disorders in the stimulus conduction of the heart and orthostatic hypotension, there may also occur weight gain, obstipation, retention of urine, dry mouth, impaired vision and cognitive limitation.

Serotonin noradrenaline reuptake inhibitors (SNRI) as for example venlafaxine, milnacipran, duloxetine: In pain management, dually effective antidepressants are equally effective as TCA. However, they have significantly less severe side effects and a lower toxicity. Vomiting and nausea can be reduced by a slow dosage titration during the initial therapy phase. When administering venlafaxine the risk of arterial hypertonia must be considered. Furthermore the QTc-interval can be longer and arrythmia might occur. Milnycipran is recommended in patients with polypharmacy because it is not metabolized in the liver by cytochrome P450.

Regional anesthesia

Regional anesthesia is an effective additional option in the analgesic therapy and can be applied if there are no objections concerning hygiene to a sterile catheterization. However in severe burns the increased bacterial colonization (e. g. pseudomonas aeruginosa) has to be considered. A precondition for a secure application is regular nursing and checking.

Potential benefits of regional anesthesia are the reduced vigilance impairment as a result of lower opioid administration and the possible preventive effects concerning chronic pain syndromes. Furthermore an epidural catheter improves perfusion and intestinal motility due to sympathicolysis (application of local anesthetics).

In any phase of the burn trauma management the indication to the following blockades should be examined:

epidural anesthesia

intercostal blockade

blockade of the plexus brachialis (interscalenary, intraclaviculary and axillary)

3 in 1 block, fascia iliaca block, psoascompartment block

single nerve blockades

Apart from the continuous supply of the local anesthetic or the opioid a patient-controlled analgesia with bolus administration is also possible. Due to the few data that exist for perineural PCA systems, no extensive recommendations concerning basal rates, gap intervals and bolus size can be given.

Some studies have already examined the topic application of local anesthetics with differing success.

Pain management without analgesics

In awake, responsive and cooperative patients, various treatments without the use of analgesics can be additionally applied.

Adequate communication

Lack of communication about diagnostic and therapeutic measures causes anxiety, frustration and rejection to the therapy in the patients. Burn patients need thoughtful support in all phases of the treatment. They need more information and more communication than any other patient group. A thorough explanation of the pain management concept to the patient (and the personnel) improves the compliance in the practical application.

Psychological techniques [65]

Interventions in the field of behavior therapy have proven effective in the treatment of chronic pain. It has also been shown that behavior therapy is also effective in the treatment of acute pain.

Those interventions can only be carried out by professional psychologists. Psychological techniques are useful to relieve anxiety and worries. Patients should be given advice on how to cope with the treatment-induced pain and the rehabilitation phase.

In burn patients the psychological therapy must start as early as possible. In the initial phase it should be evaluated how susceptible the patient is to such a treatment.

For a perioperative treatment, techniques which are effective without a long training phase are recommended.