Pain management for burned patients is often unsatisfactory because of misconceptions about the sources of pain and the optimal use of various analgesic agents in burned patients, and because of such pragmatic factors as unit staffing. A common misconception is that deep burns, which are insensate to touch, are not painful. They frequently produce a severe dull pressure-like pain. Although the presence of pain can usually be recognized from physical signs such as pupillary dilation, sweating, tachycardia, tachypnea, and increased blood pressure, these findings are relatively poor indicators of its severity. Quantitation of pain severity should rely on the patient's own assessment via systems such as the visual analog scale or numerical and graphical rating scales ( Kremer..etal 1981).
In the early postburn period, pain management relies on intravenous narcotics administered as periodic boluses or continuous infusion. Morphine is the most widely used agent, but fentanyl is popular because of its rapid onset, short duration of action, and fewer adverse effects such as histamine release and peripheral vasodilation. The use of patient-controlled intravenous narcotics has been very effective for older children and adults, as this not only provides better steady state pain relief but also gives the patient a sense of control. Regardless of the technique, it is important to realize that there will be pain breakthroughs during dressing changes or therapy, and supplemental medication should be given. Unfortunately, any episodes of poorly controlled pain may lead to fear and anxiety prior to the next procedure. The combination of an anxiolytic agent, such as a benzodiazepine, with the analgesic may reduce the narcotic requirement.
Intravenous catheters are a major risk of infection in the burned patient and should be removed as soon as possible. Although this is not usually possible during the intensive care phase, it should be recognized that if an intravenous catheter is not required for other reasons, a variety of effective non-intravenous accesses are available, including transdermal and sublingual fentanyl, intranasal butorphanol and midazolam, and oral agents such as sustained-release or immediate-release morphine (SiddaiJ and..„Cousins.M1995).
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