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physiotherapy, and possibly to minimise the development of chronic pain, which is reported in
35% to 58% of burn patients (Choiniere et al, 1989; Dauber et al, 2002).
Immediately after the injury, simple measures such as cooling (Davies, 1982), covering,
elevating and immobilising the burn may provide analgesia (Kinsella & Booth, 1991; Gallagher, Rae
& Kinsella, 2000). With severe burn pain, analgesia is best achieved by titration of IV opioids.
Opioid doses do not require adjustment, as the pharmacokinetics of morphine are unchanged
in burns patients (Perreault et al, 2001). Absorption of IM and SC opioids may be unreliable in
the presence of hypovolaemia and vasoconstriction associated with burns (Kinsella & Rae, 2008).
PCA with morphine is effective for burn pain in adults (Choiniere et al, 1992 Level II) and children
(Gaukroger et al, 1991 Level IV). Conversion to oral opioids is possible once normal
gastrointestinal (GI) function has returned; even severe burn injury does not affect gastric
emptying or the absorption of oral paracetamol (Hu et al, 1993 Level III‐2).
Opioids may be supplemented with non‐opioid drugs. There is experimental evidence for
beneficial effects of ketamine (Ilkjaer et al, 1996) and dextromethorphan (Ilkjaer et al, 1997) on
hyperalgesia, and clinical evidence of an opioid‐sparing effect with clonidine (Viggiano et al,
1998 Level II).
Gabapentin reduced pain and opioid consumption following acute burns injury (Cuignet et al,
2007 Level III‐3) and reduced neuropathic pain descriptors in a small case series (Gray et al, 2008
Level IV).
Parenteral methylprednisolone or ketorolac reduced secondary hyperalgesia surrounding an
experimental burn injury in human volunteers, however further clinical research is required
(Stubhaug et al, 2007 Level II).

9.3.1 Management of procedural pain

Procedural pain may be difficult to manage in burn patients. Dressing changes may be
associated with frequent and prolonged periods of pain with up to 84% of burn patients
reporting extreme, intense pain during therapeutic procedures (Ashburn, 1995). The choice
of dressing has an effect on time to healing and pain during dressing change; biosynthetic
dressings have been found to be superior (Wasiak et al, 2008 Level I).
CHAPTER 9 Opioid therapy is the mainstay of analgesia for burn procedures. However, very high doses
may be required (Linneman et al, 2000 Level IV) and opioid‐related sedation and respiratory
depression may develop when the pain stimulus decreases following the procedure.
Short‐acting opioids such as fentanyl (Prakash et al, 2004 Level II) or alfentanil (Sim et al, 1996
Level IV) administered via PCA or target‐controlled infusions (Gallagher, Rae, Kenny et al, 2000
Level IV) have been used successfully to provide analgesia during burn dressing changes.
IN fentanyl was a viable alternative to oral morphine in children for burn dressings (Borland et
al, 2005 Level II). In adults, there was no difference in pain scores or rescue analgesic
requirements between IN fentanyl and oral morphine for burn dressings (total surface less
than 26%) (Finn et al, 2004 Level II). Oral transmucosal fentanyl provided similar analgesia to
oral oxycodone (Sharar et al, 2002 Level II) and hydromorphone (Sharar et al, 1998 Level II) with a
similar side‐effect profile, for daily burn care in children and adolescents (see Section 10.4.1).
Nitrous oxide (N 2O), ketamine and IV lignocaine infusions (Jonsson et al, 1991 Level IV) have also
been used to provide analgesia for burn procedures (see Sections 4.3.1, 4.3.2 and 4.3.5),
however a Cochrane review reported that more trials were required to determine the efficacy
of lignocaine (Wasiak & Cleland, 2007 Level I).
PCA with a ketamine and midazolam mixture was effective and well‐tolerated when used for
analgesia and sedation during burn dressings (MacPherson et al, 2008 Level IV).
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