Procedural Burn Pain

Original Date: 09/2020
Purpose: To standardize a responsible approach to the procedural pain experienced by patients during admission to the burn center.

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

  1. 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.
  2. Procedural pain are brief but intense episodes of pain that occur during procedures such as wound debridement, dressing changes, baths, or physical therapy.
  3. 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.
  4. 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.
  5. 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 treatment of procedural pain during the initial wound debridement upon arrival to the burn center and daily dressing changes. Some patients will only require a small amount of pain medication or have small burns in which the procedures are short and not intensely painful. This protocol is for patients with severe pain during procedures who require substantial medication therapy. We consider three types of patients:

  • Intubated patients
  • Non intubated patients receiving tube feeds
  • Non intubated patients receiving regular diet

“Opt out” strategy for moderate sedation. Patients should be considered for moderate sedation given the following:

  • TBSA burns ≥20%
  • Excision of large wound down to fascia without temporary coverage

A faculty member with moderate sedation privileges must be present for any procedural sedation.

Procedural Sedation Algorithm by Patient Type

 

No Data Intubated Patients Non-intubated patients with tube feeds Non-intubated patients on regular diet
Feeding algorithm HUNGRES See Burn Nutrition Policy (consider bolus feeds) INGEST
Gastric tube feeds Discontinue tube feeds prior to procedure and place gastric tube to suction. Measure gastric residual volume and record in procedural sedation note. Bolus feeds: give first bolus of day 8 hours prior to procedure and schedule remaining 4 bolus feeds to start 45 minutes after procedure ends.
Continuous: discontinue tube feeds 8 hours prior to procedure and place gastric tube to low suction.		 n/a
Jejunal tube feeds Continue tube feeds during procedure Stop tube feeds prior to procedure. n/a
NPO Status n/a Clear liquid diet after midnight
NPO except medications 3 hours prior to procedure		 Clear liquid diet after midnight
NPO except medications 3 hours prior to procedure
Prior to beginning
  • Document ASA classification
  • Document Mallampati score
  • Document ASA score
Medications At initiation of procedure:

  • Midazolam 1 mg IV x 1
  • Ketamine 0.5 mg/kg bolus x 1
  • Fentanyl 25 micrograms IV x 1 (if needed)

During procedure:

  • Ketamine 0.3 mg/kg bolus repeated as needed according to patient comfort
  • Fentanyl 25 micrograms IV x 1 (if needed)
 At initiation of procedure:

  • Ketamine 0.5 mg/kg bolus x 1
  • Fentanyl 25 micrograms IV x 1 (if needed)

During procedure:

  • Ketamine 0.3 mg/kg boluses as needed
  • Fentanyl 25 micrograms IV as needed
Post Procedure
  • Resume tube feeds at goal after procedure is complete
  • Continue monitoring for 45 minutes after
    procedure completion
  • Bolus feeds: schedule remaining 4 bolus feeds for rest of day
  • Continuous feeds: Resume tube feeds at goal 45 minutes after procedure once patient’s mental status returns to baseline
  • Continue monitoring for 45 minutes after procedure completion
  • Resume diet 45 minutes after procedure once patient’s mental status returns to baseline
Notes For patients on a ketamine drip, continue during procedure

 

Procedural Sedation

Pre:

  • Medical evaluation:
    • Cardiovascular status
    • Past problems with anesthesia
    • ASA Physical Status Classification (ASA 1 – healthy patient; ASA 2 – patient with mild systemic disease; ASA 3 – patient with severe systemic disease; ASA 4 – patient with severe systemic disease that is a constant threat to life)
    • Mallampati score (Class 1 – complete visualization of the soft palate; Class 2 – complete visualization of the uvula; Class 3 – visualization of the only the base of the vulva; Class 4 – soft palate not visible)
    • NPO status (according to chart above)
  • Informed consent (may be for multiple episodes of moderate sedation)
  • Equipment available and functioning:
    • Crash cart outside room
    • Suction
    • Supplemental oxygen, including ambu bag

During:

  • Monitoring:
    • Continuous pulse oximetry
    • Blood pressure monitoring
    • Continuous electrocardiography (ECG)
    • Continuous end tidal CO2

Post:

  • Documentation (see next page for template):
    • Pre- and post-procedure diagnosis
    • Procedure
    • Monitoring used
    • ASA Score
    • Mallampati score
    • NPO status
    • Medications and doses provided
    • Procedure duration
    • Patient’s response to sedation
    • Note if sedation provider also performed the procedure or if another person performed the procedure
  • Recovery
    • Monitoring can be stopped 45 minutes after procedure end

Procedural Sedation for Dressing Change Template

Burn ICU Staff

Pre-procedure diagnosis: _% TBSA burn

Post-procedure diagnosis:_% TBSA burn

Procedure:
Moderate sedation for dressing change of _% TBSA burn (dressing change performed by nursing staff)

Monitoring:
_ continuous blood pressure monitoring via invasive arterial line
_ non-invasive blood pressure monitoring
x telemetry
x pulse oximetry
x end tidal CO2

Feeding status:
_ HUNGRY protocol (NG tube placed to suction prior to procedure) – _ gastric residual volume
_ BURN protocol (NG tube placed to suction 1 hour prior to procedure) – _ gastric residual volume
_ INGEST protocol (NPO after midnight, clear liquid diet 2 hours prior to procedure)

ASA: _

Intubated: _
Mallampati score: _
Medications provided:
_ mg midazolam
_ micrograms fentanyl
_ mg ketamine
_ mg propofol
Procedure duration:
_ minutes

I was present for the entirety of this procedural sedation. The patient tolerated the dressing change well. There were no untoward hemodynamic or respiratory changes.