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Management of pain during debridement: a survey of U.S. burn units
Pain, 13 (1982) 267-280 Elsevier Biomedical Press
267
Management of Pain during Debridement: a Survey of U.S. Burn Units Samuel Perry ,,2 and George Heidrich ** * Cornell University and The New York Hospital Burn Center-CorneU University Medical Center, New York, N. Y. and * * Department of Anesthesiology, University of Wisconsin, Madison, Wis. (U. S.A.)
(Received 28 September 1981, accepted 12 October 1981)
Summary To determine how bum pain is assessed and managed during debridement, questionnaires were sent to 151 U.S. burn facilities. 181 staff members from 93 burn units responded. For a typical adult patient, most respondents preferred a narcotic, but the dosages varied widely without a corresponding variation in assessed paha. The assessment of pain also did not vary with the type of analgesia used or the route of administration (i.v., i.m., p.o. or gas). Half the respondents used psychotropic drugs in conjunction with narcotics, but without a reduction in dosage of the narcotic or a reduction in assessed pain. For a typical burned child, although more respondents recommended using no narcotics or no psychotropics or no analgesics at all, the assessed pain for children and adults was the same, i.e. in the moderate range. Pain during debridement was rated as more severe by those with less job experience and by those who gave higher dosages of analgesics before the procedure. The survey's findings indicate a need to reevaluate current analgesic practices for debridement and to document pain and pain relief.
Introduction The limited quantifiable data regarding burn pain have led to uncertainty about how analgesia can best be provided for hospitalized burn patients. Different methods have been suggested, including narcotics [1,2], nitrous oxide [3,4], ketamine Supported in part by NIH Grant PSOGM26145 2 Send reprint requests to: Samud Perry, M.D., iqew York Hospital (PWC), 525 East 68th Street. New York, N.Y. 10021, U.S.A. 0304-3959/82/0000-0000/$02.75 © 1982 Elsevier Biomedical Piess
268
[5,6], methoxyflurane [7-10], hypnosis [11-13], behavioral modification [14-I6], supportive psychotherapy [ 17-20] and relaxation training [21]. Because no definitive analgesic method has been well documented, methods vary from unit to unit depending on the experience and judgment of the prescribing physicians. As one component of an ongoing NIH-supported project to study and improve the management of burn pain, questionnaires were distributed to the directors and staff of ! 51 burn facilities in the United States. The goals were to establish a baseline for current analgesic practices and possibly to discover any unshared innovative techniques as well as methods which might be considered unacceptable. The questionnaire especially addressed analgesic methods for debridement or 'tanking,' a potentially painful procedure used by many burn units during which the wound is washed and necrotic epithelium is cut away with forceps and scissors. This paper reports current analgesic methods used for the tanking procedure and discusses what factors correlate with the different ways burn pain is assessed and treated.
Method
Four questionnaires were mailed to each director of the 151 burn facilities in ti~e United States [22]. Enclosed was an explanatory letter suggesting that the forms be completed by the director and by physicians, nurses, or other staff members most knowledgeable about analgesic methods used on the burn unit. The questionnaire had 3 sections. Section I sought demographic information about the unit (such as the average number of adult and child patients per day) and information about the respondent (such as his or her position on the unit and the number of months working with burn patients). Section II asked about common analgesic practice and pain assessment. Typical burn cases of an adult and of a child were described and followed by a ser~es of specific questions: Adult. The patient is a 34-year-old, 70 kg male who has suffered a 28~ second and third degree thermal burn to his lower extremities. He has been on the unit for 2 weeks, is physiologically stable and has no respiratory compromise. What would be a typical medication order for tanking? Child. The patient is a 3-year-old, 14 kg boy who has suffered 28% second and third degree burns to his lower extremities. He has been on the unit for 2 weeks, is physiologically stable and has no respiratory compromise. What would be a typical medication order for tanking? After each of these clinical examples, the form provided a checklist to note the analgesic drug, anesthetic gas, and psychotropic usually prescribed as well as the dosage, frequency, route of administration, and times given before the procedure. The respondent was then asked to note from i to 5 how much pain the patient would likely experience during tanking after being given that unit's typical method of analgesia: l - none, 2 = mild, 3 = moderate, 4 - severe, 5 = excruciating [40-43]. Section III addressed more general issues, such as how the patient's pain affected
269
the respondent and if any patient had become iatrogenically addicted. Open-ended comments about burn pain were invited. The name of the respondent and of the burn unit could be included if the respondent so chose.
Results
One or more completed forms were received from 93 burn facilities representing 37 states and 62~ of those surveyed. All sizes of units were represented: the mean number of adult patients was 7.8 with a range from 0 to 25; the mean number of child patients was 3.3 with a range from 0.5 to 30. Of the 181 respondents, about one-third were attending physicians (66) and about one-third were head nurses or nurse clinicians (67). The final third was composed of staff nurses (28), house staff physicians (1 !), physical therapists (6), anesthesiologists (2), and occupational therapist (I). The average respondent was highly experienced and had worked with burn patients for over 6 years; the mean number of months was 75. The tanking procedure for debridement was performed in 89 (96%) of the facilities surveyed. The other 4 units always used early wide excision or some other method instead of tanking. Table I illustrates the analgesic drug, dosage and route of administration preferred for debridement of the adult patient described in the questionnaire. About two-thirds of the respondents used morphine or meperidine as the drug of choice, but the dosage varied widely; for example, although the mean dosage of intramuscular meperidine was 75 mg, the standard deviation was over 50 mg with a range between 25 mg and 375 mg. As Table !I illustrates, about one-half (52%) of the respondents used psychotropic
TABLE ! ANALGESIC
PREFERENCE/DOSE/ROUTE
DEBRIDEMENT
FOR ADULTS
N
X, d o s e ( m g ) - S . D .
Range (mg)
i.m. i.v.
Morphine Morphine
50 32
10.7-- 4.5 8.9 +- 5.4
2 - 35 2 - 25
i.m. i.v.
Meperidine Meperidine
37 8
75.7 +- 52.9 70,5 +- 14. !
2 5 - 375 50-100
p.o. i.m.
Codeine Codeine
30 3
63.0 +- 22.7 * *
3 0 - ! 30 *
p.o. i.m. i.v. p.o. p.o.
Oxycodone Alphaprodine Alphaprodine Pentazocine Methadone
5 2 1 2 1
* * * * *
* * * * *
* * * * *
None
6
*
*
*
270 T A B L E Ii P S Y C H O T R O P I C D R U G USE D E B R I D E M E N T F O R A D U LTS N p.o. i.m. i.v.
Diazepam (Valium) Diazepam Diazepam
26 19 13
i.m. p.o. i,v.
Hydroxyzine (Vistaril)
19 4 I
i.v. i.m.
Ketamine Ketamine Chlorpromazine (Thorazine) Chlordiazepoxide (Librium)
p.o. p.o. i.m.
Hydroxyzine Hydroxyzine
Chlordiazepoxide
N dose (mg) ± S.D. 7.3± 7.9± 6 . 9 +-
1.8 1.9 1.5
48.9 ± 22.7 * * * *
Range (mg) 5 - 10 5 - 12.5 5 - !0 25- i 25 * *
3 2
* *
* *
* *
2 2 I
* * *
* * *
* * *
drugs for the debridement of the described adult patient. Diazepam by different routes was the preferred drug (63%) with hydroxyzine a distant second (26%). Most psychotropic drugs were used in conjunction with narcotics (91%), but 8 of the respondents indicated they used only intravenous diazepam or ketamine without other analgesics. Of note, if a psychotropic drug was used in conjunction with a narcotic analgesic, the mean dosage of the narcotic was not decreased. The 43% of the respondents who used psychotropics in addition to narcotics recommended as a dosage the mean equivalent of 8.9 mg of the intramuscular morphine, or 8.9 MS,.m EQ* [23]. The respondents who used only narcotic analgesics for tanking recommended 9.1 MS,.m.EQ, a difference which is not statistically significant. In addition to morphine or meperidine, five of the respondents used nitrous oxide and one respondent used methoxyflurane. Only 4 respondents indicated that an anesthesiologist participated in providing analgesia for adult tanking: two helped with the nitrous oxide and two helped with the ketamine. Table III illustrates how the respondents rated the pain experienced by the described adult patient after the preferred method of analgesia was given for tanking. None believed the pain would be excruciating; most believed the pain would be in the moderate range. Various analyses were done to determine what factors did or did not influence * MS,m EQ represents milligram units of intramuscula, morphi:,~e equivalent in total analgesic effect to
the administered dose of other narcotic analgesics. The convt~rsion is based on the best estimate of relative potency in the literature and on available controlled relative potency assays. For instance, meperidine 75 mg i.m. is estimated to be equivalent in analgesic activity to 10 mg of morphine i.m, thus meperidine 75 mg i.m.= 10 MSLm EQ: levorphanol 2 mg p . o . = 5 MSi,m.EQ; codeine 60 mg i.m.=:4,6 MSi.m.EQ. The conversions are based on total drug effects (area under the analgesic time-effect curves) and do not reflect differences in peak effect, onset of action or duration of action, which may vary from drug to drug as well as from parenteral to oral route of administration.
271
T A B L E III N,61 40 (/1 ,4-=.
PAI___N. CATEGORIES
c
0j 3 0 "1o
l®!iil
o o. U)
w
I
I~!
20
•
= None
z= Mild
I®iili I~;il . i®iiil
3= Moderale 4 = severe
5
= Excruciating
o
0
I ~ i i i i l N ' Z ~ N 1 1.5 2 :>.5 3 3.5 4
,
4.5
0 5
Staff rated pain response (tanking) how the staff rated the patient's pain. For example, the addition of psychotropics did not make a significant difference. Those respondents who used psychotropics in conjunction with narcotics assessed the patient's pain as being 3.0 (moderate) ± 0.59 S.D. Those not using psychotropics assessed the patient's pain as being 2.9 ± 0.73 S.D. Similarly, the staff's assessment of the patient's pain showed no significant difference regarding the type of drug used (i.e., morphine vs. meperidine vs. codeine) or the route of administration (i.e., morphine i.m. vs. morphine i.v.). In fact, when comparing the pain assessment by those respondents who used intravenous morphine with those who used p.o. codeine, no statistical difference was found; both groups rated the patient's pain as moderate (3.05 vs. 3.13 respectively). Most striking, the respondents who assessed the pain as most severe after analgesia was given were inclined to give the higher dosages before tanking. For instance, those who rated the pain as severe to excruciating (N = 19) recommended 10.3 MSi.mEQ whereas those who rated the patient as having no pain to mild (N.= 22) gave 6.4 MSi.mEQ. This difference in dosage is significant t o < the 0.01 level. As a corollary to this analysis, those respondents who gave no narcotics or anesthesia pretanking (N = 6) stated the patient experienced 2.5 mean pain whereas those who gave > 16 MSi.m.EQ (N = 9) assessed the patient's pain as 3.5. Though the numbers are small, the d, fference is significant (<0.01) when the t test is performed. As Table IV illustrates, the staff assessment of the patient's pain did not significantly differ from one professional role to another. Physicians and nurses tended to rate the pain the same. Analysis did reveal, however, that the staff members who had spent less time working with burn patients believed debridement was more painful: those working over 5 years (N = 57) gave a mean pain rating of 2.80 whereas those working less than 5 years (N = 80) gave a mean rating of 3.14, a significant difference ( < 0.01).
272 TABLE IV STAFF PERCEPTION OF PATIENT PAIN BY DISCIPLINE N
X*-+S.D.
Atter~ding M.D.'s House Staff M.D.'s
5! 9
2.8 ± 0.68 3.0-+-0.56
All physicians
60
2.9 ± 0.66
Head R.N.'s. R.N. clinicians Staff R.N.'s
57 19
3.1 -+0.64 3.1 -+0.78
All nurses
76
3.1 -+0.68
136
3.0-+0.67
All staff
* Mean pain response on a scale ~f I-5.
In regard to the size of the burn units, smaller facilities tended to use more psychotropic drugs or only p.o. codeine whereas larger units tended to use less psychotropics and more intravenous morphine. The units that used psychotropic drugs (N = 49) had a mean number of 6.2 patients; the units that did not use psychotropics (N = 77) had a mean number of 8.8 patients, a significant difference (<0.02). Those units using only p.o. codeine for tanking ( N = 19) had a mean number of 6.3 patients; those using only intravenous morphine (N = 17) had a mean number of 11.2 patients, a significant difference ( < 0.05). But, as the graphic of the United States shows, when the units are divided into those which give small, medium o r large dosages of narcotics, no prominent geographical tendencies are revealed (Fig. 1). Some notable differences were found between how analgesia was provided for the child described in Ihe questionnaire as compared to the adult patient. Table V indicates that meperidirze was preferred slightly more than morphine and that 24 respondents (17~) recommended no narcotic analgesia for the 3-year-old patient. Of these 24 - - all from different burn facilities m 11 gave diazepam, hydroxyzine or barbiturates; 11 gave no medication or anesthetic gases whatsoever; and 3 gave 1 mg p.o. methadone TID but no pretanking medication. Those units using narcotics for the debridement of children tended to give larger dosages on a m g / k g basis. For instance, the mean m g / k g dose of i.m. morphine for the adult patient was 0.15, whereas for the child it was 0.20. This means that the child would receive approximately 25~g more morphine on a mg/kg basis than the adult. The tendency of those units working with children to give a larger relative dose of morphine stands in sharp contrast to the number of units not using analgesi:s for the debridement of children. Six respondents stated that they would not routinely premedicate the adult tanking patient with a narcotic whereas 24 respondents stated they would not routinely premedicate the child. The use of psychotropic drugs for children is displayed on Table Vl. Of the 139 respondents who were engaged in the tanking of children, 34 (or 25%) recoinmended
273
a~k
oo.oo
<;oOoOOo o.o
-'][--
~
*
;
_
o
uuO
nnnn~|
OO DO
t3
&bOO
gN
Fig. I. Categories of drug amounts in terms of MSi.m. equivalents. i.m./p.o, • [] •
i.v.
N
<4
<5 6-15 >!6
41
5-10 >11
88 13
TABLE V ANALGESIC PREFERENCE/DOSE/ROUTE
DEBRIDEMENT FOR CHILDREN
N
,~ dose (rag)± S.D.
Range (rag) 5 -50 2.5-22
i.m." i.v. p.o.
Meperidine Meperidine Meperidine
33 5 1
2 0 . 7 - 9.08 10.0* * *
i.m. i.v.
Morphine Morphine
22 14
2.9 +- 1.5 3. I ± 1.9
p.o. i.m.
Codeine Codeine
24 4
16. I -~-8.6 *
p.o. p.o.
Oxycodone Methadone
p.o.
Alphaprodine Tylenol None
2 I
* *
* *
1 1 24
* * *
* * *
1.3- 7.5 - 7.5
I
5 -45
B
274 T A B L E VI PSYCHOTROPIC DRUG USE DEBRIDEMENT FOR CHILDREN N p.o. i.m. i.v.
D i a z e p a m (Valium) Diazepam Diazepam
i.m. p.o. i.v.
X dose (rag)-+ S.D.
Range (mg)
14 5 5
3.8--- 3.0 2.9+ - 0.7 1.8 +- 0.9
i -10 2.5 - 3.5 0 . 7 5 - 2.5
Hydroxyzine (Vistaril) Hydroxyzine Hydroxyzine
6 5 1
14.6-+ 3.3 35.0-+ 16.4 * *
10 - 17.5 17.5 - 5 0 *
i.m. p.o.
C h l o r p r o m a z i n e (Thorizine) Chlorpromazine
5 2
21.0-+ 13.9 * *
10 *
-40
i.m. i.v.
Ketamine Ketamine Other
5 2 10
44.8-+ 14.7 * * * *
25 * *
-56
psychotropics be used in conjunction with narcotic analgesics (and ! ! recommended using only psychotropics). Two of the 7 units using ketamine employ an anesthesiologist, and one unit of the 3 recommending nitrous oxide uses an anesthesiologist as well as pretanking narcotic analgesics. Of note, despite the higher percentage of respondents who recommended using no narcotics or no psychotropics or no analgesia at all, the difference between the mean assessment of pain for children (2.9) and that for adults (3.0) was not significant. Finally, 67% of the respondents (116 out of 174) stated that the treatment of pain at their burn facilities was satisfactory. Only 8% of the respondents (14 out of 174) indicated they thought the side effects of analgesics or the risk of addiction prevented using higher dosages. Of the 12% who knew of a patient who had become a drug abuser upon discharge from the hospital as a result of receiving narcotic analgesics for burn pain, all but one said the patient had a previous history of drug abuse. The exception was one respondent who said that a 3-year-old child became 'addicted' because he required methadone upon discharge from the hospital.
Discussion
This survey was intended to document the analgesic methods used for debridement by burn facilities in the United States. That goal was accomplished. The 181 completed questionnaires represented burn units throughout the country and offered an opportunity for a statistical analysis of how a typical adult and child would be provided pain relief for tanking. At first glance the data would suggest a fair degree of uniformity: most adult patients before tanking are given a narcotic analgesic with or without a psychotropic drug and experience moderate pain during the procedure. When the data are examined more carefully, this apparent uniformity breaks down. An important
275 difference between units is the relative amount of narcotics used. On one extreme are those respondents who recommend 35 m S i.m. morphine and at the other extreme are those who for the same described adult patient would use 30 mg p.o. codeine, a 35-fold difference, when the route and relative potency are considered [24]. Although these respondents represented the extremes, a wide range of dosages is reflected throughout; for example, the mean dosage of intravenous morphine was 8.9 mg with a standard deviation of 5.4 rag. Thus, as many respondents were inclined to give 3.5 mg i.v. morphine as 14.3 mg, a notable difference. The spectrum becomes even wider when one considers that many respondents recommend using no narcotics at all, preferring diazepam, ketamine, nitrous oxide or nothing. Eleven respondents - - all from different units - - indicated that no drug or gas would be given to the described child for the tanking procedure. Despite the extreme difference of opinion regarding the amount of analgesia required, the respondents showed little variation in their rating of how much pain the described patient would then experience during the tanking procedure after the recommended drugs or anesthetic gases were given. As already shown by Table Ill, a large majority (70%) placed the patient's pain in the moderate range between 2.5 and 3.5. The idea that a patient could receive 5, 10, 15 or even 35 times more pain medication for a procedure and still be rated as having the same degree of pain is an interesting finding and one worth trying to explain. One possible explanation is that the tanking itself varies from unit to unit. At one facility the debridement may be extensive, painful and require large amounts of analgesia whereas at another facility the procedure may be less vigorous or ambitious and accordingly not require as much pain medication. The skill and gentleness of the debrider and the non-pharmacological methods may also vary from one place to another. These intangibles could not be assessed by a questionnaire. Although we appreciate that each unit inevitably has its own means of offering comfort and support, without further documentation we are reluctant to assume that these differences explain why patients at one facility require so much more analgesia than at another facility when the task of removing necrotic skin is basically the same. Another possible explanation for why some respondents recommended far more pain medication than others is that on many units the analgesic requirements for the tanking procedure may be underestimated; that is, although the staff may believe that patients only experience moderate pain during debridement, the pain is actually more severe. Some unpublished studies support this possibility: a group of researchers studying pain at the Burn Center in Seattle [25] reported that two-thirds of the patients they surveyed rated their pain after an analgesic and during tanking as equal to or worse than the worst pain they had ever experienced; similarly, patients in the Burn Center of The New York Hospital were given a mean of 8.9 MSi.m.EQ and 84~ of the 52 patients studied rated their pain as severe or excruciating during tanking [26]. This discrepancies between how staff and patients rate the severity of pain is not unusual. Studies have documented the poor reliability between objective and subjective assessment [27,28] and the tendency for staff members to underestimate the degree of pain [29]. This tendency may be even more pronounced on a burn unit where the staff is not only responsible for relieving the pain, but also is
2"/6 responsible for causing the pain during therapeutic procedures. Those inflicting the pain may understandably be reluctant to acknowledge the pain severity. The group of respondents recommending relatively low dosages of narcotics and the group recommending no narcotics at all are both worth noting. This survey revealed that on many units patients receive only psychotropics or, particularly with children, receive no drugs or anesthetic gas whatsoever. In the case of using only a psychotropic such as diazepam or chlorpromazine, studies have shown that the majority of tranquilizers may reduce the anxiety associated with pain and may alter the behavioral expression of pain, but do not in themselves have documented analgesic properties [30,31]; nor is the evidence yet sufficient to support the belief that these drugs potentiate the analgesic properties of narcotics [32]. If such tranquilizers are being used primarily for pain relief, then further evidence will be necessary to establish their efficacy. In the same way, although hydroxyzine (Vistaril) has been shown to have analgesic properties of its own in high dosages [33], the analgesic properties of this drug for tanking may be overvalued when used alone in dosages less than 100 mg i.m. or when used with small dosages of narcotic analgesics. The number of respondents recommending no analgesia, psychotropics or anesthetics for debridement is also perplexing, especially since their rating of the patient's pain is no greater than the rating given by those who do provide some pharmacological method of pain relief. In fact, this survey found that the pain was rated most severe by those who provided the most analgesia. But caution must be exercised before arbitrarily condemning those who recommend no pretanking medication. Until the efficacy of other methods has been more fully evaluated, the possibility exists that even those prescribing moderate or high dosages of narcotics are not providing any more pain relief than those prescribing no drugs at all. A concern does remain, however, that some burn units have prematurely given up a search for providing adequate analgesia either because of frustration over ever finding a safe and effective method or perhaps because of the belief that children do not remember pain [34]. Although the findings of this survey did raise several questions about the efficacy of some analgesic methods currently in use, two issues regarding the management of burn pain were somewhat demythologized. First, anecdotal reports have suggested that physicians and nurses differ in how they assess a patient's pain, the notion being that nurses are more directly aware of the patient's pain problems and believe that analgesic requirements are greater. This study did not reveal such a discrepancy. Regardless of the respondent's role, staff members tended to rate the patient's pain the same. The one statistically significant difference we did find was that staff members who had spent less time on the job tended to rate the patient's pain higher, suggesting either staff members become more impervious to the patient's pain over time or that those who rate the patient's pain as less severe tend to remain working with burn patients longer. A second myth which this study may have partially corrected is that the prolonged use of narcotic analgesics for burn pain will lead ~o addiction. Of the 181 respondents h with an average experience of over 6 years on a burn unit and representing the accumulated knowledge of at least 10,000 hospital-
277 TABLE VII HOW DOES T H E PAIN O F BURN PATIENTS A F F E C T YOU? 'It takes time getting used to but in time it is fairly easy to block out.' 'Have feeling of empathy - - try to be quick.' "It is almost an unavoidable part of burn care.' 'I apologize to patients - - I rock an infant - - I don't like to hurt them.' 'It bothers me - - sometimes I think 1 have become calloused to some of the pain.' 'Since burn care can be a very long process - - months - - I feel that giving medication every day will only hurt the patient. If he can tolerate the pain during tanking, why take the chance of having to detoxify the patient from possible addiction to drugs?' 'So much of the problem seems to be fear complicated by pain.' 'I strongly feel that more aggressive treatment of pain in burned children is indicated.' 'There are times when I feel guilty about the pain the patient is experiencing - - alter painful debridement I try to spend time with my patients by playing with them." "Pretank reeds do not seem to relieve the pain unless given in large doses." 'Makes me feel uneasy.' 'I feel it.' 'Bothersome but not troubling.'
ized burn patients m not one case of an actual iatrogenic addiction could be documented. The 22 patients reported to abuse drugs after discharge all had a prior history of drug abuse. We have reserved until last any discussion about the effects of burn pain on the respondents because this area is more impressionistic and hard to quantify in any way that conveys the poignancy of the many statements made on the open-ended section of the questionnaire. Just as the prompt and large response to the time-consuming form showed a general interest in the management of burn pain, so the personal comments indicated a concern about how the pain affected patients and staff. This same concern is reflected in the many presentations about pain at recent meetings of the American Burn Association [35-38]; yet the staff's attitude about pain is not always consistent with the pharmacological management [39]. For example, Table VII lists some of the comments made by the respondents who recommended no pretanking analgesia for children and who assessed the pain as moderate or less. This kind of ambivalence is implied by the last statement listed, 'bothersome but not troubling.' What does this mean?
Conclusion Because of the generous participation by 181 staff members of 93 burn units throughout the United States, this study was able to document current analgesic methods used for the tanking procedure and was able to determine what factors correlated with how burn pain was assessed and treated.
278
In reference to debridement for adults: (!) about two-thirds of the respondents used morphine or meperidine, but the dosage varied widely; (2) the assessment of pain was not statistically different regarding the type of narcotic used or the route of administration (i.v., i.m. or p.o.); (3) about half the respondents used psychotropic drugs (particularly diazepam or hydroxyzine) in conjunction with narcotics, but without a reduction in the dosage of the narcotics or a reduction in the assessment of pain; (4) the respondents who assessed the pain as most severe after analgesia, preferred higher dosages before tanking; (5) no difference was found between how nurses and physicians rated the patient's pain, but those staff members who had spent less time on the job rated the patient's pain as more severe. In reference to debridement for children: (1) narcotics, if used, tended to be given in a larger milligram per kilogram dosage; (2) psychotropic drugs in conjunction with narcotics were used less than with adults (24% vs. 52%); (3) despite the higher percentage of respondents who recommended using no narcotics or no psychotropics or no analgesia at all, the general assessment of pain for children and adults was the same, i.e. the moderate range. This study was not capable of determining what analgesic methods for debridem,ent of burn patients are most effective, but the issues raised by the survey might stimulate all of us to reconsider our routine prescriptions for pain and to document more carefully the pain relief we provide.
Acknowledgements The authors wish to express their appreciation to Michael DeMeo, Annette Pols, Ruth Strassner, Florence Weicker and Eienor West for their assistance in the preparation of this paper and to Kathleen Foley, M.D. and Stanley Wallenstein, M.S. for their critical appraisals.
References I Butzer, S. Kuehn, C., Wilcox, F. and Solem, L., Methodone: an old analgesic rediscovered, Presented at the American Burn Association I lth Annual Meeting, 1979. 2 Nova, J., Large dose morphine for pain control, Presented at the American Burn Association Meeting, San An~0~nio,Texas, 1980. 3 Baskett, P., Analgesia for the dressing of burns in children: a method using neuroleptanalgesia and entonox. Postgrad. Med., 48 (1972) 138-142. 4 Cosgrave, P., Filkins, $., Marvin, J. et ai., Dolonox: a method of pain control, Presented at the American Burn Association Meeting, San Antonio, Texas, 1980. 5 Demling, R.H., Ellerby, S. and Jarrett, F., Ketamine anesthesia for tangential excision of burn eschar: burn unit procedure, J. Traume 18 (1978) 269-270. 6 Slogoff, S., Allen, G.W., Wessels, J.V. and Cheney, D.H., Clinical experience with subanesthetic ketamine, Anesth. Anaig. Curr. Res., 53 (1974) 354-358. 7 Calverley, R.K., Repeated methoxyflurane analgesia for burns dressings, Brit. J. Anaesth., 44 (1972) 628. 8 Firn, S., Methoxyflurane analgesia for burns, dressings and other painful ward procedures in children, Brit. J. Anaesth., 44 (1972) 517, 520-522.
279 9 Marshall, M.A. and Ozorio, H.P., Analgesia for burns dressing using methoxyflurane. Brit. J. Anaesth., 44 (1974) 80-82. I0 Packer, K.J., Methoxyflurane analgesia for burns dressing.g, Postgrad. Med., 48 (1972) 128-132. I i Hartley, R.B., Hypnosis for alleviation of pain in treatment of burns: case report, Arch. phys. Med. Rehab., 49 (1968) 39-41. 12 Wakeman, RJ. and Kaplan, J.Z., An experimental study of hypnosis in painful burns, Amer. J. clin. Hypnos., 21 (1978) 3-11. 13 Dahinterova, J., Some experiences with the use of hypnosis in the treatment of burns, Int. J. clin. exp. Hypnos., 15 (1967) 49-53. 14 Simons, R.D., Morris, J.L., Frank, H.A., Green, L.C. and Malin, R., Pain medication contracts for problem patients, Psychosomatics, 20 (1979) 123-127. 15 Simons, R.D., McFadd, A., Frank, H.A., Green, L.C., Malin, R.M. and Morris, J.L., Behavioral contracting in a burn care facility: a strategy for patient participation, J. Trauma, 18 (1978) 257-260. 16 Fagerbaugh, S., Pain expression and control on a burn care unit. Nsg Outlook, 22 (1974) 645-650. 17 Morris, J, and McFadd, A., The mental health team on a burn unit: a multidisciplinary approach, J. Trauma, 18 (1978) 658-663. 18 Miller, W.C., Gardner, N. and Inholt, S., Psychosocial support in the treatment of severely burned patients, J. Trauma, 16 (1976) 722-725. 19 Mattson, E.I., Psychological aspects of severe physical injury and its treatment. J. Trauma. 15 (1975) 217-235. 20 Goodstein, R.K. and Hurwitz, T.D., The role of the psychiatric consultant in the treatment of burned patients, Int. J. Psychiat. Med., 6 (1975) 413-429. 21 Cromes, G.F., McDonald, M. and Robinson, C., The effects of relaxation training on anxiety and pain during burn wound debridement, Presented at the American Burn Association Meeting, San Antonio, Texas, 1980. 22 Directory of Burn Care Facilities, Alisa Ann Ruch Burn Foundation. Sherman Oaks, Calif., 1980. 23 Houde, R.W., The management of pain. In" R.L. Clark, R.W. Cumby, J.E. McCoy and M.M. Copeland (Eds.), Oncology: Diagnosis and Management of Cancer, Vol. 111. Year Book Medical Publishers, Chicago, 111., 1971, pp. 489-496. 24 Houde, R.W., lbid, p. 493. 25 Charlton, J.E., Burns, M., Heinbach, D.M. et al., Factors affecting pain complaints in patients with bums, Presented at the American Pain Society Meeting, San Diego. Calif.. 1979. 26 Unpublished data, Burn Pain Research Section, New York Hospital, Cornell Medical Center Burn Center. 27 Lira, R.K.S. and Guzman, F., Manifestations of pain in analgesic evaluation in animals and man. In: J. Cahn and J. Charpentier (Eds.), Pain Proceedings of the International Symposium on Pain. Academic Press, New York, 1968, pp. 139-152. 28 Wailenstein, S.L. and Houde, R.W., The clinical evaluation of analgesic effectiveness. In: S. Ehrenpreis and A. Neidle (Eds.), Methods in Narcotics Research, Marcel Dekker, New York, 1975. pp. 127-145. 29 Marks, R.M. and Sachir, EJ., Undertreatment of medical inpatients with narcotic analgesics. Ann. intern. Med., 78 (1973) 17.~-181. 30 Houde, R.W. and Wallenstein, S.L., Analgetic power of chlorpromazine alone and in combination with morphine, J. Pharmacol. exp. 1"her., 14 (1955) 353. 31 Keats, A.S., Telford, J. and Kurow, Y., Potentiation of meperidine by promethazone, Anesthesiology, 22 (1961) 34-41. 32 Beaver, W.T., Interaction of narcotics and mood altering drugs: a brief historical rcview. In" Recent Studies of the Nature and Management of Acute Pain: a Symposium. HP Publishing Co., New York, 1976, pp. 8-13. 33 Beaver, W.T. and Feise, G., Comparison of the analgesic effects of morphine, hydroxyzine, and their combination in patients with postoperative pain. In: J.J. Bonica and D. Albe-Fessard (Eds.). Advances in Pain Research and Therapy, Raven Press, New York, 1976, pp. 553-557. 34 Eland, J.M. and Anderson, J.E., The experience of pain in children. In: A. Jac~x (Ed.), A Source Book for Nurses and Other Health Professionals, Little, Brown and Co., Boston, Mass., 1977. pp. 453-473.
280 35 36 37 38 39 40 41 42
43
Nova, J., Ibid, 1980. Cromes, G.H., Ibid, 1980. Butzer, S., Ibid, 1979. Cosgrave, P., Ibid, 1980. Orgun, C., Marvin, 3. and Heh'lbach, D.M., Exploring pain management practices, Presented at the American Bum Association Meeting, New Orleans, La., 1979. Mattssin, E.I., Psychological aspects of ~vere physical inju~ and its treatment, J. Tr~tuma, 15 (19"15) 217-235. Wallenstein, S.L., Heidrich, III, G., Kaiko, R. et al., Clinical evaluation of mild analgesics: the management of clinical pain, Brit. J. cfin. Pharmacol., 10 (1980) 319S-327S. Tursky, B., The development of a pain perception profile: a psychophysical approach. In: M. Weisenberg and B. Tursky (Eds.), Pain: New Perspectives in Therapy and Research, Plenum Press, New York, 1975, pp. 171-194, Wallenstein, S.L. and Houde~ R W., The clinical evaluation of analgesic effe~Aiveness.In: S. Ehrenpreis and A. Neidle (Eds.), Methods in NarcoticsResearch, Marcel Dekker, New York, 1975, pp. 127-145.
267
Management of Pain during Debridement: a Survey of U.S. Burn Units Samuel Perry ,,2 and George Heidrich ** * Cornell University and The New York Hospital Burn Center-CorneU University Medical Center, New York, N. Y. and * * Department of Anesthesiology, University of Wisconsin, Madison, Wis. (U. S.A.)
(Received 28 September 1981, accepted 12 October 1981)
Summary To determine how bum pain is assessed and managed during debridement, questionnaires were sent to 151 U.S. burn facilities. 181 staff members from 93 burn units responded. For a typical adult patient, most respondents preferred a narcotic, but the dosages varied widely without a corresponding variation in assessed paha. The assessment of pain also did not vary with the type of analgesia used or the route of administration (i.v., i.m., p.o. or gas). Half the respondents used psychotropic drugs in conjunction with narcotics, but without a reduction in dosage of the narcotic or a reduction in assessed pain. For a typical burned child, although more respondents recommended using no narcotics or no psychotropics or no analgesics at all, the assessed pain for children and adults was the same, i.e. in the moderate range. Pain during debridement was rated as more severe by those with less job experience and by those who gave higher dosages of analgesics before the procedure. The survey's findings indicate a need to reevaluate current analgesic practices for debridement and to document pain and pain relief.
Introduction The limited quantifiable data regarding burn pain have led to uncertainty about how analgesia can best be provided for hospitalized burn patients. Different methods have been suggested, including narcotics [1,2], nitrous oxide [3,4], ketamine Supported in part by NIH Grant PSOGM26145 2 Send reprint requests to: Samud Perry, M.D., iqew York Hospital (PWC), 525 East 68th Street. New York, N.Y. 10021, U.S.A. 0304-3959/82/0000-0000/$02.75 © 1982 Elsevier Biomedical Piess
268
[5,6], methoxyflurane [7-10], hypnosis [11-13], behavioral modification [14-I6], supportive psychotherapy [ 17-20] and relaxation training [21]. Because no definitive analgesic method has been well documented, methods vary from unit to unit depending on the experience and judgment of the prescribing physicians. As one component of an ongoing NIH-supported project to study and improve the management of burn pain, questionnaires were distributed to the directors and staff of ! 51 burn facilities in the United States. The goals were to establish a baseline for current analgesic practices and possibly to discover any unshared innovative techniques as well as methods which might be considered unacceptable. The questionnaire especially addressed analgesic methods for debridement or 'tanking,' a potentially painful procedure used by many burn units during which the wound is washed and necrotic epithelium is cut away with forceps and scissors. This paper reports current analgesic methods used for the tanking procedure and discusses what factors correlate with the different ways burn pain is assessed and treated.
Method
Four questionnaires were mailed to each director of the 151 burn facilities in ti~e United States [22]. Enclosed was an explanatory letter suggesting that the forms be completed by the director and by physicians, nurses, or other staff members most knowledgeable about analgesic methods used on the burn unit. The questionnaire had 3 sections. Section I sought demographic information about the unit (such as the average number of adult and child patients per day) and information about the respondent (such as his or her position on the unit and the number of months working with burn patients). Section II asked about common analgesic practice and pain assessment. Typical burn cases of an adult and of a child were described and followed by a ser~es of specific questions: Adult. The patient is a 34-year-old, 70 kg male who has suffered a 28~ second and third degree thermal burn to his lower extremities. He has been on the unit for 2 weeks, is physiologically stable and has no respiratory compromise. What would be a typical medication order for tanking? Child. The patient is a 3-year-old, 14 kg boy who has suffered 28% second and third degree burns to his lower extremities. He has been on the unit for 2 weeks, is physiologically stable and has no respiratory compromise. What would be a typical medication order for tanking? After each of these clinical examples, the form provided a checklist to note the analgesic drug, anesthetic gas, and psychotropic usually prescribed as well as the dosage, frequency, route of administration, and times given before the procedure. The respondent was then asked to note from i to 5 how much pain the patient would likely experience during tanking after being given that unit's typical method of analgesia: l - none, 2 = mild, 3 = moderate, 4 - severe, 5 = excruciating [40-43]. Section III addressed more general issues, such as how the patient's pain affected
269
the respondent and if any patient had become iatrogenically addicted. Open-ended comments about burn pain were invited. The name of the respondent and of the burn unit could be included if the respondent so chose.
Results
One or more completed forms were received from 93 burn facilities representing 37 states and 62~ of those surveyed. All sizes of units were represented: the mean number of adult patients was 7.8 with a range from 0 to 25; the mean number of child patients was 3.3 with a range from 0.5 to 30. Of the 181 respondents, about one-third were attending physicians (66) and about one-third were head nurses or nurse clinicians (67). The final third was composed of staff nurses (28), house staff physicians (1 !), physical therapists (6), anesthesiologists (2), and occupational therapist (I). The average respondent was highly experienced and had worked with burn patients for over 6 years; the mean number of months was 75. The tanking procedure for debridement was performed in 89 (96%) of the facilities surveyed. The other 4 units always used early wide excision or some other method instead of tanking. Table I illustrates the analgesic drug, dosage and route of administration preferred for debridement of the adult patient described in the questionnaire. About two-thirds of the respondents used morphine or meperidine as the drug of choice, but the dosage varied widely; for example, although the mean dosage of intramuscular meperidine was 75 mg, the standard deviation was over 50 mg with a range between 25 mg and 375 mg. As Table !I illustrates, about one-half (52%) of the respondents used psychotropic
TABLE ! ANALGESIC
PREFERENCE/DOSE/ROUTE
DEBRIDEMENT
FOR ADULTS
N
X, d o s e ( m g ) - S . D .
Range (mg)
i.m. i.v.
Morphine Morphine
50 32
10.7-- 4.5 8.9 +- 5.4
2 - 35 2 - 25
i.m. i.v.
Meperidine Meperidine
37 8
75.7 +- 52.9 70,5 +- 14. !
2 5 - 375 50-100
p.o. i.m.
Codeine Codeine
30 3
63.0 +- 22.7 * *
3 0 - ! 30 *
p.o. i.m. i.v. p.o. p.o.
Oxycodone Alphaprodine Alphaprodine Pentazocine Methadone
5 2 1 2 1
* * * * *
* * * * *
* * * * *
None
6
*
*
*
270 T A B L E Ii P S Y C H O T R O P I C D R U G USE D E B R I D E M E N T F O R A D U LTS N p.o. i.m. i.v.
Diazepam (Valium) Diazepam Diazepam
26 19 13
i.m. p.o. i,v.
Hydroxyzine (Vistaril)
19 4 I
i.v. i.m.
Ketamine Ketamine Chlorpromazine (Thorazine) Chlordiazepoxide (Librium)
p.o. p.o. i.m.
Hydroxyzine Hydroxyzine
Chlordiazepoxide
N dose (mg) ± S.D. 7.3± 7.9± 6 . 9 +-
1.8 1.9 1.5
48.9 ± 22.7 * * * *
Range (mg) 5 - 10 5 - 12.5 5 - !0 25- i 25 * *
3 2
* *
* *
* *
2 2 I
* * *
* * *
* * *
drugs for the debridement of the described adult patient. Diazepam by different routes was the preferred drug (63%) with hydroxyzine a distant second (26%). Most psychotropic drugs were used in conjunction with narcotics (91%), but 8 of the respondents indicated they used only intravenous diazepam or ketamine without other analgesics. Of note, if a psychotropic drug was used in conjunction with a narcotic analgesic, the mean dosage of the narcotic was not decreased. The 43% of the respondents who used psychotropics in addition to narcotics recommended as a dosage the mean equivalent of 8.9 mg of the intramuscular morphine, or 8.9 MS,.m EQ* [23]. The respondents who used only narcotic analgesics for tanking recommended 9.1 MS,.m.EQ, a difference which is not statistically significant. In addition to morphine or meperidine, five of the respondents used nitrous oxide and one respondent used methoxyflurane. Only 4 respondents indicated that an anesthesiologist participated in providing analgesia for adult tanking: two helped with the nitrous oxide and two helped with the ketamine. Table III illustrates how the respondents rated the pain experienced by the described adult patient after the preferred method of analgesia was given for tanking. None believed the pain would be excruciating; most believed the pain would be in the moderate range. Various analyses were done to determine what factors did or did not influence * MS,m EQ represents milligram units of intramuscula, morphi:,~e equivalent in total analgesic effect to
the administered dose of other narcotic analgesics. The convt~rsion is based on the best estimate of relative potency in the literature and on available controlled relative potency assays. For instance, meperidine 75 mg i.m. is estimated to be equivalent in analgesic activity to 10 mg of morphine i.m, thus meperidine 75 mg i.m.= 10 MSLm EQ: levorphanol 2 mg p . o . = 5 MSi,m.EQ; codeine 60 mg i.m.=:4,6 MSi.m.EQ. The conversions are based on total drug effects (area under the analgesic time-effect curves) and do not reflect differences in peak effect, onset of action or duration of action, which may vary from drug to drug as well as from parenteral to oral route of administration.
271
T A B L E III N,61 40 (/1 ,4-=.
PAI___N. CATEGORIES
c
0j 3 0 "1o
l®!iil
o o. U)
w
I
I~!
20
•
= None
z= Mild
I®iili I~;il . i®iiil
3= Moderale 4 = severe
5
= Excruciating
o
0
I ~ i i i i l N ' Z ~ N 1 1.5 2 :>.5 3 3.5 4
,
4.5
0 5
Staff rated pain response (tanking) how the staff rated the patient's pain. For example, the addition of psychotropics did not make a significant difference. Those respondents who used psychotropics in conjunction with narcotics assessed the patient's pain as being 3.0 (moderate) ± 0.59 S.D. Those not using psychotropics assessed the patient's pain as being 2.9 ± 0.73 S.D. Similarly, the staff's assessment of the patient's pain showed no significant difference regarding the type of drug used (i.e., morphine vs. meperidine vs. codeine) or the route of administration (i.e., morphine i.m. vs. morphine i.v.). In fact, when comparing the pain assessment by those respondents who used intravenous morphine with those who used p.o. codeine, no statistical difference was found; both groups rated the patient's pain as moderate (3.05 vs. 3.13 respectively). Most striking, the respondents who assessed the pain as most severe after analgesia was given were inclined to give the higher dosages before tanking. For instance, those who rated the pain as severe to excruciating (N = 19) recommended 10.3 MSi.mEQ whereas those who rated the patient as having no pain to mild (N.= 22) gave 6.4 MSi.mEQ. This difference in dosage is significant t o < the 0.01 level. As a corollary to this analysis, those respondents who gave no narcotics or anesthesia pretanking (N = 6) stated the patient experienced 2.5 mean pain whereas those who gave > 16 MSi.m.EQ (N = 9) assessed the patient's pain as 3.5. Though the numbers are small, the d, fference is significant (<0.01) when the t test is performed. As Table IV illustrates, the staff assessment of the patient's pain did not significantly differ from one professional role to another. Physicians and nurses tended to rate the pain the same. Analysis did reveal, however, that the staff members who had spent less time working with burn patients believed debridement was more painful: those working over 5 years (N = 57) gave a mean pain rating of 2.80 whereas those working less than 5 years (N = 80) gave a mean rating of 3.14, a significant difference ( < 0.01).
272 TABLE IV STAFF PERCEPTION OF PATIENT PAIN BY DISCIPLINE N
X*-+S.D.
Atter~ding M.D.'s House Staff M.D.'s
5! 9
2.8 ± 0.68 3.0-+-0.56
All physicians
60
2.9 ± 0.66
Head R.N.'s. R.N. clinicians Staff R.N.'s
57 19
3.1 -+0.64 3.1 -+0.78
All nurses
76
3.1 -+0.68
136
3.0-+0.67
All staff
* Mean pain response on a scale ~f I-5.
In regard to the size of the burn units, smaller facilities tended to use more psychotropic drugs or only p.o. codeine whereas larger units tended to use less psychotropics and more intravenous morphine. The units that used psychotropic drugs (N = 49) had a mean number of 6.2 patients; the units that did not use psychotropics (N = 77) had a mean number of 8.8 patients, a significant difference (<0.02). Those units using only p.o. codeine for tanking ( N = 19) had a mean number of 6.3 patients; those using only intravenous morphine (N = 17) had a mean number of 11.2 patients, a significant difference ( < 0.05). But, as the graphic of the United States shows, when the units are divided into those which give small, medium o r large dosages of narcotics, no prominent geographical tendencies are revealed (Fig. 1). Some notable differences were found between how analgesia was provided for the child described in Ihe questionnaire as compared to the adult patient. Table V indicates that meperidirze was preferred slightly more than morphine and that 24 respondents (17~) recommended no narcotic analgesia for the 3-year-old patient. Of these 24 - - all from different burn facilities m 11 gave diazepam, hydroxyzine or barbiturates; 11 gave no medication or anesthetic gases whatsoever; and 3 gave 1 mg p.o. methadone TID but no pretanking medication. Those units using narcotics for the debridement of children tended to give larger dosages on a m g / k g basis. For instance, the mean m g / k g dose of i.m. morphine for the adult patient was 0.15, whereas for the child it was 0.20. This means that the child would receive approximately 25~g more morphine on a mg/kg basis than the adult. The tendency of those units working with children to give a larger relative dose of morphine stands in sharp contrast to the number of units not using analgesi:s for the debridement of children. Six respondents stated that they would not routinely premedicate the adult tanking patient with a narcotic whereas 24 respondents stated they would not routinely premedicate the child. The use of psychotropic drugs for children is displayed on Table Vl. Of the 139 respondents who were engaged in the tanking of children, 34 (or 25%) recoinmended
273
a~k
oo.oo
<;oOoOOo o.o
-'][--
~
*
;
_
o
uuO
nnnn~|
OO DO
t3
&bOO
gN
Fig. I. Categories of drug amounts in terms of MSi.m. equivalents. i.m./p.o, • [] •
i.v.
N
<4
<5 6-15 >!6
41
5-10 >11
88 13
TABLE V ANALGESIC PREFERENCE/DOSE/ROUTE
DEBRIDEMENT FOR CHILDREN
N
,~ dose (rag)± S.D.
Range (rag) 5 -50 2.5-22
i.m." i.v. p.o.
Meperidine Meperidine Meperidine
33 5 1
2 0 . 7 - 9.08 10.0* * *
i.m. i.v.
Morphine Morphine
22 14
2.9 +- 1.5 3. I ± 1.9
p.o. i.m.
Codeine Codeine
24 4
16. I -~-8.6 *
p.o. p.o.
Oxycodone Methadone
p.o.
Alphaprodine Tylenol None
2 I
* *
* *
1 1 24
* * *
* * *
1.3- 7.5 - 7.5
I
5 -45
B
274 T A B L E VI PSYCHOTROPIC DRUG USE DEBRIDEMENT FOR CHILDREN N p.o. i.m. i.v.
D i a z e p a m (Valium) Diazepam Diazepam
i.m. p.o. i.v.
X dose (rag)-+ S.D.
Range (mg)
14 5 5
3.8--- 3.0 2.9+ - 0.7 1.8 +- 0.9
i -10 2.5 - 3.5 0 . 7 5 - 2.5
Hydroxyzine (Vistaril) Hydroxyzine Hydroxyzine
6 5 1
14.6-+ 3.3 35.0-+ 16.4 * *
10 - 17.5 17.5 - 5 0 *
i.m. p.o.
C h l o r p r o m a z i n e (Thorizine) Chlorpromazine
5 2
21.0-+ 13.9 * *
10 *
-40
i.m. i.v.
Ketamine Ketamine Other
5 2 10
44.8-+ 14.7 * * * *
25 * *
-56
psychotropics be used in conjunction with narcotic analgesics (and ! ! recommended using only psychotropics). Two of the 7 units using ketamine employ an anesthesiologist, and one unit of the 3 recommending nitrous oxide uses an anesthesiologist as well as pretanking narcotic analgesics. Of note, despite the higher percentage of respondents who recommended using no narcotics or no psychotropics or no analgesia at all, the difference between the mean assessment of pain for children (2.9) and that for adults (3.0) was not significant. Finally, 67% of the respondents (116 out of 174) stated that the treatment of pain at their burn facilities was satisfactory. Only 8% of the respondents (14 out of 174) indicated they thought the side effects of analgesics or the risk of addiction prevented using higher dosages. Of the 12% who knew of a patient who had become a drug abuser upon discharge from the hospital as a result of receiving narcotic analgesics for burn pain, all but one said the patient had a previous history of drug abuse. The exception was one respondent who said that a 3-year-old child became 'addicted' because he required methadone upon discharge from the hospital.
Discussion
This survey was intended to document the analgesic methods used for debridement by burn facilities in the United States. That goal was accomplished. The 181 completed questionnaires represented burn units throughout the country and offered an opportunity for a statistical analysis of how a typical adult and child would be provided pain relief for tanking. At first glance the data would suggest a fair degree of uniformity: most adult patients before tanking are given a narcotic analgesic with or without a psychotropic drug and experience moderate pain during the procedure. When the data are examined more carefully, this apparent uniformity breaks down. An important
275 difference between units is the relative amount of narcotics used. On one extreme are those respondents who recommend 35 m S i.m. morphine and at the other extreme are those who for the same described adult patient would use 30 mg p.o. codeine, a 35-fold difference, when the route and relative potency are considered [24]. Although these respondents represented the extremes, a wide range of dosages is reflected throughout; for example, the mean dosage of intravenous morphine was 8.9 mg with a standard deviation of 5.4 rag. Thus, as many respondents were inclined to give 3.5 mg i.v. morphine as 14.3 mg, a notable difference. The spectrum becomes even wider when one considers that many respondents recommend using no narcotics at all, preferring diazepam, ketamine, nitrous oxide or nothing. Eleven respondents - - all from different units - - indicated that no drug or gas would be given to the described child for the tanking procedure. Despite the extreme difference of opinion regarding the amount of analgesia required, the respondents showed little variation in their rating of how much pain the described patient would then experience during the tanking procedure after the recommended drugs or anesthetic gases were given. As already shown by Table Ill, a large majority (70%) placed the patient's pain in the moderate range between 2.5 and 3.5. The idea that a patient could receive 5, 10, 15 or even 35 times more pain medication for a procedure and still be rated as having the same degree of pain is an interesting finding and one worth trying to explain. One possible explanation is that the tanking itself varies from unit to unit. At one facility the debridement may be extensive, painful and require large amounts of analgesia whereas at another facility the procedure may be less vigorous or ambitious and accordingly not require as much pain medication. The skill and gentleness of the debrider and the non-pharmacological methods may also vary from one place to another. These intangibles could not be assessed by a questionnaire. Although we appreciate that each unit inevitably has its own means of offering comfort and support, without further documentation we are reluctant to assume that these differences explain why patients at one facility require so much more analgesia than at another facility when the task of removing necrotic skin is basically the same. Another possible explanation for why some respondents recommended far more pain medication than others is that on many units the analgesic requirements for the tanking procedure may be underestimated; that is, although the staff may believe that patients only experience moderate pain during debridement, the pain is actually more severe. Some unpublished studies support this possibility: a group of researchers studying pain at the Burn Center in Seattle [25] reported that two-thirds of the patients they surveyed rated their pain after an analgesic and during tanking as equal to or worse than the worst pain they had ever experienced; similarly, patients in the Burn Center of The New York Hospital were given a mean of 8.9 MSi.m.EQ and 84~ of the 52 patients studied rated their pain as severe or excruciating during tanking [26]. This discrepancies between how staff and patients rate the severity of pain is not unusual. Studies have documented the poor reliability between objective and subjective assessment [27,28] and the tendency for staff members to underestimate the degree of pain [29]. This tendency may be even more pronounced on a burn unit where the staff is not only responsible for relieving the pain, but also is
2"/6 responsible for causing the pain during therapeutic procedures. Those inflicting the pain may understandably be reluctant to acknowledge the pain severity. The group of respondents recommending relatively low dosages of narcotics and the group recommending no narcotics at all are both worth noting. This survey revealed that on many units patients receive only psychotropics or, particularly with children, receive no drugs or anesthetic gas whatsoever. In the case of using only a psychotropic such as diazepam or chlorpromazine, studies have shown that the majority of tranquilizers may reduce the anxiety associated with pain and may alter the behavioral expression of pain, but do not in themselves have documented analgesic properties [30,31]; nor is the evidence yet sufficient to support the belief that these drugs potentiate the analgesic properties of narcotics [32]. If such tranquilizers are being used primarily for pain relief, then further evidence will be necessary to establish their efficacy. In the same way, although hydroxyzine (Vistaril) has been shown to have analgesic properties of its own in high dosages [33], the analgesic properties of this drug for tanking may be overvalued when used alone in dosages less than 100 mg i.m. or when used with small dosages of narcotic analgesics. The number of respondents recommending no analgesia, psychotropics or anesthetics for debridement is also perplexing, especially since their rating of the patient's pain is no greater than the rating given by those who do provide some pharmacological method of pain relief. In fact, this survey found that the pain was rated most severe by those who provided the most analgesia. But caution must be exercised before arbitrarily condemning those who recommend no pretanking medication. Until the efficacy of other methods has been more fully evaluated, the possibility exists that even those prescribing moderate or high dosages of narcotics are not providing any more pain relief than those prescribing no drugs at all. A concern does remain, however, that some burn units have prematurely given up a search for providing adequate analgesia either because of frustration over ever finding a safe and effective method or perhaps because of the belief that children do not remember pain [34]. Although the findings of this survey did raise several questions about the efficacy of some analgesic methods currently in use, two issues regarding the management of burn pain were somewhat demythologized. First, anecdotal reports have suggested that physicians and nurses differ in how they assess a patient's pain, the notion being that nurses are more directly aware of the patient's pain problems and believe that analgesic requirements are greater. This study did not reveal such a discrepancy. Regardless of the respondent's role, staff members tended to rate the patient's pain the same. The one statistically significant difference we did find was that staff members who had spent less time on the job tended to rate the patient's pain higher, suggesting either staff members become more impervious to the patient's pain over time or that those who rate the patient's pain as less severe tend to remain working with burn patients longer. A second myth which this study may have partially corrected is that the prolonged use of narcotic analgesics for burn pain will lead ~o addiction. Of the 181 respondents h with an average experience of over 6 years on a burn unit and representing the accumulated knowledge of at least 10,000 hospital-
277 TABLE VII HOW DOES T H E PAIN O F BURN PATIENTS A F F E C T YOU? 'It takes time getting used to but in time it is fairly easy to block out.' 'Have feeling of empathy - - try to be quick.' "It is almost an unavoidable part of burn care.' 'I apologize to patients - - I rock an infant - - I don't like to hurt them.' 'It bothers me - - sometimes I think 1 have become calloused to some of the pain.' 'Since burn care can be a very long process - - months - - I feel that giving medication every day will only hurt the patient. If he can tolerate the pain during tanking, why take the chance of having to detoxify the patient from possible addiction to drugs?' 'So much of the problem seems to be fear complicated by pain.' 'I strongly feel that more aggressive treatment of pain in burned children is indicated.' 'There are times when I feel guilty about the pain the patient is experiencing - - alter painful debridement I try to spend time with my patients by playing with them." "Pretank reeds do not seem to relieve the pain unless given in large doses." 'Makes me feel uneasy.' 'I feel it.' 'Bothersome but not troubling.'
ized burn patients m not one case of an actual iatrogenic addiction could be documented. The 22 patients reported to abuse drugs after discharge all had a prior history of drug abuse. We have reserved until last any discussion about the effects of burn pain on the respondents because this area is more impressionistic and hard to quantify in any way that conveys the poignancy of the many statements made on the open-ended section of the questionnaire. Just as the prompt and large response to the time-consuming form showed a general interest in the management of burn pain, so the personal comments indicated a concern about how the pain affected patients and staff. This same concern is reflected in the many presentations about pain at recent meetings of the American Burn Association [35-38]; yet the staff's attitude about pain is not always consistent with the pharmacological management [39]. For example, Table VII lists some of the comments made by the respondents who recommended no pretanking analgesia for children and who assessed the pain as moderate or less. This kind of ambivalence is implied by the last statement listed, 'bothersome but not troubling.' What does this mean?
Conclusion Because of the generous participation by 181 staff members of 93 burn units throughout the United States, this study was able to document current analgesic methods used for the tanking procedure and was able to determine what factors correlated with how burn pain was assessed and treated.
278
In reference to debridement for adults: (!) about two-thirds of the respondents used morphine or meperidine, but the dosage varied widely; (2) the assessment of pain was not statistically different regarding the type of narcotic used or the route of administration (i.v., i.m. or p.o.); (3) about half the respondents used psychotropic drugs (particularly diazepam or hydroxyzine) in conjunction with narcotics, but without a reduction in the dosage of the narcotics or a reduction in the assessment of pain; (4) the respondents who assessed the pain as most severe after analgesia, preferred higher dosages before tanking; (5) no difference was found between how nurses and physicians rated the patient's pain, but those staff members who had spent less time on the job rated the patient's pain as more severe. In reference to debridement for children: (1) narcotics, if used, tended to be given in a larger milligram per kilogram dosage; (2) psychotropic drugs in conjunction with narcotics were used less than with adults (24% vs. 52%); (3) despite the higher percentage of respondents who recommended using no narcotics or no psychotropics or no analgesia at all, the general assessment of pain for children and adults was the same, i.e. the moderate range. This study was not capable of determining what analgesic methods for debridem,ent of burn patients are most effective, but the issues raised by the survey might stimulate all of us to reconsider our routine prescriptions for pain and to document more carefully the pain relief we provide.
Acknowledgements The authors wish to express their appreciation to Michael DeMeo, Annette Pols, Ruth Strassner, Florence Weicker and Eienor West for their assistance in the preparation of this paper and to Kathleen Foley, M.D. and Stanley Wallenstein, M.S. for their critical appraisals.
References I Butzer, S. Kuehn, C., Wilcox, F. and Solem, L., Methodone: an old analgesic rediscovered, Presented at the American Burn Association I lth Annual Meeting, 1979. 2 Nova, J., Large dose morphine for pain control, Presented at the American Burn Association Meeting, San An~0~nio,Texas, 1980. 3 Baskett, P., Analgesia for the dressing of burns in children: a method using neuroleptanalgesia and entonox. Postgrad. Med., 48 (1972) 138-142. 4 Cosgrave, P., Filkins, $., Marvin, J. et ai., Dolonox: a method of pain control, Presented at the American Burn Association Meeting, San Antonio, Texas, 1980. 5 Demling, R.H., Ellerby, S. and Jarrett, F., Ketamine anesthesia for tangential excision of burn eschar: burn unit procedure, J. Traume 18 (1978) 269-270. 6 Slogoff, S., Allen, G.W., Wessels, J.V. and Cheney, D.H., Clinical experience with subanesthetic ketamine, Anesth. Anaig. Curr. Res., 53 (1974) 354-358. 7 Calverley, R.K., Repeated methoxyflurane analgesia for burns dressings, Brit. J. Anaesth., 44 (1972) 628. 8 Firn, S., Methoxyflurane analgesia for burns, dressings and other painful ward procedures in children, Brit. J. Anaesth., 44 (1972) 517, 520-522.
279 9 Marshall, M.A. and Ozorio, H.P., Analgesia for burns dressing using methoxyflurane. Brit. J. Anaesth., 44 (1974) 80-82. I0 Packer, K.J., Methoxyflurane analgesia for burns dressing.g, Postgrad. Med., 48 (1972) 128-132. I i Hartley, R.B., Hypnosis for alleviation of pain in treatment of burns: case report, Arch. phys. Med. Rehab., 49 (1968) 39-41. 12 Wakeman, RJ. and Kaplan, J.Z., An experimental study of hypnosis in painful burns, Amer. J. clin. Hypnos., 21 (1978) 3-11. 13 Dahinterova, J., Some experiences with the use of hypnosis in the treatment of burns, Int. J. clin. exp. Hypnos., 15 (1967) 49-53. 14 Simons, R.D., Morris, J.L., Frank, H.A., Green, L.C. and Malin, R., Pain medication contracts for problem patients, Psychosomatics, 20 (1979) 123-127. 15 Simons, R.D., McFadd, A., Frank, H.A., Green, L.C., Malin, R.M. and Morris, J.L., Behavioral contracting in a burn care facility: a strategy for patient participation, J. Trauma, 18 (1978) 257-260. 16 Fagerbaugh, S., Pain expression and control on a burn care unit. Nsg Outlook, 22 (1974) 645-650. 17 Morris, J, and McFadd, A., The mental health team on a burn unit: a multidisciplinary approach, J. Trauma, 18 (1978) 658-663. 18 Miller, W.C., Gardner, N. and Inholt, S., Psychosocial support in the treatment of severely burned patients, J. Trauma, 16 (1976) 722-725. 19 Mattson, E.I., Psychological aspects of severe physical injury and its treatment. J. Trauma. 15 (1975) 217-235. 20 Goodstein, R.K. and Hurwitz, T.D., The role of the psychiatric consultant in the treatment of burned patients, Int. J. Psychiat. Med., 6 (1975) 413-429. 21 Cromes, G.F., McDonald, M. and Robinson, C., The effects of relaxation training on anxiety and pain during burn wound debridement, Presented at the American Burn Association Meeting, San Antonio, Texas, 1980. 22 Directory of Burn Care Facilities, Alisa Ann Ruch Burn Foundation. Sherman Oaks, Calif., 1980. 23 Houde, R.W., The management of pain. In" R.L. Clark, R.W. Cumby, J.E. McCoy and M.M. Copeland (Eds.), Oncology: Diagnosis and Management of Cancer, Vol. 111. Year Book Medical Publishers, Chicago, 111., 1971, pp. 489-496. 24 Houde, R.W., lbid, p. 493. 25 Charlton, J.E., Burns, M., Heinbach, D.M. et al., Factors affecting pain complaints in patients with bums, Presented at the American Pain Society Meeting, San Diego. Calif.. 1979. 26 Unpublished data, Burn Pain Research Section, New York Hospital, Cornell Medical Center Burn Center. 27 Lira, R.K.S. and Guzman, F., Manifestations of pain in analgesic evaluation in animals and man. In: J. Cahn and J. Charpentier (Eds.), Pain Proceedings of the International Symposium on Pain. Academic Press, New York, 1968, pp. 139-152. 28 Wailenstein, S.L. and Houde, R.W., The clinical evaluation of analgesic effectiveness. In: S. Ehrenpreis and A. Neidle (Eds.), Methods in Narcotics Research, Marcel Dekker, New York, 1975. pp. 127-145. 29 Marks, R.M. and Sachir, EJ., Undertreatment of medical inpatients with narcotic analgesics. Ann. intern. Med., 78 (1973) 17.~-181. 30 Houde, R.W. and Wallenstein, S.L., Analgetic power of chlorpromazine alone and in combination with morphine, J. Pharmacol. exp. 1"her., 14 (1955) 353. 31 Keats, A.S., Telford, J. and Kurow, Y., Potentiation of meperidine by promethazone, Anesthesiology, 22 (1961) 34-41. 32 Beaver, W.T., Interaction of narcotics and mood altering drugs: a brief historical rcview. In" Recent Studies of the Nature and Management of Acute Pain: a Symposium. HP Publishing Co., New York, 1976, pp. 8-13. 33 Beaver, W.T. and Feise, G., Comparison of the analgesic effects of morphine, hydroxyzine, and their combination in patients with postoperative pain. In: J.J. Bonica and D. Albe-Fessard (Eds.). Advances in Pain Research and Therapy, Raven Press, New York, 1976, pp. 553-557. 34 Eland, J.M. and Anderson, J.E., The experience of pain in children. In: A. Jac~x (Ed.), A Source Book for Nurses and Other Health Professionals, Little, Brown and Co., Boston, Mass., 1977. pp. 453-473.
280 35 36 37 38 39 40 41 42
43
Nova, J., Ibid, 1980. Cromes, G.H., Ibid, 1980. Butzer, S., Ibid, 1979. Cosgrave, P., Ibid, 1980. Orgun, C., Marvin, 3. and Heh'lbach, D.M., Exploring pain management practices, Presented at the American Bum Association Meeting, New Orleans, La., 1979. Mattssin, E.I., Psychological aspects of ~vere physical inju~ and its treatment, J. Tr~tuma, 15 (19"15) 217-235. Wallenstein, S.L., Heidrich, III, G., Kaiko, R. et al., Clinical evaluation of mild analgesics: the management of clinical pain, Brit. J. cfin. Pharmacol., 10 (1980) 319S-327S. Tursky, B., The development of a pain perception profile: a psychophysical approach. In: M. Weisenberg and B. Tursky (Eds.), Pain: New Perspectives in Therapy and Research, Plenum Press, New York, 1975, pp. 171-194, Wallenstein, S.L. and Houde~ R W., The clinical evaluation of analgesic effe~Aiveness.In: S. Ehrenpreis and A. Neidle (Eds.), Methods in NarcoticsResearch, Marcel Dekker, New York, 1975, pp. 127-145.