Doctors at the U.S. Army Institute of Surgical Research Burn Center at Joint Base San Antonio-Fort Sam Houston are utilizing a novel method of administering pain medication to burn patients in the burn intensive care unit in hopes to mitigate opioid addiction and other complications associated with burn care.
"It's something different," said Dr. Clayne Benson, assigned to Brooke Army Medical Center, collocated with the USAISR Burn Center. "But the promise and benefits are huge."
The pain medication is managed with the placement of an intrathecal catheter and infusion of preservative-free morphine. The concept is similar to epidural anesthesia used during labor for pain relief, except the catheter resides in the intrathecal space where the cerebrospinal fluid resides instead of the epidural space.
The catheter used is exactly like an epidural catheter used for laboring women.
"It's an FDA-cleared device for a procedure that a lot of anesthesiologists have done for other reasons," Benson said. "It had never been done on burn patients and we presented the idea of the study to the burn center leadership [Drs. Booker King, Lee Cancio, Jennifer Gurney, Kevin Chung and Craig Ainsworth] and they agreed to try this initiative."
Benson, an Air Force Reserve lieutenant colonel, got the idea of using this technique in the intensive care unit while taking care of polytrauma soldiers at Landstuhl Regional Medical Center in Germany from 2009-2012. Benson said he is excited about the potential of this new pain management for burn patients.
"The results are amazing," he said. "The best thing about it is that it only uses one-one hundredth of the amount of pain medication used with the traditional [intravenous] method."
Intrathecal medication is delivered straight to where it is effective, the spinal cord, thereby minimizing systemic complications of IV medications.
Intravenous medication disperses pain medication throughout the entire body and only a tiny percentage of it gets to where it is needed. This is especially beneficial for burn patients who require numerous painful operations and traditionally require being placed on a ventilator, with one of the reasons being pain control.
Longer ventilator times lead to complications like deconditioning, delirium, and pneumonia, which all impact quality of life and time in the Burn Intensive Care Unit.
Dr. Richard Erff, chief of the Carl R. Darnall Army Medical Center Pain Clinic, administers cervical epidural steroid injections to a Soldier who suffers from chronic neck and back injuries stemming from his deployment to Iraq. (Army Photo by Patricia Deal)
"Also, the majority of patients who are mechanically ventilated are diagnosed with delirium and are likely to have increased length of hospitalization, increased ventilator days, and higher rates of long-term cognitive dysfunction," Benson said.
Delirium is another complication burn patients experience with exposure to sedatives and pain medications.
"Delirium is when a patient's awareness changes and they become confused, agitated, or they completely shut down," said Sarah Shingleton, chief wound care nurse and clinical nurse specialist at the USAISR Burn Center Intensive Care Unit. "It can come and go, and is caused by a number of things to include different pain medications, pain, infections, a disturbed sleep cycle, or an unfamiliar environment."
Members of the USAISR Burn Center Intensive Care Unit will present the data of the initiative at the 2018 American Burn Association meeting in April 2018. The presentation will describe a patient who sustained 45 percent burns to her body and had her pain and sedation managed with the placement of the intrathecal catheter.
The abstract prepared for the ABA meeting states, "During intrathecal administration of morphine, IV infusions of ketamine, propofol, and dexmedetomidine were discontinued. The patient was awake and responsive, reporting adequate pain control without systemic opioid administration. Following removal of the intrathecal morphine infusion, the patient's opioid requirement remained lower than prior to catheter placement despite repeated surgical interventions."
"This novel way of achieving pain control helped us get our patients off mechanical ventilation faster and shorten the time they needed to be in the [intensive care unit]," said Maj. (Dr.) Craig Ainsworth, Burn Intensive Care Unit medical director. "We are excited to share this treatment option with other members of the burn care community so that we can better care for our patients."
Benson's goal is to someday apply this type of pain management to patients with polytrauma to reduce pain and the amount of pain medication which could potentially lessen addictions to pain medication.
"It's a new approach and I hope that eventually it becomes the main mode of pain control for burn and polytrauma patients," Benson said. "It has been a good team effort with the burn staff and their 'can do' attitude. I'm looking forward to where this leads. I believe it will change pain management as well as help to prevent opioid addiction in patients who have suffered from polytrauma and burns."