Anaesthesia for BurnsDr. Alex Kan
Senior ConsultantDept of Anaesthesia & SICUSingapore General Hospital
Introduction
• Survival from burns have steadily increased in the last 50 years.– 50% of adults (age <45) survive 75% burns
• Exception of the elderly (age > 64)– Still 50% mortality with 20% burns
• Multiple operations & anaesthetics required for initial injury and subsequent rehabilitation.
Improved Outcome
• Team approach• Early surgery• Improved understanding of pathophysiology
and prevention of Multi-Organ Failure•Aggressive resuscitation• Infection surveillance & routine line change•Directed antimicrobial therapy•Pulmonary toilet•Enteral feeding
Early Excision - advantages
• Wounds uncolonized - less tissue excision• Allows complete excision in one sitting• Blood loss minimised• Improved mortality
Pathophysiologic Response
• Thermal injury produces – predictable early and late pathophysiologic
responses – in all major organs of the body.
• These responses must be considered when formulating an anaesthetic plan.
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Preoperative Management
• Airway, breathing and circulation (ABC’s) should be assessed in the primary survey
• Secondary survey, a head-to-toe evaluation is done, while resuscitation is started
• Associated injuries must be stabilised ( eg cervical spine, pneumothorax ) prior to anaesthesia.
Preoperative Management
• Correct severe acid-base abnormalities• Correct electrolyte disturbances• Correct coagulopathies. • Order enough colloid and blood products
Preoperative Management
• Provide adequate analgesia and sedation• Ketamine prior to transfer may be useful• Ensure fluid resuscitation is adequate or• Limit period of fluid fasting.
Parkland’s Formula
• 4 ml /kg / %TBSA burn over 24h• Ringer’s Lactate• Half - within 8 h of time of burn• Half - next 16h• End point = haemodynamic stability and
Urine output of 0.5-1 ml/kg/h.• Inhalational injury increases fluid
requirements independently
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Monitoring
• Large-bore iv lines are mandatory• Rapid / Level 1 infusion system• ECG - staples or needle electrodes• Arterial lines are indispensable• Central venous pressure lines • Urine output• Pulmonary artery catheter (if indicated)
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Blood Loss
• 70kg man, BSA 1.8 m2 with 20% burns– Estimated blood volume = 5000ml– Day 1 ( 0.4 ml/cm2 ) = EBL of 1440 ml– Day 2-4 (0.7 ml/cm2 ) = EBL of 2520 ml– After day 4 (0.9 ml/cm2 ) = EBL of 3240
ml– Infected burns wounds (1.0-1.25 ml/cm2)– = EBL of 4500 ml
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Inhalational Injury
• Suspected in the presence of – closed space fires / noxious vapours– burns of the head or neck; singed nasal hairs;– swelling of the oropharyngeal mucosa– hoarseness; carbonaceous sputum or– unexplained hypoxaemia (24 - 36 h post burn)– Intra-op fibreoptic bronchoscopy to confirm
Techniques for difficult intubation
• Alternative laryngoscope blades• Awake / Fibreoptic intubation• Blind intubation (oral or nasal)• Bougie/Intubating stylet/Light wand• Non-surgical airway (LMA, Proseal)• Surgical airway access (last resort)
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Anaesthetic Agents• There is no single preferred agent.• Ketamine and etomidate
– if uncertain volume status. – May still decompensate if inadequately resuscitated
• Ketamine– reduce morphine requirements– less respiratory depression, early extubation– side effects, minimize with midazolam, atropine
• Volatile agents - Induction / maintenance.
Muscle Relaxant
• Rapid sequence induction and intubation– Indicated for full stomach e.g. ileus
• Succinylcholine - contraindicated – 24 hours to 2 years after major burns, – profound hyperkalemia and cardiac arrest.
• Rocuronium in dosage of 0.9 mg/kg– Can intubate in 45 sec– Must be confident of airway management
Muscle Relaxant
• Nondepolarizing relaxants. -“resistance”• increase extra-junctional cholinergic
receptors, • altered affinity of these receptors• Alpha-1 acid glycoprotein increased, which
binds basic drugs (muscle relaxants)
Pharmacokinetic
• Acute phase – reduced organ blood flow – (hypovolaemia, decreased cardiac output). – Delayed absorption if drug not given iv.
• Albumin is decreased
– reduced protein binding of acidic/neutral drugs (benzodiazepines) - increased free fraction
– increased renal and hepatic drug clearance.
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Temperature Control
• Patient comfort = 38 ‘C • Maintain normothermia - OT and transport• Thermoneutral = 28-32 ‘C , OT > 25 ‘C • Warm IV fluids and blood• Inspired gases heated and humidified or use
HME (artificial nose). • Paediatrics - radiant heater and warming
blanket.
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Infection and Immunity
• All aspects of immunity impaired• Delayed healing / graft taking• Endotoxaemia / septicaemia• Management
– Meticulous aseptic techniques– Early excision and coverage– Topical antimicrobial– Systemic antibiotics
Anaesthetic Plan
• Preoperative management• IV access and Monitoring• Blood loss• Airway• Drugs• Temperature regulation• Immunosuppression• Postoperative period
Burn Pain
• Postoperative and burn pain may be severe • Intravenous morphine infusion or PCA• Midazolam infusion supplement. • Paracetamol for background analgesia is
useful especially in children.• Nitrous oxide for change of dressing
Nitrous Oxide
• Demand valve - cylinder or wall supply• Mask or mouth-piece• Administered by Medical/Nursing Staff• Used in ward
NO Cook-book RecipesNeed to individualise and titrate drug effect
LA / RA Asleep AwakeMask LMA ETTLaryngoscope Bougie FiberopticEtomidate Propofol MidazolamKetamine Morphine FentanylAtracurium Rocuronium IsofluraneExtubated Ventilated Sevoflurane
Conclusion
• To maximise patient survival• Take full advantage of early excision• Providing meticulous Anaesthesia / Surgery
• Meticulous Preoperative management • Meticulous Intraoperative Care
– IV access and Monitoring– Keep up with Blood loss– Optimum Airway management– Optimum Temperature regulation– Contain Immunosuppression
• Meticulous Postoperative management
The End
Thank You
Respiratory System
• Direct Effects– Early (Airway obstruction, smoke inhalation)– Late ( Chest wall eschar)
• Indirect Effects– Early (inflammatory mediators)
• pulmonary oedema, ARDS
– Late complications• IPPV (O2 toxicity, barotrauma, pneumonia)• Intubation (tracheal stenosis, laryngeal damage)
Inhalational Injury
• closed space fires / noxious vapours • Suspected in the presence of
– burns of the head or neck; singed nasal hairs;– swelling of the oropharyngeal mucosa, – hoarseness; carbonaceous sputum or– unexplained hypoxaemia (24-36 h post burn)
• Mortality is increased up to two-fold.
Inhaled Toxic Chemicals
• Direct damage to tracheobronchial tree or produce other systemic effects.– Polyurethane products -> hydrogen cyanide
• inhibit mitochondrial cytochrome oxidase.– Cotton and synthetic fibres -> aldehydes
• damage mucosa and cilia– Wood -> carbon monoxide– Particulate matter (smoke, soot) -> obstruction
Carboxyhaemoglobin
• Diagnosis is difficult• absorbs light at the same wavelength (660nm)• normal or falsely high pulse oximetry readings• Partial oxygen pressure (PaO2) in the normal range• direct measurement with cooximetry
– <20% (headache, tinnitus, nausea), 20-40% (weakness, drowsiness), >40% (neurologic dysfunction and coma)
• Half-life is related to the inspired FiO2 • 4-6 h (room air); 40 to 60 min (100% oxygen)• 20 to 30 minutes (Hyperbaric oxygen at 3 atm)
Evaluation of Resp System
• Chest x-ray is done - insensitive.• Fibreoptic naspharyngoscopy/bronchoscopy
– diagnosis and also aid in difficult intubation• Endotracheal intubation - done early
– if upper airway injury (oedema onset is rapid)• Cricothyrotomy and tracheostomy
– reserved as last resort– high complication rate.
Indications for Intubation
• Respiratory insufficiency• Cardiovascular instability• CNS depression• Massive burns (60% TBSA)• Head and neck burns
Cardiovascular System
• Early– Burn shock, hypovolaemia– Impaired cardiac contractility
• Late– Hyperdynamic state
• hypermetabolism• decrease SVR
Metabolism & Nutrition
• Metabolic rate - initial decrease• Hypermetabolism from day 3 up to day 12• Offset this with
– early wound closure– early enteral feeding
• Impaired thermoregulation• low ambient temp increases BMR
Haematologic
• Early– Haemoconcentration– Haemolysis– Dilutional thrombocytopaenia (after resus)– Activation of thrombotic - fibrinolytic system
• Late– Anaemia– DIC in severe sepsis
Renal
• Early dysfunction due to– Decrease renal blood flow and function– Myoglobinuria / haemoglobinuria– Nephrotoxic drugs
• Late– Increased renal blood flow– Variable drug clearance
Gastro-intestinal
• Early– Ileus - nasogastric tube needed– Stress ulceration (Curling’s)– Impaired intestinal barrier function
• Late– Dysphagia– Oesophagitis, TOF, cholecystitis
Endocrine System
• Increases in these catabolic hormones – catecholamine, corticosteroid, and glucagon
• Insulin, growth hormone and testosterone levels are dercreased. – Testosterone - anabolic stimulus – Insulin can provide similar benefits, with
improved outcome.
Neuro-musculoskeletal System
• Circumferential burns of the extremities– Escharotomy is required
• Neuropathy found in 11% of patients.• Muscle and nerve injury in electrical burns,
– rhabdomyolysis and neuropathy.• A high incidence of encephalopathy
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