Anaesthesia for Burns

Dr. Alex Kan

Senior Consultant
Dept of Anaesthesia & SICU
Singapore 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 (ABCs)
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.
Parklands Formula
4 ml /kg / %TBSA burn over 24h
Ringers 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 m
2
with 20% burns
Estimated blood volume = 5000ml
Day 1 ( 0.4 ml/cm
2
) = EBL of 1440 ml
Day 2-4 (0.7 ml/cm
2
) = EBL of 2520 ml
After day 4 (0.9 ml/cm
2
) = EBL of 3240 ml
Infected burns wounds (1.0-1.25 ml/cm
2
)
= 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 Recipes
Need to individualise and titrate drug effect
LA / RA Asleep Awake
Mask LMA ETT
Laryngoscope Bougie Fiberoptic
Etomidate Propofol Midazolam
Ketamine Morphine Fentanyl
Atracurium Rocuronium Isoflurane
Extubated 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 (Curlings)
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