d. Reduced renal function and medication clearance even in the absence of renal disease, in patients/residents aged ≥65 years might have increased susceptibility to accumulation of opioids and a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose (contextual evidence review). Some older adults suffer from cognitive impairment, which can increase the risk of medication errors and make opioid-related confusion more dangerous. In addition, older adults are more likely than younger adults to experience co-morbid medical conditions and more likely to receive multiple medications, some of which might interact with opioids (such as benzodiazepines). Clinicians should use additional caution and increased monitoring to minimize the risks of opioids prescribed for patients/residents aged ≥65 years. e. Monitor for safety and side effects of medications. ○ Utilize the Four As of pain treatment outcomes, which are:
1. Analgesia (pain control). 2. Activities of daily living (patient/resident functioning and quality of life). 3. Adverse events (medication side effects). 4. Aberrant drug-related behavior (addiction-related outcomes). f. Administer medication routinely, not PRN (as needed). PRN analgesic may be administered for breakthrough pain or when resident/staff identifies circumstances when pain may be anticipated, On-going communication is recommended with the healthcare provider for optimal pain management before wound treatment or skilled therapy. g. Pain assessment findings shall be documented in the resident’s medical record. This shall include, but not be limited to, the date, pain rating, pain rating tool, treatment plan, and patient/resident response. 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
American Burn Association Guideline on the management of acute pain in adult burn patients This guideline was developed to update the principles of acute pain management in adult burn patients and present a reasonable approach to the management of the complex pain associated with burn injury based on a review of the literature and expert opinion. For easy comprehension, this guideline was subdivided into different sections of recommendations with each recommendation graded accordingly. Grades of recommendations include: A. Consistent level 1 studies. B. Consistent level 2 or 3 studies or extrapolations from level 1 studies.
C. Level 4 studies or extrapolations from level 2 or 3 studies. D. Level 5 evidence or troublingly inconsistent or inconclusive studies of any level. This course covers the different sections of this guideline relevant to its theme. Pain Assessment ● Guideline 1 : Pain assessments should be done repeatedly during the day during different activities. This would allow assessment of pain during all phases of care and capture fluctuations that occur throughout 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
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