SUMMARY. Pain in burn patients has many causes, both functional and organic. Peak pain comes during wound dressing and/or physiotherapy. This is a comparative study of four groups of patients (15 per group). Three groups received a particular modality of pain control, and the results were compared with those of a fourth group, the control group, that did not receive any pain relief. We used the pain-rating scale described by Chambers and Price to assess the patients’ physiological and behavioural pain response.
Pain is defined as whatever the person experiencing says it is, existing whenever he or she says it does.1,2 It is an elusive and complex phenomenon, but despite its universality its exact nature remains a mystery.3 Mersky4 defined pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage”.
There are two types of pain in burn patients:
The effects of pain are various:
Burn specialists are faced with a challenge if they are to achieve proper analgesia without interference, with awareness before, during or after the procedure.9 The basis of pain control is either pharmacological, non-pharmacological, or mixed. The pharmacological strategy includes:
Fentanyl (Sublimaze) is a synthetic, potent narcotic analgesic. Its potency is up to 100 times that of morphine, it is a highly lipid soluble agent, and it has a rapid onset (1-2 min). The duration of analgesia is 1 h. Its action is binding to specific receptors in brain, spinal cord, and peripheral tissue. There are two doses, an analgesic dose of 2 Ìg/kg and an anaesthetic dose of 50-100 Ìg/kg. Possible side effects are hypotension, bradycardia, apnoea, chest wall spasm, muscle rigidity, and respiratory depression.
Piroxicam is an anti-prostaglandin drug of the non-steroidal anti-inflammatory group. The dose is 20 mg, once only. It produces analgesia after 1 h. The duration of its action is 2-3 days. Possible side effects are nausea, vomiting, constipation, diarrhoea, gastrointestinal ulceration, abdominal pain, and gastrointestinal bleeding.
The non-pharmacological strategy includes education, distraction, relaxation and cutaneous stimulation, acupuncture, bio-feedback, hypnosis, and imagery.
Education: Knowledge of the procedure helps patients to control their anxiety and cognitively to gain a level of pain relief. This not only corrects misconceptions and decreases anxiety but also allows patients to play an active role in the procedure and to benefit fully from pain-reducing strategies. Education must be concise and of brief duration.
Distraction: This reduces the perception of pain by stimulating the descending control system that leads to painful stimuli being transmitted to the brain. Distraction includes talking, singing, praying, describing photographs, listening to music, and playing games.
The aim of this study was to examine and investigate the effect of different pain-relieving strategies on patients’ pain response during burn wound dressing.
This study was carried out in 60 patients admitted to the Assiut University Hospital Burns Unit in Egypt. The ages ranged from 15 to 45 yr (mean, 29 ± 9.7 yr). Thirty-four patients were female and 26 male. The burned body surface area ranged from 15 to 35% (mean, 29 ± 9.4%).
The patients were classified in four equally divided groups of 15 patients. The first group was the education and distraction group (non-pharmacological pain relief strategy). These patients received information about the progressive steps of the dressing of their wounds, the antimicrobial agent and the instrument used, the onset and expected duration of pain, and the way their safety was ensured. These procedures were carried out in addition to the distraction during wound dressing achieved by talking to the patients on subjects unrelated to pain and the burn wound. The second group was the drug group (pharmacological pain relief strategy). These received piroxicam 20 mg IM, 1 h before the procedure, and fentanyl 2 Ìg/kg IV, 2 min before the procedure. The third group was the mixed group, which received both the pharmacological and the non-pharmacological pain relief strategy. The fourth group was the control - these patients received none of the cited methods of pain relief. The pain relief strategies started from the first to the tenth day post-burn day in all patients.
The tools used for data collection were as follows: 1. demographic data (age, sex, etc.); 2. a drug monitoring sheet to record the dosage and possible side effect of the drugs used in the study; 3. the pain rating scale described by Chambers and Price15 to assess the patients’ physiological and behavioural pain response (this consists of nine variables [attention, anxiety, verbal response, restlessness, tense muscles, frowning and grimacing, perspiration, pain sounds, and nausea] - each variable was rated on a one-to-five scale, the minimum pain score therefore being 45 and the minimum, i.e. no pain,9.
The statistical analysis of the demographic data, burn circumstances, and burn wound in the four groups did not reveal any significant differences.
The total pain score presented in Fig. 10 shows that it was significantly much lower in the mixed group, in which we used pharmacological and non-pharmacological pain control strategies, than in the control group. The pharmacological strategy alone reduced the total pain score significantly in comparison with control, although the significance was only moderate. Education and distraction also reduced the score significantly (slight significance). The total pain score in the pharmacological and mixed groups was significantly decreased when we compared the score of the first day with that of the last day of the study, while it was unchanged in the education group and increased in the control group.
The statistical analysis of the data relative to the nine items separately (attention score, anxiety score, verbal score, skeletal muscle response [resting condition], skeletal muscle response [tense muscles], skeletal muscle response [frowning and grimacing], perspiration, pain sound score, nausea score) showed that they were the same as the total pain score finding and were significantly lower in the mixed, drug, and education groups than in control (Figs. 1-9).
<% immagine "Fig. 1","gr0000001.jpg","Attention score.",230 %> <% immagine "Fig. 2","gr0000002.jpg","Anxiety score.",230 %> <% immagine "Fig. 3","gr0000003.jpg","Verbal score.",230 %> <% immagine "Fig. 4","gr0000004.jpg","Skeletal muscle response.",230 %> <% immagine "Fig. 5","gr0000005.jpg","Skeletal muscle response.",230 %> <% immagine "Fig. 6","gr0000006.jpg","Skeletal muscle response.",230 %> <% immagine "Fig. 7","gr0000007.jpg","Perspiration score.",230 %> <% immagine "Fig. 8","gr0000008.jpg","Pain sounds score.",230 %>The use of length of stay as an indication of wound healing showed that this was longer in the control group than in other groups, but that the difference was insignificant.
<% immagine "Fig. 9","gr0000009.jpg","Nausea score.",230 %> <% immagine "Fig. 10","gr0000010.jpg","Total pain score.",230 %> <% riquadro "E = education & distraction (——— —–); (D = drugs (——— ..—–); E & D = both strategies (.........); C = Control (——— )." %>A study of the drug monitoring sheet for the medications used showed that no complications were recorded.
Why treat pain in burn patients? Pain should of course be treated for obvious humanitarian reasons of which no burn care specialist can be unaware, and also because pain can itself be detrimental to burn patients.16 That is are why, although we are not pain specialists, we are trying to attack this problem in the absence of participation from the specialties concerned.
Byers et al.17 stated that burn pain and anxiety are multifactorial and that procedural pain (e.g. during wound dressing) is significantly higher than resting pain.
The classification of the causes of pain in burn patients as psychological (functional) and organic is at the basis of pain control in such patients. This study was a trial to evaluate two different modalities and the effect of their combination on the control of the two pain components. We followed the recommendation in the literature18 that pain scores rated by the patient, and not by the doctor or the nurse, are by far the most accurate.
Huber et al.19 and Rybarczyk et al.20 emphasized that education procedures in the adult burn patient and a realistic understanding of the procedure, including the sensations to be expected, will have a positive effect on anxiety levels and the patient’s intentions. This was proved in our study, in which the group that underwent pre-procedural education and distraction during wound dressing showed a significantly lower pain score than the control group. This finding emphasized the extremely important role of nurses in patient education.
The results of our study on the effect of education and distraction are consistent with those in the literature,21,22 i.e. that such procedures reduce the pain score and anxiety, but to an extent too limited for them to be considered a single strategy of pain control during wound dressing.
Naylor23 reports that pain treatment by means of pharmacotherapy often includes opioid analgesics, non-opioid analgesics, and co-analgesics. The use of partial agonists, mixed agonists, and non-steroidal anti-inflammatory agents can provide objective and subjective analgesia without precipitating addictive behaviour or significant iatrogenic effects.
When the state of anxiety is significant, and mild to moderate analgesia is needed to achieve effective deep sedation during painful burn debridement, fentanyl can be administered24 by various routes - intravenously, intramuscularly, transdermally, or orally.
The use of fentanyl together with a non-steroidal anti-inflammatory drug (piroxicam) was associated in our study with a significant reduction of pain during wound dressing. The progressive reduction of pain scores from the first day of the trial to the last was probably due to decreased anxiety and fear of painful dressing procedures.
Itoh28 states that pharmacological treatment is the commonest method in non-malignant chronic pain. Opioid analgesics cannot be used for non-malignant chronic pain syndromes because of the strict regulations for opioid use imposed by the Ministry of Health and Welfare. Non-steroidal anti-inflammatory drugs do not have sufficient analgesic effect in certain painful conditions and they may also have serious side effects on the gastrointestinal tract and the kidneys.
Linneman et al.29 report that fentanyl has been shown to be effective in the management of intense pain of short duration (this is a variety of procedural burn pain).
An average quantity of 7-8 Ìg/kg was required for the first wound procedure with fentanyl. Transient respiratory depression was observed in 31% of the patients, but none required intubation or additional supplemental oxygen after conclusion of the procedure.
When we used fentanyl and non-steroidal anti-inflammatory agents together, in combination, this enabled us to reduce the dose of both (fentanyl 2 Ìg/kg IV and piroxicam 20 mg IM), administered only before wound dressing. For this reason no side effects are recorded related to either drug in the drug monitoring sheets.
Helmrich et al.30 pointed out that the use of non-pharmacological therapies offers several advantages in the management of burn pain and in the patients’ general well-being. These therapies are recognized as useful adjuncts while waiting for medication to take effect, and they also facilitate the effect of pharmacological methods.31,32
This recommendation was confirmed by our results, since we achieved the best effects in the mixed-strategy group. Also, a combination of pharmacological and non-pharmacological strategies was associated with a significant reduction in the pain score from the first day of the trial to the last. The absence of any side effects of the drugs may be due to the fact that a combination of them allows use of a small dose of each.
Circumstances may prevent the use of pain control in burn patients throughout the whole day, but we can now offer it successfully during wound dressing and physiotherapy.
Pain control strategies make the patients more co-operative during wound dressing and physiotherapy. It facilitates all steps of wound dressing, for both patients and nurses.
Teaching and distraction are effective methods for pain control during wound dressing.
A mixed strategy of pain control (teaching and pharmacological treatment markedly reduces pain.
The dosage of drugs used in this study was not associated with any significant side effect.
RESUME. Dans les patients brûlés la douleur présente diverses causes soit fonctionnelles, soit organiques. La douleur se produit pendant les procédures de pansement et/ou de physiothérapie. Les Auteurs ont effectué une étude comparative de quatre groupes de patients (15 par groupe). Trois groupes ont reçu une modalité particulière de contrôle de la douleur, et les résultats ont été confrontés avec les résultats du quatrième groupe, le groupe témoin, qui n’a pas reçu aucun modalité de soulagement de la douleur. La méthode utilisée pour évaluer la réponse physiologique et comportementale à la douleur des patients a été celle de Chambers et Price.