Burn patients endure some of the most intense pain, not only during injury but in recovery as well. Damage to the receptors for pain in the skin occurs immediately. Nerve endings which are exposed but not injured also cause pain. There is an increased sensitivity to painful stimuli ( hyperalgesia) that occurs. There is also a secondary hyperalgesia in adjacent tissue that is not injured.
There are several types of pain that a burn patient experiences; Background pain which is constant, Procedural pain during operations and debridement, Post-operative pain after procedures. Opioids are the mainstay of pain control. Tolerance to these agents can occur due to prolonged use. Additionally, there is an entity called opioid induced hyperalgesia (OIH) that causes increased pain with increasing doses of narcotics.
Non-opioids such as non-steroidal anti-inflammatory agents (NSAIDS), acetaminophen and gabapentinoids (lyrica and gabapentin) can be used as adjunctive agents. They may decrease the dose of narcotics necessary to provide pain relief, limit tolerance and OIH.
Pain management in burn patients undergoing procedures can involve general anesthesia or other intravenous agents such as ketamine. IV propofol and remifentanil, two potent agents can be used as well. Topical and intravenous lidocaine has been reported to be useful in the treatment of pain in burn patients.
Non-pharmacologic techniques have been used in the management of pain in the burn patient as well. These include hypnosis, cognitive behavioral therapy, and distraction.
Managing the pain in burn patients is a challenging issue. Multi-modal therapy using all the techniques described above may be needed. Each modality has its benefits, side effects and risks. A thorough knowledge of all of these modalities is key to effective treatment.