How to manage pain in an ICU patient with burns due to pressure on the skin?

Managing Pain from Pressure on Skin in ICU Burn Patients

Immediately place the patient on a pressure-relieving mattress in a temperature-controlled environment (25-28°C) and use non-adherent dressings to minimize shearing forces, while administering titrated IV opioids (fentanyl preferred) combined with ketamine for severe pain. 1, 2

Environmental and Positioning Interventions

Pressure Relief (Critical First Step)

• Place patient on a pressure-relieving mattress immediately to minimize pressure-related pain and prevent further skin damage 1
• Maintain ambient room temperature between 25°C and 28°C to reduce metabolic stress and improve comfort 1
• Control humidity in the patient's room to support skin barrier function 1
• Practice anti-shear handling techniques when moving or repositioning the patient, as burn skin is extremely fragile and prone to detachment at pressure points 1

Skin Protection Measures

• Apply frequent bland emollient (50% white soft paraffin with 50% liquid paraffin) over the entire epidermis to support barrier function and reduce transcutaneous water loss 1
• Use non-adherent dressings (such as Mepitel™ or Telfa™) on denuded areas to prevent adherence and minimize pain during dressing changes 1
• Apply secondary foam or burn dressings to collect exudate and provide cushioning 1
• Leave detached epidermis in situ when possible to act as a biological dressing 1

Pharmacological Pain Management

Primary Analgesic Strategy

• Administer titrated IV short-acting opioids (fentanyl preferred) as the mainstay of burn pain management due to hypermetabolism and tolerance in burn patients 2, 3
• Combine IV ketamine with short-acting opioids for severe burn-induced pain, as this reduces morphine consumption while maintaining spontaneous breathing 2
• Titrate all analgesic medications based on validated pain assessment scales (CPOT for non-communicative patients, NRS for communicative patients) to prevent under- and overdosing 2, 4

Background vs. Procedural Pain

• Distinguish between continuous background pain and procedural pain, as they require different management approaches 2, 5
• For background pain: Use potent IV opioid infusions or patient-controlled analgesia, transitioning to oral opioids as tolerated 3
• For procedural pain (dressing changes, repositioning): Increase breakthrough analgesia with additional IV opioids and ketamine, or consider brief general anesthesia for highly painful procedures 2, 3

Multimodal Analgesia

• Consider drug combinations for optimal effect, as they often work better than single agents 3
• Administer acetaminophen and NSAIDs as adjuncts when not contraindicated 6
• Avoid alpha-2 receptor agonists (dexmedetomidine) in the acute phase due to hemodynamic instability risks 2

Non-Pharmacological Interventions

Cooling and Topical Measures

• Apply cooling to limited burned surfaces to improve pain control and limit burn deepening, but monitor for hypothermia 2, 7
• Cover burns with fatty substances (petrolatum-based products) to improve pain control 2

Psychological Support

• Consider virtual reality or hypnosis techniques to reduce pain intensity and anxiety when the patient is stable 2
• Implement cognitive and behavioral techniques, massage, or auricular electrical stimulation as adjuncts 3

Critical Safety Considerations

Monitoring Requirements

• Perform routine pain evaluation using validated scales (CPOT for mechanically ventilated/non-communicative patients, NRS for communicative patients) 1, 4
• Monitor for signs of inadequate pain control: tachycardia, hypertension, agitation, or behavioral indicators 1
• Assess for complications of unrelieved pain: increased catecholamines causing vasoconstriction, hypermetabolism, hyperglycemia, and muscle breakdown 1

Long-term Implications

• Recognize that burn pain often persists beyond wound healing and requires extended management 2, 5
• Be aware that inadequate pain control increases risk of chronic pain syndromes (38%), PTSD (27%), and reduced quality of life 1
• Understand that repetitive highly nociceptive procedures can lead to central neuronal sensitization if pain control is inappropriate 2, 5

Common Pitfalls to Avoid

• Never use IM or subcutaneous opioid administration in acute burn patients due to unpredictable absorption from capillary leakage and hypovolemia 2
• Do not underestimate pain in non-communicative patients; use behavioral pain assessment tools 1
• Avoid inadequate dosing of opioids due to fear of respiratory depression—burn patients often require significantly higher doses than typical postoperative patients 2, 5
• Do not neglect the psychological component of pain; address anxiety and provide psychological support 3, 5