Acute Burn Pain Management

Original Date: 10/2019
Last Review Date: 06/2022
Purpose: To employ a standardized and evidence-based approach to the unique background and breakthrough pain management needs of burn patients in a responsible manner.

 

Burn pain has been described as a paradigm with 5 phases.

  • Background pain is the pain present while the patient is at rest and is due to the thermal injury. It is usually low to moderate in intensity and has a long duration.
  • Procedural pain are brief but intense episodes of pain that occur during procedures such as wound debridement, dressing changes, baths, or physical therapy.
  • Breakthrough pain are unexpected spikes of pain that occur when the medication regimen for background or procedural pain are exceeded. Breakthrough pain can also occur with spikes in anxiety.
  • Perioperative pain is predictable and temporary increases in pain that occur after burn excision, skin harvesting, and skin grafting due to the creation of new, painful wounds. The duration of this type of pain is typically 2-5 days.
  • Chronic pain is pain that persists longer than six months or remains after all burn wounds and donor sites have healed. Neuropathic pain is the most common form of chronic pain after burn injury.

The purpose of this protocol is to standardize the medication regimen used to treat the background and breakthrough burn pain for patients admitted to the burn center.  While limited evidence from clinical trials exist for the use of multimodal pain therapy in burn patients, this protocol was derived from our experience in the burn and trauma centers.(1, 2)

Consider patient’s age, allergies, weight, renal/hepatic function, surgical procedures, injuries, and prior opioid use when ordering and dosing medications.  Dosage adjustments should be determined by patient’s response.  Unless specifically contraindicated, the ASA Acute Pain Task Force Guidelines recommend the use of a multimodal pain management therapy plan, neuraxial/regional blockade with local anesthetics, and an around-the-clock regimen of COXIBs, NSAIDs, or acetaminophen.

Background and Breakthrough Pain

The multimodal regimen for background pain should be ordered upon admission should include the following, unless specific contraindications exist (discussed further below):

  • Scheduled:
    • Acetaminophen 1000 mg PO every 6 hours.
    • Ibuprofen 400 mg PO every 8 hours
      • eGFR <30mL/min: contraindicated
    • Gabapentin 300 mg PO every 8 hours
      • eGFR <30mL/min: 100mg PO every 8 hours
      • Lidoderm 5% topical patch apply for 12 hours on, then 12 hours off daily
    • As needed (prn):
      • Oxycodone 5mg PO q 4 hours prn pain score 6-10
      • Oxycodone 10mg PO q daily prn dressing change

For patients with pain not relieved with the above regimen, consider adding one of the following to the baseline pain regimen:

  • Ketamine drip:
    • Ketamine infusion (sub-dissociative pain dose; see below for more information)
  • Opioids:
    • Methadone 5 mg PO Q8 hours
    • Oxycodone (extended release) 10 mg PO Q8 hours

Other adjuncts for specific indications:

  • Dronabinol:
    • Dronabinol 5 mg PO Q12 hours
    • Max dose is 20 mg per day
    • Helpful to augment pain control, alleviate nausea, improve mood, and improve appetite
  • Hydroxyzine:
    • Hydroxyzine 25 mg PO Q6 hours
    • Used for treatment of itching, anxiety, and nausea; can be sedating
  • Pregabalin:
    • Pregabalin 50 mg PO every 8 hours
    • Consider pregabalin for neuropathic pain not responsive to gabapentin
  • Methocarbamol
    • For muscular spasms or pain during occupational/physical therapy
    • Dose 500-1,000 mg PO q8 hours

Multimodal Pain Medications:

(Central Prostaglandin Inhibitor)
Acetaminophen 1000 mg PO every 6 hours.

  • Do not exceed 4000 mg every 24 hours.
  • If <50 kg: 75 mg/kg/day max dose, divided in 4 doses.
  • Liver disease patients
    • MELD <15, Child class A or B – standard acetaminophen regimen
    • MELD >15, Child C – Begin normal regimen. Check serum acetaminophen level 3 hours after 3rd Adjust acetaminophen dosage as indicated. Target level <30.

(NSAID COX Inhibitor)
Ibuprofen 400 mg PO every 8 hours
Naproxen 500 mg PO every 12 hours
Celecoxib 200 mg PO every 12 hours

  • Acute kidney injury: hold in all patients if eGFR < 30.
  • Consider celecoxib in patients with a history of or at high risk for upper GI bleeding.

(Gabapentinoid)
Gabapentin 300 mg PO every 8 hours
Pregabalin 50 mg PO every 8 hours

  • Titrate gabapentin higher as indicated for uncontrolled neuropathic pain or pruritus. Max dose 1200 mg every 8 hours.
  • Gabapentin in setting of renal failure:
    • eGFR <30 mL/min start 100mg PO every 8 hours, max dose 700 mg daily
  • Consider pregabalin for neuropathic pain not responsive to gabapentin.

(Ketamine infusion)

  • Sub-dissociative dose for pain:
    • Initial bolus:1 to 0.5 mg/kg (by physician)
    • Infusion:1 to 0.25 mg/kg/hr continuous
    • Note: patients on ketamine drips must be in ICU or IMU (not available for floor patients)
    • If a patient has altered mental status attributed to the ketamine infusion, turn the infusion off for two hours and then resume at a lower rate.

(Lidocaine infusion)

  • Dose: 20 micrograms/kg/minute, do not titrate
  • Child C cirrhosis is not a contraindication; use with caution.
  • Contraindication: heart failure with EF < 20%.
  • Note: patients on lidocaine drips must be in ICU or IMU (not available for floor patients)

Bowel Regimen

  • Docusate 100 mg PO every 12 hours
  • Senna 2 mg PO every 12 hours
  • Polyethylene glycol 3350 17 g PO every 12 hours
  • Bisacodyl suppository 10 mg rectally daily PRN for no bowel movement

De-escalation and Discharge Medications:

  • As patients progress during hospital stay, de-escalation of pain medications should occur with the goal regimen being: acetaminophen, gabapentin, ibuprofen, and prn opioid.
  • At discharge, please provide prescriptions (including acetaminophen and ibuprofen) for the following:
    • Acetaminophen 1 gm PO Q6H (four-week supply)
      • Maximum total acetaminophen dose should not exceed 4 grams in 24 hours
      • See weight restrictions above for patients <50kg
      • Do not prescribe acetaminophen at discharge if:
        • Patient has cirrhosis (any Child’s Class)
        • Patient is being discharged on an opioid-acetaminophen combination pill, such as hydrocodone-acetaminophen or oxycodone-acetaminophen
      • Gabapentin current dose (four-week supply) (may have been titrated up or down during hospital stay)
      • Ibuprofen 400 mg PO every 8 hours (four-week supply)
      • To calculate the number of opioid pills to prescribe the patient:
        • Take average prn oral opioid doses received in the two days prior to discharge and multiply by 7
      • If a patient is on a pain regimen that required significant titration and deviation from normal de-escalation practice, please discuss outpatient pain regimen with attending physician

References:

  1. Harvin JA, Albarado R, Truong VTT, Green C, Tyson JE, Pedroza C, et al. Multi-Modal Analgesic Strategy for Trauma: A Pragmatic Randomized Clinical Trial. J Am Coll Surg. 2021;232(3):241-51.e3.
  2. Donthula D, Conner CR, Truong VTT, Green C, Jiang C, Wandling MW, et al. Impact of Opioid Minimizing Pain Protocols After Burn Injury. J Burn Care Res. 2021;42(6):1146-51.