Use of patient-controlled analgesia with alfentanil for burns dressing procedures: a preliminary report of five patients

doi:10.1016/0305-4179(95)00121-2

Burns

Volume 22, Issue 3, May 1996, Pages 238-241

https://doi.org/10.1016/0305-4179(95)00121-2 Get rights and content

Abstract

The use of patient-controlled analgesia with alfentanil (PCA-alfentanil) as a form of pain relief for dressing procedures in patients during the acute phase of their burn injuries was investigated. Five ASA 1 and 2 patients with 10–30 per cent total body surface area (TBSA) thermal burns, had PCA-alfentanil for their dressing procedures after standard fluid resuscitation. One patient who did not receive a loading dose and a background infusion of alfentanil had unsatisfactory pain relief. Four patients had good pain relief after a loading dose of IV alfentanil 1 mg followed by a continuous background infusion of 200–800 μg/h. Demand dose ranged from 200 to 400 μg and lockout time ranged from 1 to 3 min. The total dose of alfentanil delivered ranged from 0.8 to 4.48 mg and duration of the dressings ranged from 30 to 60 min. All patients were mildly sedated, calm, communicative and cooperative during dressing procedures. None of them experienced hypotension or respiratory depression. One patient experienced nausea but no vomiting, no other adverse effects of alfentanil were noted. From the pilot study, PCA-alfentanil may be an effective form of pain relief for dressing procedures in patients during their acute phase of burn injuries. The optimal PCA-alfentanil setting has yet to be determined.

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Cited by (26)

Feasibility of monomodal analgesia with IV alfentanil during burn dressing changes at bedside (in spontaneously breathing non-intubated patients)
2017, Burns
Citation Excerpt :
Continuous infusion ranged from 0.125 to 1 μg/kg mn−1. Finally, alfentanil alone has already proven to be an efficient alternative in two small pilot studies: in 1996, Sim reported 5 cases of patient-controlled analgesia with alfentanil for burns dressing procedures with satisfactory pain relief and no respiratory depression (demand dose 200–400 μg, background infusion 200–800 μg/h) [24]. In 2000, Gallagher reported 10 cases where alfentanil was administered using an operator adjusted target-controlled infusion with a starting target blood concentration of 25 ng ml−1 for burn dressing changes [25].
The severe pain related to repeated burn dressing changes at bedside is often difficult to manage. However these dressings can be performed at bedside on spontaneously breathing non-intubated patients using powerful intravenous opioids with a quick onset and a short duration of action such as alfentanil. The purpose of this study is to demonstrate the efficacy and safety of the protocol which is used in our burn unit for pain control during burn dressing changes.
Cohort study began after favorable opinion from local ethic committee has been collected. Patient’s informed consent was collected. No fasting was required. Vital signs for patients were continuously monitored (non-invasive blood pressure, ECG monitoring, cutaneous oxygen saturation, respiratory rate) all over the process. Boluses of 500 (±250) mcg IV alfentanil were administered. A continuous infusion was added in case of insufficient analgesia. Adverse reactions were collected and pain intensity was measured throughout the dressing using a ten step verbal rating scale (VRS) ranging from 0 (no pain) to 10 (worst pain conceivable).
100 dressings (35 patients) were analyzed. Median age was 45 years and median burned area 10%. We observed 3 blood pressure drops, 5 oxygen desaturations (treated with stimulation without the necessity of ventilatory support) and one episode of nausea. Most of the patients (87%) were totally conscious during the dressing and 13% were awakened by verbal stimulation. Median total dose of alfentanil used was 2000 μg for a median duration of 35 min. Pain scores during the procedure were low or moderate (VRS mean = 2.0 and maximal VRS = 5). Median satisfaction collected 2 h after the dressing was 10 on a ten step scale.
Pain control with intravenous alfentanil alone is efficient and appears safe for most burn bedside repeated dressings in hospitalized patients. It achieves satisfactory analgesia during and after the procedure. It is now our standard analgesic method to provide repeated bedside dressings changes for burned patients.
Management of Pain and Other Discomforts in Burned Patients
2017, Total Burn Care, Fifth Edition
Although a multidisciplinary approach including nonpharmacological modes of management are essential, pharmacological treatment remains the cornerstone of pain control in patients with burn injuries. Drug and dose selection must be made in the context of systemic changes that evolve over time and alter pharmacokinetics and pharmacodynamics. Opioids are the mainstay of therapy but are associated with certain adverse effects such as opiate induced hyperalgesia. A newly appreciated problem. neuropathic pain, is characterized by burning and itching in the areas of newly regenerating skin and at amputation site. Effective pharmacological analgesia requires the concomitant treatment of anxiety, depression and PTSD with anxiolytics and antidepressants to control the pain syndrome following burn injury. Pain protocols facilitate the systematic pain management. New non pharmacologic approaches such as virtual reality now have demonstrated effectiveness. Burn pain comprises background, breakthrough, procedural and postoperative pain. Each type of pain requires different drugs, doses, or strategies.
Effect of nitrous oxide on fentanyl consumption in burned patients undergoing dressing change
2016, Brazilian Journal of Anesthesiology
Thermal injuries and injured areas management are important causes of pain in burned patients, requiring that these patients are constantly undergoing general anesthesia for dressing change. Nitrous oxide (N₂O) has analgesic and sedative properties; it is easy to use and widely available. Thus, the aim of this study was to evaluate the analgesic effect of N₂O combined with fentanyl in burned patients during dressing change.
After approval by the institutional Ethics Committee, 15 adult burned patients requiring daily dressing change were evaluated. Patient analgesia was controlled with fentanyl 0.0005% administered by intravenous pump infusion on-demand. Randomly, in one of the days a mixture of 65% N₂O in oxygen (O₂) was associated via mask, with a flow of 10 L/min (N₂O group) and on the other day only O₂ under the same flow (control group).
No significant pain reduction was seen in N₂O group compared to control group. VAS score before dressing change was 4.07 and 3.4, respectively, in N₂O and control groups. Regarding pain at the end of the dressing, patients in N₂O group reported pain severity of 2.8; while the control group reported 2.87. There was no significant difference in fentanyl consumption in both groups.
The association of N₂O was not effective in reducing opioid consumption during dressing changes.
Os ferimentos térmicos e a manipulação das áreas lesadas são causas importantes de dor em pacientes vítimas de queimaduras, necessitando que estes pacientes sejam constantemente submetidos a anestesias gerais para a troca do curativo. O óxido nitroso (N₂O) tem propriedades analgésicas e sedativas, sendo capaz de fácil utilização e de ampla disponibilidade. Com isto, objetivou-se avaliar o efeito analgésico da administração de N₂O associado ao fentanil em pacientes queimados, durante a troca de curativo.
Após aprovação pela comissão de ética institucional, foram avaliados 15 pacientes adultos, vítimas de queimaduras com necessidade de troca diária de curativo. A analgesia do paciente foi controlada pelo uso de fentanil 0,0005% administrado por bomba de infusão sob demanda, intravenosa. De maneira aleatória, em um dos dias foi associada mistura de N₂O a 65% em oxigênio (O₂) sob máscara com fluxo de 10 L/min (grupo N₂O) e no outro dia apenas O₂ sob o mesmo fluxo (grupo controle).
Não se observou diminuição significativa da dor no grupo N₂O em relação ao grupo controle. A dor na EAV antes da troca do curativo foi de 4,07 e 3,4; respectivamente nos grupos N₂O e controle. Quanto à dor ao término da troca de curativo, os pacientes do grupo N₂O referiram dor intensidade 2,8; enquanto no grupo controle foi de 2,87. Não houve diferença significativa de consumo de fentanil em ambos os grupos.
A associação de N₂O não foi eficaz na redução no consumo de opióides durante a troca de curativos.
Management of pain and other discomforts in burned patients
2012, Total Burn Care: Fourth Edition
Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes
2009, Burns
Citation Excerpt :
There are many anti-nociceptive therapies described for burns pain. Background plus PCA infused opioids were demonstrated to be superior to PCA opioids alone [32]. Opioids can cause unfavourable side-effects, most notably respiratory depression, sedation and nausea and vomiting [15].
Pain arising in burns sufferers is often severe and protracted. The prospect of a dressing change can heighten existing pain by impacting both physically and psychologically. In this trial we examined whether pre-procedural virtual reality guided relaxation added to patient controlled analgesia with morphine reduced pain severity during awake dressings changes in burns patients.
We conducted a prospective randomized clinical trial in all patients with burns necessitating admission to a tertiary burns referral centre. Eligible patients requiring awake dressings changes were randomly allocated to single use virtual reality relaxation plus intravenous morphine patient controlled analgesia (PCA) infusion or to intravenous morphine patient controlled analgesia infusion alone. Patients rated their worst pain intensity during the dressing change using a visual analogue scale. The primary outcome measure was presence of 30% or greater difference in pain intensity ratings between the groups in estimation of worst pain during the dressing change.
Of 88 eligible and consenting patients having awake dressings changes, 43 were assigned to virtual reality relaxation plus intravenous morphine PCA infusion and 43 to morphine PCA infusion alone. The group receiving virtual reality relaxation plus morphine PCA infusion reported significantly higher pain intensities during the dressing change (mean = 7.3) compared with patients receiving morphine PCA alone (mean = 5.3) (p = 0.003) (95% CI 0.6–2.8).
The addition of virtual reality guided relaxation to morphine PCA infusion in burns patients resulted in a significant increase in pain experienced during awake dressings changes. In the absence of a validated predictor for responsiveness to virtual reality relaxation such a therapy cannot be recommended for general use in burns patients having awake dressings changes.
Patient controlled sedation using a standard protocol for dressing changes in burns: Patients' preference, procedural details and a preliminary safety evaluation
2008, Burns
Citation Excerpt :
PCS itself is a factor in the satisfaction among patients having cataract surgery, whether they did use the pump with propofol or not [11] which in some way may contribute to acceptance of the pain recorded in our study. Despite the fact that this study used propofol and alfentanil in concentrations higher than evaluated previously [6,7,11,12] and a device without a lock out time, PCS was accomplished without extreme values in cardiopulmonary or BIS data. The patients were monitored closely and were given supplementary oxygen and it is therefore unlikely that any adverse reaction has been overlooked.
Patient controlled sedation (PCS) enables patients to titrate doses of drugs by themselves during different procedures involving pain or discomfort.
We studied it in a prospective crossover design using a fixed protocol without lockout time to examine it as an alternative method of sedation for changing dressings in burned patients. Eleven patients with >10% total burn surface area (TBSA) had their dressings changed, starting with sedation by an anaesthetist (ACS). The second dressing change was done with PCS (propofol/alfentanil) and the third time the patients had to choose ACS or PCS. During the procedures, data on cardiopulmonary variables, sedation (bispectral index), pain intensity (VAS), procedural details, doses of drugs, and patients’ preferences were collected to compare the two sedation techniques.
The study data indicated that wound care in burned patients is feasible with a standardized PCS protocol. The patients preferred PCS to ACS on the basis of self-control, and because they had less discomfort during the recovery period. Wound care was also considered adequate by the staff during PCS. No respiratory (respiratory rate/transcutaneous PCO₂) or cardiovascular (heart rate/blood pressure) adverse events were recorded at any time during any of the PCS procedures. The doses of propofol and alfentanil and BIS index decrease were less during PCS than ACS. Procedural pain was higher during PCS but lower after the procedure.
We suggest that PCS using a standard protocol is an interesting alternative to anaesthetist-provided sedation during dressing changes. It seems effective, saves resources, is safe, and at same time is preferred by the patients. The strength of these conclusions is, however, hampered by the small size of this investigation and therefore further studies are warranted.

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Use of patient-controlled analgesia with alfentanil for burns dressing procedures: a preliminary report of five patients

Abstract

Crit Care Clin

Pain

Pain

Gen Hosp Psych

Burns

J Pain Symptom Manage

J Cardiothorac Vasc Anesth

Br J Anaesth

Br J Anaesth

Assessment of pain by burn patients

J Burn Care Rehabil

The pain of burns

The pain of burns: characteristics and correlates

J Trauma

General anesthesia