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Pain Management in Burn Patient

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Title: Pain Management in Burn Patient


1
Pain Management in Burn Patient
  • Dr. Mohammad Amin K Mirza
  • Saudi Arab Board in General Surgery ( R3 )
  • Holy Makkah KSA
  • September 2005

2
Why this Topic ?????
  • The pain associated with burn injury and
    treatment is often managed poorly .
  • The pain associated with a major burn can be the
    most excruciating experience of a person's life.
  • The severity of burn pain is difficult to predict
    from wound depth, but for many patients it is
    extremely severe.
  • The pain can last for over a year after the
    initial injury and can cause marked psychological
    and functional difficulties. ( can increase the
    hypermetabolic state leading to impaired wound
    healing and increase the susceptibility to
    infection and may cause delirium, depression,
    post traumatic stress disorder, or other
    psychiatric disorders)

3
important to avoid under treating burn pain
4
Pathophysiology
  • The immediate pain that follows a burn injury is
    due to the stimulation of skin nociceptors (pain
    sensing nerves).
  • Nerve endings that are completely destroyed will
    not transmit pain, but those that remain intact
    will trigger pain throughout the time and course
    of treatment, as will regenerating nerves - those
    still connected with intact afferent fibres
  • Nociceptors in skin stimulated by the initial
    thermal injury account for the immediate pain.

5
Primary hyperalgesia
  • A burn injury will immediately prompt an intense
    inflammatory response and the release of chemical
    mediators(e.g. bradykinin, histamine, substance
    P) that sensitise the active nociceptors at the
    site of injury.
  • The wound becomes sensitive to mechanical
    stimuli such as touch, rubbing or debridement, as
    well as chemical stimuli such as antiseptics or
    other topical applications

6
Secondary hyperalgesia
  • Continuous or repeated peripheral stimulation of
    nociceptive afferent fibres induces a significant
    increase in dorsal horn excitability, partly via
    N-methyl-D-aspartate (NMDA) receptors , leading
    to increased sensitivity in the surrounding
    unburned areas of skin.
  • 'wind-up' pain is a component of post-burn
    hyperalgesia, and is exacerbated by the
    mechanical stimulation that occurs as a result of
    frequent dressing changes. ( Pedersen and Kehlet
    )
  • may also be partly responsible for a patient's
    increased pain sensitivity observed during the
    course of burn management and reflected in the
    greater opioid requirement for dressing changes
    over time
  • opioid tolerance or increased pain sensitivity

7
Neuropathic pain
8
Causes of pain in burn patient
  • Wound.
  • Dressing
  • Procedures (Debridment Grafting)
  • The most painful stage to be the removal of the
    innermost layer of gauze, which usually adheres
    to some degree to the wound bed. (Atchison et al
    )
  • Debridement and topical applications then
    following.
  • The different types of burn pain include
    background, breakthrough, and procedure-related
    (incident) pain.

9
Factors increasing pain in Burn patient
  • Personality.
  • Gender.
  • Size
  • Duration of Dressing

10
Common causes of inadequate pain management
  • pain assessment techniques
  • analgesic knowledge deficits
  • and incomplete documentation

11
What to do ???
12
First, Control Acute Pain
  • Simple measures such as cooling the burn,
    covering the burn (e.g. with cling film),
    immobilising the patient and providing
    reassurance may provide sufficient relief in the
    period before pain can be formally assessed.

13
Give Intravenous Opioids if Pain is Severe
  • 50/50 mixture of oxygen and nitrous oxide unless
    hypoxia is present, in which case 100 oxygen
    should be used
  • Administration of opioids (e.g. morphine,
    nalbuphine) (should be administered intravenously
    during the initial period of burn resuscitation )
  • short-acting medications such as fentanyl,
    alfentanil and remifentanil are more appropriate
    for pain relief in burn patients,

14
Morfine
  • Can be titrated in small doses
  • delayed onset of action (10 minutes) and
    longlasting effects (several hours) do not allow
    for the analgesic therapy to be adjusted easily
    to meet individual needs.

15
fentanyl, alfentanil and remifentanil
  • fast-acting medication, reaching peak effect in
    one minute.
  • rapid pain relief and its relatively short
    duration of action (mean half-life 90 minutes)
    fits well with the mean time taken to change a
    dressing, providing good post-procedural
    analgesia.
  • starting dose of 10mcg/kg, which is repeated
    every minute according to the level of pain
  • Combining repeated boluses with a continuous
    infusion of 2mcg/kg/min is effective in improving
    pain relief

16
tramadol or pethidine (meperidine)
  • have been used in burn patients however,
    long-term use of pethidine is contraindicated
    because of the accumulation of a toxic
    metabolite, and experience of long-term use of
    methadone to treat burn pain is limited.
  • (normeperidine, is a cerebral irritant that can
    cause dysphoria, agitation, and seizures)

17
PCA Has Advantages
18
Managing opioid tolerance and dependence
  • can occur after just two weeks of opioid therapy
  • Because there is no maximum dose for full opioid
    agonists, tolerance is managed easily by
    increasing the dose
  • long-term opioids can lead to physical dependence
  • As opioid needs subside, physical dependence is
    easily managed by titrated opioid withdrawal.
  • Reverse titration (reducing the opioid dosage by
    10-25 daily) is recommended

19
Tolerance and physical dependence should never be
equated with addiction or psychological
dependence, which are rare
20
  • survey of burn units did not reveal any cases of
    addiction in approximately 10,000 burn patients
    treated
  • When patients are prescribed opioids at doses too
    low or spaced too far apart, they might exhibit
    behaviors that resemble psychological dependence
    or pseudo-addiction in response to uncontrolled
    pain.
  • Opioids should not be avoided due to the fear of
    addiction

21
Non-Opioid Analgesics
  • NSAID increased risk of excessive bleeding and
    gastric complications
  • Acetaminophen should be considered the
    first-line analgesic in the management of
    background burn pain, and opioids should be added
    if it does not sufficiently control the pain ( in
    Children ). Dose at 10-15 mg/kg q 4 hrs J Pain
    Symptom Manage, 13(1)50-55, 1997 Meyer ,Texas

22
Local Blocks Not Suitable for Many
  • the burn area and the area for donor skin grafts
    extend beyond the area that can be covered by a
    single block
  • risk of sepsis
  • Wound Dressings May Reduce Pain

23
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24
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25
Conclusion
  • 1. pain assessment at regular intervals
  • 2. written guidelines for pain management
    protocols, which allow flexible doses to account
    for individual variation
  • 3. avoid polypharmacy
  • 4. periodically assess and discuss the patient's
    psychological status
  • 5. pay special attention to pain in burned
    children. Several studies have shown that burned
    children are undermedicated compared to adults.

26
  • The question as to whether pain has a detrimental
    effect on the healing outcome for burn patients
    remains largely unanswered and requires further
    investigation.
  • The avoidance of patient suffering is, however, a
    key objective as under-treated pain in burn
    patients can result in noncompliance with
    hospital treatment. This can disrupt care and
    increase the risk of post-traumatic stress
    disorders.
  • Under-treatment of pain remains a significant
    problem despite the wide dissemination of
    information and educational programs.

27
Thank you
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