The risks of sedation and pain control during burn resuscitation: Increased opioids lead to over-resuscitation and hypotension

Abstract

IntroductionPain management and sedation are necessary in severely burned persons. Balancing pain control, obtundation, and hemodynamic suppression can be challenging. We hypothesized that increased sedation during burn resuscitation is associated with increased intravenous fluid administration and hemodynamic instability. MethodsA retrospective review of a single burn center was performed from 2014 to 2019 for all admissions to the burn unit with > 20% total body surface area (TBSA) burns. Within 48 h of admission, we compared total amounts of sedation/pain medications (morphine milligram equivalents (MME), propofol, dexmedetomidine, benzodiazepines) with total resuscitation volumes and frequency of hypotensive episodes. Resuscitation volumes and frequency of hypotension were modeled with multivariable linear regression adjusting for burn severity and weight. Results208 patients were included with median age of 43 years (IQR 29–55) and median %TBSA of 31 (IQR 25–44). Median 48-hour resuscitation milliliters per weight per %TBSA were 3.3 (IQR 2.28–4.92). Pain/sedative medications included a combination of opioids in 99%, benzodiazepines in 73%, propofol in 31%, and dexmedetomidine in 11% of patients. MMEs were associated with greater resuscitation volumes (95% CI: 0.15–0.54, p = 0.01) as well as number of hypotensive events (95% CI: 1.57–2.7, p < 0.001). No associations were noted with other sedative medications when comparing the number of hypotensive events and resuscitation volumes. ConclusionsIncreased opioid administration has physiological consequences and should be carefully monitored during resuscitation as higher volume administrations lead to worse outcomes. Opioids and sedating medications should be titrated to the least amount needed to achieve reasonable comfort and sedation.