28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 1/35

Official reprint from UpToDate®

www.uptodate.com

©2013 UpToDate®

AuthorsShelley Wiechman, PhDSam R Sharar, MD

Section EditorMarc G Jeschke, MD, PhD

Deputy EditorRosemary B Duda, MD, MPH,FACS

Burn pain: Principles of pharmacologic and nonpharmacologic management

Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Dec 2012. | This topic last updated: ago 9, 2012.

INTRODUCTION — Burns can be extremely painful. Pain management, which includes pharmacologic and

nonpharmacologic approaches, is a central component of the complex issues involved in treating patients with burns.

Despite advances in burn care, inadequate burn pain management still exists during both the acute and rehabilitation

phases of care [1]. Burn pain is among the most common causes of distress during the first year after discharge [2,3]. Burn

pain management is based upon tradition, personal bias, and/or institutional preference rather than based upon scientific

approaches [4].

An overview of pharmacologic and nonpharmacologic options for the management of burn pain is reviewed here. Emergency

care and local management of burns and pain are discussed elsewhere. (See "Emergency care of moderate and severe

thermal burns in adults" and "Emergency care of moderate and severe thermal burns in children" and "Local treatment of

burns: Topical antimicrobial agents and dressings" and "Paradigm-based treatment approaches for burn pain control".)

CHARACTERISTICS OF BURN PAIN — All burns are painful initially [5]. Burn pain varies greatly from patient to patient,

shows substantial fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of

anatomic, physiologic, psychosocial, and premorbid behavior issues [6]. Burn patients typically report pain as being severe

or excruciating, despite receiving opioid analgesics [7].

Burn pain also varies depending upon depth of burn (figure 1) (see "Classification of burns"):

Superficial partial thickness burns result in hyperalgesia and mild to moderate pain. They are the most painful burns

immediately following the injury. These burns damage only the outer layers of the skin.

Moderate partial thickness burns are associated with marked hyperalgesia, and produce moderate to severe pain.

Burns at this depth injure and/or inflame sensory receptors in the dermis.

Deep partial thickness to full thickness burns are typically characterized by an absence of pain. Hyperalgesia to

cutaneous stimulation is uncommon. Acute pain is typically minimal, but can be variable, and is universally present

with respect to the transition zone between burned and unburned skin. The dermis is completely destroyed,

including its sensory and vascular structures. There is little to no response to sharp stimuli, yet patients complain of

a deep aching pain related to the inflammatory response.

BURN PAIN ASSESSMENT TECHNIQUES — Pain assessment tools must be practical, reliable, and valid, and must be

able to assess three dimensions of pain: pain intensity, behavioral reactions, and physiologic reactions. A variety of pain

measurement tools have been used with adult and pediatric burn patients. However, there are no randomized trials that have

identified an optimal assessment technique for burn patients. The key is to choose an instrument and use it consistently.

The most common tools used for adults and children with burn pain include verbal adjective scales, numeric written or visual

analog scales, pain assessment in dementia scales, FACES, and FLACC (Face, Legs, Activity, Cry, Consolability) [8-13].

Adults — The more common tools for assessing post burn pain in adults are the adjective scales, which allow a patient to

describe the severity of pain in words, such as “none, mild, moderate, or severe” or “no pain, mild, discomforting,

distressing, horrible, or excruciating pain” (figure 2) [11]. An alternative to the verbal description of pain is the numeric scale,

which allows a patient to describe the pain on a scale of increasing severity typically from 0 to 10 (figure 3) [10]. The

numeric scale is administered to the patient verbally or written as a visual analog scale (figure 4). Pain assessment can be

challenging in the burned and demented patient. The Pain Assessment in Advanced Dementia Scale, an observational

scoring instrument, is a simple to administer valid and reliable instrument (table 1) [12]. (See "Pain control in the critically ill

adult patient", section on 'Assessment and monitoring'.)

Children — The measurement of children's pain is much more complex than it is for adults, especially for preverbal

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 2/35

children. Typical physiologic indicators, such as heart rate, respiratory rate, and blood pressure are unreliable in measuring

a child’s pain since all are affected by a variety of stressors related to the burn injury [13,14]. (See "Evaluation and

management of pain in children", section on 'Assessment of pain severity and cognition'.)

Behavior scales have been devised to measure pain by providing standardized instructions and guidelines for observing

behaviors thought to be specific to pain. Facial expression may be the most consistent infant indicator of pain [13].

Observational scales have been developed that are multidimensional and include length of cry, facial expressions, and

behavioral states [3]. These scales are easier to use and allow an observer to assess pain as either present or absent

without further quantification. The FLACC (Faces Legs Activity Cry Consolability scale) is the most widely used observer

rating scale in preverbal children (table 2) [8].

Simple self-report pain scales can be used with preschool children. There is no evidence that any one of these scales is

more reliable than the other, hence, it is best to select one that the evaluator prefers and it should be used consistently.

When self-report scales are used in conjunction with observational scales, a practitioner may develop a better appreciation

of the intensity of the child's response to burn pain and the effectiveness of pain management. The following are examples

of pain scales that are commonly used with children:

The Wong-Baker FACES Pain Scale is designed for children three years and older (figure 5) [9]. This pain scale

uses drawings of faces displaying varying degrees of pain and discomfort. Each face communicates a level of pain

intensity and the child is asked to choose the face that most accurately describes their pain level.

The OUCHER scale includes a picture scale for very young children and a numerical scale that can be used in

children over five years old [15]. There are different versions that can be used for children of various races, and an

example is shown for a Caucasian boy (picture 1).

PHARMACOLOGIC TREATMENT OPTIONS — Pharmacologic agents used to treat burn pain include opioid analgesics,

nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the

anticipated duration of pain, and intravenous (IV) access. These medications have variable durations of action, particularly in

burn patients, and should be titrated to meet the needs of the patient in each clinical setting.

Pharmacologic techniques should provide near-constant plasma levels of analgesics through regularly scheduled

administration of long-acting opioids (eg, methadone), or continuous IV opioid infusion (eg, morphine) in patients unable to

take oral medications. Regularly schedule benzodiazepines (eg, lorazepam) may have added value in patients with

significant anxiety that contributes to their pain experience.

A severe burn injury results in physiologic changes that may alter the pharmacokinetic and pharmacodynamic response to

drugs in inconsistent ways, hence deviation from the usual doses may be necessary to avoid toxicity or decreased efficacy

[16]. The tables linked to this topic provide dosages of opioids and nonopioid analgesias as recommended for patients

without serious pathophysiologic and metabolic changes without altered drug clearance. These dosages serve as a

reference point for administering pharmacologic agents to burned patients. Medications may be more potent and have a

prolonged effect in the burn patient. Monitoring of the airway, breathing, and circulation is necessary, particularly when

intravenous drugs are administered. (See "Hypermetabolic response to severe burn injury: Recognition and treatment".)

Opioid analgesics — Opioid analgesics, the most common type of medication used for acute pain relief, are potent and

provide a dose dependent degree of sedation important during burn wound care procedures (table 3 and table 4) [3]. Burn

pain should be treated aggressively and there is no clear evidence that the use of opioids during acute burn pain

management increases the likelihood of opioid dependency [17]. A review of intravenous opioid analgesia for adults and

children is discussed in detail elsewhere. (See "Pain control in the critically ill adult patient", section on 'Intravenous

analgesia' and "Procedural sedation in adults", section on 'Medications' and "Evaluation and management of pain in

children", section on 'Opioids'.)

Opioids can be administered intravenously or orally, depending on IV access, gastrointestinal function, and the patient’s

ability to cooperate. For severe pain, the optimal route of administration is IV, which provides faster pain relief and can be

titrated to meet the individual needs of the patient.

Patient-controlled analgesia (PCA) with IV opioids offers the burn patient a safe and efficient method of achieving more

flexible analgesia, provided the patient is alert and competent to use the device (table 5) [18]. (See "Management of

postoperative pain", section on 'Patient controlled analgesia'.) Studies comparing PCA opioid use to other routes of

administration in the burn population have shown positive, but limited benefits of PCA.

Oral or gastrointestinal administration of opioids via an enteral tube provides potent pain relief with rapid onset and short

duration of action, and requires minimal monitoring. Oral transmucosal administration is particularly helpful for performing

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 3/35

burn dressing changes in children [19,20].

Intramuscular opioid administration is not recommended for use in burn patients. The injections are painful, they need to be

repeated frequently, and the absorption is variable due to compartmental fluid shifts. (See "Emergency care of moderate

and severe thermal burns in adults", section on 'Fluid resuscitation' and "Emergency care of moderate and severe thermal

burns in children", section on 'Fluid resuscitation'.)

Nonopioid analgesics — Nonopioid analgesics, such as dexmedetomidine and ketamine, provide short-term effective

analgesia and sedation that may be helpful for limited burn debridement and/or dressing changes in adults and children.

Dexmedetomidine provides sedation, anxiolysis, and analgesia for burned children, with less respiratory depression than

other sedatives [21,22]. In case study reports, ketamine used in conjunction with clonidine has been effective in providing

analgesia and sedation in children with severe burn pain, particularly during dressing changes [23,24]. (See "Sedative-

analgesic medications in critically ill patients: Properties, dosage regimens, and adverse effects", section on

'Dexmedetomidine' and "Procedural sedation in adults", section on 'Ketamine' and "Pharmacologic agents for pediatric

procedural sedation outside of the operating room", section on 'Dexmedetomidine' and "Pharmacologic agents for pediatric

procedural sedation outside of the operating room", section on 'Ketamine' and "Pharmacologic agents for pediatric

procedural sedation outside of the operating room", section on 'Introduction'.)

Other nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDS), provide mild

analgesia and are best suited to treat minor burn pain in the outpatient setting (table 6). Oral NSAIDs and acetaminophen

exhibit a ceiling effect in their dose-response relationship, rendering them unsuitable for the treatment of severe burn pain.

There are no high quality data from randomized trials that have determined the optimal nonopioid analgesic for burn

patients. The mechanism of action and therapeutic use of NSAIDS is discussed in detail elsewhere. (See "NSAIDs:

Mechanism of action" and "NSAIDs: Therapeutic use and variability of response in adults".)

Anxiolytics — Anxiety is a common consequence of burns, due to the need for aggressive surgical treatment and

debridement of the wounds, and the persistent and repetitive qualities of background and procedural burn pain. The

recognition that anxiety can exacerbate acute pain has led to the common practice of using anxiolytic drugs in combination

with opioid analgesics, a practice that has become more widespread in burn centers in the past two decades [25,26]. This

practice is particularly useful in premedicating patients for wound care, due to the anticipatory anxiety experienced by these

patients prior to and during such procedures.

Benzodiazepine therapy improved postprocedure pain scores in burn patients (table 7). A trial that randomly assigned 79

burn patients to receive lorazepam 1 mg or placebo in addition to their standard opioid analgesics found no difference

between groups in pain score, except in patients with high baseline pain [27]. In high baseline pain patients, lorazepam

significantly reduced VAS pain score ratings (54.3 versus 69.1). (See "Sedatives and hypnotics abuse and dependence:

Pharmacology and epidemiology".)

Antipsychotic medications are also an option for management of anxiety and agitation associated with burn pain and

treatment [28].

First generation antipsychotics (eg, haloperidol) are used adjunctively for treatment or prevention of hyperactive

delirium and agitation in critically ill patients. (See "Sedative-analgesic medications in critically ill patients:

Properties, dosage regimens, and adverse effects", section on 'Neuroleptics'.)

Second generation antipsychotics (eg, quetiapine) are increasingly used for treating various anxiety disorders and

may be useful in combination with a benzodiazepine for managing anxiety and improving sleep in burn patients. (See

"Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects".)

Anesthetics — General, neuraxial, targeted nonneuraxial, and regional anesthetics are useful in managing burn pain in

various clinical settings. The specific types and administration of anesthesia are discussed in detail elsewhere. (See

"Overview of anesthesia and anesthetic choices".)

General or deep sedation — A general anesthetic or deep sedation provides relief of relatively brief, intense pain that

would be experienced during a procedure, such as skin grafting, extensive wound debridement, or dressing changes that

occur outside of the operating room. While the risks of complications following a general anesthetic are typically low in

healthy individuals, burn patients have metabolic, physiologic, and thermoregulatory abnormalities as well as possible

inhalation injuries that are associated with increased risk of complications of perioperative hypothermia, hypoxemia, and

abnormal responses to both depolarizing and non-depolarizing muscle relaxants [29].

Inhaled nitrous oxide is an anesthetic agent that can be safely administered and provides effective analgesia without loss of

consciousness (ie, moderate sedation) for moderately painful procedures. It can be used for the treatment of burn pain,

typically as a 50 percent mixture in 50 percent oxygen, and self-administered by an awake, cooperative, and spontaneously

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 4/35

breathing patient via a mouthpiece or mask [30,31].

Full anesthetic care capabilities have been extended outside the operating room into specialized, high volume burn center

intensive care units [32,33]. Drugs, such as intravenously administered propofol and remifentanil and inhaled sevoflurane,

with rapid onset and short duration of action, rapid recovery, and few side effects have facilitated burn care and pain

management in the patient’s hospital bed without transporting the patient to the operating room. The occasional provision of

brief, dense analgesia/anesthesia (eg, general anesthesia or deep sedation) should be administered in a comprehensively

monitored setting by medical professionals specifically trained to provide the service. When administered in a controlled

environment, a general anesthesia or deep sedation is safe and efficient, both in terms of allowing wound care (eg,

debridement of facial burns in children) to proceed rapidly, and in terms of cost-effective use of the operating room only for

true surgical burn care procedures [30,31].

Regional — Regional anesthesia is achieved by injecting a local anesthetic agent (eg, bupivacaine, lidocaine) around a

nerve to block the sensory stimulation from that area innervated by the nerve. A regional anesthesia is particularly useful for

procedures and burn pain relief involving the extremities. The most common nerve groups accessible for a nerve block

include the brachial plexus (interscalene block, infraclavicular block, axillary block), the sciatic nerve, and the femoral nerve.

(See "Peripheral nerve block: Techniques".)

Neuraxial — Neuraxial anesthesia is the administration of an anesthetic agent (eg, bupivacaine, lidocaine) and/or

opioid analgesics via a spinal or epidural catheter with the goal of providing background, procedural, and postoperative pain

relief. This procedure has only been anecdotally used in burn patients but theoretically has the advantage of providing an

autonomic sympathectomy and peripheral dilatation [34]. A major drawback to the use of neuraxial anesthesia is the

potential colonization of the indwelling catheter, particularly if inserted through burned skin, and the associated risks of

meningitis and epidural abscess formation [35].

Targeted non-neuraxial blockade — In contrast to neuraxial anesthesia, targeted non-neuraxial regional blockade

is relatively easy to perform and carries minimal risks [36,37]. An example of a non-neuraxial nerve block is the fascia iliaca

compartment blockade (FICB), which can be used for lower extremity analgesia following skin graft harvesting [36,37].

NONPHARMACOLOGIC TREATMENT OPTIONS — Nonpharmacologic treatments should be complementary to

pharmacologic approaches when treating pain and anxiety in the burn patient. Empirical evidence for the efficacy of

nonpharmacologic treatments has been reported with burn pain, particularly when used as an adjunct to opioid analgesics

[3].

A number of nonpharmacologic approaches are available. In choosing the most effective approach, the team should be

guided by the manner in which the patient typically responded to prior stressful medical procedures, if possible. Such

responses lie on a continuum ranging from giving up control to the health care professional and desiring little information, to

seeking out as much information as possible and actively participating in care [38]. The following examples illustrate the

types of coping styles to burn and procedural pain:

Avoidance — Those burn patients who wish to give up control to the health care professional have a tendency toward

cognitive avoidance, or an avoidance style of coping mechanism. They will likely use various types of distraction

techniques to avoid the painful stimuli.

Approach — Those burn patients who seek out information about the procedure and attempt to participate and not

relinquish control have an “approach” style of coping mechanism. These patients often find distraction techniques

distressing as trying to ignore a procedure may serve to relinquish too much control.

It is important to note that both coping styles can be adaptive and it is best for the burn care team to support an individual’s

coping style rather than try to change the natural response. Patients may also change their coping style depending on the

procedure. As an example, a patient may find it is easier to use distraction techniques for short procedures such as

receiving injections, whereas they are more comfortable attending to details of their long wound care sessions and

participating when possible. Patients may also change their coping style as they become more familiar and comfortable

with the environment.

Avoidance techniques — Avoidance interventions are designed to psychologically distract or distance the patient from the

pain. The Multiple Resource Theory of Attention suggests that diverting attention towards a nonpainful stimulus may lessen

the intensity of perceived pain [39]. The four interventions in the avoidance category include distraction, guided imagery,

hypnotic analgesia, and virtual reality [3]. The nonpharmacological techniques are described in order of those more

appropriate for avoidance coping styles towards those more appropriate for the approach coping styles. However,

randomized trials have not been performed to determine the optimal diversion approach as an adjunct for managing pain in

burn patients.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 5/35

Distraction — Distraction is the most common intervention activated by patients or the provider as an adjunct for pain

management in burned children [40].The types of distraction techniques available to reduce burn pain are limited only by the

creativity of patients and health care professionals. Common distraction techniques used with children include bubble

blowing, singing songs, reading a story, and counting. Generating distraction strategies for adults may require a bit more

creativity, and include engaging in enjoyable conversation during the procedure, listening to music, or playing a video game

[41].

Guided imagery — Imagery is an integrative therapy that incorporates imagined pictures, sounds, or sensations for

specific therapeutic goals, such as the reduction of burn pain. While the patient is engaged in the imagery scene, less

attention is available for the painful stimuli. It is the patient that selects the imagery. A related discussion on imagery and

pain control in cancer patients can be found using the following link. (See "Psychological, rehabilitative, and integrative

therapies for cancer pain", section on 'Imagery'.)

Patients using imagery simply create or recreate an image in their mind, presumably one that they find pleasant and

engaging. Prior to a painful procedure, we often have the patient elicit a “safe” or “favorite” place to go. This can be a place

where they have been before (eg, a favorite vacation spot) or simply a place that they imagine to be relaxing and safe. The

clinician then simply cues the patient with the details that they have provided and we encourage them to imagine this place

during their subsequent wound care.

Limited evidence suggests that guided imagery is effective in reducing the sensory and emotional components of pain [42].

The Agency for Health Care Policy and Research advocates the use of imagery for reduction of pain intensity and distress

for cancer pain and for the management of mild to severe acute pain [43].

Hypnotic analgesia — Hypnosis is an altered state of consciousness characterized by an increased receptivity to

suggestion, ability to alter perceptions and sensations, and an increased capacity for dissociation [44]. It is believed that

the dramatic shift in consciousness that occurs with hypnosis is the cornerstone of an individual’s ability to change their

awareness of pain [45]. Hypnotic analgesia should only be used by trained clinicians who can assess the risks and benefits

of this powerful technique [44,46].

Although hypnosis involves much more than just avoidance or distraction, the end result is often similar, the patient’s focus

is diverted from the pain or painful procedure. Several features make hypnotic analgesia a unique method of pain control that

differs markedly from imagery or relaxation. Hypnosis may or may not lead to relaxation depending on the nature of the

suggestions. In turn, it is not necessary for a patient to be relaxed or even in a deep hypnotic state in order for suggestions

to be useful [47]. A related discussion on hypnotic analgesia and pain control in cancer patients can be found using the

following link. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Hypnotic analgesia'.)

Hypnosis involves several stages, including building clinician-patient rapport, enhancing relaxation through deep breathing,

suggestions for deepening the hypnotic state, and narrowing their attention, providing posthypnotic suggestions, and

alerting stage [48]. Burn patients are good candidates for hypnotic analgesia because [49-51]:

The intense nature and severity of burn pain motivates patients to engage in hypnosis.

The behavioral regression that often occurs after a traumatic injury makes patients more willing to be taken care of

by others.

Patients with burn injuries often experience a dissociative response as a means of coping that may moderate

hypnotizability.

Procedures, which cause the most intense pain, can be scheduled and thus allow hypnosis to be performed in

advance of the painful stimulus.

Several studies have shown the positive effect of hypnosis when used in conjunction with prescribed analgesia [49,52-55].

Patients with higher baseline pain levels have a greater decrease in pain after hypnosis than patients with lower baseline

pain levels [49]. However, these studies are limited by methodological differences, lack of uniform assessment of

hypnotizability and severity of pain, and small series of burn patients.

Virtual reality — Virtual reality diverts attention away from the painful sensations by immersing patients in a computer

generated environment [3,56]. Burn patients can interact with the computer while painful procedures, such as dressing

changes, are performed. Observational and small controlled studies indicate that virtual reality is effective in reducing pain

and may have utility when used in conjunction with hypnosis [56-59].

Approach technique — The most commonly used approach technique is information provision.

Information provision — Information provision, a technique that actively involves patient input, is an essential element

of managing burn pain by providing treatment information in a timely and targeted manner. Information provision assists

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 6/35

patient’s understanding of the issues, alternatives, and solutions. This process provides information on how their input will

affect the end result, and sharing information can build trust and mutual understanding [60].

Relaxation techniques — Relaxation techniques are used to lower arousal, including unnecessary muscle tension that

can increase pain [3,61]. The techniques include deep breathing exercises, progressive muscle relaxation exercises, and

cognitive behavioral techniques. There are no randomized trials to determine the optimal relaxation technique to be used as

an adjunct for burn pain management.

Deep breathing — Deep breathing, or diaphragmatic breathing, is one of the least time consuming techniques to

employ and easiest for adults and children to learn. When a person becomes anxious and/or experiences pain, breathing

can become shallow and irregular due to the increased muscle tension in our chest wall. Such shallow breathing, known as

thoracic breathing, leads to an increase in muscle tension and subsequent heightened pain [61].

Deep breathing techniques allow patients to become aware of shallow irregular breathing and leads to relaxation that may

alleviate some pain. Children can be taught bubble blowing or blowing on a pinwheel to encourage deep breathing. Adults

can be taught to place a hand on their stomach and to take a breath deep enough that it passes through their chest and

fills their stomach (shallow breathing is more in the chest and will not cause as much hand movement on the stomach).

Their hand should rise and fall with the stomach. Exhalation is the most important part of deep breathing exercises and

should not be rushed. Diaphragmatic breathing is central to all forms of relaxation and is simple and time efficient.

Progressive muscle relaxation — Muscle tension increases as patients experience stress and pain, hence the

focused effort on relaxing and tensing muscles in a controlled manner diverts the attention away from the pain. Progressive

muscle relaxation is a technique used to reduce anxiety associated with painful stimuli, such as burn dressing changes, by

alternately tensing then relaxing muscles [62]. Muscles are sequentially tensed (10 seconds) and relaxed (20 seconds)

through various parts of the body and can be performed during dressing changes. Observational studies suggest that

progressive muscle relaxation can decrease recuperation time for hospitalized patients [62]. If a person is unable to actively

tense a muscle group due to pain or injury, he or she can still imagine each muscle becoming progressively “warm, heavy,

and relaxed” or listen to a tape, a process known as autogenic training [44].

Cognitive behavioral techniques — Cognitive-behavioral therapy (CBT) is used to treat multiple conditions by changing

thoughts and behaviors. For treatment of burn patients, CBT includes diversion, information provision, coping skills, and

relaxation techniques to modify the patient’s thought process about the painful experience [3]. (See "Overview of

psychotherapy", section on 'Cognitive and behavioral therapies'.)

Expectations of a bad outcome, such as intense pain, are associated with higher levels of perceived pain [63]. CBT can be

used adjunctively to manage these expectations and associated pain in the following manner [64]:

Recognize that the procedure will cause pain (anticipatory pain or distress).

Stop the thought that the procedure will cause pain by active efforts to block the thought process.

Distract from the pain by diverting attention to another thought.

SUMMARY AND RECOMMENDATIONS — The control of burn pain is a challenge that demands creativity and continued

staff training on pain assessment, traditional pharmacologic analgesic approaches, and adjunctive nonpharmacologic

techniques. Pharmacologic analgesics should be administered by trained and experienced staff in monitored conditions.

Pain, which is present at least initially in all burn patients, varies greatly from patient to patient, shows substantial

fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of anatomic,

physiologic, psychosocial, and premorbid behavior. (See 'Characteristics of burn pain' above.)

Pain assessment instruments use visual and/or numeric scales to assess pain intensity, behavioral reactions, and

physiologic reactions. There is no one optimal assessment technique for burn patients. The key is to choose an

instrument and use it consistently. (See 'Burn pain assessment techniques' above.)

Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and

anesthetics. The type of medication used is determined by the severity of pain, the anticipated duration of pain, and

intravenous (IV) access. (See 'Pharmacologic treatment options' above.)

Opioid analgesics (eg, morphine, fentanyl), the most common type of medication used for acute pain relief, are

potent and provide a dose dependent degree of sedation important during burn wound care procedures. (See 'Opioid

analgesics' above.)

Nonopioid analgesics (eg, dexmedetomidine, ketamine, NSAIDs), provide short-term effective analgesia and sedation

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 7/35

that may be helpful for limited burn debridement and/or dressing changes in adults and children. (See 'Nonopioid

analgesics' above.)

Anxiolytic drugs (eg, benzodiazepines) are useful in premedicating patients for wound care, due to the anticipatory

anxiety experienced by these patients prior to and during such procedures. (See 'Anxiolytics' above.)

Nonpharmacologic treatments should be adjunctive to pharmacologic approaches when treating pain and anxiety in

the burn patient. These approaches include cognitive distraction, information provision, relaxation, coping skills, and

cognitive behavioral techniques. (See 'Nonpharmacologic treatment options' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Ptacek JT, Patterson DR, Montgomery BK, Heimbach DM. Pain, coping, and adjustment in patients with burns:preliminary findings from a prospective study. J Pain Symptom Manage 1995; 10:446.

2. Askay SW, Stricklin M, Carrougher GJ, et al. Using QMethodology to identify reasons for distress in burn survivorspostdischarge. J Burn Care Res 2009; 30:83.

3. Wiechman Askay S, Patterson DR, Sharar SR, et al. Pain management in patients with burn injuries. Int RevPsychiatry 2009; 21:522.

4. Burn Pain: A Unique Challenge. Pain Clinical Updates. International Association for the Study of Pain. Vol IX, Issue 1.March 2001. www.iasp-pain.org.

5. Meyer WJ, III, Patterson DR, et al. Chapter 64. Management of pain and other discomforts in burned patients. In:Total Burn Care, 3rd, Herndon DN. (Ed), Saunders Elsevier, Philadelphia 2007. p.797.

6. Choinière M, Melzack R, Rondeau J, et al. The pain of burns: characteristics and correlates. J Trauma 1989; 29:1531.

7. Perry S, Inturrisi C. Analgesia and morphine disposition in burn patie. J Burn Care Rehabil 1983; 4:276.

8. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative pain inyoung children. Pediatr Nurs 1997; 23:293.

9. Wong DL, Hockenberry-Eaton M, Wilson D, et al. Wong's Essentials of Pediatric Nursing, 6th edition, St. Louis2001. p.1301.

10. Wibbenmeyer L, Sevier A, Liao J, et al. Evaluation of the usefulness of two established pain assessment tools in aburn population. J Burn Care Res 2011; 32:52.

11. Gaston-Johansson F, Albert M, Fagan E, Zimmerman L. Similarities in pain descriptions of four different ethnic-culture groups. J Pain Symptom Manage 1990; 5:94.

12. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the Pain Assessment in AdvancedDementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4:9.

13. Johnston CC, Strada ME. Acute pain response in infants: a multidimensional description. Pain 1986; 24:373.

14. Stoddard FJ, Sheridan RL, Saxe GN, et al. Treatment of pain in acutely burned children. J Burn Care Rehabil 2002;23:135.

15. Beyer JE, Villarruel AM, Denyes MJ. The Oucher! User’s manual and technical report, January 2010.www.oucher.org/index.html (Accessed on June 13, 2011).

16. Woodson LC, Sherwood ER, Aarsland A, et al. Chapter 14: Anesthesia for burned patients. In: Total Burn Care, 3rd,Herndon DN. (Ed), Saunders Elsevier, Philadelphia p.196.

17. Abdi S, Zhou Y. Management of pain after burn injury. Curr Opin Anaesthesiol 2002; 15:563.

18. Rovers J, Knighton J, Neligan P, Peters W. Patient-controlled analgesia in burn patients: a critical review of theliterature and case report. Hosp Pharm 1994; 29:106, 108.

19. Sharar SR, Bratton SL, Carrougher GJ, et al. A comparison of oral transmucosal fentanyl citrate and oralhydromorphone for inpatient pediatric burn wound care analgesia. J Burn Care Rehabil 1998; 19:516.

20. Sharar SR, Carrougher GJ, Selzer K, et al. A comparison of oral transmucosal fentanyl citrate and oral oxycodone forpediatric outpatient wound care. J Burn Care Rehabil 2002; 23:27.

21. Lin H, Faraklas I, Sampson C, et al. Use of dexmedetomidine for sedation in critically ill mechanically ventilatedpediatric burn patients. J Burn Care Res 2011; 32:98.

22. Walker J, Maccallum M, Fischer C, et al. Sedation using dexmedetomidine in pediatric burn patients. J Burn CareRes 2006; 27:206.

23. Kariya N, Shindoh M, Nishi S, et al. Oral clonidine for sedation and analgesia in a burn patient. J Clin Anesth 1998;10:514.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 8/35

24. Lyons B, Casey W, Doherty P, et al. Pain relief with low-dose intravenous clonidine in a child with severe burns.Intensive Care Med 1996; 22:249.

25. Martin-Herz SP, Patterson DR, Honari S, et al. Pediatric pain control practices of North American Burn Centers. JBurn Care Rehabil 2003; 24:26.

26. Perry S, Heidrich G. Management of pain during debridement: a survey of U.S. burn units. Pain 1982; 13:267.

27. Patterson DR, Ptacek JT, Carrougher GJ, Sharar SR. Lorazepam as an adjunct to opioid analgesics in the treatmentof burn pain. Pain 1997; 72:367.

28. Vulink NC, Figee M, Denys D. Review of atypical antipsychotics in anxiety. Eur Neuropsychopharmacol 2011;21:429.

29. MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology 1998; 89:749.

30. Filkins SA, Cosgrav P, Marvin JA. Self-administered anesthesia: A method of pain control. J Burn Care Rehabil 1981;2:33.

31. Baskett PJ, Hyland J, Deane M, Wray G. Analgesia for burns dressing in children. A dose-finding study forphenoperidine and droperidol with and without 50 per cent nitrous oxide and oxygen. Br J Anaesth 1969; 41:684.

32. Dimick P, Helvig E, Heimbach D, et al. Anesthesia-assisted procedures in a burn intensive care unit procedure room:benefits and complications. J Burn Care Rehabil 1993; 14:446.

33. Powers PS, Cruse CW, Daniels S, Stevens BA. Safety and efficacy of debridement under anesthesia in patients withburns. J Burn Care Rehabil 1993; 14:176.

34. Punja K, Graham M, Cartotto R. Continuous infusion of epidural morphine in frostbite. J Burn Care Rehabil 1998;19:142.

35. Still JM, Abramson R, Law EJ. Development of an epidural abscess following staphylococcal septicemia in an acutelyburned patient: case report. J Trauma 1995; 38:958.

36. Cuignet O, Pirson J, Boughrouph J, Duville D. The efficacy of continuous fascia iliaca compartment block for painmanagement in burn patients undergoing skin grafting procedures. Anesth Analg 2004; 98:1077.

37. Cuignet O, Mbuyamba J, Pirson J. The long-term analgesic efficacy of a single-shot fascia iliaca compartment blockin burn patients undergoing skin-grafting procedures. J Burn Care Rehabil 2005; 26:409.

38. Martin-Herz SP, Thurber CA, Patterson DR. Psychological principles of burn wound pain in children. II: Treatmentapplications. J Burn Care Rehabil 2000; 21:458.

39. Wickens CD, Helleberg J, Xu X. Pilot maneuver choice and workload in free flight. Hum Factors 2002; 44:171.

40. Hanson MD, Gauld M, Wathen CN, Macmillan HL. Nonpharmacological interventions for acute wound care distress inpediatric patients with burn injury: a systematic review. J Burn Care Res 2008; 29:730.

41. Landolt MA, Marti D, Widmer J, Meuli M. Does cartoon movie distraction decrease burned children's pain behavior? JBurn Care Rehabil 2002; 23:61.

42. Eller LS. Guided imagery interventions for symptom management. Annu Rev Nurs Res 1999; 17:57.

43. Acute pain management: operative or medical procedures and trauma, Part 2. Agency for Health Care Policy andResearch. Clin Pharm 1992; 11:391.

44. Patterson DR. Clinical hypnosis for pain control. American Psychological Association: Washington, DC, US. 2010.page 37.doi: 10.1037/12128-002. psycnet.apa.org/books/12128/ (Accessed on June 13, 2011).

45. Barber J. A brief introduction to hypnotic analgesia. In: Hypnosis and Suggestion in the Treatment of Pain, Barber J(Ed), WW Norton & Company, New York 1996. p.3.

46. Barber J. Rapid induction analgesia: a clinical report. Am J Clin Hypn 1977; 19:138.

47. Wark DM. Alert hypnosis: a review and case report. Am J Clin Hypn 2006; 48:291.

48. Patterson DR. Burn Pain. In: Hypnosis and Suggestion in the Treatment of Pain, Barber J (Ed), WW Norton &Company, New York 1996. p.267.

49. Patterson DR, Everett JJ, Burns GL, Marvin JA. Hypnosis for the treatment of burn pain. J Consult Clin Psychol 1992;60:713.

50. Patterson DR, Adcock RJ, Bombardier CH. Factors predicting hypnotic analgesia in clinical burn pain. Int J Clin ExpHypn 1997; 45:377.

51. Patterson DR, Ptacek JT. Baseline pain as a moderator of hypnotic analgesia for burn injury treatment. J Consult ClinPsychol 1997; 65:60.

52. Montgomery GH, DuHamel KN, Redd WH. A meta-analysis of hypnotically induced analgesia: how effective ishypnosis? Int J Clin Exp Hypn 2000; 48:138.

53. Patterson DR, Jensen MP. Hypnosis and clinical pain. Psychol Bull 2003; 129:495.

54. Patterson DR, Questad KA, Boltwood MD, et al. Patient self-reports three months after sustaining a major burn. JBurn Care Rehabil 1987; 8:274.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=0… 9/35

55. Wakeman JR, Kaplan JZ. An experimental study of hypnosis in painful burns. Am J Clin Hypn 1978; 21:3.

56. Patterson DR, Tininenko JR, Schmidt AE, Sharar SR. Virtual reality hypnosis: a case report. Int J Clin Exp Hypn2004; 52:27.

57. Hoffman HG, Patterson DR, Carrougher GJ. Use of virtual reality for adjunctive treatment of adult burn pain duringphysical therapy: a controlled study. Clin J Pain 2000; 16:244.

58. Patterson DR, Wiechman SA, Jensen M, Sharar SR. Hypnosis delivered through immersive virtual reality for burnpain: A clinical case series. Int J Clin Exp Hypn 2006; 54:130.

59. Sharar SR, Miller W, Teeley A, et al. Applications of virtual reality for pain management in burn-injured patients.Expert Rev Neurother 2008; 8:1667.

60. Burn pain: Nonpharmacologic approaches. Pain ladder treating pain painladder.com/index.php/acute-pain/burn-pain-nonpharmacologic-approaches (Accessed on June 22, 2011).

61. Greenberg JS. Part 3. General applications: Relaxation techniques. Chapter 10. Autogenic training, imagery, andprogressive relaxation. In: Comprehensive Stress Management, 12th, Greenberg JS (Ed), McGraw-Hill HigherEducation, New York 2011. p.203.

62. Jacobson E. Progressive Relaxation, University of Chicago Press, Chicago 1938.

63. Edwards RR, Haythornthwaite JA, Sullivan MJ, Fillingim RB. Catastrophizing as a mediator of sex differences in pain:differential effects for daily pain versus laboratory-induced pain. Pain 2004; 111:335.

64. Thurber CA, Martin-Herz SP, Patterson DR. Psychological principles of burn wound pain in children. I: theoreticalframework. J Burn Care Rehabil 2000; 21:376.

Topic 14989 Version 3.0

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 10/35

GRAPHICS

Burn classification

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 11/35

Adjective Rating Scale for pain assessment

The Adjective Rating Scale allows patients to use descriptive terms todescribe the severity of their pain. Scoring can be modified forconversion to a numeric scale.Original figure modified for this publication. Melzack R. The short-form McGill PainQuestionnaire. Pain 1987; 30:191. Illustration used with the permission of ElsevierInc. All rights reserved.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 12/35

Numeric Pain Scale

The Numeric Pain Scale allows patients to rate the pain on a scaleof 0 to 10, with 10 as the worst possible pain.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 13/35

Visual analog scale

Visual Analog Scale (VAS) (10 cm line).[Score = 0 - 100 mm] - measuring in millimeters from the left hand end of the line tothe point that the patient marks.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 14/35

PAINAD - Pain Assessment in Advanced Dementia scale

Items* 0 1 2 Score

Breathingindependentofvocalization

Normal. Occasional laboredbreathing. Short period ofhyperventilation.

Noisy labored breathing.Long period ofhyperventilation. Cheyne-Stokes respirations.

Negativevocalization

None. Occasional moan or groan.Low-level speech with anegative or disapprovingquality.

Repeated troubled callingout. Loud moaning orgroaning. Crying.

Facialexpression

Smiling orinexpressive.

Sad. Frightened. Frown. Facial grimacing.

Bodylanguage

Relaxed. Tense. Distressed pacing.Fidgeting.

Rigid. Fists clenched. Kneespulled up. Pulling or pushingaway. Striking out.

Consolability No need toconsole.

Distracted or reassured byvoice or touch.

Unable to console, distractor reassure.

Total:•

This pain assessment score can be used to assess pain in demented patients. Patients shouldbe observed for five minutes prior to performing the assessment. Total scores range from 0to 10, with 10 representing severe pain.* Five-item observational tool.• Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher scoreindicating more severe pain (0 = "no pain" to 10 = "severe pain").Original figure modified for this publication. Warden V, Hurley AC, Volicer L. Development and psychometricevaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4:9.Illustration used with the permission of Elsevier Inc. All rights reserved.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 15/35

Revised FLACC pain score

CategoriesScoring

0 1 2

F

Face

Noparticularexpressionor smile

Occasional grimace or frown,withdrawn, disinterested; appearssad or worried

Frequent to constant frown,clenched jaw, quivering chin;distressed-looking face: expressionof fright or panic

L

Legs

Normalposition orrelaxed

Uneasy, restless, tense; occasionaltremors

Kicking, or legs drawn up; markedincrease in spasticity, constanttremors or jerking

A

Activity

Lyingquietly,normalposition,moveseasily

Squirming, shifting back and forth,tense; mildly agitated (eg, headback and forth, aggression); shallowand splinting respirations,intermittent sighs

Arched, rigid, or jerking; severeagitation, head banging; shivering(not rigors); breath-holding,gasping or sharp intake of breath;severe splinting

C

Cry

No cry(awake orasleep)

Moans or whimpers, occasionalcomplaint; occasional verbaloutburst or grunt

Crying steadily, screams or sobs,frequent complaints; repeatedoutbursts, constant grunting

C

Consolability

Content,relaxed

Reassured by occasional touching,hugging, or being talked to,distractable

Difficult to console or comfort;pushing away caregiver, resistingcare or comfort measures

This pain score can be used to assess pain from burns and other etiologies for preverbalchildren.

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability isscored from 0-2, which results in a total score between zero and ten.Patients who are awake: Observe for at least 1-2 minutes. Observe legs and bodyuncovered. Reposition patient or observe activity, assess body for tenseness and tone.Initiate consoling interventions if needed.Patients who are asleep: Observe for at least 2 minutes or longer. Observe body andlegs uncovered. If possible reposition the patient. Touch the body and assess fortenseness and tone.The revised FLACC can be used for children with cognitive disability. The additionaldescriptors (in italics) are included with the original FLACC. The nurse can review thedescriptors within each category with parents. Ask them if there are additional behaviorsthat are better indicators of pain in their child. Add these behaviors to the tool in theappropriate category.

Reproduced with permission. Copyright © 2002 The Regents of the University of Michigan.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 16/35

Wong-Baker FACES pain rating scale

Explain to the child that each face is for a person who feels happybecause he has no pain (hurt) or sad because he has some or a lotof pain. Face 0 is very happy because he doesn't hurt at all. Face 1hurts just a little bit. Face 2 hurts a little more. Face 3 hurts evenmore. Face 4 hurts a whole lot. Face 5 hurts as much as you canimagine, although you don't have to be crying to feel this bad. Askthe child to choose the face that best describes how he is feeling.Rating scale is recommended for persons age three years and older.Point to each face using the words to describe the pain intensity. Askthe child to choose the face that best describes own pain and recordthe appropriate number.Reproduced with permission from: Wong DL, Hockenberry-Eaton M, Wilson D, etal. Wong's Essentials of Pediatric Nursing, 6th ed. Mosby, St. Louis, 2001. p.301.Copyright © 2001 Elsevier.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 17/35

OUCHER pain scale

The OUCHER pain scale uses both pictures and numbers. Thepictures can be used for preschool children, while older childrencan also use the numerical scale. The scales include pictures ofCaucasian, African-American, Hispanic, Asian, and First Nationchildren. The example here depicts a Caucasian child.The Caucasian version of the Oucher was developed and copyrighted in 1983by Judith E Beyer, Ph.D., RN, (University of Missouri-Kansas City School ofNursing, Retired), USA. For more information, please visithttp://www.oucher.org. Reproduced with permission.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 18/35

Sedative dosage regimens

DrugLoading

doseMaintenancedose range

Onset(minutes)

Duration ofintermittent

dose(minutes)

Characteristicsand role

Opioid analgesics*

Fentanyl1 to 2

mcg/kg•

(50-200 mcg)

0.7 to 10mcg/kg/hourinfusion

<0.5 30-60+Advantages:Potent analgesic-sedative withimmediate onset,minimalvenodilation,relativecardiovascularstability, lesshypotension, andrelative lack ofhistamine release.Hepaticallymetabolized bycytochrome P450-3A4 to inactivemetabolites.

Disadvantages:Highly lipophilicparent drugaccumulates withrepeated orprolongedadministration. Aswith all opioids,tolerance mayrequire doseescalation andwithdrawalsyndrome may beprecipitated uponabruptdiscontinuation.Chest wall rigiditymay occur withhigher dosing.

Role: A goodchoice foranalgesia andsedation for mostcritically illpatients.

Hydromorphone10 to 30

mcg/kg•

(1-4 mg)

7 to 15mcg/kg/hourinfusion

5-10 240-300Advantages: Noconsistentadvantage overfentanyl.

Disadvantages:Hepaticallymetabolized toinactive and activemetabolites whichcan accumulate inorgan failure andprolong effects.Some metaboliteslinked toneurotoxicitybased onpreliminaryevidence.

Morphine sulfate0.05 to 0.2

mg/kg•

(2-10 mg)

0.07 to 0.5mg/kg/hourinfusion

5-10 240

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 19/35

Histamine releaseand vagally-mediatedvenodilation andbradycardia canbe significant.Histamine releasemay precipitatebronchospasm.

Role: Limited toanalgesia andsedation incritically illpatients wherepreload reductionand myocardialdepressive effectsare desirable ortolerable.

Remifentanil None 0.6 to 15mcg/kg/hourinfusion

1-3 5-10 (aftercessation ofinfusion)

Advantages: Ultrashort acting.Cleared by non-specific plasmaesterases toinactivemetabolites. Doesnot accumulate inrenal or hepaticinsufficiency.Prompt reversal ofanalgesia andsedation upondiscontinuation.

Disadvantages:Anticipate painand discomfortupon abruptcessation. Glycineexcipient mayaccumulate inrenal insufficiency.

Role: An alternateto fentanyl forpatients requiringfrequentneurologicalassessments orwith multi-organfailure.

Benzodiazepines*

Lorazepam0.02-0.06

mg/kg•

(1 to 4 mg)

0.02-0.06mg/kg every 2-6 hours

AND/OR

0.01-0.1mg/kg/hourinfusion

(0.5-10mg/hour)

5-20 360-480+Advantages:Sedative,amnestic, potentanxiolysis withanti-convulsantproperties.Hepaticallymetabolized toinactivemetabolites.Relatively low riskof druginteractions andsafety in mild tomoderate hepaticand renalinsufficiency.

Disadvantages:

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 20/35

Relatively slowonset. Risk ofover-sedationwhen titrating dueto delayedresponse andaccumulation inperipheral tissues.IV incompatibilitiesand risk of lineprecipitate.Propylene glycolsolvent mayaccumulate withhigh dosingcausing metabolicacidosis and end-organ dysfunction.See text.

Role: A goodchoice forsedation andanxiolysis for mostpatients, includingthose who mayrequire long-termongoing sedation.Althoughintermittent bolusdosing may bepreferred, acontinuousinfusion may beinitiated forpatients requiringfrequentlyrepeated higherdosing.

Midazolam0.02 to 0.08

mg/kg•

(1 to 5 mg)

0.02 to 0.04mg/kg (1 to 2mg)intermittent

OR

0.04 to 0.2mg/kg/hourinfusion

(2 to 8mg/hour)

1-5 30Advantages: Apotent amnesticand anxiolyticagent with animmediate onsetof action and ashort duration ofeffect whenadministeredshort-term (<48hours). It is theonly intravenousbenzodiazepinethat is notdelivered inpropylene glycol.

Disadvantages:Metabolized toactive metabolitesthat mayaccumulate andcause prolongedsedation ifdelivered long-term. Also, itinteracts withnumerouscommon ICUdrugs.

Role: A goodchoice for short-term anxiolysisand treatment ofacute agitation.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 21/35

Diazepam0.1 to 0.2

mg/kg•

(5 to 20 mg)

0.03 to 0.1mg/kg every0.5 to 6 hours

Continuousinfusion is notrecommended

≅1 20-60(prolongedwith repeateddosing)

Advantages:Rapid onset withpotent sedativeand muscle-relaxant effects.

Disadvantages:Hepaticallymetabolized toactive metabolitesthat mayaccumulate andcause prolongedsedation ifdelivered long-term. Also, itinteracts withnumerouscommon ICUdrugs. Injectionsolution containspropylene glycolsolvent andcannot bedelivered as acontinuousinfusion. Injectionsite pain and riskof phlebitis limitsusefulness ofintravenousinjections.

Role: Seldom usedfor sedation ofcritically illpatients. May beuseful for criticallyill patient at risk ofalcoholwithdrawal orseizures due todrug overdose orpoisoning.

Anesthetic-sedative

Propofol Loading doseis notrecommended

5 to 80mcg/kg/minute

Initiate at 5mcg/kg/minuteand titrateevery 5-10minutes inincrements of5-10mcg/kg/minute

<1 3-10+Advantages:Potent sedativehypnotic with animmediate onsetand rapidawakening upondiscontinuationwhen deliveredfor short termuse. Metabolism isreportedlyunaltered inhepatic or renalinsufficiency andsubject to fewsignificant druginteractions.Infusion is readilytitratable todesired depth ofsedationminimizing risk ofover-sedation.Propofoleffectivelydecreasesintracranial

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 22/35

pressure, lowerscerebralmetabolism,controlsintractableseizures and mayreduce shiveringin rewarmingphase of inducedhypothermiafollowingresuscitation fromcardiac arrest.

Disadvantages:With long termuse propofol hasno advantageover lorazepam ormidazolamregarding theduration of ventweaning. Adverseeffects includehypotension,decreasedmyocardialcontractility,elevatedtriglycerides,peripheralinjection site pain,and propofolinfusionsyndrome. Seetext. Specificproductpresentationsmay includepotentialallergens (egg,soy, peanut,others). Consultproduct labelinformation.

Role: A goodchoice for shortterm sedation forpatients in whomrapid awakeningis advantageoussuch asneurosurgicalpatients requiringfrequentneurologicassessments. Alsoa good choice todecrease elevatedintracranialpressure or forshort-termsedation in ageneral criticalcare populationthat is likely to beready soon forventilatorweaning trials.

Central alpha-2 agonist

Dexmedetomidine Loading doseis notrecommended

0.2 to 1.4mcg/kg/hour

>5-10 60-120Advantages:Effective sedativesympatholytic

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 23/35

Initiate at 0.2mcg/kg/hourand titrateevery 30minutes

(central alpha-2agonist) withmoderateanxiolysis andanalgesia, yet noclinically significanteffect onrespiratory drive.Character anddepth of sedationmay permitcritically illmechanicallyventilatedpatients to beinteractive oreasily awakened,yet comfortable.Reduces shiveringin rewarmingphase of inducedhypothermiafollowingresuscitation fromcardiac arrest.May be less likelyto cause deliriumthan othersedative choices.

Disadvantages:Potentiallysignificanthypotension andbradycardia orhypertension thatdo not resolvequickly uponabruptdiscontinuation.Hepaticallymetabolized byglucuronidationand cytochromeP450-2A6. Dosereductionrecommendedwith renal and/orhepaticinsufficiency.Rapidadministration ofloading dose maybe associatedwithcardiovascularinstability,tachycardia,bradycardia, orheart-block.Limited datasupport higherdose and longerterm use (>24hours) than in theUS FDA approvedinformation. Doesnot induce deepsedation neededfor neuromuscularblockade.

Role: An alternatechoice for shortand long-termsedation incritically ill

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 24/35

patients withoutrelevant cardiacconditions. May beuseful forsedation ofpatients with or athigh risk ofdevelopingdelirium, althoughthis has not beenwell established.

Neuroleptics

Haloperidol0.03-0.15mg/kg

(2-10 mg)•

0.03 to 0.15mg/kg every 30minutes to 6hours

Variousregimens; seetext

30-60minutes

30-360+CAUTION: Notrecommended asa first or secondline of treatmentfor burn patients.

Advantages:Sedatingdopamine 2antagonist forcontrol of positivesymptoms ofdelirium and ICUpsychoses.Minimalcardiorespiratoryeffects ineuvolemichemodynamicallystable patients.

Disadvantages:Complex hepaticmetabolismincludescytochrome P450-3A4 andcytochrome P450-2D6transformations.Some expertsconsider certainmetabolites to beactive orpotentiallyneurotoxic. Half-life becomesprolonged withrepeatedadministration.Adverse effectsinclude dosedependent QTintervalprolongation andhypotension.Interacts withsome common ICUdrugs byinterference withmetabolismand/or additive QTprolongation.Extrapyramidalsymptoms andneurolepticmalignantsyndrome rare incritical care use.

Role: A commonlyused treatment

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 25/35

for delirium incritically illpatients or forprevention ofdelirium whiletapering sedationin preparation forventilatorweaning. Use withextreme caution inburn patients.

QuetiapineΔ None Initially 50 mgorally every 12hours; increaseevery 24 hoursas needed upto 400 mg perday

24 hours --Advantages:Relatively lowerrisk ofextrapyramidalsymptoms andless QTprolongation thanhaloperidol.

Disadvantages:Requires enteralroute ofadministrationand scheduleddosing due toslow onset ofaction andrelatively gradualtitration schedule.Adverse effectsmay includesedation ororthostatichypotension.Hepaticallymetabolized bycytochrome P450-3A4 to active andinactivemetabolites. Dosereduction inhepaticinsufficiencyneeded.

Role: A potentialchoice as adjunctto as-neededintravenoushaloperidol fortreatment orprevention ofdelirium. Theprecise role ofquetiapine intreating orpreventing ICUdelirium is not yetwell established.

Doses shown are for adult patients, intravenous administration, unless stated otherwise.Data on drug metabolism and activity of metabolite(s) are for assessment of potential fordrug interactions and risk of accumulation.+: Duration of action shown for initial dose. Duration becomes significantly prolonged after repeateddosing or with administration as a continuous infusion due to accumulation of drug in non-lean tissue.* For patients with significant obesity, standard initial dosing (shown in parentheses based on idealbody weight) is preferred. For additional information see "Management of the critically ill obese patient".• One or more loading doses may be needed. See onset of action data for minimum time between re-dosing. Loading dose should be reduced or omitted in patients that are older, hypovolemic, havingincreasing vasopressor requirements or at-risk of hemodynamic compromise.Δ Quetiapine recommendations and data based on limited experience and small trial results (CCM 2010;38:419).

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 26/35

Data from:1. Lexicomp Online. Copyright © 1978-2013 Lexicomp, Inc. All Rights Reserved.2. Brunton BL, et al. (Eds). Goodman & Gilman's The Pharmacological Basis of Therapeutics 11th ed.

McGraw-Hill, NY. Copyright © 2006.3. Wynn GH, et al. (Eds). Clinical Manual of Drug Interaction Principles for Medical Practice APA publishing,

Washington, DC. Copyright © 2009.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 27/35

Opioid analgesics for use in children with burns

Drug

Equianalgesicdose* Oral dose and

frequency• IV dose and frequency•

Oral(mg)

IV (mg)

MorphineΔ 30 10 0.3 mg/kg every three to fourhours

0.1 mg/kg every two to fourhours

Hydromorphone 7.5 1.5 0.04 to 0.08 mg/kg everythree to four hours

0.015 mg/kg every two tofour hours

Oxycodone 20 N/A 0.1 to 0.2 mg/kg every threeto four hours

N/A

Fentanyl◊ N/A 0.1 (100mcg)

N/A 0.5 to 1 mcg/kg every one totwo hours

Methadone § § 0.1 mg/kg every eight totwelve hours

0.5 to 0.1 mg/kg every eightto twelve hours

N/A: not available. * Approximate equianalgesic dose for estimation when changing opioid agents.• Doses are for individuals over 6 months of age with a maximum weight of 50 kg. Oral doses refer toimmediate release products. Δ Dose adjustment for renal insufficiency may be required. Not recommended in severe renalinsufficiency.◊ Oral transmucosal fentanyl is commonly used in pediatric burn patients for procedural pain, due to itsacceptance by children, its relatively fast onset of action, and its relatively short duration of action, at adose of 10-20 mcg/kg. § Due to gradual drug accumulation at tissue sites, the dose and frequency of methadone differ forinitial compared with repeated use; dose and interval given is usual after repeated use; methadoneshould be initiated and titrated by a clinician experienced with its use.Data from: Gutstein HB, Akil H. Opioid analgesics. In: Goodman & Gilmans pharmacological basis oftherapeutics, 11th ed, McGraw-Hill, New York 2006.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 28/35

PCA dosing

Drug

Morphine Dilaudid Fentanyl

General PCA dosing*

StandardConcentration

1 mg/ml 1 mg/ml 10 mcg/ml

PCA Dose 1.5 mg 0.2 mg 20 mcg

LockoutInterval

7 7 7

4 Hour DoseLimit

30 mg 3 mg 300 mcg

Continuous infusion dosing should be avoided (0 mg/hr)

Typical PCADose Change

0.5 mg 0.1 mg 5 mcg

Rescue Doses 3 mg IV q 5 min x3 0.3 mg IV q 5 min x3 25 mcg IV q 5 min x3

Notes Preferred in renal dysfunctionover morphine

Shorter clinical effect

High Risk PCA dosing•

StandardConcentration

1 mg/ml 1 mg/ml 10 mcg/ml

PCA Dose 1 mg 0.1 mg 15 mcg

LockoutInterval

7 7 7

4 Hour DoseLimit

30 mg 3 mg 300 mcg

Continuous infusion dosing should be avoided (0 mg/hr)

Typical PCADose Change

0.5 mg 0.1 mg 5 mcg

Rescue Doses 2 mg q15 min, mayrepeat x1 prn

0.2 mg q 15 min, may repeatx1 prn

25 mcg I q 15 min, mayrepeat x1 prn

Notes Preferred in renal dysfunctionover morphine

Shorter clinical effect

IV: intravenous; q: every; prn: as needed; PCA: patient controlled analgesia; mg: milligrams; mcg:micrograms; ml: milliliters.* May be recorded as: PCA dose/lockout interval/4 hour limit/infusion rate).• May be recorded as: PCA dose/lockout interval/4 hour limit/infusion rate). Indications for High Risk are:Patients identified as elderly (age 70 or above), morbidly obese, history of sleep apnea, or patients whohave received more than 25 mg morphine sulfate IV (or its equivalent).Reproduced with permission from: Pain Management Tables and Guidelines. Dana Farber CancerInstitute/Brigham and Women's Hospital Pain and Pallitative Care Program. Copyright © 2004.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 29/35

Selected nonopioid analgesic and nonsteroidal antiinflammatory drugs (NSAIDs):Usual dosing for adults with pain or inflammation

Drug

Initialdose

per day(mg)

Usualanalgesicdose andinterval

Maximumdose perday (mg)

Role in therapy

Para-aminophenol derivative

Acetaminophen*(paracetamol)

<2600 325 to1000 mgevery 4 to6 hours

4000 Treatment of mild pain and minorfebrile conditions. Lacks significantantiinflammatory effect. Usefuladjunct to opioid analgesics andNSAIDs. Lacks antiplatelet effect andgastrointestinal (GI) toxicity. Cancause hepatotoxicity in chronic oracute overdosage. Avoid, or use alower daily dose, in older adults andpatients at risk for hepatoxicity (eg,heavy alcohol use or malnourished).Interacts with warfarin (prolongationof INR) and CYP-450 inducing drugs(elevated risk of hepaticinflammation).

Acetaminophenintravenous

<2600 650 mgevery 4hours or1000 mgever 6hours, or15 mg/kgevery sixhours forpatientsweighing<50 kg

4000;maximaldaily dose75 mg/kg if<50 kg

Short term treatment of mild tomoderate acute pain and febrileconditions when oral administrationis not available and as an adjunct toopiate analgesics for the treatmentof moderate to severe pain. Patientshould be well hydrated and dosereduced for hepatic or renalimpairment. Not indicated fortreatment of chronic cancer pain.

Non-selective nonsteroidal antiinflammatory (NSAID) agents•

Salicylate (acetylated)

Aspirin* 2600 325 to 650mg every 4to 6 hours

4000 Standard for comparison but nowused infrequently for treatment ofchronic pain and inflammation due toits association with severegastropathy. Unlike other NSAIDs,irreversibly inhibits platelet functionfor platelet life (7 to 10 days) andsalicylism may occur with high dosesor chronic use at analgesic doses.

Salicylates (non-acetylated)

Diflunisal 1000onceΔ

500 mgevery 8 to12 hours

1500 All agents: Treatment of mild tomoderate pain and acute or chronicinflammatory conditions. Relativelylower risk of gastropathy comparedto aspirin and possibly other NSAIDs.Generally tolerated by patients withasthma. Slower onset and possiblylonger duration of action than aspirinor acetaminophen. Do not inhibitplatelet function.

Cholinemagnesiumtrisalicylate

1500onceΔ

750 mgevery 8 to12 hours

3000

Salsalate 1500 750 to1000 mgevery 8 to12 hours

3000

Propionic acids

Ibuprofen* 1600 400 mgevery 4 to6 hours

3200 acute,2400chronic

Treatment of mild to moderate pain,minor fever and acute or chronicinflammatory conditions. A 200 to400 mg dose is comparable inanalgesic effect to 650 mgacetaminophen or aspirin. Reversibly

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 30/35

inhibits platelet function andincreases bleeding time. Can altercardioprotective effect of low doseaspirin◊. Minimal risk of severe

gastropathy with daily dose ≤2400mg.

Ibuprofen(intravenous)

1600 400 to 800mg every 6hours

3200(acute)

Short term treatment of mild tomoderate acute pain and febrileconditions when oral administrationis not available and as an adjunct toother analgesics for the treatment ofmoderate to severe postoperativepain. Patients should be wellhydrated and without significantkidney disease. Not indicated fortreatment of chronic cancer pain.

Naproxen* 500 onceΔ

(naproxenbase)

250 mgevery 8hours or500 mgevery 12hours(naproxenbase)

1250 acute,1000chronic(naproxenbase)

Treatment of mild to moderate pain,minor fever and acute and chronicinflammatory conditions. 250 mgdose (base) comparable in analgesiceffect to 650 mg aspirin.

In the treatment of rheumatologicdisorders, total daily dose may beincreased to a maximum of 1500 mgbase (1650 mg naproxen sodium)when needed for added effect.

Reversibly inhibits platelet functionand increases bleeding time. Canalter cardioprotective effect of low

dose aspirin◊.

Appears to have the greatestrelative cardiovascular safety profileamong nonselective COX-2inhibitors.

550 onceΔ

(naproxensodium)

275 every8 hours or550 mgevery 12hours(naproxensodium)

1375 acute,1100chronic(naproxensodium)

Ketoprofen* 100 25 to 50mg every 6to 8 hours

300 mg For treatment of mild to moderatepain and acute or chronicinflammation. 25 mg dosecomparable to analgesic effect of400 mg ibuprofen.

Flurbiprofen 100 50 to 100mg every 6to 12 hours

300 mg For treatment of mild to moderatepain and acute or chronicinflammation. In some countries it isavailable as a lozenge for throatpain and as an intravenous injection.

Oxaprozin 600 1200 26 mg/kgup to 1800mg

For treatment of chronic pain andinflammation, osteo- and rheumatoidarthritis. Once daily dosing may beuseful.

Acetic acids

Diclofenac 75 or 100mg onceΔ

50 mgevery 8hours

150 mg For treatment of mild to moderatepain and acute or chronicinflammation. Also available as atopical patch for pain due to traumaand as a gel for treatment of painfuljoints.

Etodolac 600 200 to 400mg every 6to 8 hours

1200 mg For treatment of mild to moderatepain and acute or chronicinflammation. 200 mg dose has acomparable analgesic effect to 400mg of ibuprofen.

Tolmetin 600 400 to 600mg every 8hours

1800 For treatment of chronic pain andinflammation, osteo- and rheumatoidarthritis.

Sulindac 300 150 to 200 400 For treatment of acute and chronic

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 31/35

mg every12 hours

pain and inflammatory conditions.More frequently implicated inhepatotoxicity than other NSAIDs.Parent drug and metabolites canaccumulate with hepaticinsufficiency. Drug and metaboliteshave been identified in renal calculi.

Indomethacin(indometacin)

7525 to 50mg every 8to 12 hours

Controlledrelease: 75mg every12 hours

150 An alternate, non first-line option fortreatment of mild to moderate painand acute or chronic inflammatoryconditions. GI and central nervoussystem adverse effects may be morefrequent or severe than with otherNSAIDs. Intravenous formulation notindicated for pain.

Ketorolac(intravenousandintramuscular)

<65 yrs60 mg IVor IMonce

15 to 30mg every 6hours

120 Short term treatment of moderateacute pain when oral administrationof an NSAID is not available and asan adjunct to other analgesics forthe treatment of moderate to severepostoperative pain. Not indicated fortreatment of chronic cancer pain.Risk of gastropathy is increasedwhen use exceeds five days. An oralpreparation of ketorolac is availablebut offers no advantage over otheroral NSAIDs.

≥65 yrs30 mg IVor IMonce

15 mgevery 6hours

60

Oxicams (enolic acids)

Meloxicam 7.5 7.5 to 15mg every24 hours

15 For treatment of chronic pain andinflammation, osteo- and rheumatoidarthritis. Once daily dosing may beuseful. While reported to beselective for COX-2 at lower dose of7.5 mg, overall adverse effects aresimilar to other NSAIDs.

Piroxicam 10 10 to 20mg every24 hours

20 An alternate, non first-line option fortreatment of chronic pain andinflammation poorly responsive toother NSAIDs. Comparatively highincidence of gastropathy in dailydose above 20 mg and in olderadults. Concurrent pharmacologicgastroprotection is suggested.

Fenamates (anthranilic acids)

Meclofenamate(meclofenamicacid)

150 50 mgevery 4 to6 hours

400 For treatment of acute or chronicpain and inflammation, osteo- andrheumatoid arthritis, dysmenorrhea.

Mefenamic acid 500 onceΔ 250 mgevery 6hours

1000 For acute pain and dysmenorrhea.Anti-inflammatory efficacy iscomparatively low. Not indicated fortreatment of chronic cancer pain.

Non-acidic (naphthylalkanone)

Nabumetone 1000onceΔ

500 to 750mg every 8to 12 hoursor 1000 to1500 mgonce daily

2000 For treatment of chronic pain andinflammation, osteo- and rheumatoidarthritis. While reported to becomparatively selective for COX-2 atthe lower dose of 500 mg twicedaily, the overall adverse effectswhen dosed in the usual range aresimilar to the other NSAIDs. Oncedaily dosing may be useful.

Selective COX-2 inhibitors§

Celecoxib 400 onceΔ 200 mgdaily or 100mg every

400 An option for patients requiringchronic NSAID treatment who maybe at risk for gastropathy.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 32/35

12 hours Demonstrated efficacy and relativereduction in GI toxicity compared tonon-selective NSAIDs. No effect onplatelet function. Dosage above 200mg daily associated with increasedcardiovascular risk.

Etoricoxib¥ 30 30 to 90mg oncedaily

120 For treatment of acute and chronicpain and inflammation, osteo- andrheumatoid arthritis.

Parecoxib¥

(intravenous andintramuscular)

40 onceΔ 20 to 40mg every 6to 12 hours

80 For short-term treatment ofpostoperative pain where oral routeof administration is not available.Not indicated for treatment ofchronic cancer pain.

Doses are for adults, oral administration, except where noted otherwise.NSAID: nonsteroidal antiinflammatory drug. * Available without a prescription in US.• NSAIDs may interact with aspirin, warfarin, methotrexate, anti-hypertensives, highly protein boundagents and other drugs. See "NSAIDs: Therapeutic use and variability of response in adults", section'Drug interactions'. See Lexi-Interact for information on interaction of specific combinations of drugs. Δ Optional initial loading dose for pain or inflammation.◊ See "Nonselective NSAIDs: Cardiovascular effects", section on 'Interference with beneficial effects ofaspirin'. § For additional information on gastroprotective strategies including selective COX-2 inhibitors and otheroptions, see "Overview of selective COX-2 inhibitors" and "NSAIDs (including aspirin): Primary preventionof gastroduodenal toxicity". ¥ Not available in US.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 33/35

Pharmacology of benzodiazepines

Drug

Adultoraldose

(mg)*

Comparativepotency

(mg)•

Onsetafter oral

doseMetabolism

Eliminationhalf-life

(hours)Δ

Used primarily to treat anxiety disorders

Alprazolam 0.5-4 0.5 Intermediate Hepatic byCYP3A4oxidation. Onemetabolitepossessespartial activity.

12-15

Alprazolamextendedrelease◊

0.5-6once daily

Clonazepam 0.5-4 0.25-0.5 Intermediate Hepatic byCYP3A4oxidation. Noactivemetabolite.

18-50

Lorazepam0.5-6

0.5-4(hypnotic)

1 Intermediate Hepatic byglucuronidation(rapid). Noactivemetabolite.

10-14

Oxazepam30-120

15-30(hypnotic)

15-30 Intermediate Hepatic byglucuronidation(rapid). Noactivemetabolite.

5-15

Chlordiazepoxide 5-100 10 Intermediate Hepatic byCYP3A4oxidation toactivemetabolites.

30-100

Diazepam 4-40 5 Rapid Hepatic byCYP2C19 and3A4 oxidation.Multiple activemetabolites.

50-100

Clorazepate 7.5-60 7.5 Rapid Hepatic byCYP3A4oxidation toactivemetabolite.Requires acidityfor activation ofparentcompound.

36-200

Prazepam§ 10-60 15 Slow Hepatic byCYP3A4oxidation.Multiple activemetabolites.Extensive first-passmetabolism.

30-200

Used primarily to treat insomnia¥

Triazolam 0.125-0.25

0.1 Rapid Hepatic by rapidCYP3A4hydroxylation.No activemetabolite.

2-5

Estazolam 1-2 0.3 Intermediate Hepatic byCYP3A4

10-24

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 34/35

oxidation. Noactivemetabolite.

Temazepam 15-30 5 Intermediate Hepatic byUGT2B7, 2C19,3A4glucuronidation.No activemetabolite.

10-40

Flurazepam 15-30 5 Intermediate Hepatic byCYP3A4oxidation toactivemetabolites.

40-114

Quazepam 15 5 Intermediate Hepatic byCYP3A4 (major)and 2C19(minor)oxidation toactivemetabolites.

28-114

Data on drug metabolism and activity of metabolite(s) are for assessment of potential fordrug interactions and risk of accumulation. Risk of accumulation is greater, and dosereduction necessary, for older or debilitated adults and for patients with renal or hepaticinsufficiency.* Range of usual effective total daily dose for adults. Dosages usually given in divided doses two to fourtimes daily for anxiety or panic.• Important: data shown are for comparing potencies and are NOT recommendations for initation oftherapy or for conversion between agents.Δ Half-life of parent drug and active metabolite(s), if any.◊ Give once daily in am; do not crush, break, or chew. Duration of effect longer than predicted by half-lifedue to extended release.§ Not available in US or Canada.¥ Range of usual effective hypnotic dose for adults, given once daily at bedtime.

28/01/13 Burn pain: Principles of pharmacologic and nonpharmacologic management

www.uptodate.com/contents/burn-pain-principles-of-pharmacologic-and-nonpharmacologic-management?topicKey=SURG%2F14989&elapsedTimeMs=… 35/35

© 2013 UpToDate, Inc. All rights reserved. | Subscription and License Agreement | Release: 21.1 - C21.7

Licensed to: Morehouse School of Medicine | Support Tag: [1103-200.54.114.2-5B29A75D3C-473950.14]