apy in patients with chronic tumor pain. However it is increasingly administered in chronic pain (with breakthrough symptoms) of other reasons.

Generally the initial dosage is 200 μg. The dosage is increased as necessary in the available doses (200 μg, 400 μg, 600 μg, 800 μg, 1200 μg, and 1600 μg). In the oromucosal application the absorption kinetics is an interaction between a rapid absorption by the oral mucosa (25% of the total dosage) and a slower absorption by swallowed fentanyl by the gastrointestinal tract (75% of the total dosage). The action takes place within 15 minutes. Administration should be limited to 4 doses per day.

Intervention-induced pain

Intervention-induced pain require a potent analgesia for a short period of time. An additional aim of the therapy should be to reduce anxiety and worries of the patients.

The therapeutic management needs to be carried out in accordance with the severity of the intervention [75].

Necrosectomy and skin grafting

Necrosectomy can be more painful than wound pain after burn injuries. In such cases the method of choice is an intervention under surgical conditions with general anesthesia. However, long preoperative and postoperative nutrition gaps must be accepted.

Dressing change of large burn wounds and removal of clamps in skin grafts

In an ideal case these interventions take place on a spontaneously breathing patient with good pain therapy directly in the burn unit. An intravenous administration of potent opioids in combination with sedatives is essential. The patient should be sedated to such an extent that an adequate pain evaluation is still possible. Sedating and anxiety relieving preparations must not be used as a replacement for analgesics.

An analgosedation of burn patients outside of the operating room has to be carried out by qualified personnel (generally anesthetists). A standard moni-

toring with pulse oxymetry, blood pressure measurement and continuous ECG recordings is a precondition for a secure process. Furthermore, oxygen should be supplied via mask or glasses [76].

Remifentanil is only approved for the administration in intensive care patients receiving artificial respiration. There are single reports about the administration of remifentanil in extubated intensive care patients. However, the increased rate of apnea or bradypnea has to be considered then [77].

In a study with spontaneously breathing, nonintubated burn patients, remifentanil could be administered successfully for analgesia and sedation during dressing change [78]. A randomized prospective study with 79 patients showed that the combination of opioids and Lorazepam could reduce the intervention-induced burn pain [79].

Patient-controlled therapies are very promising. Apart from the intravenous patient-controlled analgesia [44], the patient-controlled sedation has become a very well evaluated form of therapy in burn patients.

In a prospective study on a small number of burn patients (TBSA > 10%), a patient-controlled sedation with propofol/alfentanil showed a higher contentment among the patients during dressing change than when they were treated by an anesthetist during the interventions. Although there were no lockout times provided in the protocol, cardio-vascular complications did not occur in any case [80].

In another study on 44 patients in a burn unit, dressing changes were carried out under patient-con- trolled administration of midazolam/ketanest. Also in this case the contentedness among the patients as well as among the health care personnel was significantly higher than in the traditional treatment. In this study neither preoperative nor postoperative nutrition gaps were maintained. Side effects occurred rarely, the most common side effect was short-timed hallucinations [81]. For the application of patientcontrolled analgesia relevant structural conditions must be present, so that in case of technical or medical problems a competent stand-by service (e. g. 24 hours acute pain service) is always available.

A limiting factor for the patient-controlled analgesia is that in severe burn injuries the upper extremities are very often affected and the patients cannot operate the pump sufficiently.