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Ростовский Государственный Медицинский Университет

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Медицина общая

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CHAPTER45 Face transplantation

Summary

Facial CTA oers an alternative approach to extensive facial injuries, which may be otherwise very dicult to restore. Although there are signicant risks associated with the procedure, it can be a powerful reconstructive tool to restore both facial form and function in the carefully selected patient. Additionally, human skin allografts should be used cautiously in treatment of acute burn patients as they limit a possible match of donors, while acceptable alternative dressings exist (Fig. 45.1).

(a) (b) (c)

Fig.45.1 The gure demonstrates the operative course of a patient who suered

a 4th degree electrical burn of the face, including loss of nose, maxilla, and upper lip. Preoperatively (A), the patient has a ap covering his midface defect following extensive debridement. (B)Acute postoperative period. (B)The patient is within the acute period following facial CTA. (C)The patient has undergone minor revisions.

Figure45.1A reproduced with permission from Pomahac B etal. Restoration of f acial form and function after severe disgurement from burn injury by a composite facial allograft. American Journal of Transplantation 201;11(2):386– 93, Copyright © 2011 The Authors. Journal Compilation, Copyright © 2011 The American Society of Transplantation and the American Society of Transplant Surgeons.

Further reading

Barret JP, Gavaldà J, Bueno J, et al. Full face transplant: the rst case report. Annals of Surger y

2011;254:252– 6.

Cendales LC, Kanitakis J, Schneeberger S, et al. The Ban 2007 working classication of

skin- containing composite tissue allograft pathology. American Journal of Transplantation 2008;8:1396– 400.

Dubernard JM, Lengelé B, Morelon E, etal. Outcomes 18months after the rst human partial face

transplantation. New England Journal of Medicine 2007;357:2451– 60.

Fischer S, Kueckelhaus M, Pauzenberger R, et al. Functional outcomes of f ace transplantation.

American Journal of Transplantation 2015;15:220– 33.

Petruzzo P, Lanzetta M, Dubernard JM, etal. The International Registry on Hand and Composite

Tissue Transplantation. Transplantation 2010;90:1590– 4.

Pomahac B, Nowinski D, Diaz- Siso JR, et al. Face transplantation. Current Problems in Surgery

2011;48:293– 357.

Theodorakopoulou, E, Meghji, S, Patanis, G. A review of the world’s published face transplant

cases:ethical perspectives. Scars, Burns & Healing 2017;3: 1–10. Doi:10.1177/ 2059513117694402.

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Chapter46

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Pain management

Introduction to pain management 384 Pathophysiology 384 Assessment of pain 385 Treatment strategies 386 Further reading 390

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CHAPTER46 Pain management

Introduction topain management

Treatment of pain in the burn patient presents a unique set of challenges. The pathology of pain with these injuries, while consistent at its most basic level, varies considerably with factors such as the burn severity and the stage of treatment/ healing. The experience of pain shows similar variation. The assessment of pain and recognition of contributing factors such as anxiety and depression require vigilance and persistence, especially among paediatric populations. A systematic approach to pain management can help to ensure adequate, consistent treatment of pain and may be implemented in the form of a pain protocol. We recommend that the adult/ paediatric British National Formulary is used to ensure correct doses are given when not known.

Pathophysiology

Initial injury

Noxious thermal stimuli are transduced by peripheral nociceptors in the skin and their signals are relayed via Aand C nerve bres to the central nervous system. Modulation of the sensitivity of these bres may play a role in the development of the hyperalgesia that is commonly seen in burn wounds and surrounding tissues. The pattern of pain, but not necessarily its intensity, following this initial stimulus is dependent upon the severity of the burn injury.

• Supercial partial thickness burns typically produce mild pain that is especially aggravated by frictional stimuli such as clothing

• Deep partial thickness burns produce pain that varies in intensity according to the extent of dermal destruction. Burns extending only to the supercial dermis produce the most painful injuries, leaving the nerve endings of the dermis stripped of the protective epidermis

• Full thickness burns may be insensate to sharp stimulus, at least initially. Still, these deeper burns may be associated with a dull or pressure- like pain that worsens as the inammatory process progresses

Treatment/ healing period

Despite the overall trend of pain decreasing with time, there exists considerable variation in pain reports. This variation is partly attributed to the increases in pain associated with surgical procedures and other wound therapies.

• For the purposes of assessment and treatment, categorizing pain as procedural or background is useful

• As deeper, previously anaesthetic wounds heal, granulation tissue brings new nerve endings to life and the return of sharp pain sensation

• During this time, the potential exists for the development of chronic pain syndromes such as complex regional pain syndrome and phantom limb pain

• Providers must also be vigilant for psychological factors contributing to pain, including depression and anxiety, and address them

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ASSESSMENT OFPAIN

Assessment ofpain

Multiple techniques for the measurement of pain in patients have been evaluated and are suitable for routine use.

• These include numeric scales, agitation scales, and visual analogue scales

• Assessment of pain in paediatric patients poses challenges. For pre-

school and school- aged children, self- reporting of pain levels is possible, and tools tailored to each age group have been developed. For nonverbal children, other techniques can be employed such as behaviour and observation scales

More important than the technique used is the frequent and consistent application to guide and evaluate therapy.

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CHAPTER46 Pain management

Treatment strategies

General aspects

• Amultimodal approach to the treatment of pain should be employed.

• Any therapy should be tailored to the individual patient’s stage of treatment and be guided by systematic and frequent assessments and monitoring

• Pain specialist consultation should be considered early on.

• Organ dysfunctions such as renal or respiratory failure have to be taken into account regarding any pain management plan.

• Protocols should be implemented to treat pain and pain management- associated side eects such as pruritus, constipation, nausea, and vomiting, or respiratory depression

• During the resuscitative phase after a burn, intravenous (IV) analgesics should be chosen due to the potentially altered pharmacokinetics of intramuscular (IM), or per oral (PO) routes of administration.

• Opioid analgesics are the mainstay during the resuscitative phase with patient- controlled analgesia (PCA) a preferred mode of delivery in adult and select paediatric groups

• Treat pain actively to avoid breakthrough pain; scheduled preferred over as- needed administration if no side eects

• After the resuscitative phase, background pain has to be separated from procedural pain (or pain related to activity such as physical therapy); analgesics should be adjusted

• With the frequent concomitant need for sedation during procedures, medications with both analgesic and sedative properties have particular utility (ketamine)

• Consider transitioning to PO analgesics when condition stabilizes and PO absorption becomes more predictable.

• Regional analgesia can be considered if deemed appropriate; the anaesthesiology service should be consulted

Pharmacological therapies

Opioid analgesics

Opioid analgesics act on specic receptors in the central nervous system, but also in the periphery.

• Opiate analgesics form the mainstay of therapy, especially during the initial phase

• Flexibility in the route of administration:PO, IV, subcutaneous (SC), IM, rectal, intranasal, transmucosal, transdermal, and neuraxial

• Includes morphine, hydromorphone, fentanyl, pethidine, and methadone

• Opioids are equianalgesics if dose and route of administration, as well as incomplete cross- tolerance and variation in the patient’s response, are considered

• Opioids have a similar prole of side eects:

• Respiratory and cardiovascular depression, sedation, euphoria, dysphoria, nausea, vomiting, constipation, and pruritus

• If opioids are considered, a prophylaxis against constipation should be initiated

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TREATMENT STRATEGIES

• Specic antagonists are available (eg. naloxone) to reverse lifethreatening side eects, but also will reverse the analgesic response

• May be associated with the development of tolerance, physical dependence, addiction, and pseudoaddiction. However, these concerns should not limit the use if indicated

• Tolerance and hyperalgesia has been observed, especially in ventilated patients, leading to poorly controlled pain. Adjuvants such as ketamine or clonidine have been used successfully in these critical situations

• Special legal requirements and documentation must be followed

Morphine

• Standard opioid analgesic. Metabolites can accumulate in renal failure

Fentanyl

• Eighty times more potent than morphine, rapid onset, metabolites

inactive

Remifentanil

• Potent with rapid onset, but also ultrashort duration of action requires

continuous infusion. Useful for procedural pain

Pethidine

• Possesses some local anaesthetic activity as well. It can be used to treat

postoperative shivering. Metabolites can accumulate in renal failure, causing central nervous system excitement and resultant seizures

Methadone

• Longer half-life gives smoother control and it is eective when pain

is poorly controlled by morphine due to tolerance, opioid induced hyperalgesia, or neuropathic pain.

Opioid analgesics:patient- controlled analgesia (PCA)

Allows the patient to titrate his opioid medication (usually IV) via a pump, to eect and provides more patient autonomy. Only the patient is to use the PCA demand button.

• Morphine, fentanyl, hydromorphone, and pethidine are commonly used,

with none being particularly superior

• Patients may need a loading dose of an opioid analgesic before

initiation of PCA

• The use of a continuous opioid infusion in addition to demand dosing

may be considered when variability in plasma opioid levels is leading to severe breakthrough pain. Special monitoring should be instituted, however, to monitor for drug overdose

• PCA requires special equipment and operator failure is a risk factor

Ketamine

• Depending on the dose, it has analgesic and hypnotic eects. Its NMDA

receptor antagonism may be useful in cases of opiate tolerance and neuropathic pain

• It contrasts with opioids in its preservation of respiratory drive

• Associated dysphoria can be an issue in adolescents and adults which

can be eectively prevented/ treated with benzodiazepines

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CHAPTER46 Pain management

Clonidine

• It is an α2 adrenergic agonist- possessing analgesic has sedative

properties

• Has opiate- sparing eects when used during procedures

• Its main side eects include sedation and hypotension, which may limit

use during the acute phase after burn in critically ill patients

• Rebound hypertension may occur with abrupt discontinuation of

clonidine but only in cases of chronic use

Non- steroidal anti- inammatory drugs (NSAIDs)

• Their use in the acute phase is limited due to a side eect prole that

includes platelet inhibition, renal dysfunction, and gastrointestinal complications

• They do reduce the classic metabolic response to burn injury.

• NSAIDs are useful adjuncts to opioid medications and an opioid- sparing

eect has been noted

Paracetamol/ acetaminophen

• It possesses opiate- sparing properties with minimal side eects when

compared to NSAIDs

• Daily intake should be limited to avoid hepatic toxicity and special care

should be taken when other paracetamol- containing medications, such as various oral hydrocodone preparations, are given

Topicals

• The use of topically applied analgesics, including local anaesthetics,

NSAIDs, opioids, and ketamine, has been evaluated with limited success

• Topical lidocaine shows benet but is limited by the burn size due to

systemic absorption and associated toxicity

Adjuvants forneuropathic pain, burn- induced pruritus, anxiety

Gabapentin

• Gabapentin can be used in patients with neuropathic pain and patients

with burn wound- induced pruritus

• It can accumulate in renal failure and renal dosing guidelines should be

followed

• Its main side eects are sedation and peripheral oedema. It should not

be discontinued abruptly

• Pregabalin (Lyrica) is an alternative for patients refractory/ intolerant to

gabapentin and similar caution should be exercised in patients with renal failure

• Dosing and safety has not been established in paediatric patients

Tricyclic antidepressants

• Oral preparations such as amitriptyline or nortriptyline show ecacy

in the treatment of neuropathic pain. These medications may take a considered amount of time before an eect is noted

• Topical preparations of doxepin can be used to treat pruritus, although

its use may be limited by excess sedation

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TREATMENT STRATEGIES

Antihistamines

• Useful in treatment of anxiety and burn- induced pruritus

• Main side eect:sedation

Benzodiazepines

• Potent anxiolytics with apparent opioid- sparing properties in cases

where anxiety is contributing to pain

• Useful as procedural premedication

• Added benet of muscle relaxation, especially diazepam

Surgical therapies

• Closure of open wounds can markedly reduce pain levels.

• For full- thickness burns, early excision and grafting, if possible, is ideal

• Use of temporary measures such as xenograft, allograft, or synthetic

dressings, like biobrane, is extremely benecial for pain control as well, especially for second- degree burns

Non- pharmacological and psychological therapies

• Given that pain is complex in nature, with strong contributions from

psychological factors, a multimodal approach to pain management should address these factors as well

• This includes a psychologist/ psychiatrist

• As mentioned before, anxiety and depression can exacerbate pain and

should be treated when identied

• Active eorts to prevent such negative psychological consequences

should be employed by using strategies based on cognitive approaches as well as operant and classical conditioning

• Cognitive techniques can involve improving patients’ coping by giving

them more control over their treatment, especially procedures. They can be guided in restructuring their thoughts on pain to more constructive ones

• Distraction is an additional technique that follows under this category

and one that technology is bringing to the forefront via virtual reality

• Operant conditioning requires addressing how caregivers respond

to patient pain behaviours. Patients are rewarded for constructive behaviour such as meeting therapy goals. Reinforcement of negative behaviours such as avoidance of therapy and drug seeking are strictly avoided

• Aclassical conditioning approach can be implemented by thoroughly

preparing patients for what to expect during procedures/ therapies and making the whole experience as non- threatening as possible

• Support groups

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CHAPTER46 Pain management