Pain management after burn trauma

Analgesia

A vital problem of pain management in the intensive care unit is the limited communication. A study by Whipple JK et al. (1995) showed that 74% of intensive care patients suffered from pain [104].

Opioids

As in non-intensive care patients, opioids are a basic medication in the pain management in this case.

Sufentanil

Sufentanil is the strongest opioid that is currently used (500 to 1000-fold higher analgesic potency than morphine) and has a high affinity to the μ-receptor. Compared to other opioids, its context-sensitive half-life is relatively low. Thus it is very well suited for a long-term sedation. Another benefit of sufentanil is its very good cardiovascular stability.

Remifentanil

Remifentanil is a very well controllable analgesic with a context-sensitive half-life of 3 to 4 minutes, which remains constant even after a longer time of supply. Its degradation is carried out independently of liver and renal function by unspecific blood and tissue esterases. Thus its application is particularly beneficial in patients with liver and renal disorders. Remifentanil can only be administered as continuous infusion because a bolus application causes respiratory insufficiency and skeletal muscle rigidity, which can inhibit artificial respiration. Remifentanil does not cause release of histamines.

Literature describes the occurrence of an opioidinduced hyperalgesia and allodynia or the development of an opioid tolerance from a continuous supply of 0.1 μg/kg/min [35, 38, 101].

Alfentanil

Alfentanil is a short-time effective, potent opioid with a maximum action time within one minute after administration. Its slow metabolic degradation makes it not very well suited for a long-term sedation. More effective is bolus application as on-top analgesia for care measures and short therapeutic interventions. When administered too fast, bradycardia and increased thoraxrigidity must be considered.

Other possible fields of application are during dressing change as patient-controlled analgesia with basic function and bolus application or as targetcontrolled infusion [105, 106]. In both studies, the patients were alert and cooperative without respiratory depression or haemodynamic instability.

Non-opioids

In critic indication and consideration of the side effects, non-opioids are an important part of a multimodal therapy concept as well in the intensive care unit. Particular attention must be paid when treating older burn patients or burn patients with pre-existing cardiac and renal disorders. Furthermore interactions with other preparations must be considered (e. g. with diuretics, antihypertensives and corticosteroids).

References

[1]Kehlet H, Jensen TS, Woolf CJ (2006) Persistent postsurgical pain: risk factors and prevention. The Lancet 367: 1618–1625

[2]Dauber A, Osgood PF, Breslau AJ et al (2002) Chronic persistent pain after severe burns: a survey of 358 burn survivors. Pain Med 3: 6–17

[3]Ratcliff SL, Brown A, Rosenberg L et al (2006) The effectiveness of a pain and anxiety protocol to treat the acute pediatric burn patient. Burns 32(5): 554–562

[4]Spacek A (2006) Der neuropathische Schmerz – aktuelle Therapiekonzepte. 1. Aufl. UNI-MED Verlag AG Bremen S. 20–23

[5]Gray P, Williams B, Cramond T (2008) Successful use of Gabapentin in acute pain management following burn injury: a case series. Pain Med 9 (3): 371–376

[6]Malenfant A, Forget R, Papillon J et al (1996) Prevalence and characteristics of chronic sensory problems in burn patients. Pain 67(2–3): 493–500

[7]Choiniere M, Melzack R, Papillon J (1991) Pain and paresthesia in patients with healed burns: An exploratory study. J Pain Symptom Manage 6(7): 437–444

[8]Macrae WA (2001) Chronic pain after surgery. Br J Anaesth 87: 88–98

[9]Thomans CR, Brazeal BA, Rosenburg L et al (2003) Phantom limb pain in pediatric burns survivors. Burns 29(2): 139–142

[10]Kumbhat S, Meyer N, Schurr MJ (2004) Complex regional pain syndrome as a complication of a chemical burn to the foot. J Burn Care Rehabil 25(2): 189–191

[11]Van der Laan L, Goris RJA (1996) Reflex sympathetic dystrophy after burn injury. Burns 22(4): 303–306

[12]Isakov E, Boduragin N, Korzets A, Susak Z (1995) Reflex sympathetic dystrophy of both patellae following burns. Burns 21(8): 616–618

357

R. Girtler, B. Gustorff

[13]Kim CT, Bryant P (2001) Complex regional pain syndrome (type I) after electrical injury: A case report of treatment with continuous epidural block. Arch Phys Med Rehabil 82(7): 993–995

[14]Melzack R (1975) The McGill pain questionnaire: major properties and scoring methods. Pain 1: 277–299

[15]Payen JF, Bru O, Bosson JL et al (2001) Assessing pain in critically ill sedated patients by using a behavioral pain scale. Crit Care Med 29(12): 2258–2263

[16]Abbey J, Piller N, De Bellis A et al (2004) The Abbey Pain Scale: a 1-minute numerical indicator for people with end-stage dementia. Int J Palliative Nurs 10(1): 6–13

[17]Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S (1997) The FLACC: a behavioral scale for scoring postoperative pain in young children. Paediatr Nurs 23(3): 293–297

[18]Büttner W et al (1998) Entwicklung eines Fremdbeobachtungsbogens zur Beurteilung des postoperativen Schmerzes bei Säuglingen. AINS 33: 353–361

[19]Taal LA, Faber AW, Van Loey NEE et al (1999) The abbreviated burn specific pain anxiety scale: a multicenter study. Burns 25(6): 493–497

[20]Rae CP, Gallagher D, Watson S, Kinsella J (2000) An audit of patient perception compared with medical and nursing staff estimation of pain during burn dressing changes. Eur J Anaesthesiol 17(1): 43–45

[21]Pallua N (2009) Kompendium der Schmerztherapie bei Verbrennungen. Deutsche Gesellschaft für Verbrennungsmedizin und Deutsche Gesellschaft zum Studium des Schmerzes. URL: http://www.dgss.org/filead min/pdf/Schmerz_KompendiumVerbrennung0901. pdf

[22]Barden J, Edwards J, Moore RA, MyQuay HJ (2004) Single dose oral diclofenac for postoperative pain. Cochrane Database Syst Rev(2): CD004 768

[23]Elia N, Lysakowski C, Tramer MR (2005) Does multimodal analgesia with acetaminophen, nonsteroidal anti-inflammatory drugs, or selective cyclooxygen- ase-2 inhibitors and patientcontrolled analgesia morphine offer advantages over morphine alone? Anesthesiology 103: 1296–1304

[24]Koppert W, Wehrfritz A, Korber N et al (2004) The cyclooxygenase isoenzyme inhibitors parecoxib and paracetamol reduce central hyperalgesia in humans. Pain 108: 148–153

[25]Tröster A, Sittl R, Singer B et al (2006) Modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by parecoxib in humans. Anesthesiology

105:1016–1023

[26]Pelissier T, Alloui A, Caussade F et al (1996) Paracetamol exerts a spinal antinociceptive effect involving an indirect interaction with 5-hydroxytryptamine3 receptors: in vivo and in vitro evidence. J Pharm Exp Ther

278:8–14

[27]Beubler E (2009) Kompendium der medikamentösen Schmerztherapie, 4. Aufl. Springer Wien New York, S 19

[28]Larsen R (2001) Anästhesie, 7. Aufl. Urban und Fischer Verlag, München, S 806

[29]Kramer MS, Lane DA, Hutchinson TA (1988) The International Agranulocytosis and Aplastic Anemia Study (IAAAS). J Clin Epidemiol 41 (6): 613–616

[30]Hedenmalm K, Spigset O (2002) Agranulocytosis and other blood dyscrasias associated with dipyrone (metamizole). Eur J Clin Pharmacol 58(4): 265–274

[31]Ott E, Nussmeier NA, Dukie PC et al (2003) Efficacy and safety of the cyclooxygenase 2 inhibitors parecoxib and valdecoxib in patients undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg 125(6): 1481–192

[32]McGettigan P, Henry D (2006) Cardiovascular risk and inhibition of cyclooxygenase. A systematic review of the oberservational studies of selective and nonselective inhibitors of cyclooxygenase2. JAMA 296(13): 1633–1644

[33]Nussmeier NA, Whelton AA, Brown MT et al (2005) Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. N Engl J Med 352: 1081–1091

[34]Freye E, Latasch L (2003) Development of opioid tolerance – molecular mechanisms and clinical consequences. AINS 38: 14–26

[35]Koppert W, Sittl R, Scheuber K et al (2003) Differential modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by s-ketamine and clonidine in humans. Anesthesiology 99(1): 152–159

[36]Célèrier E, Rivat C, Jun Y et al (2000) Long-lasting hyperalgesia Induced by Fentanyl in rats. Anesthesiology 92(2): 465–472

[37]Xiangqi Li, Angst MS, Clark JD (2001) Opioid-induced hyperalgesia and incisional pain. Anesth Analg 93: 204–209

[38]Joly V, Richebe Ph,Guignard B et al (2005) Remifenta- nil-induced postoperative hyperalgesia and its prevention with small-dose ketamine. Anesthesiology 103(1): 147–155

[39]Smith MT, Watt JA et al (1990) Morphine-3-glucoron- ide – a potent antagonist of morphine analgesia. Life Sci 47: 579–585

[40]Stamer UM, Lehnen K, Höthker F et al (2003) Impact of CYP2D6 genotype on postoperative tramadol analgesia. Pain 105: 231–238

[41]Duhmke RM, Cornblath DD, Hollingshead JR (2004) Tramadol for neuropathic pain. Cochrane Database Syst Rev(2): CD003 726

[42]Tosun Z, Esmaoglu A, Coruh A (2008) Propofol-keta- mine vs propofol-fentanyl combinations for deep sedation and analgesia in pediatric patients undergoing burn dressing changes. Pediatric Anesthesia 18: 43–47

[43]Linneman PK, Terry BE, Burd RS (2000) The efficacy and safety of fentanyl for the management of severe procedural pain in patients with burn injuries. J Burn Care Rehabil 21(6): 519–522

358

Pain management after burn trauma

[44]Prakash S, Fatima T, Pawar M (2004) Patient-controlled analgesia with fentanyl for burns dressing changes. Anesth Analg 99(2): 552–555

[45]Ong EC (2008) Controlled-release oxycodone in the treatment of neuropathic pain of nonmalignant and malignant causes. Oncology 74(1): 72–75

[46]Gatti A, Sabato AF, Occhioni R et al (2009) Controlledrelease oxycodone and pregabalin in the treatment of neuropathic pain: results of a multicenter Italian study. Eur Neurol 61(3): 129–137

[47]Altier N, Dion D, Boulanger A, Choiniere M (2001) Successful use of methadone in the treatment of chronic neuropathic pain arising from burn injuries: a casestudy. Burns 27(7): 771–775

[48]Subramaniam K, Subramaniam B, Steinbrook RA (2004) Ketamine as adjuvant analgesic to opioids: a quantitative and qualitative systematic review. Anesth Analg 99: 482–495

[49]Mao J, Price DD, Mayer GJ (1995) Mechanisms of hyperalgesia and morphine tolerance: a current view of their possible interactions. Pain 62: 259–274

[50]Weinbroum AA, Gorodezky A, Niv D et al (2001) Dextromethorphan attenuation of postoperative pain and primary and secondary thermal hyperalgesia. Can J Anaesth 48: 167–174

[51]Weinbroum AA (2003) A single small dose of postoperative ketamine provides rapid and sustained improvement in morphine analgesia in the presence of morphine-resistant pain. Anesth Analg 96: 789–795

[52]Bell R, Dahl J, Moore R, Kalso E (2006) Perioperative ketamine for acute postoperative pain. Cochrane Database Syst Rev (1): CD004 603

[53]De Kock M, Lavand’homme P, Waterloos H (2001) Balanced analgesia in the perioperative period: is there a place for ketamine? Pain 92: 373–380

[54]Lavand’homme P, De Kock M, Waterloos H (2005) Intraoperative epidural analgesia combined with ketamine provides effective preventive analgesia in patients undergoing major digestive surgery. Anesthesiology 103: 813–820

[55]Owens VF, Palmieri TL, Comroe CM et al (2006) Ketamine: A safe and effective agent for painful procedures in the pediatric burn patient. J Burn Care Res 27(2): 211–216

[56]Menigaux C, Adam F, Guignard B et al (2005) Preoperative gabapentin decreases anxiety and improves early functional recovery from knee surgery. Anesth Analg 100: 1394–1399

[57]Pollack MH, Matthews J, Scott EL (1998) Gabapentin as a potential treatment for anxiety disorders. Am J Psychiatry 155: 992–993

[58]Chouinard G, Beauclair L, Belanger MC (1998) Gabapentin: long-term antianxiety and hypnotic effects in psychiatric patients with comorbid anxiety-related disorders. Can J Psychiatry 43: 305

[59]Eckhardt K, Ammon S, Hofmann U et al (2000) Gabapentin enhances the analgesic effect of morphine in healthy volunteers. Anesth Analg 91: 185–191

[60]Field MJ, Oles RJ, Lewis AS et al (1997) Gabapentin (neurontin) and S-(+)-3-isobutylgaba represent a novel class of selective antihyperalgesic agents. Br J Pharmacol 121(8): 1513–1522

[61]Cuignet O, Pirson J, Soudon O, Zizi M (2007) Effects of gabapentin on morphine consumption and pain in severely burned patients. Burns 33(1): 81–86

[62]Mendham JE et al (2004) Gabapentin for the treatment of itching produced by burns and wound healing in children: a pilot study. Burns 30: 851–853

[63]Pal SK, Cortiella J, Herndon D (1997) Adjunctive methods of pain control in burns. Burns 23(5): 404–412

[64]Tcheung WJ, Robert R, Rosenberg L et al (2006) Early treatment of acute stress disorder in children with major burn injury. Pediatr Crit Care Med 7(5): 498–499

[65]Deutsche Interdisziplinäre Vereinigung für Schmerztherapie, S3Leitlinie “Behandlung akuter perioperativer und posttraumatischer Schmerzen”, Stand: 21. 05. 2007, inkl. Änderungen vom 20. 04. 2009

[66]Cheung LH, Callaghan P, Chang AM (2003) A controlled trial of psycho-educational interventions preparing Chinese women for elective hysterectomy. Int J Stud 40(2): 207–216

[67]Good M, Anderson GC, Stanton-Hicks M et al (2002) Relaxation and music reduce pain after gynecologic surgery. Pain Manag Nurs 3(2): 61–70

[68]Good M, Anderson GC, Ahn S et al (2005) Relaxation and music reduce pain following intestinal surgery. Res Nurs Health 28(3): 240–251

[69]Huth MM, Broome ME, Good M (2004) Imagery reduces children’s post-operative pain. Pain 110(1–2): 439–448

[70]Nilsson U, Rawal N, Unestahl LE et al (2001) Improved recovery after music and therapeutic suggestions during general anaesthesia: a double-blind randomised controlled trial. Acta Anaesthesiol Scand 45(7): 812–817

[71]Montgomery GH, David D, Winkel G et al (2002) The effectiveness of adjunctive hypnosis with surgical patients: a meta-analysis. Anesth Analg 94(6): 1639–45, table of contents

[72]Saadat H, Drummond-Lewis J, Maranets I et al (2006) Hypnosis reduces preoperative anxiety in adult patients. Anesth Analg 102(5): 1394–1396

[73]Frenay MC, Faymonville ME, Devlieger S et al (2001) Psychological approaches during dressing changes of burned patients: a prospective randomised study comparing hypnosis against stress reducing strategy. Burns 27(8): 793–799

[74]Bjordal JM, Johnson MI, Ljunggreen AE (2003) Transcutaneous electrical nerve stimulation (TENS) can reduce postoperative analgesic consumption. A meta-analysis with assessment of optimal treatment parameters for postoperative pain. Eur J Pain 7(2): 181–188

[75]Richardson P, Mustard L (2009) The management of pain in the burns unit. Burns 35(7): 921–936

359

R. Girtler, B. Gustorff

[76]Gregoretti C, Decaroli D, Piacevoli Qu et al (2008) Anal- go-sedation of patients with burns outside the operating room. Drugs 68(17): 2427–2443

[77]Wilhelm W, Wrobel M, Kreuer S, Larsen R (2003) Remifentanil – Eine Bestandsaufnahme. Anaesthesist 52: 473–494

[78]Le Floch R, Naux E, PilorgetA, Arnould J-F (2006) Use of remifentanil for analgesia during dressing changes in spontaneously breathing non-intubated burn patients. Ann Burns Fire Disasters XIX (3)

[79]Patterson DR, Ptacek JT, Carrougher GJ, Sharar SR (1997) Lorazepam as an adjunct to opioid analgesics in the treatment of burn pain. Pain 72(3): 367–374

[80]Nilsson A, Steinvall I, Bak Z, Sjoberg F (2008) Patient controlled sedation using a standard protocol for dressing changes in burns: patients preference, procedural details and a preliminary safety evaluation. Burns 34: 929–934

[81]MacPherson RD, Woods D, Penfold J (2008) Ketamine and midazolam delivered by patient-controlled analgesia in relieving pain associated with burns dressings. Clin J Pain 24(7)568–571

[82]Gupta A, Bhandari PS, Shrivastava P (2007) A study of regional nerve blocks and local anesthetic creams

(Prilox) for donor sites in burn patients. Burns

33: 87–91

[83]Cuignet O, Pirson J, Boughrouph J, Duville D (2004) The efficacy of continuous fascia iliaca compartment block for pain management in burn patients undergoing skin grafting procedures. Anesth Analg 98: 1077–1081

[84]Jellis WS, Gamelli RL, Furry PA et al (1999) Effect of topical local anesthetic application to skin harvest sites for pain management in burn patients undergoing skin-grafting procedures. Ann Surg 229(1): 115–120

[85]Pedersen JL, Callesen S, Møiniche S, Kehlet H (1996) Analgesic and anti-inflammatory effects of lignocaineprilocaine (EMLA) cream in human burn injury. Br J Anaesthesia 76: 806–810

[86]Raymond I, Nielsen TA, Lavigne G et al (2001) Quality of sleep and its daily relationship to pain intensity in hospitalized adult burn patients. Pain 92(3): 381–388

[87]Schraag S, Checketts M et al (1999) Lack of rapid development of opioid tolerance during alfentanil and remifentanil infusions for postoperative pain. Anesth Analg 89: 753-757

[88]Luger TJ, Hayashi T, Grabner Weiss C, Hill H (1995) The spinal potentiating effect and the supraspinal inhibitory effect of midazolam on opioidinduced analgesia in rats. European J Pharmacol 275(2): 153–162

[89]Palaoglu O, Ayhan IH (1986) The possible role of benzodiazepine receptors in morphine analgesia. Pharmacol Biochem Behav 25: 15–217

[92]Martin J, Bäsell K, Bürkle H et al (2005) Analgesie und Sedierung in der Intensivmedizin. S2-Leitlinien der deutschen Gesellschaft für Anästhesiologie und Intensivmedizin. Anaesthesiol Intensivmed 46 [Suppl 1: 1–20

[93]Ramsay MA, Savege TM, Simpson BR, Goodwin R (1974) Controlled sedation with alphaxalone-alpha- dolone. Br Med J 2(920): 656–659

[94]Riker R, Picard F, Fraser G (1999) Prospective evaluation of the sedation-agitation-scale for adult critically ill patients. Crit Care Med 27(7): 1325–1329

[95]Ely EW, Inouye SK, Bernard GR et al (2001) Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 286(21): 2703–2710

[96]Ambuel B, Hamlett KW, Marx CM, Blumer JL (1992) Assessing distress in pediatric intensive care enviroments: the COMFORT scale. J Pediatr Psychol 17(1): 95–109

[97]Weinert CR, Chlan L, Gross C (2001) Sedating critically ill patients: factors affecting nurses’delivery of sedative therapy. Am J Crit Care 10(3): 156–65; quiz 166–7

[98]Giessler GA, Mayer T, Trupkovic T (2009) Das Verbrennungstrauma. Anaesthesist 58: 474–484

[99]Costa J, Cabre L, Molina R Carrasco G (1994) Cost of ICU sedation: comparison of empirical and controlled sedation methods. Clin Intensive Care 5 [5Suppl.:17–21

[100]Frölich MA, Price DD, Robinson ME et al (2005) The effect of propofol on thermal pain perception. Anesth Analg 100: 481–486

[101]Guignard B, Coste C, Costes H et al (2002) Supplementing Desflurane-Remifentanil anesthesia with smalldose ketamine reduces perioperative opioid analgesic requirements. Anesth Analg 95: 103–108

[102]Edrich T, Friedrich AD, Eltzschig HK, Felbinger TW (2004) Ketamine for long-term sedation and analgesia of a burn patient. Anesth Analg 99: 893–895

[103]Jung C, Granados M, Marsol P (2008) Use of sevoflurane sedation by the AnaConDa device as an adjunct to extubation in a pediatric burn patient. Burns 34: 136–138

[104]Whipple JK, Lewis KS, Quebbeman EJ et al (1995) Analysis of pain management in critically ill patients. Pharmacotherapy 15(5): 592–599

[105]Sim KM, Hwang NC, Chan YW, Seah CS (1996) Use of patient-controlled analgesia with alfentanil for burns dressing procedures: a preliminary report of five patients. Burns. 22(3): 238–241

[106]Gallagher G, Rae CP, Kenny GN, Kinsella J (2000) The use of a target-controlled infusion of alfentanil to provide analgesia for burn dressing changes: A dose finding study. Anaesthesia 55(12): 1159–1163

[90]Perkins FM, Kehlet H (2000) Chronic pain as an outCorrespondence: Dr. Richard Girtler, DEAA. Facharzt für

come of surgery. Anesthesiology 93: 1123–1133

[91]Kong R, Payen D (1994) Controlling sedation rather than sedation controlling you. Clin Intensive Care 5[5Suppl]:5–7

Anästhesie und Intensivmedizin, Abteilung für Anästhesie und Intensivmedizin am Wilhelminenspital der Stadt Wien, Montleartstraße 37, 1160 Wien, Austria, E-mail: richard. girtler@wien kav.at

360