UPTODATE Management of Burn Wound Pain and Itching

Management of burn wound pain and itching
Authors:
Shelley Wiechman, PhD
Sam R Sharar, MD
Section Editor:
Marc G Jeschke, MD, PhD
Deputy Editor:
Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2018. | This topic last updated: Apr 30, 2018.
INTRODUCTION — Burns can be extremely painful. Pain management, which includes pharmacologic and nonpharmacologic approaches, is a central component of the complex issues involved in treating patients with burns. Management of anxiety is
also important given that high levels of anxiety can increase the perception of pain. Poor pain and anxiety management can also contribute to delayed wound healing [1]. Despite advances in burn care, inadequate burn pain management still exists during
both the acute and rehabilitation phases of care [2]. Burn pain is among the most common causes of distress during the first year after discharge [3,4]. Unfortunately, burn pain management is frequently based upon tradition, personal
bias, and/or institutional preference rather than evidence-based protocols, which report that such protocols reduce both pain and anxiety [5].
An overview of pharmacologic and nonpharmacologic options for the management of burn pain is reviewed here. Emergency care and local management of burns and pain are discussed elsewhere. (See "Emergency care of moderate and severe thermal
burns in adults" and "Emergency care of moderate and severe thermal burns in children" and "Topical agents and dressings for local burn wound care" and "Paradigm-based treatment approaches for burn pain control".)
CHARACTERISTICS OF BURN PAIN — All burns are painful initially [6]. Burn pain varies greatly from patient to patient, shows substantial fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of anatomic,
physiologic, psychosocial, and premorbid behavior issues. Burn patients typically report pain as being severe or excruciating, despite receiving opioid analgesics.
Burn pain also varies depending upon depth of burn (figure 1) (see "Classification of burn injury"):
●Superficial partial-thickness burns result in hyperalgesia and mild-to-moderate pain. They are the most painful burns immediately following the injury. These burns damage only the outer layers of the skin.
●Moderate partial-thickness burns are associated with marked hyperalgesia and produce moderate-to-severe pain. Burns at this depth injure and/or inflame sensory receptors in the dermis.
●Deep partial-thickness to full-thickness burns are typically characterized by an absence of pain. Hyperalgesia to cutaneous stimulation is uncommon. Acute pain is typically minimal but can be variable and is universally present with respect to the
transition zone between burned and unburned skin. The dermis is completely destroyed, including its sensory and vascular structures. There is little to no response to sharp stimuli, yet patients complain of a deep aching pain related to the
inflammatory response.
BURN PAIN ASSESSMENT TECHNIQUES — Pain assessment tools must be practical, reliable, and valid and must be able to assess three dimensions of pain: pain intensity, behavioral reactions, and physiologic reactions. A variety of pain measurement
tools have been used with adult and pediatric burn patients. However, there are no randomized trials that have identified an optimal assessment technique for burn patients. The key is to choose an instrument and use it consistently. The most common
tools used for adults and children with burn pain include verbal adjective scales, numeric written or visual analog scales, pain assessment in dementia scales, FACES, and FLACC (Face, Legs, Activity, Cry, Consolability) [6-11].
Adults — The more common tools for assessing post-burn pain in adults are the adjective scales, which allow a patient to describe the severity of pain in words, such as "none, mild, moderate, or severe" or "no pain, mild, discomforting, distressing,
horrible, or excruciating pain" (figure 2) [10]. An alternative to the verbal description of pain is the numeric scale, which allows a patient to describe the pain on a scale of increasing severity typically from 0 to 10 (figure 3) [9]. The numeric scale is
administered to the patient verbally or written as a visual analog scale (figure 4). Pain assessment can be challenging in the burned and demented patient. The Pain Assessment in Advanced Dementia Scale, an observational scoring instrument, is a
simple-to-administer, valid, and reliable instrument (table 1) [11]. (See "Pain control in the critically ill adult patient", section on 'Goals of pain control'.)
Children — The measurement of children's pain is much more complex than it is for adults, especially for preverbal children. Typical physiologic indicators, such as heart rate, respiratory rate, and blood pressure are unreliable in measuring a child's pain
since all are affected by a variety of stressors related to the burn injury [6,12]. (See "Evaluation and management of pain in children", section on 'Assessment of pain severity'.)
Behavior scales have been devised to measure pain by providing standardized instructions and guidelines for observing behaviors thought to be specific to pain. Facial expression may be the most consistent infant indicator of pain. Observational scales
have been developed that are multidimensional and include length of cry, facial expressions, and behavioral states [4]. These scales are easier to use and allow an observer to assess pain as either present or absent without further quantification. The
FLACC (Faces, Legs, Activity, Cry, Consolability scale) is the most widely used observer rating scale in preverbal children (table 2) [7,13].
Simple self-report pain scales can be used with preschool children. There is no evidence that any one of these scales is more reliable than the other; hence, it is best to select one that the evaluator prefers, and it should be used consistently. When self-
report scales are used in conjunction with observational scales, a practitioner may develop a better appreciation of the intensity of the child's response to burn pain and the effectiveness of pain management. The following are examples of pain scales that
are commonly used with children:
●The Wong-Baker FACES Pain Scale is designed for children three years and older (figure 5) [8]. This pain scale uses drawings of faces displaying varying degrees of pain and discomfort. Each face communicates a level of pain intensity, and the
child is asked to choose the face that most accurately describes their pain level.
●The OUCHER scale includes a picture scale for very young children and a numerical scale that can be used in children over five years old [14]. There are different versions that can be used for children of various races, and an example is shown for
a Caucasian boy (figure 6).
PHARMACOLOGIC TREATMENT OPTIONS — Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the anticipated
duration of pain, and intravenous (IV) access. These medications have variable durations of action, particularly in burn patients, and should be titrated to meet the needs of the patient in each clinical setting [15].
To best target the always-present "background pain" associated with acute burn wounds, pharmacologic techniques should provide near-constant plasma levels of analgesics through regularly scheduled administration of long-acting oral opioids
(eg, methadone), nonopioid analgesics (eg, acetaminophen), or continuous IV opioid infusion (eg, morphine) in patients unable to take oral medications. Regularly scheduled benzodiazepines (eg, lorazepam) may have added value in patients with
significant anxiety that contributes to their pain experience.
A severe burn injury results in physiologic changes that may alter the pharmacokinetic and pharmacodynamic response to drugs in inconsistent ways; hence, deviation from the usual doses may be necessary to avoid toxicity or decreased efficacy [16].
The tables linked to this topic provide dosages of opioids and nonopioid analgesias as recommended for patients without serious pathophysiologic and metabolic changes without altered drug clearance. These dosages serve as a reference point for
administering pharmacologic agents to burned patients. Medications may be more potent or less potent and have a prolonged or shortened effect in the burn patient, depending only somewhat reliably on either the drug or patient factors. Monitoring of the
airway, breathing, and circulation is necessary, particularly when intravenous drugs are administered. (See "Hypermetabolic response to severe burn injury".)
Opioid analgesics — Opioid analgesics, the most common type of medication used for acute pain relief, are potent and provide a dose-dependent degree of sedation important during burn wound care procedures (table 3 and table 4) [4]. Burn pain should
be treated aggressively. In fact, the risks of under-medicating burn pain on long-term negative outcomes are well documented [17,18], despite growing concern over the perceived overprescription of opiates. A review of intravenous opioid analgesia for
adults and children is discussed in detail elsewhere. (See "Evaluation and management of pain in children", section on 'Opioids' and "Pain control in the critically ill adult patient" and "Procedural sedation in adults outside the operating room", section on
'Medications'.)
Opioids can be administered intravenously or orally, depending on IV access, gastrointestinal function, and the patient's ability to cooperate. For severe pain, the optimal route of administration is IV, which provides faster pain relief and can be effectively
titrated to meet the individual needs of the patient.
Patient-controlled analgesia (PCA) with IV opioids offers the burn patient a safe and efficient method of achieving more flexible analgesia, provided the patient is alert and competent enough to use the device (table 5) [19]. Studies comparing PCA opioid
use to other routes of administration in the burn population have shown positive, but limited, benefits [20]. (See "Management of acute perioperative pain", section on 'Patient-controlled analgesia'.).
Oral or gastrointestinal administration of opioids via an enteral tube provides potent pain relief with rapid onset and short duration of action and requires minimal monitoring. Oral transmucosal administration is particularly helpful for performing burn
dressing changes in children [21,22].
Intramuscular opioid administration is not recommended for use in burn patients. The injections are painful, they need to be repeated frequently, and the absorption is variable due to compartmental fluid shifts.
Nonopioid analgesics — Nonopioid analgesics, such as dexmedetomidine and ketamine, provide short-term effective analgesia and sedation that may be helpful for limited burn debridement and/or dressing changes in adults and children.
Dexmedetomidine provides sedation, anxiolysis, and analgesia for burned children, with less respiratory depression than other sedatives [23,24]. Ketamine has a long history of use in burn-injured patients, particularly for procedural wound care pain.
Studies suggest it is both an effective and safe analgesic in adult [25] and pediatric [26] patients with burns. (See "Procedural sedation in adults outside the operating room" and "Pharmacologic agents for pediatric procedural sedation outside of the
operating room".)
Other nonopioid analgesics, such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), provide mild analgesia and can supplement opiates. They are best suited to treat minor burn pain in the outpatient setting (table 6) [27]. Oral NSAIDs
and acetaminophen exhibit a ceiling effect in their dose-response relationship, rendering them unsuitable as single agents for the treatment of severe burn pain; however, their "opioid-sparing" effects may offer benefit when combined with more potent
analgesics in such cases. There are no high-quality data from randomized trials that have determined the optimal nonopioid analgesic for burn patients. The mechanism of action and therapeutic use of NSAIDs is discussed in detail elsewhere.
(See "NSAIDs: Therapeutic use and variability of response in adults".)
Anxiolytics — Anxiety is a common consequence of burns, due to the need for aggressive surgical treatment and debridement of the wounds, and the persistent and repetitive qualities of background and procedural burn pain. The recognition that anxiety
can exacerbate acute pain has led to the common practice of using anxiolytic drugs in combination with opioid analgesics, a practice that has become more widespread in burn centers in the past three decades [28]. This practice is particularly useful in
premedicating patients for wound care, due to the anticipatory anxiety experienced by these patients prior to and during such procedures. (See "Anesthesia for burn patients".)
Benzodiazepine therapy improved postprocedure pain scores in burn patients. A trial that randomly assigned 79 burn patients to receive lorazepam 1 mg or placebo in addition to their standard opioid analgesics found no difference between groups in pain
score, except in patients with high baseline pain [29]. In high baseline pain patients, lorazepam significantly reduced visual analog scale (VAS) pain score ratings. (See "Pharmacotherapy for generalized anxiety disorder in adults", section on
'Benzodiazepines'.)
Antipsychotic medications are also an option for management of anxiety and agitation associated with burn pain and treatment [30].
●First-generation antipsychotics (eg, haloperidol) are used adjunctively for treatment or prevention of hyperactive delirium and agitation in critically ill patients. (See "Sedative-analgesic medications in critically ill adults: Properties, dosage regimens,
and adverse effects", section on 'Antipsychotics'.)
●Second-generation antipsychotics (eg, quetiapine) are increasingly used for treating various anxiety disorders and may be useful in combination with a benzodiazepine for managing anxiety and improving sleep in burn patients. (See "Second-
generation antipsychotic medications: Pharmacology, administration, and side effects".)
Anesthetics — A variety of anesthetic techniques can be used (eg, general anesthesia, peripheral nerve block, neuraxial anesthesia) for managing burn pain in various clinical settings. The details of administration of anesthesia are discussed elsewhere.
(See "Anesthesia for burn patients".)
General anesthesia or deep sedation — A general anesthetic or deep sedation provides relief of relatively brief, intense pain that would be experienced during a procedure, such as extensive wound debridement, or dressing changes that occur outside
of the operating room. While the risks of complications following a general anesthetic are typically low in healthy individuals, burn patients have metabolic, physiologic, and thermoregulatory abnormalities as well as possible inhalation injuries that are
associated with increased risk of complications of perioperative hypothermia, hypoxemia, and abnormal responses to some anesthetic agents and to both depolarizing and nondepolarizing muscle relaxants [31]. As an example, propofol clearance and
volume of distribution are increased in patients with major burns and may require larger bolus and/or infusion doses to maintain therapeutic plasma drug concentrations [32].
Inhaled nitrous oxide is an anesthetic agent that can be safely administered and provides effective analgesia without loss of consciousness (ie, moderate sedation) for moderately painful procedures. It can be used for the treatment of burn pain, typically as
a 50 percent mixture in 50 percent oxygen, and self-administered by an awake, cooperative, and spontaneously breathing patient via a mouthpiece or mask [27,33].
Full anesthetic care capabilities have been extended outside the operating room into specialized, high-volume burn center intensive care units [34,35]. Drugs, such as intravenously administered propofol or remifentanil and inhaled sevoflurane, with rapid
onset and short duration of action, rapid recovery, and few side effects can facilitate burn care and pain management in the patient's hospital location without transporting the patient to the operating room. The occasional provision of brief,
dense analgesia/anesthesia (eg, general anesthesia or deep sedation) should be administered in a comprehensively monitored setting by medical professionals specifically trained to provide the service. When administered in a controlled environment,
general anesthesia or deep sedation is safe and efficient, both in terms of allowing wound care (eg, debridement of facial burns in children) to proceed rapidly and in terms of cost-effective use of the operating room only for true surgical burn care
procedures.
Peripheral nerve block — Regional anesthesia is achieved by injecting a local anesthetic agent (eg, bupivacaine, lidocaine) around a nerve to block the sensory stimulation from that area innervated by the nerve. These are particularly useful for
procedures and burn pain relief involving the extremities [36]. The most common nerve groups accessible for a nerve block include the brachial plexus (interscalene block, infraclavicular block, axillary block), the sciatic nerve, and the femoral nerve. Other
nerve blocks include the fascia iliaca compartment blockade (FICB) and lateral femoral cutaneous nerve block, which can be used for lower extremity analgesia following skin graft harvesting [37-39]. (See "Overview of peripheral nerve blocks".)
Neuraxial anesthesia — Neuraxial anesthesia is the administration of an anesthetic agent (eg, bupivacaine, lidocaine) and/or opioid analgesics via a spinal or epidural catheter with the goal of providing background, procedural, and postoperative pain
relief. This procedure has only been anecdotally used in burn patients [40]. A major drawback to the use of neuraxial anesthesia is the potential colonization of the indwelling catheter, particularly if inserted through burned skin, and the associated risks of
meningitis and epidural abscess formation [41].
LOCAL TREATMENT OF PRURITUS — Severe pruritus occurs in as many as 87 percent of adult and 100 percent of pediatric burn patients during the healing process [42-44]. Pruritus tends to present early during wound healing and continues well after
reepithelialization and scar maturation and can significantly impact quality of life [45]. Some studies have shown pruritus to persist for up to 10 years post-burn in almost one-half of burn patients [46]. An overview of the treatment of burn scar complications
often causing pruritus and pruritus in general are presented elsewhere. (See "Hypertrophic scarring and keloids following burn injuries" and "Pruritus: Overview of management".)
A variety of therapies, both systemic and topical, have been used for the treatment of post-burn pruritus. Proof of efficacy is primarily anecdotal as high-quality randomized trials have not been performed [42,47]. Systemic first-line treatment for post-burn
pruritus consists of H1 and H2 antihistamines (eg, diphenhydramine, cetirizine, cimetidine), but none has provided complete relief. Other systemic agents that may prove helpful include cyproheptadine, hydroxyzine, gabapentin, and tricyclic
antidepressants (eg, doxepin).
Topical treatments, which may provide relief of pruritus, include [42,47-50]:
●Aloe vera
●Vaseline-based creams
●Cocoa butter
●Mineral oil
●Hydrogel sheets (eg, Tegagel, Vigilon, FlexiGel)

●Topical glucocorticoids
●Colloidal oatmeal in liquid paraffin
●UNNA boot (glycerin, zinc oxide, and calamine lotion)
●EMLA, which is a mixture of local anesthetics
●Topical doxepin
●Silicone gel sheeting
●Compression garments
●Massage therapy
The role of topical glucocorticoids (eg, hydrocortisone, triamcinolone) varies importantly with the stage of the burn. These agents can be applied to reepithelialized wounds. In contrast, topical glucocorticoids are not used on unhealed burns, since they can
lead to thinning of the healing skin, infection, and systemic absorption.
Topical agents high in lanolin should be avoided, since they can worsen pruritus [51].
Other therapies that have been evaluated for the treatment of pruritus in burn patients include pulsed dye laser [52-55] and transcutaneous electrical nerve stimulation (TENS), which remains predominantly experimental [49,56]. The use of laser may
improve pruritus but is predominantly indicated to improve the appearance of burn scars and is discussed separately. (See "Hypertrophic scarring and keloids following burn injuries", section on 'Laser therapy'.)
NONPHARMACOLOGIC TREATMENT OPTIONS — Nonpharmacologic treatments should be complementary to pharmacologic approaches when treating pain, anxiety, and pruritus in the burn patient.
Empirical evidence for the efficacy of nonpharmacologic treatments has been reported with burn pain, particularly when used as an adjunct to opioid analgesics [4]. In choosing an approach, the team should be guided by the manner in which the patient
typically responded to prior stressful medical procedures, if possible. Such responses lie on a continuum ranging from giving up control to the health care professional and desiring little information to seeking out as much information as possible and
actively participating in care [57]. The following examples illustrate the types of coping styles to burn and procedural pain:
●Avoidance – Those burn patients who wish to give up control to the health care professional have a tendency toward cognitive avoidance, or an "avoidant" style of coping mechanism. They will likely use various types of distraction techniques to
avoid the painful stimuli.
●Approach – Those burn patients who seek out information about the procedure and attempt to participate and not relinquish control have an "approach" style of coping mechanism. These patients often find distraction techniques distressing as trying
to ignore a procedure may serve to relinquish too much control.
It is important to note that both coping styles can be adaptive and it is best for the burn care team to support an individual's coping style rather than try to change the natural response. Patients may also change their coping style depending on the
procedure. As an example, a patient may find it is easier to use distraction techniques for short procedures such as receiving injections, whereas they are more comfortable attending to details of their long wound care sessions and participating when
possible. Patients may also change their coping style as they become more familiar and comfortable with the environment.
Avoidance techniques — Avoidance interventions are designed to psychologically distract or distance the patient from the pain. The Multiple Resource Theory of Attention suggests that diverting attention toward a nonpainful stimulus may lessen the
intensity of perceived pain [58]. The four interventions in the avoidance category include distraction, guided imagery, hypnotic analgesia, and virtual reality [4]. These nonpharmacologic techniques are described below in order of those more appropriate for
avoidant coping styles toward those more appropriate for the approach coping styles. However, randomized trials have not been performed to determine the optimal diversion approach as an adjunct for managing pain in burn patients.
Distraction — Distraction is the most common intervention activated by patients or the provider as an adjunct for pain management in burned children [59].The types of distraction techniques available to reduce burn pain are limited only by the creativity of
patients and health care professionals. Common distraction techniques used with children include bubble blowing, singing songs, reading a story, and counting. Generating distraction strategies for adults may require a bit more creativity and include
engaging in enjoyable conversation during the procedure, listening to music, or playing a video game [60]. Gaming technology has gained more attention as evidence shows that playing an engaging, interactive video game can decrease pain during wound
dressing changes, as well as physical therapy [61-63].
Guided imagery — Imagery is an integrative therapy that incorporates imagined pictures, sounds, or sensations for specific therapeutic goals, such as the reduction of burn pain. While the patient is engaged in the imagery scene, less attention is available
for the painful stimuli. It is the patient who selects the imagery. A related discussion on imagery and pain control in cancer patients can be found using the following link. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section
on 'Imagery'.)
Patients using imagery simply create or recreate an image in their mind, presumably one that they find pleasant and engaging. Prior to a painful procedure, we often have the patient elicit a "safe" or "favorite" place to go. This can be a place where they
have been before (eg, a favorite vacation spot) or simply a place that they imagine to be relaxing and safe. The clinician then simply cues the patient with the details that they have provided and we encourage them to imagine this place during their
subsequent wound care.
Limited evidence suggests that guided imagery is effective in reducing the sensory and emotional components of pain [64]. The Agency for Health Care Policy and Research advocates the use of imagery for reduction of pain intensity and distress for
cancer pain and for the management of mild-to-severe acute pain [65].
Hypnotic analgesia — Hypnosis is an altered state of consciousness characterized by an increased receptivity to suggestion, ability to alter perceptions and sensations, and an increased capacity for dissociation [66]. It is believed that the dramatic shift in
consciousness that occurs with hypnosis is the cornerstone of an individual's ability to change his/her awareness of pain [67]. Hypnotic analgesia should only be used by trained clinicians who can assess the risks and benefits of this powerful technique
[66,68].
Although hypnosis involves much more than just avoidance or distraction, the end result is often similar; the patient's focus is diverted from the pain or painful procedure. Several features make hypnotic analgesia a unique method of pain control that differs
markedly from imagery or relaxation. Hypnosis may or may not lead to relaxation depending on the nature of the suggestions. In turn, it is not necessary for a patient to be relaxed or even in a deep hypnotic state in order for suggestions to be useful [69]. A
related discussion on hypnotic analgesia and pain control in cancer patients can be found using the following link. (See "Psychological, rehabilitative, and integrative therapies for cancer pain", section on 'Hypnotic analgesia'.)
Hypnosis involves several stages, including building clinician-patient rapport, enhancing relaxation through deep breathing, suggestions for deepening the hypnotic state, and narrowing the patient's attention, providing posthypnotic suggestions, and
alerting stage [70]. Burn patients are good candidates for hypnotic analgesia because [71-73]:
●The intense nature and severity of burn pain motivates patients to engage in hypnosis.
●The behavioral regression that often occurs after a traumatic injury makes patients more willing to be taken care of by others.
●Patients with burn injuries often experience a dissociative response as a means of coping that may moderate hypnotizability.
●Procedures, which cause the most intense pain, can be scheduled and thus allow hypnosis to be performed in advance of the painful stimulus.
Several studies have shown the positive effect of hypnosis when used in conjunction with prescribed analgesia [73-77]. Patients with higher baseline pain levels have a greater decrease in pain after hypnosis than patients with lower baseline pain levels.
However, these studies are limited by methodological differences, lack of uniform assessment of hypnotizability and severity of pain, and small series of burn patients.
Virtual reality — Virtual reality diverts attention away from the painful sensations by immersing patients in a computer-generated environment [4,78]. Burn patients can interact with the computer while painful procedures, such as dressing changes, and
range-of-motion therapy are performed. Observational and small controlled studies indicate that virtual reality is effective in reducing pain and may have utility when used in conjunction with hypnosis [61,78-82].
Approach technique — The most commonly used approach technique is information provision.
Information provision — Information provision, a technique that actively involves patient input, is an essential element of managing burn pain by providing treatment information in a timely and targeted manner. Information provision assists the patient's
understanding of the issues, alternatives, and solutions. This process provides information on how his/her input will affect the end result, and sharing information can build trust and mutual understanding [83]. This helps to create a sense of control over
one's environment. Caution should be taken to always follow a patient's lead in how much information is to be provided in that some patients who have an avoidant coping style would prefer less information, and too much information can increase anxiety.
Relaxation techniques — Relaxation techniques are used to lower arousal, including unnecessary muscle tension that can increase pain [4,84]. The techniques include deep breathing exercises, progressive muscle relaxation exercises, and cognitive
behavioral techniques. There are no randomized trials to determine the optimal relaxation technique to be used as an adjunct for burn pain management.
Deep breathing — Deep breathing, or diaphragmatic breathing, is one of the least time-consuming techniques to employ and the easiest for adults and children to learn. When a person becomes anxious and/or experiences pain, breathing can become
shallow and irregular due to the increased muscle tension in our chest wall. Such shallow breathing, known as thoracic breathing, leads to an increase in muscle tension and subsequent heightened pain [84].
Deep breathing techniques allow patients to become aware of shallow irregular breathing and leads to relaxation that may alleviate some pain. Children can be taught bubble blowing or blowing on a pinwheel to encourage deep breathing. Adults can be
taught to place a hand on their stomach and to take a breath deep enough that it passes through their chest and fills their stomach (shallow breathing is more in the chest and will not cause as much hand movement on the stomach). Their hand should rise
and fall with the stomach. Exhalation is the most important part of deep breathing exercises and should not be rushed. Diaphragmatic breathing is central to all forms of relaxation and is simple and time efficient.
Progressive muscle relaxation — Muscle tension increases as patients experience stress and pain; hence, the focused effort on sequentially relaxing and tensing muscles in a controlled manner diverts the attention away from the pain. Progressive
muscle relaxation is a technique used to reduce anxiety associated with painful stimuli, such as burn dressing changes, by alternately tensing then relaxing muscles [85]. Muscles are sequentially tensed (10 seconds) and relaxed (20 seconds) through
various parts of the body, and the technique can be performed during dressing changes. Observational studies suggest that progressive muscle relaxation can decrease recuperation time for hospitalized patients [85]. If a person is unable to actively tense
a muscle group due to pain or injury, he/she can still imagine each muscle becoming progressively "warm, heavy, and relaxed" or listen to a tape, a process known as autogenic training [66].
Cognitive behavioral techniques — Cognitive behavioral therapy (CBT) is used to treat multiple conditions by changing thoughts and behaviors. For treatment of burn patients, CBT includes diversion, information provision, coping skills, and relaxation
techniques to modify the patient's thought process about the painful experience [4]. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies'.)
Expectations of a bad outcome, such as intense pain, are associated with higher levels of perceived pain [86]. This is known as catastrophizing. CBT can be used adjunctively to manage these expectations and associated pain in the following manner [87]:
●Recognize that the procedure will cause pain (anticipatory pain or distress).
●Stop the thought that the procedure will cause pain by active efforts to reduce catastrophic thinking.
●Distract from the pain by diverting attention to another thought.
Mindfulness meditation — Mindful meditation is another nonpharmacologic strategy that combines attention, cognitive restructuring, and relaxation. It has gained popularity for its effectiveness for managing acute or chronic pain in adults and adolescents
[88,89]. Mindfulness involves purposeful attention on the present moment in a nonjudgmental and accepting manner [90]. Meditation refers to a broad variety of practices that are aimed at clearing the mind to self-regulate the body to achieve a state of
relaxation. Several mindfulness meditation practices have been developed to address acute pain [91,92]. Although none has specifically addressed burn pain, its effectiveness in mediating procedural pain for other conditions makes it a promising
intervention for acute pain during burn wound care. With the help of a trained professional, mindfulness meditation can be implemented in as little as 20 minutes prior to or during a procedure.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)
SUMMARY AND RECOMMENDATIONS
●The control of burn pain and associated anxiety, as well as pruritus, is challenging and demands creativity and continued staff training on pain assessment, traditional pharmacologic analgesic approaches, and adjunctive nonpharmacologic
techniques. Pharmacologic analgesics should be administered by trained and experienced staff in monitored conditions.
●Pain, which is present at least initially in all burn patients, varies greatly from patient to patient, shows substantial fluctuation over the hospitalization course, and can be unpredictable due to the complex interaction of anatomic, physiologic,
psychosocial, and premorbid behavior. (See 'Characteristics of burn pain' above.)
●Pain assessment instruments use visual and/or numeric scales to assess pain intensity, behavioral reactions, and physiologic reactions. There is no one optimal assessment technique for burn patients. The key is to choose an instrument and use it
consistently. (See 'Burn pain assessment techniques' above.)
●Pharmacologic agents used to treat burn pain include opioid analgesics, nonopioid analgesics, anxiolytics, and anesthetics. The type of medication used is determined by the severity of pain, the anticipated duration of pain, and intravenous (IV)
access. (See 'Pharmacologic treatment options' above.)
●Opioid analgesics (eg, morphine, fentanyl), the most common type of medication used for acute pain relief, are potent and provide a dose-dependent degree of sedation important during burn wound care procedures. (See 'Opioid analgesics'above.)
●Nonopioid analgesics (eg, dexmedetomidine, ketamine, nonsteroidal anti-inflammatory drugs [NSAIDs]) provide short-term effective analgesia and sedation that may be helpful for limited burn debridement and/or dressing changes in adults and
children. (See 'Nonopioid analgesics' above.)
●Anxiolytic drugs (eg, benzodiazepines) are useful in premedicating patients for wound care due to the anticipatory anxiety experienced by these patients prior to and during such procedures. (See 'Anxiolytics' above.)
●Nonpharmacologic treatments should be adjunctive to pharmacologic approaches when treating pain and anxiety in the burn patient. These approaches include cognitive distraction, information provision, relaxation, coping skills, and cognitive
behavioral techniques. (See 'Nonpharmacologic treatment options' above.)
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Topic 14989 Version 14.0
GRAPHICS
Burn classification
Graphic 73309 Version 1.0
Adjective Rating Scale for pain assessment

The Adjective Rating Scale allows patients to use descriptive terms to describe the severity of their pain. Scoring can be modified for conversion to a numeric scale.
Original figure modified for this publication. Melzack R. The short-form McGill Pain Questionnaire. Pain 1987; 30:191. Illustration used with the permission of Elsevier Inc. All rights reserved.
Numeric pain scale
The numeric pain scale allows patients to rate the pain on a scale of 0 to 10, with 10 as the worst possible pain.
Visual analog scale

Visual Analog Scale (VAS) (10 cm line).
Score = 0 to 100 mm: measuring in millimeters from the left-hand end of the line to the point that the patient marks.
Pain Assessment in Advanced Dementia (PAINAD) scale
Items* 0 1 2 Score
Breathing independent of vocalization Normal Occasional labored breathing. Short period of hyperventilation. Noisy labored breathing. Long period of hyperventilation. Cheyne-Stokes respirations.
Negative vocalization None Occasional moan or groan. Low-level speech with a negative or disapproving quality. Repeated troubled calling out. Loud moaning or groaning. Crying.
Facial expression Smiling or inexpressive Sad. Frightened. Frown. Facial grimacing.

Body language Relaxed Tense. Distressed pacing. Fidgeting. Rigid. Fists clenched. Knees pulled up. Pulling or pushing away. Striking out.
Consolability No need to console Distracted or reassured by voice or touch. Unable to console, distract, or reassure.
Total¶:
This pain assessment score can be used to assess pain in demented patients. Patients should be observed for five minutes prior to performing the assessment. Total scores range from 0 to 10, with 10 representing severe pain.
* Five-item observational tool.
¶ Total scores range from 0 to 10 (based on a scale of 0 to 2 for five items), with a higher score indicating more severe pain (0 = "no pain" to 10 = "severe pain").
Original figure modified for this publication. Warden V, Hurley AC, Volicer L. Development and psychometric evaluation of the pain assessment in advanced dementia (PAINAD) scale. J Am Med Dir Assoc 2003; 4:9. Illustration used with the permission of Elsevier Inc. All rights reserved.
Revised FLACC pain score
Categorie Scoring
s
0 1 2
F No particular expression or smile Occasional grimace or frown, withdrawn, disinterested; appears sad or worried Frequent to constant frown, clenched jaw, quivering chin; distressed-looking face: expression of fright or panic
Face
L Normal position or relaxed Uneasy, restless, tense; occasional tremors Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking
Legs
A Lying quietly, normal position, Squirming, shifting back and forth, tense; mildly agitated (eg, head back and forth, aggression); shallow and Arched, rigid, or jerking; severe agitation, head banging; shivering (not rigors); breath-holding, gasping or sharp
Activity moves easily splinting respirations, intermittent sighs intake of breath; severe splinting
C No cry (awake or asleep) Moans or whimpers, occasional complaint; occasional verbal outburst or grunt Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting
Cry
C Content, relaxed Reassured by occasional touching, hugging, or being talked to, distractable Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures
Consolability
This pain score can be used to assess pain from burns and other etiologies for preverbal children.
 Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, which results in a total score between zero and ten.
 Patients who are awake: Observe for at least 1-2 minutes. Observe legs and body uncovered. Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling interventions if needed.
 Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If possible reposition the patient. Touch the body and assess for tenseness and tone.
 The revised FLACC can be used for children with cognitive disability. The additional descriptors (in italics) are included with the original FLACC. The nurse can review the descriptors within each category with parents. Ask them if there are additional behaviors that
are better indicators of pain in their child. Add these behaviors to the tool in the appropriate category.
Reproduced with permission. Copyright © 2002 The Regents of the University of Michigan.
Wong-Baker FACES pain rating scale

Explain to the child that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even
more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the child to choose the face that best describes how he is feeling. Rating scale is recommended for persons age three years and older. Point
to each face using the words to describe the pain intensity. Ask the child to choose the face that best describes own pain and record the appropriate number.
Reproduced with permission from: Wong DL, Hockenberry-Eaton M, Wilson D, et al. Wong's Essentials of Pediatric Nursing, 6th ed. Mosby, St. Louis, 2001. p.301. Copyright © 2001 Elsevier.
OUCHER pain scale

The OUCHER pain scale uses both pictures and numbers. The pictures can be used for preschool children, while older children can also use the numerical scale. The scales include pictures of Caucasian, African-American, Hispanic, Asian, and First Nation children. The
example here depicts a Caucasian child.
The Caucasian version of the Oucher was developed and copyrighted in 1983 by Judith E Beyer, Ph.D., RN, (University of Missouri-Kansas City School of Nursing, Retired), USA. For more information, please visit http://www.oucher.org. Reproduced with permission.
Intravenous* sedative and analgesic dosing regimens for managing pain, agitation, and delirium in the intensive care unit
Duration of
Onset
Drug Loading dose Maintenance dose range intermittent dose Characteristics and role
(minutes)
(minutes)
Opioid analgesics¶
Fentanyl¶ 1 to 2 mcg/kgΔ 0.35 to 0.5 mcg/kg every 0.5 to 1 hour intermittent (25 to <1 to 2 30 to 60◊ Advantages: Potent analgesic-sedative with immediate onset and less hypotension than other opioid
(25 to 100 mcg)¶ 35 mcg)¶ analgesic choices due to relative lack of histamine release. Metabolized hepatically by cytochrome P450-
AND/OR 3A4 (CYP3A4) to inactive metabolites.
0.7 to 10 mcg/kg/hour infusion (50 to 700 mcg/hour)[1] Disadvantages: Highly lipophilic parent drug accumulates in adipose and other tissue with repeated or
For most patients, 1 to 3 mcg/kg/hour infusion (50 to 200 prolonged administration. Chest wall rigidity may occur with higher dosing §.
mcg/hour)¶with as-needed intermittent bolus doses is Role: A good choice for analgesia for most critically ill patients.
sufficient
Hydromorphone 0.5 to 2 mgΔ 0.2 to 0.6 mg every one to two hours intermittent 5 to 10 240 to 300 Advantages: IV administration requires small volumes relative to other opioids. Non-CYP metabolism
AND/OR (glucuronidation) may be an advantage for patients receiving drugs that significantly alter CYP3A4
0.5 to 3 mg/hour infusion metabolism and thereby interact with fentanyl.
Disadvantages: Potentially neurotoxic (excitatory) metabolite(s) may accumulate in hepatic and/or renal

dysfunction§.
Role: Analgesic option alternative to fentanyl or morphine. Dose adjustment and gradual titration
needed for patients with renal and/or hepatic impairment.
Morphine sulfate 2 to 10 mgΔ 2 to 4 mg every one to two hours intermittent 5 to 10 240 to 300 Advantage: Non-CYP metabolism (glucuronidation) may be an advantage for selected patients
AND/OR receiving drugs that significantly alter CYP3A4 metabolism and thereby interact with fentanyl.
2 to 30 mg/hour infusion Disadvantages: Can accumulate in hepatic or renal dysfunction and prolong effects. Histamine release
and vagally mediated venodilation, hypotension, and bradycardia can be significant §.
Role: Analgesic alternative to fentanyl or hydromorphone where preload reduction and myocardial
depressive effects are desirable or tolerable. Dose adjustment and gradual titration needed for patients
with renal and/or hepatic impairment. Avoid in patients with advanced or decompensated liver disease
with renal impairment due to risk of accumulation of neurotoxic metabolite.
Remifentanil¶ Optional: 0.5 to 15 mcg/kg/hour infusion 1 to 3 5 to 10 (after Advantages: Ultra-short-acting. Cleared by nonspecific plasma esterases to inactive metabolites. Does
1.5 mcg/kg¶[1] Use ideal body weight to determine dose for obese cessation of infusion) not accumulate in renal or hepatic impairment. Prompt reversal of analgesia and sedation upon
Most ICU patients can be managed without patients¶ discontinuation.
bolus doses; if required, a bolus of 0.5 mcg/kg is Disadvantages: Anticipate pain and discomfort upon abrupt cessation. Glycine excipient may
usually sufficient; larger boluses are associated accumulate in renal impairment§.
with significant reductions in HR and MAP Role: An alternative to fentanyl for patients requiring frequent neurologic assessments or those with
multiorgan failure.
Nonopioid analgesics (adjunctive or opioid sparing)
Acetaminophen None Oral, rectal: 325 to 1000 mg every four to six hours Oral: 30 to 60 240 to 360 Advantages: Lacks dependence and tolerance of opioids. Lacks antiplatelet effect and gastrointestinal
(paracetamol) IV: 650 mg IV every four hours to 1000 mg IV every six Rectal: Variable toxicity of NSAIDs.
hours, or 15 mg/kg IV every six hours for patients IV: 5 to 10 Disadvantages: Lacks significant anti-inflammatory effect. IV preparation requires administration over
weighing <50 kg 15 minutes. Can cause hepatotoxicity in chronic or acute overdose. Avoid or use a lower daily dose in
Maximum ≤4 g/day older adults and patients at risk for hepatotoxicity (eg, heavy alcohol use or malnourished). Interacts
with warfarin (may prolong INR) and CYP450-inducing drugs (elevated risk of hepatic inflammation).
Role: First choice for treatment of mild to moderate acute pain and febrile conditions. Adjunctive
analgesic that may reduce opioid requirements. When hepatic dysfunction is significant, consider
avoiding or reducing dose (eg, ≤2 g/day total).
Ketorolac Optional: Age <65 years and weight ≥50 kg: 15 to 30 mg every six IV: ~30 360 to 480 Advantages: Lacks dependence and tolerance of opioids. Effective anti-inflammatory.
30 mg once hours; maximum 120 mg/day for up to five days Disadvantages: Can cause or worsen renal insufficiency. Dose-related risk of gastropathy. Reversibly
Age ≥65 years or weight <50 kg: 15 mg every six hours; inhibits platelet functioning. May alter cardioprotective effect of aspirin.
maximum 60 mg/day for up to five days Role: Adjunctive analgesic that may reduce opioid requirements.
Avoid in renal impairment, gastrointestinal bleeding, platelet dysfunction, ischemic heart disease, heart
failure, reduced cardiac output, hypovolemic state, asthma, or cirrhosis. Contraindicated in treatment of
perioperative pain in coronary artery bypass graft surgery. Patients should be well hydrated.
Ibuprofen None Oral: 400 mg orally every four hours (maximum 2.4 Oral: 30 240 to 360 Advantages: Lacks dependence and tolerance of opioids. Effective anti-inflammatory.
g/day chronic) IV: ~30 Disadvantages: Can cause or worsen renal insufficiency. Dose-related risk of gastropathy. Reversibly
IV: 400 to 800 mg IV every six hours (maximum 3.2 inhibits platelet functioning. Can alter cardioprotective effect of aspirin.
g/day acute) Role: Short-term treatment of moderate acute pain and febrile conditions. Adjunctive analgesic that may
reduce opioid requirements.

Avoid in renal impairment, gastrointestinal bleeding, platelet dysfunction, ischemic heart disease, heart
failure, reduced cardiac output, hypovolemic state, asthma, or cirrhosis. Contraindicated in treatment of
perioperative pain in coronary artery bypass graft surgery. Patients should be well hydrated.
Gabapentin None Oral: Initially 100 mg three times per day Variable -- Advantages: Effective for treatment of neuropathic pain. Low risk of drug interactions.
Oral: Maintenance 900 to 3600 mg per day in three Disadvantages: Requires enteral administration, scheduled dosing, and individualized titration over
divided doses days to weeks. Oral bioavailability is variable (27 to 60%) and inversely proportional to dose. Adverse
effects include sedation, dizziness, and ataxia, which may be intensified in renal impairment, requiring
dose adjustment. Should not be abruptly stopped, due to risk of discontinuation symptoms.
Role: Useful adjunct to other analgesics for treatment of neuropathic and postoperative pain or
dysesthesias in patients who can be treated with enteral medication. Dose adjustment needed for renal
impairment.
Pregabalin None Oral: Initially 75 mg once or twice per day Variable (hours to -- Advantages: Effective for treatment of neuropathic pain. Oral bioavailability (>90%) is more reliable
Oral: Maintenance 150 to 300 mg twice per day days) than gabapentin and may provide for more rapid onset of analgesia with a shorter amount of time needed
to titrate to full dose. Low risk of drug interactions.
Disadvantages: Requires enteral administration, scheduled dosing, and titration over days to weeks.
Adverse effects include sedation, blurred vision, dry mouth, dizziness, and ataxia, which may be
intensified in renal impairment, requiring dose adjustment. Should not be abruptly stopped, due to risk of
discontinuation symptoms.
Role: Useful adjunct to other analgesics for treatment of neuropathic and postoperative pain or
dysesthesias in patients who can be treated with enteral medication. Dose adjustment needed for renal
impairment.
Anesthetic-sedative
Propofol¶ Bolus doses are usually not given in the ICU 5 to 50 mcg/kg/minute¶ <1 to 2 3 to 10◊ Advantages: Potent sedative-hypnotic associated with an immediate onset and rapid awakening upon
Titrate every 5 to 10 minutes in increments of 5 to 10 discontinuation when administered for short-term use. Metabolism is reportedly unaltered in hepatic or
mcg/kg/minute renal impairment and subject to few significant drug interactions. Infusion is readily titratable to desired
Some patients require up to 70 mcg/kg/minute, which depth of sedation, minimizing risk of oversedation. Propofol effectively decreases intracranial pressure,
can increase risk of propofol infusion syndrome (refer to lowers cerebral metabolism, controls intractable seizures, and may reduce shivering in the rewarming
UpToDate topics on sedative-analgesic medications in phase of induced hypothermia following resuscitation from cardiac arrest.
critically ill patients: properties, dose regimens, and Disadvantages: Adverse effects include hypotension, bradycardia, respiratory depression, decreased
adverse effects) myocardial contractility, elevated triglycerides, peripheral injection site pain, and rarely propofol
infusion syndrome (refer to UpToDate topics on sedative-analgesic medications in critically ill patients:
properties, dose regimens, and adverse effects). Specific product presentations may include potential
allergens (egg, soy, peanut, others). Consult product label information. No analgesic effects.
Role: A good choice in conjunction with appropriate analgesia for short-term sedation of patients in
whom rapid awakening is advantageous. Also a good choice to decrease elevated intracranial pressure or
for short-term sedation in a general critical care population that is likely to be ready soon for ventilator
weaning trials.
Ketamine 0.1 to 0.5 mg/kg 0.05 to 0.4 mg/kg/hour ≤1 10 to 15 (single dose) Advantages: A potent dissociative sedative-anesthetic with marked analgesia that maintains cardiac
output and mean arterial pressure without inhibition of respiratory drive. Does not inhibit protective
reflexes. May reduce acute opioid tolerance.
Disadvantages: Sympathetic stimulation (ie, increased heart rate and myocardial oxygen demand,
elevated intracranial pressure and systemic blood pressure) may be intolerable depending upon clinical
setting. Rarely, cardiorespiratory depression associated with rapid administration or higher doses.
Adverse effects may include hallucinations, delirium upon withdrawal, tonic-clonic movements,
dissociative experiences, unpleasant recall, hypersalivation, nausea, and vomiting. Complex metabolism
includes CYP3A4, 2C9, 2B6, and non-CYP hepatic transformations and an active metabolite
(norketamine), which may accumulate in renal and/or hepatic impairment or due to drug interactions.
Role: An alternate choice for postsurgical pain management, severe agitation, or as an adjunctive
analgesic in patients with severe refractory pain in clinical settings where increased myocardial oxygen
demand and sympathetic tone are tolerable.
Central alpha2 agonist
Dexmedetomidin Optional: 0.2 to 0.7 mcg/kg/hour 5 to 10 (optional 60 to 120 Advantages: Effective sedative sympatholytic (central alpha 2 agonist) with moderate anxiolysis and
e 1 mcg/kg over 10 minutes if hemodynamically Initiate at 0.2 mcg/kg/hour and titrate every 30 minutes loading dose) analgesia, yet no clinically significant effect on respiratory drive. Character and depth of sedation may
stable Some patients require doses up to 1.5 mcg/kg/hour 15 (without permit critically ill, mechanically ventilated patients to be interactive or easily awakened, yet
Usually not given loading dose) comfortable. Can be used in non-mechanically ventilated ICU patients and continued as needed
following extubation. Reduces shivering in the rewarming phase of induced hypothermia following
resuscitation from cardiac arrest. May be less likely to cause delirium than other sedative choices.
Disadvantages: Potentially significant hypotension and bradycardia or hypertension that do not resolve
quickly upon abrupt discontinuation. Metabolized hepatically by glucuronidation and CYP2A6. Dose
reduction recommended with renal and/or hepatic impairment. Rapid administration of loading dose may
be associated with cardiovascular instability, tachycardia, bradycardia, or heart block. Does not induce
the deep sedation needed for neuromuscular blockade.
Role: A good choice for short- and long-term sedation in critically ill patients without relevant cardiac
conditions. May be useful for sedation of patients with or at high risk of developing delirium, although
this has not been well established.
Benzodiazepines¶
Midazolam¶ 0.01 to 0.05 mg/kgΔ 0.02 to 0.1 mg/kg/hour infusion 2 to 5 30◊ Advantages: A potent amnestic and anxiolytic agent with an immediate onset of action and a short
(0.5 to 4 mg)¶ (2 to 8 mg/hour)¶ duration of effect when administered short term (<48 hours). It is the only IV benzodiazepine that is not
delivered in propylene glycol.
Disadvantages: Hepatically metabolized by CYP3A4 to active metabolites that may accumulate and
cause prolonged sedation if delivered long term. Half-life may be prolonged in critically ill patients with
hepatic or renal impairment. Risk of delirium. Also, it interacts with drugs used in the ICU (eg, some
antiretrovirals, azole antifungals) that alter CYP metabolism such that excess sedation can occur with
concomitant use of midazolam and drugs metabolized by CYP3A4.
Role: A good choice for short-term anxiolysis and treatment of acute agitation. Dose adjustment and
gradual titration are needed for patients with renal and/or hepatic impairment.
Lorazepam¶ 0.02 to 0.04 mg/kgΔ 0.02 to 0.06 mg/kg 15 to 20 360 to 480◊ Advantages: Sedative, amnestic, potent anxiolysis with anticonvulsant properties. Hepatically
(1 to 2 mg)¶ every two to six hours metabolized by glucuronidation to inactive metabolites. Relatively low risk of drug interactions and
intermittent safety in mild to moderate hepatic and renal impairment.
(1 to 4 mg)¶ Disadvantages: Relatively slow onset. Risk of over-sedation when titrating due to delayed response and
AND/OR accumulation in peripheral tissues. Risk of delirium. IV incompatibilities and risk of line precipitate.
0.01 to 0.1 mg/kg/hour infusion Propylene glycol solvent may accumulate with prolonged use or high dosing causing metabolic acidosis
(0.5 to 10 mg/hour) ¶
and end-organ dysfunction (refer to UpToDate topics on sedative-analgesic medications in critically ill
patients: properties, dose regimens, and adverse effects). Long half-life, with significant risk of
accumulation in older adults or in patients with significant renal or hepatic impairment.
Role: A good choice for sedation and anxiolysis for most patients, including those who may require
long-term ongoing sedation. Although intermittent bolus dosing may be preferred, a continuous infusion
may be initiated for patients requiring frequently repeated higher dosing.
Diazepam¶ 0.05 to 0.2 mg/kgΔ 0.03 to 0.1 mg/kg 2 to 5 20 to 60◊ Advantages: Rapid onset with potent sedative and muscle-relaxant effects.
(5 to 10 mg)¶ every 0.5 to 6 hours Disadvantages: Hepatically metabolized by CYP2C19 and 3A4 to active metabolites that may
intermittent accumulate and cause prolonged sedation if delivered long term. Half-life may be prolonged in critically
(1 to 7 mg)¶ ill patients with hepatic and/or renal impairment. Risk of delirium. Also, it interacts with drugs used in
Continuous infusion is not recommended the ICU that alter CYP metabolism. Injection solution contains propylene glycol solvent and cannot be
delivered as a continuous infusion. Injection site pain and risk of phlebitis limit usefulness of IV
injections.
Role: Seldom used for sedation of critically ill patients. May be useful for critically ill patients at risk of
alcohol withdrawal or seizures due to drug overdose or poisoning.
Antipsychotics
Haloperidol¥ 0.03 to 0.15 mg/kgΔ 0.03 to 0.15 mg/kg every 30 minutes to six hours 30 to 60 30 to 360◊ Advantages: Moderately sedating dopamine2 antagonist for control of positive symptoms of delirium
Variable doses; refer to UpToDate topics on Various regimens; refer to UpToDate topics on sedative- and ICU psychoses. Minimal cardiorespiratory effects in euvolemic, hemodynamically stable patients.
sedative-analgesic medications in critically ill analgesic medications in critically ill patients: properties, Disadvantages: Complex hepatic metabolism includes CYP3A4 and 2D6 transformations. Some experts
patients: properties, dose regimens, and adverse dose regimens, and adverse effects consider certain metabolites to be active or potentially neurotoxic. Half-life becomes prolonged with
effects repeated administration. Adverse effects include dose-dependent QT interval prolongation and
hypotension. Interacts with some common ICU drugs by interference with metabolism and/or by having
an additive effect, prolonging the QTc. Extrapyramidal symptoms and neuroleptic malignant syndrome
are rare in critical care use.
Role: Potential treatment for agitation and/or delirium in critically ill patients.
Olanzapine‡ Optional: Oral: Initially 5 to 10 mg once daily; increase every 24 IM: 15 to 45 IM: ≥120 Advantages: Availability of short-acting IM formulation; less risk of extrapyramidal symptoms and QT
5 to 10 mg IM hours as needed by 5-mg increments up to 20 mg/day prolongation than haloperidol.
May repeat every two to four hours if needed Disadvantages: Adverse effects include orthostatic hypotension, hyperglycemia, somnolence, QT
(maximum total 30 mg) interval prolongation, and anticholinergic effects. Undergoes extensive hepatic metabolism including
non-CYP (ie, glucuronidation) and CYP1A2 transformations. Half-life may be prolonged (ie, ≥50 hours)
with increased risk of accumulation in patients who are older, female, nonsmoking, and/or in the setting
of hepatic or renal impairment.
Role: Potential alternative or add-on to as-needed IV haloperidol for treatment of acute agitation and/or
delirium in the ICU. Use lowest starting dose and titrate more gradually in patients with renal and/or
hepatic impairment and/or other factors that predispose for slowed metabolism (see "Disadvantages"
above).
Quetiapine‡ None Oral: Initially 50 mg every 12 hours; increase every 24 Oral: 60 (initial Oral: 6 to 12 hours Advantages: Less risk of extrapyramidal symptoms and possibly less risk of QT prolongation than
hours as needed up to 400 mg/day effect); ≥24 hours haloperidol.
(full effect) Disadvantages: Requires enteral route of administration and scheduled dosing due to slow onset of
action and relatively gradual titration schedule. Adverse effects may include sedation or orthostatic
hypotension, and risk of QT interval prolongation remains. Hepatically metabolized by CYP3A4 to
active and inactive metabolites.
Role: A potential choice as adjunct to as-needed IV haloperidol for treatment of agitation and/or
delirium. In advanced hepatic impairment initiate with reduced dose and titrate in lower increments.
Ziprasidone† Optional: Oral: 10 to 40 mg orally every 12 hours IM: 30 IM: ≥90 Advantages: Availability of short-acting IM formulation; less risk of extrapyramidal symptoms than
10 mg IM haloperidol.
May repeat every two hours if needed Disadvantages: Orthostatic hypotension, hyperglycemia, QT prolongation; undergoes extensive hepatic
(maximum 40 mg total) metabolism by hepatic non-CYP and CYP3A4 transformations to active and inactive metabolites; IM
OR formulation contains cyclodextrin (a potential nephrotoxin), which can accumulate in renal impairment;
20 mg IM an IV formulation is not available.
May repeat once after four hours if needed Role: A potential alternative or add-on to as-needed IV haloperidol for treatment of acute agitation in
(maximum 40 mg total) the ICU†. Dose reduction is needed in advanced hepatic impairment. Specific recommendations are not
available. Avoid prolonged use of IM preparation in patients with renal impairment due to risk of
accumulation of cyclodextrin additive.
Dosing information in this table is for critically ill adults and includes indications, dosing, duration of use, and routes of administration not listed in the US Food & Drug Administration approved product labeling. Refer to UpToDate content on managing pain, agitation, and
delirium in critically ill adults, the Lexicomp drug monographs [2], and most recent product labeling for additional information.
Data provided in "Characteristics and role" on drug metabolism and the presence of active metabolite(s) are included and may be useful for assessing the potential for drug interactions and risk of drug accumulation in renal and/or hepatic organ impairment.
CYP: cytochrome P-450 metabolism; IV: intravenous; ICU: intensive care unit; HR: heart rate; MAP: mean arterial pressure; NSAIDs: nonsteroidal anti-inflammatory drugs; INR: international normalized ratio; QT: QT interval on the electrocardiogram; QTc: corrected QT interval; IM:
intramuscularly.
* All doses shown are for IV administration except where otherwise noted (eg, oral or rectal acetaminophen, IM olanzapine optional initial dose).
¶ In patients who are obese, standard, non-weight-based initial dosing is preferred. Standard adult doses, ie, scaled to ideal body weight, are shown in parentheses following weight-based doses. A separate calculator to determine ideal body weight is available in UpToDate. For additional
information, refer to UpToDate topic reviews on ICU management of the complicated postoperative bariatric surgery patient.
Δ One or more loading doses may be needed. See onset of action data for minimum time between re-dosing. Loading dose should be reduced or omitted in patients who are older, hypovolemic, having increasing vasopressor requirements, or at-risk for hemodynamic compromise.
◊ Duration of action shown is for initial dosing. Duration becomes significantly prolonged after repeated dosing or with administration as a continuous infusion due to accumulation of drug in adipose tissue.
§ As with all opioids, tolerance may require dose escalation, and withdrawal syndrome may be precipitated upon abrupt discontinuation.
¥ Dosing of haloperidol in agitated schizophrenia differs from the recommendations listed in this table for delirium in the ICU and is reviewed separately. Refer to UpToDate topic reviews of emergency management of the acutely agitated or violent patient and pharmacotherapy for acute
schizophrenia.
‡ The precise role of second-generation antipsychotics in the treatment or prevention of delirium in ICU is not established. Quetiapine and olanzapine recommendations and data are based on limited experience and small trial results (Devlin et al. Crit Care Med 2010; 38:419; Skrobik et
al. Intensive Care Med 2004; 30:444).
† Ziprasidone recommendations and data are based on limited experience and small trial results in treatment of undifferentiated agitation without symptoms of delirium in non-critically ill emergency department patients (Martel et al. Acad Emerg Med 2005; 12:1167; Mantovani et al. J
Clin Psychopharmacol 2013; 33:306). Small trial results failed to demonstrate a benefit for scheduled oral ziprasidone in prevention of delirium in a general ICU population (Girard et al. Crit Care Med 2010; 38:428).
Data from:
1. Barr J, Fraser GL, Puntillo K, et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Crit Care Med, 2013; 41:263.
2. Lexicomp Online. Copyright © 1978-2018 Lexicomp, Inc. All Rights Reserved.
Opioid analgesics commonly used in children
Equianalgesic dose*
Drug Oral dose and frequency¶ IV dose and frequency¶

Oral IV
(mg) (mg)
MorphineΔ 30 10 0.3 mg/kg every three to four hours 0.05 to 0.1 mg/kg every two to four hours
Hydromorphone 7.5 1.5 0.03 to 0.06 mg/kg every three to four hours 0.015 mg/kg every two to four hours
Oxycodone◊ 20 N/A 0.1 to 0.2 mg/kg every four to six hours N/A
Hydrocodone◊ 30 N/A 0.1 to 0.2 mg/kg every four to six hours N/A
Fentanyl N/A 0.1 (100 mcg) N/A 0.5 to 1 mcg/kg every one to two hours
Methadone § § 0.1 mg/kg every 4 to 8 hours 0.05 to 0.1 mg/kg every 4 to 8 hours
N/A: not available.
* Approximate equianalgesic dose for estimation when changing opioid agents.
¶ Doses are for individuals >6 months old with a maximum weight of 50 kg. Suggested dose ranges are for management of acute pain. Oral doses refer to immediate release products.
Δ Dose adjustment for renal insufficiency may be required. Not recommended in severe renal insufficiency.
◊ If a combined opioid-acetaminophen product is prescribed, caregivers should be instructed not to give the child other acetaminophen-containing medications as this can lead to acetaminophen overdose and hepatotoxicity.
§ Due to gradual drug accumulation at tissue sites, the dose and frequency of methadone differs for initial compared with repeated use; dose and interval given is usual after repeated use; methadone should be initiated and titrated by a clinician experienced with its use.
Adapted from: Gutstein HB, Akil H. Opioid analgesics. In: Goodman & Gilmans pharmacological basis of therapeutics, 11th ed, McGraw-Hill, New York 2006.
Patient controlled analgesia (PCA) regimens for opioid naïve adult patients: commonly-prescribed dose ranges
Drug Concentration Initial loading and rescue loading dose range Demand (PCA) dose range Lockout interval Maximum in four hours
Morphine 1 mg/mL 0.5 to 2.5 mg* 0.5 to 2.5 mg 5 to 10 minutes 30 mg
Hydromorphone 0.2 mg/mL 0.05 to 0.4 mg¶ 0.05 to 0.4 mg 5 to 10 minutes 6 mg
Fentanyl 10 mcg/mL 5 to 20 mcgΔ 5 to 20 mcg 4 to 10 minutes 300 mcg
 Dosing should be individualized according to patient-specific factors, clinical situation, comorbidities, and concurrent medications. Lower doses and closer monitoring including continuous pulse oximetry and end-tidal carbon dioxide are recommended during the
early post-operative period, in older adults, and in patients at elevated risk for respiratory depression, hypoxia, and/or opioid accumulation, eg, due to obstructive airway disease, sleep apnea, obesity, low body weight, frailty, renal and/or hepatic impairment, or use
with other medications with sedating and/or respiratory depressant properties.
 Adjunctive medications for management of opioid-associated pruritus and nausea may be needed (eg, diphenhydramine, prochlorperazine). Refer to "Management of acute perioperative pain" topic for detail.
 The use of a continuous infusion (basal opioid infusion) is not recommended; such use should be limited to carefully selected patients who are opioid tolerant and/or receiving care in a critical care unit.
 PCA dose ranges and other detail shown in the table are based upon recommendations used at experienced centers; protocols will vary by institution. For additional detail, refer to the individual drug monographs provided by Lexicomp included with UpToDate.
PCA: Patient-controlled analgesia.
* Morphine initial loading dose may be given incrementally in smaller divided doses every six minutes as needed. A single loading dose should not exceed 2.5 mg and total loading dose should not exceed 10 mg. A rescue loading dose may be repeated after eight hours if needed.
¶ Hydromorphone initial loading dose may be given incrementally in smaller divided doses every six minutes as needed. A single dose should not exceed 0.4 mg and total loading dose should not exceed 2 mg. A rescue loading dose may be repeated after eight hours if needed.
Δ Fentanyl initial loading dose may be given incrementally in smaller divided doses every six minutes as needed. A single loading dose should not exceed 20 mcg and total loading dose should not exceed 100 mcg. A rescue loading dose may be repeated after eight hours if needed.
Orally available nonopioid analgesic and nonsteroidal anti-inflammatory drugs (NSAIDs): Usual dosing for adults with pain or inflammation
Optional initial Usual analgesic dose Maximum dose per day
Drug Selected characteristics and role in therapy
loading dose (oral) (mg)
Para-aminophenol derivative
Acetaminophen* (paracetamol, None 325 to 650 mg every 4 to 6 hours 3000 mg Effective for noninflammatory pain; may be opioid-sparing.
APAP) Or
Doses <2000 mg per day do not increase risk of serious GI complications.
1000 mg every 6 hours up to three
Does not alter platelet functioning.
times per day
Can cause hepatotoxicity in chronic or acute overdose.
Avoid or use a lower total daily dose (maximum 2000 mg per day) in older adults, patients at risk for hepatotoxicity (eg, regular alcohol
use, malnourished) or with organ dysfunction.
For short-term or one-time use, may use a total dose of up to 4000 mg per day in selected medically supervised patients.
Interacts with warfarin (prolongs INR), isoniazid, and CYP450-inducing drugs ¶ (transaminitis).
Warn patients about acetaminophen content in combination prescription (eg, oxycodone-acetaminophen) and OTC preparations.
NSAID agents
Applies to all nonselective NSAIDs:
 Effective for treatment of acute and chronic painful and inflammatory conditions. May decrease opioid requirements. Short-to-moderate-acting NSAIDs (eg, naproxen, ibuprofen) are preferred for most patients.
 Dose- and age-related risk of gastropathy.
 May cause or worsen renal impairment.
 Nonselective NSAIDs reversibly inhibit platelet functioning and can alter cardioprotective effects of aspirin.
 Avoid NSAIDs in patients with renal insufficiency (CrCl <60 mL/minute), GI bleeding, platelet dysfunction, reduced cardiac output, difficult-to-control hypertension, hypovolemia, hyponatremia, aspirin-sensitive asthma, or cirrhosis.
 Safety concerns of NSAID use in patients with, or at elevated risk for, cardiovascular disease or thrombotic events are addressed in a separate topic in UpToDate.
 Use with caution or avoid in patients receiving comedication with anticoagulants, systemic glucocorticoids, lithium, loop diuretics, and other interacting drugs Δ.
 Though some older adults may benefit from a brief course of NSAIDs at the lowest effective dose, use in most older adults should be avoided. Refer to the UpToDate topics on treatment of pain in older adults and older adults with organ dysfunction.
Salicylate (acetylated)
Aspirin* 2600 mg 325 to 650 mg every 4 to 6 hours 4000 mg Standard for comparison, but now used infrequently for treatment of chronic pain and inflammation.
Unlike other NSAIDs, irreversibly inhibits platelet functioning for life of the platelet (7 to 10 days).
Salicylates (nonacetylated)
Diflunisal 1000 mg 500 mg every 8 to 12 hours 1500 mg Applies to all nonacetylated salicylates:
Choline magnesium 1500 mg 750 mg every 8 to 12 hours 3000 mg No significant effect on platelet function at usual analgesic doses.
trisalicylate Less frequently associated with GI bleeding than nonselective NSAIDs at usual analgesic doses.
Generally tolerated by adults with asthma at lower daily doses: Diflunisal ≤1000 mg, choline magnesium trisalicylate and
Salsalate 1500 mg 750 to 1000 mg every 8 to 12 3000 mg
salsalate ≤2000 mg.
hours
Relatively slow onset.
500 mg dose of diflunisal has a comparable analgesic effect with 650 mg acetaminophen or aspirin.
Propionic acids (phenyl-propionic acid)
Naproxen* 500 mg (naproxen 250 to 500 mg every 12 hours 1250 mg acute, 1000 mg chronic A good choice for treatment of acute or chronic pain and inflammation in most patients if NSAID therapy is indicated.
base) (naproxen base) (naproxen base)
High doses (eg, 500 mg twice daily) may have less cardiovascular toxicity than comparable doses of other NSAIDs. ◊
550 mg (naproxen 275 to 550 mg every 12 hours 1375 mg acute, 1100 mg chronic
For the treatment of rheumatologic disorders, total daily dose may be increased to a maximum of 1500 mg base (1650 mg naproxen
sodium) (naproxen sodium) (naproxen sodium)
sodium), when needed.
Naproxen sodium has more rapid absorption and onset of effect than naproxen base.
Ibuprofen* 1600 mg 400 mg every 4 to 6 hours 3200 mg (acute), 2400 mg 200 to 400 mg dose has a comparable analgesic effect with 650 mg acetaminophen or aspirin.
(chronic)
Short duration of effect.
Useful alternative to naproxen in patients without cardiovascular risks.
Ketoprofen 100 mg 50 mg every 6 hours or 75 mg 300 mg 25 mg dose has a comparable analgesic effect to 400 mg ibuprofen.
every 8 hours
Short duration of effect.
Flurbiprofen 100 mg 50 to 100 mg every 6 to 12 hours 300 mg Lozenge preparation available in some countries.
Oxaprozin None 1200 mg once daily 26 mg/kg up to 1800 mg Long duration of effect.
(whichever is lower)
Acetic acids (pyrano-indoleacetic acid)
Diclofenac 75 or 100 mg 50 mg every 8 hours 150 mg Diclofenac is also available as a topical patch, solution, and gel for treatment of musculoskeletal pain and osteoarthritis of superficial joints,
(conventional tablets) Approved maximum daily dose in which may be useful in combination with or as an alternative to systemic NSAIDs. Refer to the UpToDate topic on initial treatment of osteoarthritis
some countries is 100 mg and separate table.
Interacts with drugs that are strong inhibitors or inducers of CYP2C9 drug metabolism; use Lexi-Interact to determine specific interactions.
Etodolac 400 to 600 mg Immediate release: 200 to 400 mg Immediate release: 1000 mg Relatively COX-2 selective at lower total daily dose of 600 to 800 mg.
every 6 to 8 hours Extended release: 1200 mg
200 mg dose has a comparable analgesic effect with 400 mg of ibuprofen.
Extended release: 400 to 1000 mg
once daily
Indomethacin 75 mg Immediate release: 25 to 50 mg 150 mg Useful for treatment of acute gout and specific types of headache.
every 8 to 12 hours
Potent inhibitory effects on renal prostaglandin synthesis.
Controlled release: 75 mg once or
More frequently associated with CNS side effects (eg, headache) compared with other NSAIDs.
twice daily
Carefully select and monitor patients to reduce risk of renal and cardiovascular toxicities.
Tolmetin 600 mg 400 to 600 mg every 8 hours 1800 mg
Sulindac 300 mg 150 to 200 mg every 12 hours 400 mg More frequently associated with hepatic inflammation (idiosyncratic or with features of hypersensitivity) compared with other NSAIDs.
Sulindac metabolites implicated in the formation of renal calculi; refer to the UpToDate topic on nonselective NSAID adverse effects.
Prescribing should be limited to specialists with experience in treatment of chronic pain and inflammation.
Oxicams (enolic acids)
Meloxicam 7.5 mg (conventional 7.5 to 15 mg once daily 15 mg Long duration of effect; slow onset.
tablets)
Relatively COX-2 selective and minimal effect on platelet function at lower total daily dose of 7.5 mg.
Rarely associated with serious cutaneous allergic reactions, including Stevens-Johnson syndrome.
Piroxicam 10 mg 10 to 20 mg once daily 20 mg A long-acting option for treatment of chronic pain and inflammation poorly responsive to other NSAIDs.
Daily doses ≥20 mg increase risk of serious GI complications.
Concurrent pharmacologic gastroprotection is suggested.

Rarely associated with serious cutaneous allergic reactions, including Stevens-Johnson syndrome.
Prescribing should be limited to specialists with experience in treatment of chronic pain and inflammation.
Fenamates (anthranilic acids)
Meclofenamate 150 mg 50 mg every 4 to 6 hours 400 mg Alternate NSAID choice for treatment of acute or chronic pain, inflammation, and dysmenorrhea.
(meclofenamic acid)
Appears to be associated with higher incidence of GI disturbance (including diarrhea) compared with other nonselective NSAIDs.
Mefenamic acid 500 mg 250 mg every 6 hours 1000 mg Alternate NSAID choice for treatment of acute pain and dysmenorrhea.
Duration of use not to exceed seven days (acute pain) or three days (dysmenorrhea).
Anti-inflammatory efficacy is comparatively low.
Not indicated for treatment of chronic pain or inflammation.
Nonacidic (naphthylalkanone)
Nabumetone 1000 mg 500 to 750 mg every 8 to 12 hours 2000 mg Moderate duration of effect; slow onset.
or 1000 to 1500 mg once daily
Relatively COX-2 selective at lower total daily dose of 1000 mg or less.
Minimal effect on platelet function at total daily dose of 1000 mg or less.
Selective COX-2 inhibitors§
Celecoxib 400 mg 200 mg daily or 100 mg every 12 400 mg Relative reduction in GI toxicity compared with nonselective NSAIDs.
hours
No effect on platelet function.
Cardiovascular and renal risks are dose-related and appear similar to those of nonselective NSAIDs.
Patients with indications for cardioprotection require aspirin supplement; individuals may require concurrent gastroprotection.
Etoricoxib (not available in the None 30 to 60 mg once daily 60 mg (chronic pain and May be associated with more frequent and severe dose-related cardiovascular effects (eg, hypertension) compared with nonselective and
United States) inflammation) other COX-2 selective NSAIDs.
120 mg (acute pain for up to eight
Otherwise, risks and benefits as with celecoxib (see above).
days)
GI: gastrointestinal; INR: international normalized ratio; CYP450: cytochrome P450; OTC: over-the-counter, available without prescription; CrCl: creatinine clearance; COX-2: cyclooxygenase, isoform 2; CYP2C9: cytochrome 2C9; CNS: central nervous system; SSRIs: selective serotonin
reuptake inhibitors.
* Available without a prescription in the United States.
¶ A list of CYP450-inducing drugs is available separately in UpToDate.
Δ NSAIDs may interact with aspirin, warfarin, methotrexate, antihypertensives, serotonin reuptake inhibitor antidepressants (eg, SSRIs, cyclic antidepressants, venlafaxine), and other drugs. For specific interactions, use the Lexi-Interact program included with UpToDate.
◊ Refer to the UpToDate topic on the cardiovascular effects of nonselective NSAIDs.
§ For additional information on gastroprotective strategies, including selective COX-2 inhibitors and other options, refer to the UpToDate topics on the overview of selective COX-2 inhibitors and on NSAIDs (including aspirin) and the primary prevention of gastroduodenal toxicity.
Prepared with data from:
1. Anon. Drugs for pain. Treatment guidelines from the Medical Letter; 2013. 11:31.
2. Castellsague J, Riera-Guardia N, Calingaert B, et al. Individual NSAIDs and upper gastrointestinal complications: A systematic review. Drug Saf 2012; 35:1127.
3. Lexicomp Online. Copyright © 1978-2018 Lexicomp, Inc. All Rights Reserved.
Contributor Disclosures
Shelley Wiechman, PhDNothing to discloseSam R Sharar, MDNothing to discloseMarc G Jeschke, MD, PhDNothing to discloseKathryn A Collins, MD, PhD, FACSNothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content.
Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
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UPTODATE Management of Burn Wound Pain and Itching

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UPTODATE Management of Burn Wound Pain and Itching

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Management of burn wound pain and itching

Topical treatments, which may provide relief of pruritus, include [42,47-50]:

●Hydrogel sheets (eg, Tegagel, Vigilon, FlexiGel)

●Colloidal oatmeal in liquid paraffin

●UNNA boot (glycerin, zinc oxide, and calamine lotion)

●EMLA, which is a mixture of local anesthetics

●Silicone gel sheeting

Approach technique — The most commonly used approach technique is information provision.

●Distract from the pain by diverting attention to another thought.

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 14989 Version 14.0

Graphic 73309 Version 1.0

Adjective Rating Scale for pain assessment

Numeric pain scale

Visual analog scale

Pain Assessment in Advanced Dementia (PAINAD) scale

Facial expression Smiling or inexpressive Sad. Frightened. Frown. Facial grimacing.

* Five-item observational tool.

Revised FLACC pain score

Wong-Baker FACES pain rating scale

OUCHER pain scale

example here depicts a Caucasian child.

AND/OR 3A4 (CYP3A4) to inactive metabolites.

0.5 to 3 mg/hour infusion metabolism and thereby interact with fentanyl.

Disadvantages: Potentially neurotoxic (excitatory) metabolite(s) may accumulate in hepatic and/or renal

needed for patients with renal and/or hepatic impairment.

and vagally mediated venodilation, hypotension, and bradycardia can be significant §.

Role: Analgesic alternative to fentanyl or hydromorphone where preload reduction and myocardial

with renal impairment due to risk of accumulation of neurotoxic metabolite.

Most ICU patients can be managed without patients¶ discontinuation.

usually sufficient; larger boluses are associated accumulate in renal impairment§.

Nonopioid analgesics (adjunctive or opioid sparing)

avoiding or reducing dose (eg, ≤2 g/day total).

reduce opioid requirements.

to titrate to full dose. Low risk of drug interactions.

reflexes. May reduce acute opioid tolerance.

demand and sympathetic tone are tolerable.

Disadvantages: Potentially significant hypotension and bradycardia or hypertension that do not resolve

the deep sedation needed for neuromuscular blockade.

this has not been well established.

delivered in propylene glycol.

Disadvantages: Hepatically metabolized by CYP3A4 to active metabolites that may accumulate and

concomitant use of midazolam and drugs metabolized by CYP3A4.

intermittent safety in mild to moderate hepatic and renal impairment.

may be initiated for patients requiring frequently repeated higher dosing.

alcohol withdrawal or seizures due to drug overdose or poisoning.

are rare in critical care use.

Role: Potential treatment for agitation and/or delirium in critically ill patients.

5 to 10 mg IM hours as needed by 5-mg increments up to 20 mg/day prolongation than haloperidol.

of hepatic or renal impairment.

hours as needed up to 400 mg/day effect); ≥24 hours haloperidol.

hypotension, and risk of QT interval prolongation remains. Hepatically metabolized by CYP3A4 to

active and inactive metabolites.

20 mg IM an IV formulation is not available.

accumulation of cyclodextrin additive.

al. Intensive Care Med 2004; 30:444).

2. Lexicomp Online. Copyright © 1978-2018 Lexicomp, Inc. All Rights Reserved.

Graphic 79667 Version 28.0

Opioid analgesics commonly used in children

Drug Oral dose and frequency¶ IV dose and frequency¶

Hydrocodone◊ 30 N/A 0.1 to 0.2 mg/kg every four to six hours N/A

N/A: not available.