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Appendix 1. Pietermaritzburg Burn Service (PBS) analgesia protocols

Background analgesia and sedation

Drug Paediatric Adult

IV access/ 1 mg/kg IVI titrations 1 mg/kg IVI titrations ICU/high care quick onset quick quick onset quick offset offset Ward Ketamine 5 mg/kg per os 5 mg/kg per os Dose 1 Midazolam 0.25 mg/kg per os 2.5 - 5 mg per os mixed together mixed together 20 - 30 mins to work 20 - 30 mins to work Ward Ketamine Half the previous dose 100 mg ketamine IMI Dose 2 NO Midazolam ketamine IMI 5 - 10 min onset (for pain score >3) 5 - 10 mins onset

Ward Ketamine Half the previous dose 100 mg ketamine IMI Dose 3 NO Midazolam ketamine IMI (for pain score >3)

The final total dose of ketamine given at the procedure must be written as the script for the following dressing change, do not leave the inadequate dose as the prescription

Clinic Ketamine 5 mg/kg IMI 5 mg/kg IMI

OR

Morphine - 10 - 15 mg IMI Emergency Ketamine 5 mg/kg IMI 5 mg/kg IMI department - 0.05 mg/kg IVI - 50 - 100 mcg IVI

Background analgesia and sedation

Drug Paediatric Adult

These are oral doses unless otherwise stated

Mandatory 15 mg/kg 6-hrly 1 g 6-hrly (syrup = 120 mg/5 mL) Mandatory Tilidine 1 mg/kg 6-hrly - (1 drop = 2.5 mg) Mandatory - 50 - 100 mg 6-hrly Add if pain not 10 mg/kg 8-hrly 400 mg 8-hrly controlled and for (100 mg/5 mL) donor site pain

Consider contraindications: Curling’s ulcer, acute kidney injury, comorbidities Consider if Morphine syrup Start at 0.2 mg/kg 6- 0.2 mg/kg 6-hrly >15%TBSA/pain still 1 mg/mL hrly Increase frequency up uncontrolled Increase frequency up to 2-hrly then increase to 2-hrly then increase dose by 25%, consider dose by 25%, consider infusion infusion Add if pain not 25 mcg 8-hrly increase 75 mcg 8-hrly increase controlled OR (25 mcg tablets that to maximum 50 mcg in increments of neuropathic pain cannot be broken) 8- hrly 25 mcg per dose up to 150 mcg 8-hrly Add if pain at night/ Amitryptiline - 25 mg nocte, can be difficulty sleeping increased to 50 and then 75 mg nocte For neuropathic pain Start at 25 mg 12-hrly, Start at 75 mg 12-hrly, and or severe itch 75 or 150 mg tabs increase in 25 mg increase to max mixed into suspension increments to max 150 mg 12-hrly for paeds 75 mg 12-hrly 10 mg/kg 8-hrly, 300 mg 8-hrly, 100 mg or 300 mg increments of increase up to 600 mg tablets 100 mg/dose up to 8-hrly 600 mg 8-hrly Add if neuropathic Tegretol - 200 mg 12-hrly pain and no 200 mg tabs increase to max. gabapentin/pregablin 1 200 mg/day (400 mg 8-hrly) If itch and no Allergex 0.1 mg/kg start 12- 4 mg 8-hrly pregaba/gabapentin hrly, can be increased to 8-hrly Pyridoxine - 25 mg daily

For ICU Morphine IVI 0.1 mg/kg loading 0.1 mg/kg loading patients/large TBSA Remember this needs dose then 0.1 dose then burns to be weaned and not mg/kg/hour infusion 0.1 mg/kg/hour stopped suddenly! increase to effect, infusion increase to (MORPHINE mixed (wean the infusion rate reload and increase effect, reload and as a 1 mg/mL then move to bolus rate by 0.05 mg/kg increase rate by solution, i.e. dosing and increase the 0.05 mg/kg 10 mg in 10 mL dose interval over or 50 mg in 50 mL) time) For PTSD Valium 2.5 mg nocte, titrate to 5 mg nocte, titrate to OR anxiety effect can be increased effect can be increased OR to 8-hrly up to 5 - 10 mg 4-hrly withdrawal For delirium Haloperidol - 2.5 - 5 mg 8-hrly