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.     

Effectiveness of Jaw Relaxation for Burn Dressing Pain: Randomized Clinical Trial

Patients hospitalized for burn injuries experience severe pain, both immediately after the injury and during daily therapeutic procedures such as dressing changes. Relaxation is increasingly suggested as a pain control technique that can be used by nurses in daily practice. Yet the effects of relaxation on burn pain are not clear. The aim of this study was to investigate whether jaw relaxation will decrease pain intensity of burn dressing. Accordingly, a randomized clinical trial (n = 100) was conducted between 2009 and 2010 to compare jaw relaxation and usual care. Consenting patients were randomly assigned to either experimental or control groups using minimization. The experimental group practiced jaw relaxation for 20 minutes before entering the dressing room. Data were collected by visual analog scale (VAS), and several structured questions were asked of the experimental group. No significant difference was seen between mean pain intensity scores in the experimental and control groups after dressing (p = .676). Regarding the ineffectiveness of jaw relaxation for pain intensity of burn dressing, future studies are suggested to concentrate on longer durations of relaxation time and continuing the procedure in dressing room. Simultaneous study of the effect of this technique on residual, breakthrough, and procedural burn pain is also recommended.     

Skin lipopolysaccharide-binding protein and IL-1beta production after thermal injury

In response to a burn injury, skin can have an inflammatory response characterized by the production of inflammatory cytokines, recruitment of immune cells, containment of invading organisms, and clearance of noxious substances from the wound. Lipopolysaccharide-binding protein (LBP) is a molecule that is capable of coordinating all 4 functions; we previously found evidence that suggested that LBP is produced within surgical wounds. Because of the central role of LBP in the response to bacterial infection, as well as in the high rate of infection after burn injuries, we sought to determine whether a thermal injury could affect wound LBP production and thereby affect host responses against bacterial infection. Rats were given either a burn or a sham burn and were killed 24, 48, and 72 hours after the injuries. Wound specimens were assayed for bacterial counts and for the presence of LBP, messenger (m)RNA, and interleukin (IL)-1beta mRNA. Wound LBP mRNA was significantly upregulated at 24 hours in the group with burn injuries (P < .05; burn vs sham burn); this was followed by decreases at 48 and 72 hours. Immunohistochemistry showed LBP protein in the epidermis of animals with burns. Bacterial counts increased in the group with burn injuries (P < .05; burn vs sham burn) and continued to rise for 72 hours. IL-1beta mRNA levels were elevated at all time points in the group with burn injuries (P < .05). These results suggest an inverse correlation between burn wound LBP expression and bacterial wound counts. This failure to maintain local LBP production after severe thermal injury despite localized inflammation shown by high IL-1beta levels may predispose local wounds to bacterial invasion.     

Comparing a Single Institution's Experience With Electrical Injuries to the Data Recorded in the National Burn Repository

Electrical injuries usually represent a small proportion of a burn center's admissions. Although burn size may be small, internal tissue damage is sometimes extensive. This study reviews a single institution's experience with electrical injuries and compares it to the multi-institutional data of the National Burn Repository (NBR). The 2009 NBR and the records of a large urban burn center (single institution) were queried for adult electrical injuries over an 8-year period. Data examined included demographics, %TBSA burn, length of stay (LOS), injury circumstance, and disposition. Multiple linear regression models were created to determine factors related to LOS. One hundred ninety-one single-institution patients and 2837 multi-institution patients met the criteria. Both cohorts were mostly white males approximately 30 years of age and injuries where often work-related. Single-institution patients had a mean injury size of 4% TBSA, while multi-institution patients had 7%. The most common exposure source was domestic wiring for single-institution patients and electrical power plants/lines for multi-institution patients. Single-institution data showed that females had a shorter LOS than males (P < .0001). Single-institution data showed that independent risk factors for an increased LOS were infection, amputation, fasciotomy, and being Hispanic. Independent risk factors for multi-institution patients were being Hispanic and large %TBSA burn. There was no difference in mortality, gender, age, LOS, or intensive care unit LOS between the cohorts. In this analysis, there was no statistical difference between outcomes in the single- or multi-institutional groups. However, injuries reported in the NBR were slightly larger. In both cohorts, an increase in LOS was associated with %TBSA, as expected. Interestingly, Hispanic ethnicity correlated with an increased LOS. Future work will be aimed at understanding this correlation to determine whether it is specific to electrical injury or burns in general.     

Pain is Associated With Increased Physical and Psychosocial Impairment in Youth With a History of Burn Injuries

Burn injuries are significantly painful and associated with physical and psychological impairment. However, little research to-date has examined the potential role of the subjective experience of pain in either physical or psychological impairment in this population. This may be particularly important to examine, given that the pain experience can often be a significant barrier to recovery in other pediatric populations. The current study examined the cross-sectional and predictive relationships between patient-reported experience of pain (operationalized as PROMIS pain interference and self-reported pain intensity) and physical and psychosocial outcomes. Data were gathered as part of the Burn Model System National Database (1994–2018) with the data request inclusive of pediatric self-report PROMIS measures, child PTSD, and post-traumatic growth symptoms assessed at 6- and 12-month postdischarge following initial injury. A total of 65 youth between the ages of 6 and 16 years at the time of their injury were included in the dataset. Correlational and regression analyses indicated that pain interference was cross-sectionally and longitudinally associated with decreased physical functioning, depressive symptoms, and peer relationships. Pain intensity was significantly associated with and predictive of physical functioning and pain interference. Results of the current study are an important first step in understanding the pain experience and associated outcomes in youth with a history of burn injuries. Future research is needed to further examine these relationships.PerspectiveThis study presents preliminary findings from a national database on pain-related outcomes both cross-sectionally and longitudinally in youth with a history of burn injury. To-date, pain-related outcomes are poorly understood in this population and the results of this study serve to inform future research and treatment-related efforts.     

Comparison of cultured epidermal autograft and massive excision with serial autografting plus homograft overlay.

The chief determinant of mortality in severe burn injuries has been the size and severity of the wound. Early massive excision of the wound has increased the median lethal dose to 98% of total body surface area burn but presents the problem of wound closure. Autograft substitutes must be used for a large burn. We report our experience with early massive excision in the treatment of 47 pediatric patients with burns who had greater than 80% total body surface area burn and greater than 80% full-thickness burn. Four patients died within hours of admission. Fifteen patients died of sepsis and multiorgan failure; the primary source of bacterial contamination was the open wound. The 28 survivors received approximately 2.0 m2 2:1 homograft until autograft became available. A case report of a 10-year-old boy illustrates the use of two types of cultured epidermal autograft, one "homegrown" and one commercially produced.     

Comparisons between patients' and nurses' assessment of pain and medication efficacy in severe burn injuries

In order to provide burn patients with adequate pain relief, the nurses must be able to accurately evaluate the patients' pain levels and to assess whether sufficient analgesia is achieved or not. The present study examined this issue by comparing the pain ratings in 42 patients hospitalized for burn injuries and 42 nurses. The patient and the attending nurse were asked to rate, independently of each other, the intensity of the pain felt by the patient during a therapeutic procedure and at rest. When analgesic medication was given prior to the procedure, both the patients and the nurses were asked to estimate the degree of pain relief. All ratings were obtained using visual analogue and verbal scales. The results revealed significant but small correlations between the nurses' and patients' ratings. Frequently, the nurses underestimated or overestimated the patients' pain. Discrepancies were also observed in the evaluation of pain medication efficacy, the nurses showing a tendency to overestimate the degree of pain relief. The accuracy of the nurses' perception did not vary as a function of the patients' age, socioeconomic status or burn severity. However, the number of years of experience in burn-nursing had a significant influence on the nurses' estimation of the patients' pain during therapeutic procedures. Theoretical and clinical implications of these results are discussed with a particular emphasis on the need to implement systematic procedures to assess pain and success of analgesia. Additional recommendations to optimize pain management in burn patients are also made.     

Infection prevention and treatment in patients with major burn injuries

Infection is a significant challenge in burn care, particularly for those patients who have major burn injuries. This article aims to review the literature and establish best practice in prevention and treatment of infection in patients with major burns. The article considers the causes and clinical features of wound infection, and examines systemic and local methods of prevention and treatment.     

化学物质爆炸致化学和冲击复合伤的损伤特点及紧急救治

目的 探讨化学物质爆炸致化学和冲击复合伤的的损伤特点及紧急救治。方法 结合我们已进行的有关研究和5次参加抢救101例爆炸伤及137例化学物质爆炸中毒伤员的临床救治体会，引用国内外公开发表的相关论文及著作。结果 101例爆炸伤伤员共死亡8例，其中7例严重的爆炸伤伤员死于致伤现场，1例伤员死于后期的严重并发症NOF。病死率为6．9％。12例冲烧毒复合伤伤员，死亡8例，总病死率高达66．66％。137例化学物质爆炸中毒伤员共死亡3例，病死率为2．19％。结论 化学物质爆炸致冲烧毒复合伤的损伤特点是致伤因素多，伤情伤类复杂，外伤掩盖内脏损伤，易漏诊误诊，复合效应伤情互相加重，伤情发展迅速，治疗矛盾突出等。因此正确有效的现场紧急救治至关重要。     

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.     

The assessment and management of burns

Each year many people seek medical advice or hospital treatment for burn or scald injuries. There is limited data on the number of burns patients seen in primary care, however a recent national survey suggested that there are 250,000 presentations of burn injuries to primary care teams in the UK per year (National Burn Care Review, 2001). This article discusses the nursing management of burns in the community, outlining the initial assessment of the burns patient in terms of trauma management, and focusing primarily on those patients with non-complex burns. A full patient assessment incorporates the patient's general condition, the type, cause, depth and extent of the burn and the effects on the individual patient. Good patient management is an essential element of care and the focus of this is the management of pain, prevention of infection, provision of evidence based wound care and onward referrals as appropriate. However not all patients can be managed solely in the community and the nurse needs to know when to refer and to whom to refer. The article outlines the recommendations from the National Burn Care Review in terms of patient referral.     

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.     

Psychological principles of burn wound pain in children. II: Treatment applications

The pain involved in acute burn care can be excruciating and intractable. Even the best pharmacologic pain control efforts often fail to adequately control pain, especially procedure-related pain, in pediatric patients with burn injuries. Nonpharmacologic interventions have been found to be effective in reducing pain in both children and adults and can be extremely important adjuvants to standard pharmacologic analgesia in the burn care setting. In the first article in this series, we outlined psychological factors that influence the emotions, cognitions, and behaviors of children during wound care. Building on this theoretical framework, we now present a detailed discussion of the implementation of nonpharmacologic intervention strategies in the burn care setting. Because accurate measurement of discomfort is imperative for the development of interventions and for the evaluation of their efficacy, we begin with a brief review of pain measurement techniques. We follow this with suggestions for tailoring interventions to meet specific patient needs and conclude with a detailed and practical discussion of specific intervention techniques and the implementation of those techniques.     

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.     

Minor burns: treatment using a new drug delivery system with silver sulfadiazine

We investigated a new product for treatment of burn wounds in outpatients. The product is a drug delivery system composed of polyethylene glycol 400, poly-2-hydroxyethyl methacrylate, and dimethyl sulfoxide into which silver sulfadiazine is incorporated for sustained release. It is applied to the wound and changed every four to five days until the wound has epithelialized. Of the 20 patients we treated by this method, none had wound infections. Most patients had partial-thickness injuries that epithelialized without difficulty. One patient with full-thickness injuries required subsequent excision and grafting. Application of the product over joint surfaces facilitated range of motion. The product was easy to apply, it diminished pain, and it produced no abnormal effects except for an occasional bad odor.     

Enzymatic debridement as an effective treatment for combined flame and chemical burns caused by e-cigarettes

Since its introduction on the market in 2007, the number of reports on injuries caused by the ignition or explosion of electronic nicotine delivery systems (ENDS) has increased significantly.Two male patients have been treated at our burn center, the for ENDS-related injuries. Their batteries came into contact with metal objects stored in their pants pockets, resulting in a short circuit and finally ignition. In both patients, the combined flame and chemical burn wounds were initially irrigated with water upon arrival at the emergency department, leading to increased levels of pain. In our burn center, the wounds were extensively cleansed which led to a subsequent drop in NRS-scores. Laser Doppler Imaging showed a clear indication for surgery as both patients suffered a partial-thickness burn, with one patient having a patch of full-thickness burn as well. We swiftly performed an enzymatic debridement in both patients, followed by conservative wound management. Although enzymatic debridement is not generally recommended in the treatment of chemical burns, we successfully made use of this treatment option.Different authors advocate the use of mineral oils to irrigate or cover alkali burns, as contact between the chemical compounds and water can set off an exothermic reaction, leading to further injury. We believe that a hypertonic rinsing solution could be recommended as well in an emergency setting and we want to stress the importance of rapid removal of the chemical compounds in suspected chemical burns as well as swift debridement.     

Burn therapy 1985: Acute management

Mortality occurs from a burn injury because of infections which result from the metabolic and bacterial consequences of a large open wound, depression of the host's resistance, and both protein and total caloric malnutrition. Systemic antibiotics, topical wound therapy, and gentle wound debridement constitute traditional burn therapy. The systemic antibiotics and topical wound therapy do not solve problems presented by large open wounds and the related protein and caloric deprivation. A more rational approach uses antibiotics and topical wound therapy only as adjuncts to a program of early operative removal or excision of the devitalized, burned tissue and immediate closure of the wound. The excised wound is normally closed with available autograft, but in massive burn injuries, donor skin is insufficient. In these massive injuries, artifical skin can provide that immediate wound closure. As long as devitalized, burned tissue remains present in the setting of depressed host resistance, cross infection tends to colonize those remaining devitalized burn wounds with more virulent organisms than those that were already present. Bacterial controlled nursing units (BCNU) provide strict protection against that cross infection. Though inevitably a catabolic response occurs with massive injury, intensive nutritional support provides the calories necessary for the response to injury to avoid a prolongation of that negative nitrogen balance.     

Ambulatory management of burns

Burns often happen unexpectedly and have the potential to cause death, lifelong disfigurement and dysfunction. A critical part of burn management is assessing the depth and extent of injury. Burns are now commonly classified as superficial, superficial partial thickness, deep partial thickness and full thickness. A systematic approach to burn care focuses on the six "Cs": clothing, cooling, cleaning, chemoprophylaxis, covering and comforting (i.e., pain relief). The American Burn Association has established criteria for determining which patients can be managed as outpatients and which require hospital admission or referral to a burn center. Follow-up care is important to assess patients for infection, healing and ability to provide proper wound care. Complications of burns include slow healing, scar formation and contracture. Early surgical referral can often help prevent or lessen scarring and contractures. Family physicians should be alert for psychologic problems related to long-term disability or disfigurement from burn injuries.     

A prospective controlled trial of Biobrane versus scarlet red on skin graft donor areas

A prospective trial of Biobrane versus scarlet red as a skin graft donor site dressing was done in 21 burn patients with mean total body surface area burns of 31.9%. Corresponding body areas were randomly selected on each patient to receive one of the dressings. Daily evaluations were made of subjective expression of pain, exudate formation and infection, and time of separation of the dressing from the wound. Biobrane was found to be superior in reducing donor site pain. However, with Biobrane there was a higher incidence of infection (57% v 9.5%) and a significant delay in separation from the wound. Scarlet red was found to be more cost-effective. Occlusive dressings have previously been shown to have a high incidence of complications (30%). In extensive burns, isolating the donor site from the wound is difficult and may lead to increased complications. Scarlet red appears to be superior to Biobrane for skin graft donor sites in this patient population.     

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.