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Abstract Pain management guidelines for burn injury in pregnant women are scarce. Maternal and fetal morbidity and mortality in pregnant burn patients have been shown to be higher than that of the general population, especially in severe burns. Early intervention and interdisciplinary treatment are critical to optimize maternal and fetal outcomes. Proper pain management is central to wound treatment, as poor control of pain can contribute to delayed healing, re-epithelialization, as well as persistent neuropathic pain. We present this case of a 34-year-old female patient who suffered an 18% total body surface area burn during the third trimester of pregnancy to demonstrate that ketamine can be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multimodal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection.

IntroductionErector spinae plane blocks have become popular for thoracic surgery. Despite a theoretically favorable safety profile, intercostal spread occurs and systemic toxicity is possible. Pharmacokinetic data are needed to guide safe dosing.MethodsFifteen patients undergoing thoracic surgery received continuous erector spinae plane blocks with ropivacaine 150 mg followed by subsequent boluses of 40 mg every 6 hours and infusion of 2 mg/hour. Arterial blood samples were obtained over 12 hours and analyzed using non-linear mixed effects modeling, which allowed for conducting simulations of clinically relevant dosing scenarios. The primary outcome was the Cmaxof ropivacaine in erector spinae plane blocks.ResultsThe mean age was 66 years, mean weight was 77.5 kg, and mean ideal body weight was 60 kg. The mean Cmaxwas 2.5 ±1.1 mg/L, which occurred at a median time of 10 (7–47) min after initial injection. Five patients developed potentially toxic ropivacaine levels but did not experience neurological symptoms. Another patient reported transient neurological toxicity symptoms. Our data suggested that using a maximum ropivacaine dose of 2.5 mg/kg based on ideal body weight would have prevented all toxicity events. Simulation predicted that reducing the initial dose to 75 mg with the same subsequent intermittent bolus dosing would decrease the risk of toxic levels to <1%.ConclusionLocal anesthetic systemic toxicity can occur with erector spinae plane blocks and administration of large, fixed doses of ropivacaine should be avoided, especially in patients with low ideal body weights. Weight-based ropivacaine dosing could reduce toxicity risk.Trial registration numberNCT04807504; clinicaltrials.gov.

Introduction Burn injury is the fourth most common form of trauma worldwide, requiring unique management considerations and a collaborative approach to treatment. Thermal injuries sustained during pregnancy add considerably to case complexity. Overall, there is a low incidence of burns in gravid women living in developed countries, making management guidelines in this patient population scarce. Despite few data, it is recognized that early intervention and inter-disciplinary treatment are critical to optimize maternal and fetal outcomes. Thus, interventions including fluid resuscitation, excision and grafting, routine debridement and dressing changes, antibiotic administration, and early mobilization are the cornerstones of management. Effective pain management is crucial in allowing patients to tolerate these often-painful procedures, engage in rehabilitation, and to prevent pain-related morbidity. Methods The patient is a 34-year-old G5P3013 in her third trimester of pregnancy, who sustained partial and full thickness burns to 18% of total body surface area in a grease fire. She was brought to the ED approximately 2 hours post-injury by EMS. During her hospital stay, Acute Pain Management Service (APMS) was consulted for a comprehensive pain management plan. APMS recommendations included IV acetaminophen, hydromorphone PCA, gabapentin, and ketamine infusion with a reduced dose bolus for procedural analgesia. Risks and benefits of these medications were explained to patient and her family by the APMS, Maternal-Fetal Medicine, and the Burn team, stressing the importance of tolerating routine burn care to decrease morbidity. Although human data are limited, it was explained that low doses (as outlined in our regimen) present little fetal risk in animal models. Results The patient was discharged at hospital day 11 and seen for burn follow-up after 2 weeks post-discharge (35 weeks gestation) with returning color, no evidence of hypertrophy, and overall excellent wound healing. Patient reported no pain, and her pain regimen was discontinued. Patient demonstrated significant improvement in her injuries, and had a normal spontaneous vaginal delivery of a live born male 7 weeks post discharge, with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Additionally, the patient brought her infant to the office visit and conveyed that the child was consistently reaching pediatric milestones. Conclusions Ketamine may be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multi-modal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection. Applicability of Research to Practice Procedural pain management in a third-trimester burn patient.