded the authors.
"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," is published in the Journal of Burn Care & Research.