Burn injury pain: the continuing challenge.

The development of more effective methods of relieving pain associated with burn injury is a major unmet medical need. Not only is acute burn injury pain a source of immense suffering, but it has been linked to debilitating chronic pain and stress-related disorders. Although pain management guidelines and protocols have been developed and implemented, unrelieved moderate-to-severe pain continues to be reported after burn injury. One reason for this is that the intensity of pain associated with wound care and rehabilitation therapy, the major source of severe pain in this patient population, varies widely over the 3 phases of burn recovery, making it difficult to estimate analgesic requirements. The effects of opioids, the most commonly administered analgesics for burn injury procedural pain, are difficult to gauge over the course of burn recovery because the need for an opioid may change rapidly, resulting in the overmedication or undermedication of burn-injured patients. Understanding the mechanisms that contribute to the intensity and variability of burn injury pain over time is crucial to its proper management. We provide an overview of the types of pain associated with a burn injury, describe how these different types of pain interfere with the phases of burn recovery, and summarize pharmacologic pain management strategies across the continuum of burn care. We conclude with a discussion and suggestions for improvement. Rational management, based on the underlying mechanisms that contribute to the intensity and variability of burn injury pain, is in its infancy. The paucity of information highlights the need for research that explores and advances the identification of mechanisms of acute and chronic burn injury pain. PERSPECTIVE: Researchers continue to report that burn pain is undertreated. This review examines burn injury pain management across the phases of burn recovery, emphasizing 3 types of pain that require separate assessment and management. It provides insights and suggestions for future research directions to address this significant clinical problem.     

American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Sedation and Respiratory Depression

As the complexity of analgesic therapies increases, priorities of care must be established to balance aggressive pain management with measures to prevent or minimize adverse events and to ensure high quality and safe care. Opioid analgesia remains the primary pharmacologic intervention for managing pain in hospitalized patients. Unintended advancing sedation and respiratory depression are two of the most serious opioid-related adverse events. Multiple factors, including opioid dosage, route of administration, duration of therapy, patient-specific factors, and desired goals of therapy, can influence the occurrence of these adverse events. Furthermore, there is an urgent need to educate all members of the health care team about the dangers and potential attributes of administration of sedating medications concomitant with opioid analgesia and the importance of initiating rational multimodal analgesic plans to help avoid adverse events. Nurses play an important role in: 1) identifying patients at risk for unintended advancing sedation and respiratory depression from opioid therapy; 2) implementing plans of care to assess and monitor patients; and 3) intervening to prevent the worsening of adverse events. Despite the frequency of opioid-induced sedation, there are no universally accepted guidelines to direct effective and safe assessment and monitoring practices for patients receiving opioid analgesia. Moreover, there is a paucity of information and no consensus about the benefits of technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy. To date, there have not been any randomized clinical trials to establish the value of technologic monitoring in preventing adverse respiratory events. Additionally, the use of technology-supported monitoring is costly, with far-reaching implications for hospital and nursing practices. As a result, there are considerable variations in screening for risk and monitoring practices. All of these factors prompted the American Society for Pain Management Nursing to approve the formation of an expert consensus panel to examine the scientific basis and state of practice for assessment and monitoring practices for adult hospitalized patients receiving opioid analgesics for pain control and to propose recommendations for patient care, education, and systems-level changes that promote quality care and patient safety.     

Virtual reality pain control during burn wound debridement in the hydrotank

OBJECTIVE: Most burn-injured patients rate their pain during burn wound debridement as severe to excruciating. We explored the adjunctive use of water-friendly, immersive virtual reality (VR) to distract patients from their pain during burn wound debridement in the hydrotherapy tank (hydrotank). SETTING: This study was conducted on inpatients at a major regional burn center. PATIENTS: Eleven hospitalized inpatients ages 9 to 40 years (mean age, 27 y) had their burn wounds debrided and dressed while partially submerged in the hydrotank. INTERVENTION: Although a nurse debrided the burn wound, each patient spent 3 minutes of wound care with no distraction and 3 minutes of wound care in VR during a single wound care session (within-subject condition order randomized). OUTCOME MEASURES: Three 0 to 10 graphic rating scale pain scores (worst pain, time spent thinking about pain, and pain unpleasantness) for each of the 2 treatment conditions served as the primary dependent variables. RESULTS: Patients reported significantly less pain when distracted with VR [eg, "worst pain" ratings during wound care dropped from "severe" (7.6) to "moderate" (5.1)]. The 6 patients who reported the strongest illusion of "going inside" the virtual world reported the greatest analgesic effect of VR on worst pain ratings, dropping from severe pain (7.2) in the no VR condition to mild pain (3.7) during VR. CONCLUSIONS: Results provide the first available evidence from a controlled study that immersive VR can be an effective nonpharmacologic pain reduction technique for burn patients experiencing severe to excruciating pain during wound care. The potential applications of VR analgesia to other painful procedures (eg, movement or exercise therapy) and other pain populations are discussed.     

Use of a simple relaxation technique in burn care: literature review

Aim. This paper presents a literature review examining the implications of previous research in order to make evidence‐based decisions about the possible use of breathing exercises with adult patients with burns for pain management during wound care. Background. Adult patients with burns experience pain during wound care despite pharmacological interventions. Additional interventions are needed to improve the effectiveness of pain management. Relaxation techniques can be considered, for example breathing exercises, music and distraction. A simple breathing relaxation technique is especially relevant because it involves no risk, is easy and quick to learn, equipment does not need to be purchased and it can be employed immediately by the often exhausted and ill patient. However, the effect of breathing exercises on procedural pain during burn wound care has not been investigated. Method. The CINAHL, PubMed and Cochrane databases were searched in 2004 in order to answer two questions: are breathing exercises effective in the management of procedural pain in adult burn patients, and what are the implications of previous investigations for future research concerning pain reduction in adult patients with burns during wound care? Eleven papers were included in the review. Findings. The effect of breathing exercises for pain management in patients with burns has not been investigated. Prior to undertaking an effect study, additional basic research is needed. The number of sessions necessary to learn to use the technique should be clarified. A valid and reliable instrument to assess relaxation must be developed. The adequacy of the proposed data collection procedure needs to be assessed. Conclusion. It is not possible at this time to base decisions about the use of breathing exercises during wound care in adult patients with burns on research specific to the procedure and patient group. The most suitable relaxation technique for future investigation is concentration on breathing, in combination with jaw relaxation.     

Valdecoxib, a COX-2-specific inhibitor, is an efficacious, opioid-sparing analgesic in patients undergoing hip arthroplasty.

Opioid agents are highly effective analgesics after orthopedic surgery but are associated with several adverse effects. Valdecoxib is a new, highly selective cyclooxygenase (COX)-2-specific inhibitor with a rapid onset of action and significant analgesic properties that is being developed for the management of acute pain. The objective of this study was to demonstrate the opioid-sparing efficacy of valdecoxib as part of a multimodal treatment of pain associated with hip arthroplasty. This multicenter, multiple-dose, double-blind, parallel-group study compared the opioid-sparing effects, analgesic efficacy, and safety of 20- and 40-mg doses of valdecoxib twice daily with placebo in patients receiving morphine by patient-controlled analgesia after hip arthroplasty. Study medication was first administered 1 to 3 hours preoperatively. The total amount of morphine administered, pain intensity, and patient's global evaluation of study medication were assessed over a period of 48 hours. Patients receiving 20 or 40 mg valdecoxib twice daily required on average 40% less morphine than those receiving placebo after hip arthroplasty. Pain intensity levels and patient satisfaction were significantly improved in both valdecoxib groups compared with placebo. Valdecoxib and placebo were equally well tolerated. Pre- and postoperative administration of valdecoxib reduces the amount of morphine required for postoperative pain relief and provides greater analgesic efficacy compared with morphine alone. Thus, valdecoxib has significant clinical utility for acute pain management in orthopedic surgery patients.     

Efficacy and safety of procedural sedation and analgesia for burn wound care

The study aim was to quantify efficacy and patient safety of registered nurse-administered procedural sedation and analgesia in a regional burn center. The investigators conducted a review of procedural sedation forms for all pediatric and adult patients admitted to this burn center from January 1, 2005, through December 31, 2005, for demographic and clinical data including patient age, gender, body weight, TBSA, dates of burn injury and wound care procedures, length of procedure, pre- and postprocedural pain assessment, procedural sedation/analgesia medications and doses, adverse drug events, and related interventions. During the 12-month study period, a total of 328 burn patients received 1293 procedural sedation procedures; child subjects (≤ 18 years) received 356 procedures and adult subjects (19-87 years) received 937 procedures. The mean (SD) length of the procedure was 60.1 (22.49) minutes with a range of 10 to 170 minutes. The mean subject age was 34.2 years (range: 6 weeks to 87 years), 67% were male, and the mean TBSA was 17% (0.5-68%). Ninety-four percent received fentanyl for analgesia and 85% received midazolam for anxiolysis and amnesia. The mean preprocedural pain score was 3.2 and the mean postprocedural pain score was 2 (t = 14.795; df = 1243; P < .001). Ten adverse events, all respiratory related, were documented in eight patients, two of whom experienced a second adverse event for an overall adverse event rate of 0.77%. No patient required intubation. Procedural sedation administered by a registered nurse competent in administration and monitoring in a burn center provided safe and effective pain management during wound care.     

术前宣教和心理安抚对术后疼痛程度的影响

目的研究术前给予特别信息进行心理安抚对患者术后疼痛程度的影响。方法收集经腹子宫全切手术患者60例,随机分为治疗组和对照组各30例。治疗组术前给予特殊的心理安抚信息,而对照组只给常规信息。2组患者术后均采用静脉PCA泵自控镇痛,每天用VAS行疼痛评估并记录镇痛药用量,调查2组患者对镇痛的满意度。进行χ^2检验和t检验。结果2组间每天最高VAS及镇痛药量比较无显著差异;治疗组对镇痛的满意度明显较对照组提高。结论术前给予心理安抚对术后的疼痛程度和镇痛药的用量虽无明显影响,但能显著提高患者对镇痛和护理的满意度。     

Pediatric pain control practices of North American Burn Centers

This study investigated pediatric pain control practices in North American Burn Centers using a mail-in survey. Questions were asked regarding pain control practices, pain assessment methods, and perceived treatment efficacy for inpatients and outpatients in four age groups. Eighty-two centers responded with 111 surveys. Intravenous morphine was the most frequently used analgesic for wound care pain. The most common background pain medications were intravenous morphine, acetaminophen with codeine, and acetaminophen alone. The use of long-acting medications increased with increasing age. Additional areas reported in the text include nonpharmacologic and pharmacologic adjuvants, treatment of itching, pain assessment, outpatient pain management, and efficacy of pain control and assessment practices. There have been great advances in pediatric burn pain control and assessment in recent years, but room for improvement remains. This study provides a basis for evaluation and comparison among burn centers. It further highlights areas that may warrant additional study and intervention.     

Use of morphine sulfate (MS Contin) in patients with burns: a pilot study.

Morphine sulfate (MS Contin), a proven analgesic in the treatment of cancer pain and chronic benign pain, seems to be a good analgesic for the treatment of burn pain. MS Contin is morphine sulfate incorporated in a wax cellulose matrix delivery system. This wax cellulose delivery system gives MS Contin its duration of action. Ten patients were enrolled in an open-labeled, nonrandomized study. The study was designed to examine the analgesic efficacy of MS Contin in the burn population. Each patient remained in the study for 6 days. The efficacy of the analgesic regimen was subjectively measured by the visual pain scale. The MS Contin group was retrospectively compared with a group of patients who were given continuous intravenous infusions of morphine. The two groups were matched according to age, burn size, surgical procedures, and hospital stay. The analgesic qualities of MS Contin were comparable to those of continuous intravenous morphine sulfate infusions. MS Contin is a possible candidate for the treatment of patients with burn pain because of its analgesic qualities, oral dosing, and duration of action.     

Core Aspects of Satisfaction with Pain Management: Cancer Patients' Perspectives

ContextThe coexistence of high levels of satisfaction and high levels of pain has been perplexing.ObjectivesThe aims of this study were to 1) describe patient expectations related to the experience of cancer-related pain, 2) explore the cognitive processes and meaning that underlie patient judgments about satisfaction and dissatisfaction with pain management, and 3) explore the discrepancies between ratings of high satisfaction with pain management with high pain intensity.MethodsThe sample included 33 patients: 18 with advanced cancer and 15 experiencing pain after a surgery for a cancer diagnosis. All patients had experienced “worst pain” of at least moderate intensity and were interviewed using standard pain measures from the American Pain Society Patient Outcome Questionnaire and open-ended questions about the underlying meaning of their answers. We systematically analyzed the transcribed qualitative data using NVivo software.ResultsFifty-five percent of patients were females and were aged 25–78 years. Most (75%) were satisfied or very satisfied with their overall pain management. Key findings indicate that for some, the worst pain rating was often brief, even momentary. Most patients expected pain relief. Four key themes were important to the quality of pain management: being treated right, having a safety net, being in a partnership with their health care team, and having pain treatment that was efficacious. Key aspects of the patient-provider relationship that mattered were how the nurses and doctors behaved toward them and how quickly they responded to reports of pain. For some, an important factor was whether they had control of the amount of pain they experienced.ConclusionThe findings inform measurement of patient satisfaction with the quality of pain management.     

术前宣教和心理安抚对术后疼痛程度的影响

目的 研究术前给予特别信息进行心理安抚对患者术后疼痛程度的影响.方法 收集经腹子宫全切手术患者60例,随机分为治疗组和对照组各30例.治疗组术前给予特殊的心理安抚信息,而对照组只给常规信息.2组患者术后均采用静脉PCA泵自控镇痛,每天用VAS行疼痛评估并记录镇痛药用量,调查2组患者对镇痛的满意度.进行X2检验和t检验.结果 2组间每天最高VAS及镇痛药量比较无显著差异;治疗组对镇痛的满意度明显较对照组提高.结论 术前给予心理安抚对术后的疼痛程度和镇痛药的用量虽无明显影响,但能显著提高患者对镇痛和护理的满意度.     

Pain management of cancer patients with transdermal fentanyl: a study of 1828 step I, II, & III transfers.

The aim of this observational study was to examine pain management outcomes and quality of life (QoL) measures in cancer patients with intolerable or chronic severe pain transferring from World Health Organization's step I, II, and III analgesics to the transdermal therapeutic fentanyl system (TTS-F). This study examines the safety and efficacy of TTS-F in long-term pain management, addressing the role of TTS-F in cancer pain. Pain measures were assessed in 1828 patients (step I [na?ve], 268; step II [codeine], 1239; and step III [morphine], 321) on the basis of selected questions from the Greek-Brief Pain Inventory. Overall treatment satisfaction (scale, 1 to 4), QoL, and European Collaborative Oncology Group (ECOG) status were also recorded. These were assessed in relation to TTS-F dose, stratified by transfer step, primary cancer, metastases, type of pain, and concomitant use of anti-inflammatory drugs. Of 1828 patients, 100 (5.5%) withdrew, and an addition 14 (0.8%) discontinued because of side effects. A total of 1714 continued on study; 744 patients died, and 970 departed during the study period. In total, 93.8% were satisfied with their pain relief, and complete patient satisfaction was obtained within 2 months. Pain, QoL, and treatment satisfaction measures demonstrated statistically significant improvements over time, independent of the step transfer. Although doses of TTS-F were higher for step III > II > I and for metastatic than nonmetastatic, the median dose for all groups remained 50 microg/h throughout the study period. Pain and QoL improvements were independent of patient characteristic(s). Direct transfer to TTS-F for patients with intolerable or chronic moderate to severe cancer pain offers an efficient and safe long-term analgesic option for palliative care patients. Careful selection and follow-up by experienced palliative care specialists are mandatory. TTS-F as a first-line analgesic approach for severe cancer pain should be considered a viable option because of its durable efficacy and low incidences of side effects. PERSPECTIVE: At a fairly constant dose of 50 microg/h, the transdermal therapeutic fentanyl system offers a safe, well-tolerated pain relief treatment for carefully monitored patients with cancer pain. The authors stress that this includes patients who experience difficulties in their pain management while progressing through the WHO's ladder for pain management.     

Leveraging Interactive Patient Care Technology to Improve Pain Management Engagement

Background: Most children experience pain in hospitals; and their parents report dissatisfaction with how well pain was managed. Engaging patients and families in the development and evaluation of pain treatment plans may improve perceptions of pain management and hospital experiences. Objectives: The aim of this performance improvement project was to engage patients and families to address hospitalized pediatric patients' pain using interactive patient care technology. The goal was to stimulate conversations about pain management expectations and perceptions of treatment plan effectiveness among patients, parents, and health care teams. Methods: Plan-Do-Study-Act was used to design, develop, test, and pilot new workflows to integrate the interactive patient care technology system with the automated medication dispensing system and document actions from both systems into the electronic health record. Setting: The pediatric surgical unit and hematology/oncology unit of a free-standing, university-affiliated, urban children's hospital were selected to pilot this performance improvement project because of the high prevalence of pain from surgeries and hematologic and oncologic diseases, treatments, and invasive procedures. Results: Documentation of pain assessments, nonpharmacologic interventions, and evaluation of treatment effectiveness increased. The proportion of positive family satisfaction responses for pain management significantly increased from fiscal year 2014 to fiscal year 2016 (p = .006). Conclusion: By leveraging interactive patient care technologies, patients and families were engaged to take an active role in pain treatment plans and evaluation of treatment outcomes. Improved active communication and partnership with patients and families can effectively change organizational culture to be more sensitive to patients' pain and patients' and families' hospital experiences.     

Patient Perceptions of Pain Management Therapy: A Comparison of Real-Time Assessment of Patient Education and Satisfaction and Registered Nurse Perceptions

Nurses must have an understanding of their patients' perception to assist in meeting analgesic goals. Adequate patient teaching is essential. The value of a simplified tool to assess patients' satisfaction has not been widely examined. This study examined if nurses' perceptions of their patients' satisfaction with pain management are congruent with patients' self-report, and if patients' level of satisfaction corresponds with the type of therapy used and adequacy of teaching related to their pain management plan. Data were collected though a survey in a community hospital. It was designed as an evaluative study of the variables in two nursing units and as a pilot study of the survey tool. Ratings of patient satisfaction by nurses (3.8 ± 0.88 [mean ± SD]) were similar to patients' self-ratings (4.08 ± 1.06). Higher self-report of pain (visual analog scale 4.00 ± 2.22) was associated with lower levels of satisfaction (3.80 ± 0.881). Patients reporting adequate teaching rated a higher satisfaction score (4.46) than patients reporting inadequate teaching [3.59; t (48) = ?3.12; p = .003]. Patients receiving intravenous analgesia as needed had higher pain VAS scores (4.74) than patients receiving other analgesia protocols [3.37; t(48) = ?2.26; p = .028]. Measuring patient satisfaction has become critical in evaluating adequacy of treatment. Factors that affect patients' satisfaction with pain management include the adequacy of teaching they receive and the type of therapy they are provided. A simple survey can be a useful tool in measuring satisfaction.     

Satisfaction with treatment for chronic pain in a specialty service: preliminary prospective results.

Treatment satisfaction is an increasingly popular outcome measure in pain management. While it is a subjective variable, it may nonetheless reflect the quality of care and it may predict other important patient behaviors. The purpose of this study was to prospectively evaluate predictors of satisfaction with treatment for chronic pain. Subjects included 62 adults seeking treatment for pain at a community-based, specialty clinic. Treatment included combinations of analgesic medications (e.g., opioids, tricyclic antidepressants) and procedures performed by anesthesiologists (e.g., epidural steroid injections, facet joint blocks). Subjects completed measures of pain severity, depression, disability, and pain-related anxiety, prior to treatment and at a 6-month follow-up. Follow-up assessment also included measures of treatment satisfaction and characteristics of the patient's clinic experience and a chart review to assess medications, procedures, and number of visits. Comparison of baseline and follow-up data showed statistically significant reductions in pain (25%) and depression. Most patients were satisfied (45.6%) or extremely satisfied (43.9%) with the treatment they received (10.5% was somewhat satisfied, none were dissatisfied). Correlation analyses showed that patient demographic variables did not predict treatment satisfaction. Changes in pain, depression, and pain-related anxiety were associated with treatment satisfaction but change in pain was a relatively weak predictor. Nine of the 16 characteristics of the patient's clinic experience correlated with treatment satisfaction. Regression analyses showed that the strongest unique predictors of treatment satisfaction were the patients feeling their evaluation was complete, believing they received an explanation for clinic procedures, and finding that treatment helped them improve their daily activity.     

The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries

Fentanyl has been shown to be effective for the management of intense pain of short duration. We have recently used intravenous fentanyl for burn wound procedures because of its rapid onset, high potency, and short duration. In this report, we reviewed our experience with fentanyl in a variety of procedural burn pain settings to develop specific recommendations about its effectiveness and safety for the treatment of pain in patients with burn injuries. The medical records of patients with burn injuries who received fentanyl for wound procedures over a 2-year period were retrospectively reviewed. Patient demographics, the amount of fentanyl administered, the level of analgesia achieved, and the incidence of adverse effects were analyzed. Fifty-five patients who were 9 months to 75 years old with burn wounds (range, 1%-90% of total body surface area) received 148 doses of fentanyl for the treatment of procedural pain. An average of 8.0 +/- 7.0 microg/kg of fentanyl (range, 0.7 to 38.0 microg/kg) was required for the first wound procedure with fentanyl. No correlation between dosage of fentanyl given and either age or percentage of total body surface area burned was observed. Transient respiratory depression was observed in 17 patients (31%). No patient required intubation or additional supplemental oxygen after the conclusion of the procedure. High doses of fentanyl are required to achieve adequate analgesia during some burn wound procedures. Respiratory depression associated with fentanyl use is transient but requires adequate preparation and trained personnel. Fentanyl may be effectively integrated into the pain control strategy for patients with burn injuries.     

Pain Prevalence,Intensity, Assessment and Management in a Hospitalized Pediatric Population

New research, regulatory guidelines, and practice initiatives have improved pain management in infants, children, and adolescents, but obstacles remain. The aim of this study was to identify the prevalence and demographics of pain, as well as pain management practice patterns in hospitalized children in a tertiary-care university hospital. We prospectively collected data including patient demographics, presence/absence and location of pain, pain intensity, pain assessment documentation, analgesic use, side effects of analgesic therapy, and patient/family satisfaction. Two hundred male (58%) and female, medical and surgical (61%) patients, averaging 9 ± 6.2 years were studied. Pain was common (86%) and often moderate to severe (40%). Surgical patients reported pain more frequently when enrolled than did medical patients (99% vs. 65%). Female gender, age ≥5 years, and Caucasian race were all associated with higher mean pain scores. Furthermore, females and Caucasian children consumed more opioids than males and non-Caucasians. Identified obstacles to optimal analgesic management include lack of documented physician pain assessment (<5%), a high prevalence of “as needed” analgesic dosing, frequent opioid-induced side effects (44% nausea and vomiting, 27% pruritus), and patient/family dissatisfaction with pain management (2%-7%). The data demonstrated that despite a concentrated focus on improving pain management over the past decade, pain remains common in hospitalized children. Identification of patient populations and characteristics that predispose to increased pain (e.g., female, Caucasian, postoperative patient) as well as obstacles to analgesic management provide a focus for the development of targeted interventions and research to further improve care.     

Translating research into practice. Implications of the Thunder Project II.

The Thunder Project II study described procedural pain in a variety of acute and critical care settings. The procedures studied were turning, tracheal suctioning, wound drain removal, nonburn wound dressing change, femoral sheath removal, and central venous catheter insertion. Turning had the highest mean pain intensity, whereas femoral sheath removal and central venous catheter insertion had the least pain intensity in adults. Nonwound dressing change had the highest pain intensity for teenagers. Pain occurred in procedures that are often repeated several times a day as well as in those that may be single events. There is a wide range of pain responses to any of these procedures; as a result, standardized and thoughtful pain, and distress assessments are warranted. Planning of care, including the use of preemptive analgesic interventions, needs to be individualized. Future studies are needed to describe patient responses to other commonly performed nursing procedures and to identify effective interventions for reducing procedural pain and distress.