Letter to the Editor
Intervention to reduce pain in patients with superficial and intermediate second degree burns
A propósito de una intervención para disminuir el dolor a pacientes con quemaduras de segundo grado intermedio-superficiales
M.Á. Luengo-Pastor, R. Guerrero-Domínguez
, E.C. Navarro-Suárez, C. Rasero-Moreno
Corresponding author
Servicio de Anestesiología y Reanimación, Hospital de Rehabilitación y Traumatología, Hospital Virgen del Rocío, Sevilla, Spain
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Un caso clínico" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1160 "Ancho" => 1133 "Tamanyo" => 192454 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ultrasound imaging of the ESPB after performing the block. Note the spread of local anaesthetic beneath the erector spinae muscle. TP – transverse process, N – needle, ESM – erector spinae muscle, LA – local anaesthetic.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J. Brandão, R. Graça, M. Sá, J.M. Cardoso, S. Caramelo, C. 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Luengo-Pastor, R. Guerrero-Domínguez, E.C. Navarro-Suárez, C. Rasero-Moreno" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M.Á." "apellidos" => "Luengo-Pastor" ] 1 => array:4 [ "nombre" => "R." "apellidos" => "Guerrero-Domínguez" "email" => array:1 [ 0 => "rosanabixi7@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "E.C." "apellidos" => "Navarro-Suárez" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Rasero-Moreno" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de Rehabilitación y Traumatología, Hospital Virgen del Rocío, Sevilla, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "A propósito de una intervención para disminuir el dolor a pacientes con quemaduras de segundo grado intermedio-superficiales" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 864 "Ancho" => 905 "Tamanyo" => 80243 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Enzymatic debridement with Nexobrid<span class="elsevierStyleSup">®</span> in a patient with infraclavicular catheter (arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Burns are a major thermal insult and cause intense pain. Demand for analgesia during treatment varies due to the multiple factors involved in the aetiology of pain and the different therapeutic procedures performed.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the Burn Unit of the Virgen del Rocío Hospital, about 200 surgical procedures are performed for acute burns. Around 17 patients/year with superficial and intermediate second degree burns affecting the upper limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) are treated with several sessions of enzymatic debridement with Nexobrid<span class="elsevierStyleSup">®</span>. Acute postoperative pain has a significant affect on both the physical and mental recovery of the patient. Poor pain management can lead to chronic pain (in more than 50% of cases), paresthesia or dysesthesia.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> These patients are also at higher risk of complications, such as psychiatric disorders (depression or post-traumatic stress disorder).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">In recent years, our team of anaesthesiologists has been using an effective and novel analgesic alternative. Application and removal of the product at 4<span class="elsevierStyleHsp" style=""></span>h is particularly painful, because of the debriding activity of the gel. For this reason, 8 patients received locoregional analgesia delivered through a catheter located at the infraclavicular level of the brachial plexus.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The gold standard analgesic treatment consists of the intravenous administration of μ-opioid receptors, which are associated with several side effects, including nausea, vomiting, pruritus, constipation, urinary retention, sedation, delirium and potentially fatal adverse events such as respiratory depression and a higher rate of infection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> This can prolong hospital stay, and increase the overall cost of care.</p><p id="par0025" class="elsevierStylePara elsevierViewall">To avoid the administration of intravenous opioids, we perform loco-regional brachial plexus block using local anaesthetics. The role of local anaesthetics as an analgesic alternative is supported by several studies that have shown them to be safe and effective in burn patients. This technique reduces the incidence of opioid-related adverse effects, primary and secondary hyperalgesia, and the pain wind-up phenomenon.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Local anaesthetics block neural transmission when administered centrally (intradural or epidural) or peripherally by means of a single injection or continuous catheter infusion.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> The treatment of burns depends on the affected skin area and the depth of the lesion. The treatment strategy of choice is early surgical debridement followed by autograft, which reduces late scarring and the rate of infection, sepsis and bacterial colonisation. However, removal of eschar using dermatomes is a source of morbidity in itself, especially due to blood loss and haemodynamic changes. Several enzymatic debriding agents, such as Nexobrid<span class="elsevierStyleSup">®</span>, have been developed as an alternative to dermatome debridement. There is considerable evidence that these agents reduce the need for skin graft, the risk of infection, blood loss, the number of interventions needed and hospital stay.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Application of the agent is extremely painful, and requires analgesia, analgosedation or anaesthesia, depending on the depth and extent of the burn. Good pain management is essential before, during and after the procedure.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We use an effective alternative that involves infraclavicular brachial plexus nerve block to provide analgesia for isolated superficial and intermediate second degree burns on the upper extremities. Local anaesthetic is administered in continuous perfusion via a catheter due to the intense pain caused by application and removal of the product.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The anaesthetic used was 20–30<span class="elsevierStyleHsp" style=""></span>ml of 0.5% ropivacaine, which was administered prior to application of Nexobrid<span class="elsevierStyleSup">®</span>, followed by continuous infusion of ropivacaine 0.2% at a rate of 8<span class="elsevierStyleHsp" style=""></span>ml/h. The patient-perceived level of analgesia achieved was rated as 1–2 on visual analogue scale (VAS), except in 2 cases in which the VAS score was 4, which required a re-placement of the catheter. One of these 2 cases required additional analgesia with iv morphine. We observed the following benefits: an optimal level of analgesia was guaranteed, with complete anaesthesia of the area in 7 cases. In these 7 cases, no opioids or other drugs with a potential risk of respiratory depression were needed and, therefore, the safety profile with respect to the standard analgesic technique was improved. Less demand for analgesia and a lower incidence of analgesia-related side effects lightened the work load of the attending team. The infraclavicular catheter delivering the local anaesthetic was placed in the burn unit, thus reducing the number of surgical interventions (sacrectomy) under general anaesthesia and avoiding complications derived from the blood loss. In short, treatment outcomes were optimised, accelerating the healing and scaring process, avoiding the delays associated with the surgical approach, and reducing the hospital stay. The patients were satisfied with this analgesic approach, which reduced previously described psychological problems such as anxiety resulting from incomplete analgesia. The analgesic technique was far superior to standard analgesia, both in terms of quality and in reducing burn-related complications, and facilitated early start of rehabilitation and greater functional recovery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Analgesic treatment should evolve in parallel with the major advances made in the therapeutic management of burn patients. Therefore, we believe that this analgesic alternative should be taken into consideration as a safe, effective approach to the treatment of patients with superficial and intermediate second degree burns.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Luengo-Pastor MÁ, Guerrero-Domínguez R, Navarro-Suárez EC, Rasero-Moreno C. A propósito de una intervención para disminuir el dolor a pacientes con quemaduras de segundo grado intermedio-superficiales. 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| 2023 March | 2 | 3 | 5 |
