The purpose of this guideline is to update the previous guideline by Drs Faucher and Furukawa.1 To accomplish this, we review the principles of acute pain management in adult burn patients and present a reasonable approach to the management of the complex pain associated with burn injury based on a review of the literature and expert opinion. In addition, we provide suggestions for a research agenda that would yield evidence neccesary for the next iteration of recommendations for the treatment of acute pain associated with burn injury. Burn injury is widely considered one of the most painful injuries that a person can sustain. In addition to the intrinsic pain caused by the burn itself, the proper treatment of a burn injury requires painful procedures including debridment of the wound, daily wound care, and surgery, followed by aggressive physical and occupational therapy. Burn pain is especially complicated; it is multifaceted and frequently changes over time as the patient undergoes repeated procedures and treatments that require manipulation of their painful burn sites. Despite an understanding of the importance of pain management in recovery from burn wounds, numerous reports are discussing the inadequacy of treatment of burn pain. Furthermore, inconsistency in practice standards has been well documented for almost three decades.2–6 The International Association for the Study of Pain (IASP) defines pain as “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” 7 Introduced in 1979, it is one of the most widely promulgated definitions for pain, including adoption by the World Health Organization. As our understanding of pain has advanced, there have been calls for an update to the original definition.8–10 Nevertheless, the definition acknowledges that pain is a complex and multi-faceted phenomenon that includes subjective, psychosocial, and physiologic elements. While the IASP definition of pain is widely utilized, there are several ways to categorize types of pain in neurological, physiological, and psychological domains. Published in 1965, Melzack and Wall’s “Pain mechanisms: A new theory,” introduced the Gate Theory of Pain.11 Their work influenced subsequent pain research and provided neurophysiologic rationale and a mechanistic explanation for physical and psychologic aspects of pain and the development of chronic pain. Though many dispute specifics regarding the Gate Theory of Pain, the collective research on the neurophysiologic mechanisms of pain allow us to consider how pain signals are generated, promulgated, and perceived. Thus, pain can be described in terms of being somatogenic, nociceptive, neuropathic, and psychogenic as well as acute or chronic. The pain caused by an acute burn injury is first and foremost nociceptive in nature. The process by which the noxious burn stimulus is interpreted as what we describe as pain occurs in several stages: transduction, conduction, transmission, modulation, and perception. The initiation of this process involves the activation of nociceptors in the skin. These stimuli are converted, or transduced, into electrophysiologic signals. The nociceptors are the terminals endings of C fibers (unmyelinated) and/or A-delta (AΔ fibers (myelinated) which conduct the signal from the peripheral nervous system centrally to the dorsal horn of the spinal cord. Transmission then occurs via the spinothalamic tracts to the brain. The processing of noxious stimuli occurs via both ascending and descending pathways and can be modulated by both excitatory and inhibitory mechanisms. Several areas of the brain are involved in the perception of pain. These include the medulla, midbrain, and thalamus, then relayed to the somatosensory cortex, hypothalamus, hippocampus, and the amygdala. The involvement of these areas generates different perceptions of pain such as intensity, urgency, cognitive, and emotional aspects of the pain response. Via complex biochemical and electrophysiological mechanisms utilizing numerous receptors, cells, fibers, and neurotransmitters the painful sensation is processed in the central nervous system. Nevertheless, having at least a conceptual understanding of the stages of this process leads us to consider the utility and importance of multi-modal approaches to pain management. Knowledge of specific pathways and players involved in the process leads us to consider potential pharmacologic and nonpharmacologic treatments. Rather than considering pain from an etiologic or physiologic/affective approach, pain can also be described in terms of an individual’s arc of recovery. Using this simpler taxonomy, pain can be described in terms of being background, breakthrough, or procedural in nature. Background (or baseline) pain exists while the patient is at rest and occurs from the burn injury itself. Breakthrough pain is instances when there is a transient exacerbation of pain. Procedural pain is pain associated with any therapeutic intervention with a patient, whether it is invasive (eg, arterial/venous access, wound debridement, and surgical) or noninvasive (eg, physical/occupational therapy). Each of the approaches above provides a perspective to understanding the mechanisms and taxonomy of pain. They provide an important framework for the development and implementation of guidelines for pain management. A sub-committee of the American Burn Association’s Committee on the Organization and Delivery of Burn Care was created to revise the previously published pain guidelines.1 A MEDLINE search of the English-language publications from 1968 to 2018 was conducted using the keywords “burn pain,” “treatment,” and “assessment” as was described in the previously published guidelines. This search produced 189 results, of which 95 were found to be relevant to the assessment and treatment of burn pain. Additional selected references were also used based on the committee’s evaluation of the broader pain literature. Studies were sub-divided by topic and graded by 2 members of the committee per section using Oxford Centre for Evidence-based Medicine—Levels of Evidence.12 When there was a disagreement about the grade of a particular study a third member of the committee was used to resolve the disagreement. These articles were compiled into an evidence-based review of current knowledge regarding treatment of burn-related pain. Please see Table 1 for all included papers and their level of evidence grading and Table 2 for a description of the level of evidence. The next step was an in-person meeting to determine expert consensus on a variety of topics related to the treatment of pain in burn-injured patients. The committee consisted of a wide range of burn care providers including burn surgeons, burn nurses, anesthesiologists, a pharmacist, and a psychologist. All members had significant interest and experience caring for burn injured patients. Finally, we assessed gaps in current knowledge and proposed research questions that would provide evidence for future recommendations. In this article, we address interventions used to ameliorate the profound and (at this point) inevitable pain patients experience in the course of acute burn care. Though outside the scope of this review, it should be noted that thoughtful wound management—prompt surgical coverage where indicated, preventing wound infection, and wound care approaches that reduce the frequency of dressing changes—play a crucial role in minimizing the pain a patient experiences. Evidence-based literature review of current knowledge regarding treatment of burn-related pain Evidence-based literature review of current knowledge regarding treatment of burn-related pain Levels of evidence Levels of evidence Despite examining 10 additional years of research there are insufficient data to fully support high-level evidence-based standards of care. Nevertheless, we combine the evidence available and expert opinion to put forth several guidelines for the assessment and management of pain during acute burn hospitalization. Recommendations for the management of acute pain in the adult burn patient (see online long version of the article for detailed explanations of the recommendations; see Table 3 for levels of recommendation). Grades of recommendations Grades of recommendations Pain assessments should be performed several times a day and during various phases of care (Level A) Pain assessments should be protocolized and recorded by the physician and the nursing staff during the various stages of care to ensure consistent language when discussing pain evaluation (Level B) Pain assessment tools should use patient-reported scales when able (Level C) The Burn Specific Pain Anxiety Scale (BSPAS) should be included as one of the pain assessments used during an acute burn hospitalization as it is a validated tool for the burn patient population and includes evaluation of anxiety (Level C) Critical Care Pain Observation Tool (CPOT) can be used when a patient is not able to interact or communicate their individual assessment of pain (Level D) When choosing opioid pain medications, decisions about choice of agent should be based on physiology, pharmacology, and physician experience given the limited amount of high-quality data available (Level C) Opioid therapy should be individualized to each patient and continuously adjusted throughout their care due to the heterogeneity of individual responses, adverse effects, and the narrow therapeutic window of opioids (Level D) Attempts should be made to use as few opiate equivalents as needed to achieve the desired level of pain control (Level C) Opioid pain medications should not be used in isolation but in conjunction with nonopioid and nonpharmacological measures (Level C) Patients should be educated about the role of opioids and other pain medications in their recovery from burn injury (Level D) Acetaminophen should be utilized on all burn patients, with care taken to monitor the maximal daily dose (Level D) Nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in all patients due to their safety profile and efficacy in other settings; however, the patient’s clinical picture including baseline comorbidities and kidney function as well as surgeon preference should be included in this decision (Level D) Agents for the treatment of neuropathic pain (eg, gabapentin or pregabalin) should be considered as an adjunct to an opioid in patients who are having neuropathic pain or who are refractory to standard therapy (Level C) Ketamine should be considered for procedural sedation, with appropriate training and monitoring for the physician and nursing staff who are administering (Level B) Low-dose ketamine should be considered as an adjunct to opioid therapy in patients who could benefit from reduced opioid consumption, particularly in the postoperative period (Level D) Dexmedetomidine and clonidine are recommended as pain management adjuncts, particularly in patients showing signs of withdrawal or prominent anxiety symptoms and dexmedetomidine as a first-line sedative in the intubated burn patient (Level D) The use of IV lidocaine for burn pain management cannot be recommended at this time as a first-line agent, but it is a reasonable second- or third-line adjuvant agent (Level D) Given the lack of evidence and the potential legal and political obstacles, we are unable to make a recommendation for the use of cannabinoids in the treatment of acute burn pain (Level D) Regional anesthesia for burn pain management has the potential to provide improved pain relief, patient satisfaction, and opioid use reduction without serious risks or complications (Level C) Every patient should be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen. When the expertise and/or equipment is available, cognitive-behavioral therapy, hypnosis and virtual reality have the strongest evidence. (Level A) The management of pain following a burn is extremely complex and the various phases of care must be considered in pain assessments as well as when choosing which treatment modalities to use. All of the various modalities of pain control discussed above have a role in pain control for the burn-injured patient and can be used to create an individualized multimodal pain plan for each patient. While there is increasing research on all of these modalities, the available studies are inadequate to support a true standard of care. Moving forward we call for more burn specific research into all modalities for burn pain control as well as research on multimodal pain control. Additionally, we call for the use of common data elements in burn pain research studies so studies and protocols created can be reliably compared. Funding: This project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through grant number UL1 TR001860. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Conflict of interest statement. No competing financial interests exist.
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Romanowski et al. (2020) studied this question.
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