the day. Attempting to capture assessments at different time points would help with identifying acute pain needs as well as determining the degree of background pain. (Level A) (Romanowski et al., 2020). ● Guideline 2 : Pain assessments should be protocolized and recorded by the physician and the nursing staff during various stages of care to ensure consistent language when discussing pain evaluation. Protocolized burn pain assessment strategies were effective for capturing and treating pain during a patient’s hospital care. (Level B). ● Guideline 3 : Pain assessment tools should use patient- reported scales when able. Burn pain is an experience of the individual patient and observation-based pain assessments correlated poorly with patient assessments of pain (Level C). ● Guideline 4 : The Burn Specific Pain Anxiety Scale (BSPAS) should be included as one of the pain assessments used during an acute burn hospitalization as it is a validated tool for the burn patient population and includes the evaluation of anxiety. This scale had a high correlation with patient pain assessments and captures the impact of anxiety on the patient’s pain experience (Level C). ● Guideline 5 : Critical Care Pain Observation Tool (CPOT) can be used when a patient is not able to interact with care providers or communicate their assessment of pain. While this tool has not been extensively tested in a burn population, there are no other assessment tools available for critically ill patients (Level D). Opioid Use in pain management ● Guideline 1 : When choosing opioid pain medications, decisions about the choice of agent should be based on physiology, pharmacology, and physician experience given the limited amount of high-quality data available regarding their use in burn pain management (Level C). ● Guideline 2 : Opioid therapy should be individualized to each patient and continuously adjusted throughout their care due to the heterogeneity of individual responses, adverse effects, and the narrow therapeutic window of opioids (Level D). ● Guideline 3 : While we certainly support the responsible use of opioids to alleviate severe pain, attempts should be made to use as few opiate equivalents as needed to achieve the desired level of pain control. This can be accomplished by the use of nonopioid medications and nonpharmacologic adjuncts to opioid pharmacological therapies. While data on dosing and scheduling strategies is limited, principles of pharmacology and behavioral science support the use of long-acting opioid agents for background pain, where feasible, to minimize the frequency and individual doses of short-acting agents needed for “breakthrough pain” (Level C). ● Guideline 4 : Opioid pain medications should not be used in isolation but in conjunction with nonopioid and nonpharmacological measures (Level C). ● Guideline 5 : Patients should be educated about the role of opioids and other pain medications in their recovery from burn injury (Level D). Pain Management with nonopioids ● Guideline 1 : Acetaminophen should be utilized on all burn patients, with care taken to monitor the maximal daily dose. While acetaminophen has an excellent safety
profile, maximal doses should be monitored to decrease the risk of hepatotoxicity (Level D). ● Guideline 2 : Nonsteroidal anti-inflammatory drugs (NSAIDs) should be considered in all patients due to their safety profile and efficacy in other settings; however, the patient’s clinical picture including baseline comorbidities and kidney function as well as surgeon preference should be included in this decision. This recommendation is made by weighing the likely analgesic benefits against patient-specific risk factors such as renal insufficiency, coagulopathy, gastritis, or other complications. Given the paucity of data addressing the impact of NSAID use on skin graft hematoma and graft take, the patient’s surgeon should be involved in this decision process (Level D). ● Guideline 3 : We suggest agents for the treatment of neuropathic pain (e.g., gabapentin or pregabalin) should be considered as an adjunct to an opioid in patients who are having neuropathic pain or who are refractory to standard therapy. In patients without neuropathic complaints, a trial of such agents is appropriate in patients with pain proving resistant or refractory to standard therapy. Providers and patients should be aware of potential adverse effects, which may become more profound with dose escalation (Level C). ● Guideline 4 : Ketamine should be considered for procedural sedation, utilizing appropriate training and monitoring for the physician and nursing staff who are administering it (Level B). ● Guideline 5 : Low-dose ketamine should be considered as an adjunct to opioid therapy in patients who could benefit from reduced opioid consumption, particularly in the postoperative period (Level D). ● Guideline 6 : Dexmedetomidine and clonidine are recommended as pain management adjuncts, particularly in patients showing signs of withdrawal or prominent anxiety symptoms, and dexmedetomidine as a first-line sedative in the intubated burn patient (Level D). ● Guideline 7 : The use of IV lidocaine for burn pain management cannot be recommended at this time as a first-line agent, but it is a reasonable second- or third- line adjuvant agent (Level D). ● Guideline 8 : Given the lack of evidence and the potential legal and political obstacles we cannot recommend the use of cannabinoids in the treatment of acute burn pain (Level D). ● Guideline 9 : Regional anesthesia for burn pain management has the potential to provide improved pain relief, patient satisfaction, and opioid use reduction without serious risks or complications. Given the limited amount of good-quality evidence, we cannot at this time make specific recommendations about either the timing or dosing of regional anesthesia techniques or the potential long-term benefits of early regional anesthesia use in this population (Level C). Non-drug treatment ● Guideline 1 : We recommend that every patient be offered a nonpharmacological pain control technique, at least as an adjunctive measure to their pain control regimen. When the expertise and/or equipment is available, cognitive-behavioral therapy, hypnosis, and virtual reality have the strongest evidence (Level A).
American Society of Hematology Guideline for Pain in Sickle Cell Disease (SCD) Designed by the American Society of Hematology, this evidence-based guideline is intended to support patients, clinicians, and other healthcare professionals in pain management decisions for children and adults with
SCD. The recommendations of this guideline are based on updated and original systematic reviews of evidence conducted under the direction of the Mayo Evidence-Based
Book Code: PYCA2725
Page 152
EliteLearning.com/Psychology
Powered by FlippingBook