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J. B. Starr et al.
In patients who are able to communicate or use a PCA,
continuous opioid infusions increase the risk of respiratory
depression. Nevertheless, they have a role in young children
and intubated patients, typically in the form of a fentanyl
infusion.
Methadone also plays a unique role in burn care. In
addition to long-acting mu-receptor agonism, it causes
N-methyl- D-aspartate (NMDA) antagonism and serotonin
and norepinephrine reuptake inhibition [18]. It can be
prescribed up to four times daily for pain, with starting doses
of 5–10 mg. It is especially useful for non-opioid naïve
patients. It is important to monitor the QTc in patients on
methadone, with a QTc over 500 ms necessitating a dose
reduction. Buprenorphine, a partial mu-agonist, can also play
a role in burn patients with opioid use disorders.
Regardless of the opioid chosen, side effects include
pruritus, nausea, vomiting, constipation, respiratory
depression, opioid induced hyperalgesia, along with tolerance
and addiction. It is therefore important to provide multimodal
analgesia and reduce opioid dosing as soon as tolerated.
Ketamine
Ketamine, either in high doses for procedures or in low-dose
infusions for background pain, is a useful adjunct for burn
pain management. It is an NMDA receptor antagonist that
functions synergistically with opioids. Analgesic infusions
range from 1 to 3mcg/kg/min with negligible adverse effects.
Dosing for procedures is associated with unpleasant hallucinations although this can be mitigated with coadministration
of benzodiazepines [18].
Lidocaine
Topical and IV lidocaine are adjunct options that can be
offered to burn patients. For small burns, topical lidocaine can
be effective, though systemic toxicity becomes a concern for
larger burns [24]. IV lidocaine can be used for background or
Chapter 15. Pain Management inBurn Patients
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procedural pain, albeit with limited evidence [25]. Dosing at
1mg/kg/h for up to 48h has been used safely at our institution in patients without hepatic compromise. The primary
adverse effect is nausea.
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Anxiolytics
Anxiolytics for burns includes benzodiazepines and
hydroxyzine. Benzodiazepines are the standard for anxiolysis
and amnesia for painful procedures, but they are associated
with respiratory depression, delirium, tolerance, and addiction.
Hydroxyzine is an antihistamine, FDA approved for anxiety.
With a reduced side-effect profile compared to benzodiazepines, it can be used for background anxiety symptoms, typically at 25–50mg every 6h as needed.
Anesthetics
For particularly painful procedures and operations, monitored
anesthesia care (MAC) or general anesthesia will be necessary.
However, inhaled nitrous oxide has been used by nonanesthesia personnel. It is typically inhaled via a mask held
by the patient in a 50:50 mixture with oxygen. It can be used
for procedures, but it is associated with nausea, dysphoria,
spontaneous abortion, and bone marrow suppression [24].
Regional Anesthesia
Regional anesthesia involves placing local anesthetic near
specific nerves in order to anesthetize a large area of the
body. The nerves that are targeted can be central, near to the
spinal cord, or peripheral. Regional anesthesia can be used as
the sole anesthetic for surgery, as a supplement to general
anesthesia for surgery, or for analgesia of the targeted area of
the body. Its use for perioperative pain is well-established and
has been shown to reliably improve early quality of pain
J. B. Starr et al.
324
relief, reduce the need for opioid medication, and improve
patient satisfaction [26].
Regional anesthesia can involve a single injection of local
anesthetic (“single shot block”) or the placement of a catheter that allows for continuous infusion of local anesthetic
over several days. Other variables to consider when discussing regional anesthesia include the type of local anesthetic
used, the volume and concentration of the drug, and the addition of other drugs into the injectate (Table15.2).
Burn injury pain should be amenable to regional
anesthesia as it is mediated by peripheral nociceptors at the
injury site as well as by injuries to the nerves themselves
(peripheral neuropathic pain) and by the peripheral inflammatory response to the injury. Furthermore, local anesthetics have some intrinsic anti-inflammatory properties and
can modulate steps of the inflammatory cascade [27, 28].
Pain from surgical debridement of a burn injury and from
graft donor sites should therefore respond well to regional
anesthesia. However, the available evidence for the effectiveness of regional anesthesia specifically in burn injured
patients is limited to a small number of randomized controlled trials.
T . Factors inuencing regional anesthesia
Variable Notes on effect
Local anesthetic drug Change in duration of
numbness
Dose of local
anesthetic
Additives
Concentration Density of block
Volume Spread of local anesthetic
Dexamethasone Increase duration of block
Dexmedetomidine Increase duration of block
Epinephrine Marker for intravascular
injection, increase duration
of short-acting local
anesthetics
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Despite limited high quality trials, regional analgesia
seems to be a useful potential adjunct to systemic analgesia,
with very few adverse effects [29]. The reason it remains
underused as an analgesic modality in the burn injured population is probably due to the added complexity of care relating to regional anesthesia. Nerve blocks are usually performed
by a specially trained anesthesiologist, meaning availability of
expertise may be inconsistent. If peripheral nerve catheters
are used, appropriate nursing care must be available to identify and manage potential problems, and systems must be in
place to manage complications. Nonetheless, although further
randomized control trials are warranted, regional analgesia is
currently recommended by consensus expert opinion where
possible [30].
Neuraxial Anesthesia
Centrally acting, or neuraxial, local anesthetic techniques
include spinal (intrathecal) anesthesia, epidural anesthesia,
and paravertebral anesthesia. Spinal and epidural techniques
involve injections into appropriate areas of the back using
blind landmark techniques. Paravertebral blocks are traditionally performed blind, but, more recently, ultrasound
guided techniques have been described and used depending
on practitioner skill and comfort [31]. Neuraxial blocks
require specific patient positioning and may be technically
challenging to place. As sympathetic and motor nerves are
also affected, patients can often experience hypotension, urinary retention, and lower extremity weakness. Rare but serious adverse events include epidural abscess and spinal cord
ischemia secondary to hematoma.
Peripheral Nerve Blocks
Peripheral nerve blocks are most commonly performed using
ultrasound to visualize specific structures of interest and
guide the needle to a precise location. The upper extremity
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J. B. Starr et al.
can be blocked by a number of approaches to the brachial
plexus, and common blocks of the lower extremity target the
femoral nerve, lateral femoral cutaneous nerve, and the sciatic nerve. Peripheral blocks that target fascial planes rather
than nerves have also been described, and their use has
grown as ultrasound imaging technology has allowed these
planes to be more easily identified. Transverse abdominus
plane (TAP) blocks and quadratus lumborum (QL) blocks
target the abdomen and anterior lower thorax; serratus anterior plane blocks (SAPB) target the anterolateral thoracic
wall; erector spinae plane blocks (ESPB) target the posterolateral hemithorax. One advantage of fascial plane blocks is
that the needle is not placed near a nerve or blood vessel,
reducing the risk of neural injury or toxicity from intravascular injection of local anesthetic.
Upper extremity blocks and plane blocks of the trunk
have been successfully reported in burn injured patients [32,
33]. The use of lateral femoral cutaneous nerve block and
fascia iliaca plane blocks for donor site pain have also been
shown to be reliable for reducing pain scores and opioid use
by both single shot and nerve catheter techniques, in children
and adults, when compared to local anesthetic infiltration
[34–36].
Non-pharmacological Modalities
Pharmacological therapy for pain is often limited by actual or
potential adverse effects, and even with maximal pharmacological pain therapy, patients with severe burns may experience high or intolerable pain levels. Analgesic medications
and regional anesthesia target the sensory nociceptive component of pain, but the overall pain experience also consists
of an experiential component (the individual experience of
pain), a cognitive component (an individual’s thoughts about
pain), and a behavioral component (how an individual acts in
response to pain), all of which are influenced by an individual’s perception, expectations, and past experiences [37, 38].
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A number of non-pharmacological interventions are
available that have been shown to help with pain management
in the burn population. While there is significant heterogeneity
in methodology and outcome measures, there are also no
adverse effects associated with them other than cost. Broadly,
non-pharmacological analgesia falls into two categories.
Distraction techniques work on the principle that non- noxious
stimuli can suppress pain and redirect attention. Cognitive
techniques work by mitigating anxiety and addressing the
affective component of pain and downregulating sympathetic
tone. In reality, many non-pharmacological techniques work
in more than one of these categories.
These techniques are safe and effective as adjuncts in the
analgesic management of burn patients. Despite this, these
interventions are likely underused because of the expertise,
time, and overall expense [39]. Current American Burn
Association guidelines recommend every patient should be
offered non-pharmacological analgesia, at least as an adjunct
to their pain management regimen, and that cognitive behavioral therapy (CBT), hypnosis, and virtual reality have the
strongest evidence base [40].
Distraction Techniques
Music is easily available, portable, and customizable to
patients’ preferences. It inhibits pain by gate-control block of
sensory fibers, while also stimulating endorphin secretion. It
has been shown to improve pain, anxiety, and relaxation in
background pain and pain during dressing changes [41–43].
More interactive forms of music therapy such as music-based
imagery (MBI) and music alternate engagement (MAE) also
show significant reduction in pain, but not opioid use, during
dressing changes [44, 45].
Virtual reality (VR) uses an immersive visual and auditory
experience usually delivered through a headset to distract a
patient’s attention from painful stimuli. VR use during dressing changes and other procedures appears to have a signifi-
328
J. B. Starr et al.
cant effect on pain scores, but not opioid consumption [46].
Functional MRI suggests that although distraction is the
predominant mechanism of action, VR also may modulate
the pain experience [47]. Interactive video gaming can be
considered a subset of VR in terms of mechanism and efficacy [39, 48].
A number of other distraction techniques have been
examined for burn pain, including massage therapy, aromatherapy, and acupuncture [49–51]. All of them generally show
a moderate positive effect on pain scores but with small
sample sizes and significant heterogeneity.
Cognitive Techniques
Hypnosis causes an altered state of consciousness to a more
suggestible state, facilitating changes in pain perception,
along with increasing relaxation. Reduction in pain quality
and anxiety has been shown in adults and children although
not a reduction in pain intensity [39, 52, 53].
CBT aims to modify patients’ thought processes relating to
their pain experience [54]. Both hypnosis and CBT require
highly trained personnel to be a viable modality for burn pain
management.
Initial Treatment Approach
Although there are many options for pain management, it is
useful to have a standardized approach for all patients and
adjust as necessary. We recommend ensuring all of a patients
home psychoactive and chronic pain medications are
restarted. Assuming there are no contraindications, add basic
adjuncts such as acetaminophen and an NSAID.In patients
with moderate pain, start an oral opioid for background pain
and an IV opioid for breakthrough pain. In those with severe
pain, starting an IV opioid delivered via PCA can be more
effective initially. For procedures, ensure short-acting, quick-
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onset opioids or benzodiazepines are available. Nonpharmacologic techniques—particularly distraction
techniques such as music and VR that are simple, inexpensive, and widely available—should be included in the multimodal analgesia plan for all burn patients, regardless of the
size or severity of their burn. Once these interventions are
enacted, continually assess pain control and safety. If treatment goals are not being met, then consider pain management specialist consultation.
Other useful consultants include addiction medicine in
patients with substance use disorders, child life for pediatric
patients, palliative care for those at the end of life, and psychiatry for patients with coexisting mental health disorders. If
available, engaging specialists in non-pharmacological modalities can be helpful, including acupuncture, massage therapy,
rehabilitation psychology, and spiritual care.
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