This document discusses anaesthesia considerations for burns patients. It notes that survival from burns has improved due to a team approach, early surgery, infection control and aggressive resuscitation. Key aspects of anaesthetic management include preoperative stabilization, IV access and monitoring, managing blood loss, addressing the airway challenges posed by burns/inhalation injuries, temperature control to prevent immunosuppression, and postoperative analgesia to control severe burn pain. The document emphasizes meticulous care during all phases of management to maximize patient survival.
This document discusses anaesthesia considerations for burns patients. It notes that survival from burns has improved due to a team approach, early surgery, infection control and aggressive resuscitation. Key aspects of anaesthetic management include preoperative stabilization, IV access and monitoring, managing blood loss, addressing the airway challenges posed by burns/inhalation injuries, temperature control to prevent immunosuppression, and postoperative analgesia to control severe burn pain. The document emphasizes meticulous care during all phases of management to maximize patient survival.
This document discusses anaesthesia considerations for burns patients. It notes that survival from burns has improved due to a team approach, early surgery, infection control and aggressive resuscitation. Key aspects of anaesthetic management include preoperative stabilization, IV access and monitoring, managing blood loss, addressing the airway challenges posed by burns/inhalation injuries, temperature control to prevent immunosuppression, and postoperative analgesia to control severe burn pain. The document emphasizes meticulous care during all phases of management to maximize patient survival.
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