ABSTRACT
OBJECTIVES: Pruritus is a common and often distressing complication after a burn injury. The purpose of this review is to explore the efficacy of drugs classically used to treat neuropathic pain in the management of pruritus after burn injury. METHODS: A systematic literature search of medical databases was conducted to find studies investigating drugs listed in the National Institute for Health and Care Excellence (NICE) guideline (CG173, "neuropathic pain in adults") for the management of pruritus after burn injury in patients of any age. Controlled studies were stratified by the drug class studied and their risk of bias before conducting meta-analysis. A narrative review of case series or observational studies was presented. Severity of pruritus at any time point, with all quantitative and qualitative measures, was included. RESULTS: Fifteen studies were included in the final analysis, 10 investigated the use of gabapentinoids, 4 studied doxepin, and 1 local anesthetic agents. Meta-analysis of three randomized controlled trials (RCTs) demonstrated that the use of gabapentinoids was associated with an improvement in mean VAS (Visual Analog Scale) 0-10 scores of 2.96 (95% confidence interval (95% CI) 1.20 to 4.73, p<0.001) when compared with placebo or antihistamine. A meta-analysis of four RCTs investigating topical doxepin showed an improvement in mean VAS scores of 1.82 (95% CI 0.55 to 3.09, p<0.001). However, when excluding two studies found to be at high risk of bias, no such improvement was found (-0.32, 95% CI -1.64 to -0.99, p=0.83). CONCLUSION: This study suggests that gabapentinoids are beneficial in the management of burn-related pruritus. There is a lack of evidence to suggest that doxepin is an effective treatment. Topical local anesthetic agents may be safe and beneficial, but studies are scarce. LEVEL OF EVIDENCE: Systematic review, level II.
ABSTRACT
Rhabdomyolysis (RML), defined as creatine phosphokinase (CPK) >1000 U/L, is relatively common immediately after a significant burn. Late-onset RML, occurring a week or more after a burn, is less well understood and recognised. All patients admitted to the Intensive Care Unit (ICU) following an acute burn between May 2006 and December 2009 were retrospectively identified. Patients with CPK>1000 U/L a week or more after their burn had a detailed notes review. Seventy-six patients were admitted during 43 months. Late-onset RML was demonstrated in 7/76 (9%) patients. They had a similar pattern of normal or mildly raised CPK on admission that resolved over the following days, but suddenly increased sharply to over 1000 U/L, a week or more after their burn, usually around day ten. A severe late-onset RML occurred in 5/76 (7%) patients, with a CPK rise of over 5000 U/L, and all required haemodialysis. Potential triggering factors for late-onset RML include sepsis, nephrotoxic drugs and hypophosphataemia. It is important to consider measuring CPK in all patients with the above complications, even after it has previously been observed to be normal, in order to initiate early treatment.
