Itch in burn areas after skin transplantation: patient characteristics, influencing factors and therapy.

Pruritus is a frequently encountered symptom following burns. Higher intensity of itching has been associated with depth of the wounds and specific body locations but these differences are not well understood. Our aim was to investigate the intensity of post burn pruritus in grafted and non-grafted burns across anatomic areas and to report on itch-inducing factors and applied treatments. The study included 226 patients prospectively followed for 18 months. Results showed that grafted patients and non-grafted patients reported similar overall itch intensity in-hospital. At 3 months post burn, grafted patients had higher overall itch scores, a difference that was found robust across the study period. Grafted wounds were found to produce higher mean itch intensity at 3 months post burn but this difference disappeared at 12 months post burn. Differences in itch prevalence rates were found across anatomic areas, but only in non-grafted burns. The differences in itch intensity on patient level versus wound level suggest that on the longer run, peripheral mechanism do not explain the higher itch scores in grafted patients.

Pain in young children with burns: extent, course and influencing factors.

Little evidence is available on the extent, course and influencing factors of pain in young children with burns. At present, reliable and valid measurement instruments to assess pain behavior in these children are available, implying that valuable insight into these questions can now be obtained. The aim of this study is to document the extent and course of pain behavior with the COMFORT-B, and to assess factors that may influence procedural pain. First, cutpoints for COMFORT-B scores were established by Rasch analysis to assess clinically relevant changes. Second, the extent of background and procedural pain behavior was assessed by descriptive statistics. Third, the course and factors that may influence procedural pain behavior were investigated by latent growth modeling. Trained nurses collected pain behavior data in 168 children (mean age 20 months, mean TBSA 6%, mean length of stay 10 days). Cutpoints of COMFORT-B scores were as follows: 6-13 (mild pain), 14-20 (moderate pain) and 21-30 (severe pain). This study suggests that background pain is more adequately treated than procedural pain. Factors that influenced baseline pain scores and/or the course over 8 days included TBSA, the number of surgical procedures, acetaminophen administration by the referring hospital, and the application of hydrofiber dressings. The implications of these findings are discussed.

Repeated use of immersive virtual reality therapy to control pain during wound dressing changes in pediatric and adult burn patients.

The current study explored whether immersive virtual reality (VR) continues to reduce pain (via distraction) during more than one wound care session per patient. Thirty-six patients aged 8 to 57 years (mean age, 27.7 years), with an average of 8.4% TBSA burned (range, 0.25-25.5 TBSA) received bandage changes, and wound cleaning. Each patient received one baseline wound cleaning/debridement session with no-VR (control condition) followed by one or more (up to seven) subsequent wound care sessions during VR. After each wound care session (one session per day), worst pain intensity was measured using a visual analog thermometer, the dependent variable. Using a within-subjects design, worst pain intensity during wound care with no-VR (baseline, day 0) was compared with pain during wound care while using immersive VR (up to 7 days of wound care during VR). Compared with pain during no-VR baseline (day 0), pain ratings during wound debridement were statistically lower when patients were in VR on days 1, 2, and 3, and although not significant beyond day 3, the pattern of results from days 4, 5, and 6 are consistent with the notion that VR continues to reduce pain when used repeatedly. Results from the present study suggest that VR continues to be effective when used for three (or possibly more) treatments during severe burn wound debridement.

Construct validity of two pain behaviour observation measurement instruments for young children with burns by Rasch analysis.

In this study, construct validity of 2 pain behaviour observation measurement instruments for young children aged 1 to 56 months (mean age was 20 months) with burns is assessed by using Rasch analysis. The Rasch model, wherein data should meet the model expectations, assumes that an instrument measures one unidimensional construct, and focuses on the items of measurement instruments. The Pain Observation Scale for Young Children (POCIS) and the COMFORT Behaviour Scale (COMFORT-B) measure background and procedural pain as unidimensional. Adequate measurements for scientific research and daily practice can now be obtained.

Health-related quality of life after burns: a prospective multicenter cohort study with 18 months follow-up.

BACKGROUND: Health-related quality of life (HRQOL) is an important parameter after medical treatments. Knowledge of (predictors of) diminished quality of life can help improve medical outcome. The aim of this study was to quantify health loss in patients with burns and to assess the contribution of injury extent, age, gender, and psychologic factors to HRQOL and speed of recovery. A multicenter prospective cohort design was used to address these aims. METHODS: Data were obtained from 260 adults with burns. Patients completed the EQ-5D at 3 weeks, 3, 6, 9, and 18 months after burn and psychologic questionnaires during hospitalization. Patients' scores were compared with an age- and gender-weighted normpopulation. RESULTS: Patients suffered from substantial health losses at short term, but after 18 months the majority reached a HRQOL comparable with the norm population with the exception of patients requiring two or more surgeries. The best predictor of long-term HRQOL and the speed of recovery was the number of surgeries, followed by psychologic problems. Both predicted baseline and trajectories of improvement. Symptoms of traumatic stress were most debilitating over time. CONCLUSIONS: Both injury severity and psychologic problems play a pivotal role in reduced HRQOL and the speed of recovery. The number of surgeries seems to give a practically useful indication of the expected recovery speed that could aid in decision making and provides adequate information for patients in the aftermath of their initial surgical treatment. Screening for traumatic stress is recommended.

Reliability, validity and clinical utility of three types of pain behavioural observation scales for young children with burns aged 0-5 years.

Pain measurement is a prerequisite for individualized pain management and research into pain interventions. There is a need for reliable and valid pain measures for young children with burns. The aim of this study was to investigate whether the pain observation scale for young children (POCIS), the COMFORT behaviour scale (COMFORT-B) and the nurse observational visual analogue scale (VAS obs) are reliable, valid and clinically useful instruments to measure pain in children with burns aged 0-5years. Participating trained nurses (N=102) rated pain of 154 children during hospitalization. Two trained nurses simultaneously assessed pain at fixed intervals by using the previous mentioned measures. Cronbach's alpha for POCIS was .87 for background and .89 for procedural pain. Intraclass Correlation Coefficients (ICCs) were .75 for background and .81 for procedural pain. COMFORT-B observations yielded Cronbach's alpha of .77 for background and .86 for procedural pain and ICCs of .83 for background and .82 for procedural pain. The VAS obs resulted in ICCs of .55 for background and .60 for procedural pain. Correlation coefficient between POCIS and COMFORT-B was .79 (p<.01), Standardized response mean was 1.04 for both POCIS and COMFORT-B. Background pain measured with POCIS and COMFORT-B was lower than procedural pain (p<.001). Nurses found POCIS easier and quicker to use, but COMFORT-B was found to indicate pain more accurately. Both POCIS and COMFORT-B are reliable, valid and practical scales for pain measurement in young children with burns and can be used in practice and research. The VAS obs was found to be unreliable.

Computer-generated virtual reality to control pain and anxiety in pediatric and adult burn patients during wound dressing changes.

Changing daily wound dressings provokes a substantial amount of pain in patients with severe burn wounds. Pharmacological analgesics alone often are inadequate to solve this problem. This study explored whether immersive virtual reality (VR) can reduce the procedural pain and anxiety during an entire wound care session and compared VR to the effects of standard care and other distraction methods. Nineteen inpatients ages 8 to 65 years (mean, 30 years) with a mean TBSA of 7.1% (range, 0.5-21.5%) were studied using a within-subject design. Within 1 week of admission, standard care (no distraction), VR, or another self-chosen distraction method was administered during the wound dressing change. Each patient received the normal analgesic regimen. Pain was measured with visual analog thermometer scores, and anxiety was measured with the state-version of the Spielberger State Trait Anxiety Inventory. After comparing different distraction methods, only VR and television showed significant pain reductions during wound dressing changes. The effects of VR were superior, but not statistical significant, to that of television. Thirteen of 19 patients reported clinically meaningful (33% or greater) reductions in pain during VR distraction. No side effects were reported. No correlations were found between the reduction in pain ratings and patient variables like age, sex, duration of hospital stay, or percentage of (deep) burns. There was no significant reduction of anxiety ratings.