Evaluation of burn pain and its successful treatment has proven challenging for all staff who care for burn patients. As successful pain relief is important for full physical and psychological recovery, accurate assessment of burn pain is essential. The authors sought to prospectively evaluate two previously validated pain scales, the Critical Care Pain Observation Tool (CCPOT) and the Adult Nonverbal Scale (ANVS), in our burn population and compare them with patients' reports of pain. Both scales include nonverbal behaviors that are numerically scored and can be used in communicative as well as noncommunicative patients. Thirty-eight patients underwent 225 paired pain assessments. Assessments were compared with patients' self-reports of pain using the numeric rating scale (NRS) and the visual analog scale (VAS). Performance of the scales was evaluated by psychometric analysis. Logistic regression was used to compare pain scores with patient demographics, burn demographics, and administered analgesia. Both CCPOT and ANVS were internally consistent and able to discriminate pain intensity. However, these scales had poor interrater reliability. Furthermore, they correlated poorly with patients' self-reports of pain per the NRS and VAS pain scale scores. By logistic regression, all the pain scales showed a decrease in patient pain corresponding to the length of time after the burn. Otherwise, pain was not related to any patient demographics or evaluator experience. The size of burn was the only burn-related variable significantly associated with the pain scores, and this was only for the scores obtained with the CCPOT scale. In addition, only CCPOT and ANVS scales correlated with administered analgesia during hospitalization. The authors conclude that CCPOT and ANVS do not accurately assess pain in burn patients. However, it seems that the staff may administer analgesia based on several nonverbal clues encompassed in these scales. Future studies should address nonverbal signs of pain in burn patients. These signs could then be used in pain scales to target burn patient pain more effectively.

Administration of resuscitation volumes far beyond the estimates established by burn-body weight resuscitation formulas has been well documented. The reasons behind this increase are not clear. We sought to determine if our resuscitation volumes had increased and, if so, what factors were related to their increase. A retrospective chart review identified 154 patients admitted with burns greater than 20% of their BSA during the years of 1975-1976 (period 1), 1990-1991 (period 2), and 2006-2007 (period 3). Charts were reviewed for total fluids (crystalloid, colloid, and blood products) and opioids given before admission, during the first 8 hours of treatment, the next 16 hours of treatment, and the following 24 hours of treatment. Opioids were converted to opioid equivalents (OE). Multiple regression analysis was performed to determine the effects of variables of interest and control for confounders. Significance was assumed at the P < .05 level. Resuscitation fluid volumes increased significantly among adults from 3.97 ml/kg/%BSA during the first period to 6.40 ml/kg/%BSA during the third period (P < .01). The same trend in children <30 kg was not seen (P = .72). Fluid administered during the first 24 hours was significantly associated with age, BSA, intubation, latter two study periods, and opioid administration. Fluid administration was consistently associated with opioid administration at all measured time points. At 24 hours postburn, patients who received 2 to 4 OE/kg required an average of additional 3,650 +/- 1,704 ml of fluid, those receiving 4 to 6 OE/kg had required an average of 25,154 +/- 4,386 ml, and those who received >6 OE kg had required an average of 32,969 +/- 3,982 ml. In this single center retrospective study, we have shown a statistically significant increase in resuscitation fluids (from 1975 to 2007) and an association of resuscitation volumes with opioids. Opioids have been shown to increase resuscitation volumes in critically ill patients through both central and peripheral effects on the cardiovascular system. Because increased fluid resuscitation has been associated with adverse consequences in other studies, further research on alternative pain control strategies in thermally injured patients is warranted.