Pain relief during dressing changes of major adult burns: Ideal analgesic combination with ketamine

doi:10.1016/j.burns.2009.08.007

Burns

Volume 36, Issue 4, June 2010, Pages 501-505

https://doi.org/10.1016/j.burns.2009.08.007 Get rights and content

Abstract

Pain management during burn dressing changes is a critical part of treatment in acute burn injuries. Although several treatment options have been suggested, it is still a challenge in a clinical setting. This study is aimed at finding out an ideal analgesic, sedative and/or anxiolytic combination that would minimise the unwanted effects of ketamine.

A total of 24 patients, with burns up to 20–50% of total body surface area (TBSA), were included in the study and randomly divided into three groups. In group I, 2 mg kg⁻¹ ketamine was administered.

In group II, 1 mg kg⁻¹ tramadol was administered and 30 min later, 1 μg kg⁻¹ dexmedetomidine and 2 mg kg⁻¹ ketamine was administered. In group III, 1 mg kg⁻¹ tramadol was applied and 30 min later, 0.05 mg kg⁻¹ midazolam and 2 mg kg⁻¹ ketamine was administered. The evaluation was performed with cardiopulmonary monitoring, sedation and visual analogue pain scores and overall patient satisfaction. Any adverse effects of ketamine were recorded.

The results showed that group II had better outcomes with respect to pain management during dressing changes.

As a conclusion, the use of the combination of ketamine, tramadol and dexmedetomidine was found to be a good treatment option for the prevention of the procedural pain suffered by adult patients during dressing changes.

Section snippets

Patients and methods

The study was conducted in the Burn Center of the Gulhane Military Medical Academy, Ankara, Turkey. Following local ethics committee approval, written informed consent was obtained from 24 patients, aged between 19 and 54 years (median: 33 years) with burns of 20–50% (median: 37%) of the total body surface area (TBSA). Only patients with flame and scald injuries were included in the study and the study group was composed of ASA physical status II and III patients. Inhalation injuries,

Results

Cardiovascular instability or respiratory depression requiring urgent intervention or oxygen supplement was not observed. There were no episodes of vomiting, laryngospasm or emergency reaction noted in either group during or after the procedure. Table 2 shows the cardiorespiratory data.

Increase in HR was observed in 52.5%, 2.5% and 13.8% of the dressing changes in groups I, II and III, respectively. The difference was found to be statistically significant (p < 0.05).

SAP increase in more than 20%

Discussion

Pain management is a critical part of treatment in acute burns. Although pain due to burn injury was well described as a major problem more than two decades ago, investigators have continued to report that burn pain remains undertreated [12], [13]. Although several treatment options have been suggested for burn pain management, it is still a challenge in a clinical setting [1], [2], [12]. As one of the main drugs, ketamine can be used both in primary and secondary hyperalgesia; it also

Conflict of interest statement

The authors have no financial and personal relationships with other people or organisations that could inappropriately influence their work.

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The studies included were from 2004 onward, 21 from before 2013 and 75 from 2013 onward. Twenty-three studies were conducted in India, 16,17,86,48,51,20,90,28,61,64–66,30,21,106,107,84,71,108,32,82,78,68 sixteen in China,41,87,88,59,23–25,89,81,36,109,69,110,111,95,103 thirteen in Turkey,38,96,98,40,43,44,19,99,52,55,56,104,22 nine in Japan,49,27,54,63,77,67,33,35,100 seven in the Republic of Korea,73,42,53,80,57,58,92 five in the USA,18,74,105,29,34 four in each of the following countries: Iran 72,39,83,101 and Saudi Arabia,15,97,46,70 and two in each of the following countries: Egypt 85,75 and Singapore. 26,37 For other countries, only one study was reported.
Dexmedetomidine (DEX) is an α2-adrenergic receptor agonist used for its sedative, analgesic, and anxiolytic effects. Non-Operating Room Anesthesia (NORA) is a modality of anesthesia that can be done under general anesthesia or procedural sedation or/and analgesia. In this particular setting, a level-2 sedation, such as the one provided by DEX, is beneficial. We aimed to study the effects and safety of DEX in the different NORA settings in the adult population.
A systematic review with meta-analysis of randomized controlled trials was conducted. Interventions using DEX only or DEX associated with other sedative agents, in adults (18 years old or more), were included. Procedures outside the NORA setting and/or without a control group without DEX were excluded. MEDLINE, ClinicalTrials.gov, Scopus, LILACS, and SciELO were searched. The primary outcome was time until full recovery. Secondary outcomes included hemodynamic and respiratory complications and other adverse events, among others.
A total of 97 studies were included with a total of 6,706 participants. The meta-analysis demonstrated that DEX had a higher time until full recovery (95% CI = [0.34, 3.13] minutes, a higher incidence of hypotension (OR = 1.95 [1.25, 3.05], p = 0.003, I² = 39%) and bradycardia (OR = 3.60 [2.29, 5.67], p < 0.00001, I² = 0%), and a lower incidence of desaturation (OR = 0.40 [0.25, 0.66], p = 0.0003, I² = 60%).
DEX in NORA procedures in adults was associated with a lower incidence of amnesia and respiratory effects but had a long time to recovery and more hemodynamic complications.
A comparative study of dexmedetomidine and propofol to prevent recovery agitation in adults undergoing procedural sedation with ketamine: A randomized double-blind clinical trial
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The present study was designed to evaluate the effect of dexmedetomidine and propofol on ketamine-induced recovery agitation in adults when used as co-administration with ketamine.
In this prospective, randomized, and double-blind clinical trial, 93 patients aged 18 years or older who were candidates for painful procedures in the emergency department (ED) were enrolled and assigned into three equal groups to receive either ketadex (dexmedetomidine 0.7 μg/kg and ketamine 1 mg/kg), ketofol (propofol 0.5 mg/kg and ketamine 0.5 mg/kg) or ketamine alone (1 mg/kg) intravenously. Incidence and severity of recovery agitation were evaluated using the Richmond Agitation-Sedation Scale and compared between groups.
There were no significant differences in demographic characteristics, procedures, pain scores, pre-sedation agitation, and duration of procedure between the three groups. The incidence of recovery agitation was 26% in the Ketadex group, 29% in the Ketofol group, and 58% in the Ketamine group. The difference in incidence of recovery agitation between Ketadex group and Ketamine group was 32% (95% confidence interval (CI), 9 to 56]) and between Ketofol group and Ketamine group was 29% (95% CI, 6 to 53). The severe agitation was significantly higher in Ketamine group, with a difference between Ketamine and Ketadex group of 19% (95% CI, 6 to 33), and a difference between Ketamine and Ketofol group of 16% (95% CI, 1 to 31).
In this study, a combination of ketamine–dexmedetomidine and ketamine–propofol reduced the incidence and severity of ketamine-induced recovery agitation in adults undergoing procedural sedation in the ED.
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This study aimed to compare the sedation and analgesic effects of butorphanol alone and butorphanol in combination with dexmedetomidine on dressing changes in adult burn patients.
From June 2016 to May 2019, 44 adult burn patients from our department were enrolled in this prospective, double-blinded study. Their total burn surface area (TBSA) varied from 10% to 30%; and the depth of burn injury ranged from second degree to third degree. The patients were randomized into two groups. In the control group, butorphanol combined with saline was injected into the body via venous route during dressing change. In the observation group, butorphanol in combination with dexmedetomidine was injected. The variation in mean blood pressure, heart rate, respiratory rate, and peripheral oxygen saturation were recorded at various time-points of the procedure. Visual Analogue Scale (VAS) of pain and Ramsay Sedation Scores (RSS) were also recorded at different time points. Consumption of butorphanol and adverse events in these two groups were compared.
The mean blood pressure and heart rate were significantly decreased in the observation group before butorphanol injection (P < 0.05) and before the dressing change (P < 0.05). The respiratory rates and peripheral oxygen saturation of these two groups showed no significant differences at all time points (P > 0.05). Patients in the observation group had lower VAS scores during dressing change (P < 0.05). The RSS Scores in the observation group were higher than those in the control group during (P < 0.05) and after the dressing change (P < 0.05). The consumption of butorphanol was more in the control group (P < 0.05), and the adverse events recorded in the control group were higher (P < 0.05).
Butorphanol combined with dexmedetomidine can reduce analgesic use of butorphanol during dressing change. This combination resulted in a higher sedation score and fewer adverse effects.
Intraoperative liposomal bupivacaine for skin graft donor site analgesia: A retrospective cohort study
2021, Burns
Burn injury and reconstructive operations often result in severe pain, particularly at skin graft donor sites. Traditional local anesthetics administered intraoperatively control pain at donor sites, but the duration of action is short. Liposomal bupivacaine, a novel local anesthetic, can provide sustained-release analgesia for 72 h. The primary aim of this study was to describe the efficacy of liposomal bupivacaine for postoperative donor site pain control for patients undergoing skin graft procedures.
A retrospective cohort study was performed on patients who received a donor site liposomal bupivacaine field block and was compared to a matched control. Patients rated donor site pain on post-operative day 0 and 1, and stated whether the donor or graft site was more painful.
Fifty-eight patients were included. Twenty-nine patients received liposomal bupivacaine. Eighty-six percent of patients in the treatment group rated donor site pain as three or less on postoperative day 0 and 1, compared to 3.4% in the control (p < 0.0001). Also, 76% of patients in the treatment group stated donor site pain was less than graft site pain, compared to 3.4% in the control (p < 0.0001).
Patients who received liposomal bupivacaine reported less postoperative donor site pain and found the donor site to be less bothersome without major complications. Liposomal bupivacaine may be a safe and promising agent for prolonging postoperative analgesia and minimizing donor site pain.
Conductive polymeric film loaded with ibuprofen as a wound dressing material
2019, European Polymer Journal
Citation Excerpt :
With the intention of providing pain relief effect to obtained films and reducing infection risk of the wound, SAlg/Gel/HA w/out RGO polymeric films were loaded with ibuprofen and drug release studies were performed. Ibuprofen, which has anti-inflammatory effect promoting wound healing by preventing excessive inflammation was chosen as a non-steroidal analgesic and antipyretic drug, because acute or moderate wound pain is commonly treated with analgesics and it potentially influences healing process [24–29]. The release kinetics of ibuprofen showed that release profiles of produced SAlg/Gel/HA/RGO electroconductive polymeric film, which is highly anticipated in wound healing as a dressing material, occurred in more controlled manner over a period of hours in comparison with other studies [30,31].
In current study, sodium alginate/gelatin/hyaluronic acid/reduced graphene oxide (SAlg/Gel/HA/RGO) electroconductive composite polymeric films were fabricated for wound dressing applications. In the production of composite film, while SAlg/Gel/HA was used as a polymeric network, RGO (0, 10, 20% v/v) was employed as an electroactive material. Produced films were characterized by FT-IR, XRD and SEM analyses. In order to observe potential usage of desired material as a wound dressing, electroconductive and mechanical performances, swelling behavior, water vapor transmission rate (WVTR), oxygen permeability and cytotoxicity of the films were investigated by concerned test method. To improve the healing effect of the films and reduce pain in the wound, they were loaded with ibuprofen, which is an anti-inflammatory drug. The drug release evaluations showed that SAlg/Gel/HA/RGO films were more effective than pure films for controlled release of the model drug. All results suggested that SAlg/Gel/HA/RGO electroconductive polymeric films have a great potential for wound dressing material in the future applications.

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Pain relief during dressing changes of major adult burns: Ideal analgesic combination with ketamine

Abstract

Section snippets

Patients and methods

Results

Discussion

Conflict of interest statement

Burns

Baillieres Clin Anaesthesiol

Pain

Neuropharmacology

Pain

Pain

J Pain

Pain

J Clin Neurosci

Burn patients’ pain and anxiety experiences

J Burn Care Rehabil

Treatment of pain in acutely burned children

J Burn Care Rehabil

Ketamine for long term sedation and analgesia of a burn patient

Anesth Analg