CHAPTER 42

ANAESTHESIA AND BURNS

Outline:

Points of importance to the anaesthetist

Indications for surgery in the burned patient

Initial management of the burned patient

Anaesthesia for the burned patient

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POINTS OF IMPORTANCE TO THE ANAESTHETIST

• Reduced circulating blood volume. There is a loss of water and protein

from the circulation, so IV fluids, both crystalloids and colloids, may
be required.
• A fall in body temperature due to the loss of a large amount of skin.
• Anaemia. Deep burns result in haemolysis of red blood cells.
• Hypotension may be associated with the hypovolaemia and may also
be due to the toxins released from the damaged tissues.
• Renal failure may follow hypovolaemia and hypotension.
• There is a constant danger of infection in the burned patient. If
infection occurs the patient becomes debilitated.
• Airway damage, which may involve the upper or lower airways. It may
be due to the inhalation of hot gases, fumes, steam, smoke, etc. Upper
airway obstruction will increase over 6 to 24 hours, so intubate the
patient or consider early tracheostomy depending on nursing care
facilities.
• Pulmonary oedema may be caused by inhalation of noxious fumes
especially if the patient was in a closed space. Face, neck, nose and
mouth burns are commonly associated with this type of trauma.
Pulmonary oedema may also occur during resuscitation from fluid
overload. Dyspnoea and tachypnoea are early signs.
• Respiratory infection.
• The danger of hyperkalaemia. Burned patients should not be given
suxamethonium compounds after 48 hours and for up to 1 year after a
significant burn injury. The rapid rise in serum potassium during the
depolarisation of the muscle with suxamethonium has been known to
produce cardiac arrest.
• Venepuncture is difficult.
• Using a mask is difficult in patients with facial burns.
• Maintaining a clear airway is difficult in patients with neck
contractures.
• Monitoring is difficult in patients with burns to the upper half of the
body.
• The problem of multiple anaesthetics and the danger of repeated use of
the same anaesthetic agents.
• Fear and depression. The anaesthetist needs to establish rapport with
the patient and reassure them.

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INDICATIONS FOR SURGERY IN THE BURNED PATIENT

• Debridement
• Tracheostomy
• Fasciotomy
• Skin grafts
• Reconstructive surgery to improve function and cosmetic appearance.

INITIAL MANAGEMENT OF THE BURNED PATIENT

• Assess the depth of the burns

First degree burns affect the epidermis (superficial tissues). The burns
are painful, red and dry but they do not blister.
Second degree burns blister and are painful, mottled, red and moist.
Third degree burns reach the subcutaneous tissue. Fat, muscle and
even bone may be destroyed.
The critical burn area is that percentage of the body surface above
which the patient cannot compensate for fluid loss. When the burn area
is greater than 15% in an adult or 10% in a child the patient can no
longer compensate and IV fluids will be required.

• Assess the extent of the burns

The “Rule of Nines” is commonly used to obtain the percentage of the
surface area affected.

Area Adults Infants and young

children

Whole head 9% 18%

Each upper limb 9% 9%
Front of trunk 18% 18%
Back of trunk 18% 18%
Each lower limb 18% 14%
Perineum 1% 1%

In an adult the palm of the hand is approximately 1% of surface area.

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 Fig 42.1

The “rule of nines” for rapid

assessment of % body surface
area

• Weigh the patient if possible, otherwise estimate weight.

• Calculate intravenous fluids according to the formula 2ml x body

weight in kilograms x percentage of surface area burnt. This gives the
requirement for the first 24 hours. Half of the calculated volume can be
given as colloid and half as crystalloid solution. Half the calculated
volume can be given in the first 8 hours and the rest in the next 16
hours.
In addition to these, the volume lost by nasogastric suction is replaced
with 0.9% saline or 0.45% saline. Give extra fluid to compensate for
fluid loss from diarrhoea, vomiting and pyrexia.
Use a large bore cannula, inserted under sterile conditions, for
administering the fluid.
Re-assess fluid requirements at regular intervals.
Maintain a urine output of 1ml /kg /hour. After 24 hours the volume of
fluid given may be reduced to about half that given during the first 24
hours.
Anaemia may be corrected by the use of blood after the blood volume
is first restored with other fluids.

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• Give analgesics if the patient is in pain:
− Give the drugs IV, not intramuscularly. The muscle blood flow
is reduced in the shocked patient.
− Use adequate doses of drugs. These patients often develop
tolerance and have increasing requirements for opioids, which
should not be withheld. Sedatives and anxiolytics may also be
useful.
− Clean and manage the burn with a dressing or by open
exposure. Ketamine 0.5- 1.0 mg/kg IV is useful for dressing
changes.
− Use silver sulphadiazine cream to reduce bacterial
contamination.

• Continue to monitor the following:

− Pulse
− Blood pressure
− Temperature
− Urine output
− Serum electrolytes
− Haemoglobin and haematocrit

ANAESTHETIC TECHNIQUES FOR BURNS PATIENT

General Anaesthesia

Intubation with a muscle relaxant and IPPV. Endotracheal anaesthesia is

useful for surgery in the area of the head and neck. It is also useful for
prolonged surgery and surgery performed in abnormal positions. It ensures
adequate ventilation. Care is needed however with the use of muscle
relaxants such as suxamethonium.
Rapid sequence induction is not advised because of the dangers of
suxamethonium.
Once healing of burns has begun fibrosis and strictures may make
laryngoscopy impossible.
Tracheostomy is not desirable because of the danger of infection and awake
intubation using local anaesthesia may be necessary.

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Mask (inhalational) anaesthesia. Inhalational anaesthesia is useful for
short procedures performed in the supine position, in a patient with a secure
airway but may be difficult in patients with facial burns.
Remember that peripheral vasodilatation increases heat loss and post-
operative shivering may cause movement of the graft. However, peripheral
vasodilatation may help with venepuncture.

Ketamine (Bolus or Infusion)

The choice of the technique will depend on the site of the burn, the posture
required for surgery and the nature and duration of surgery. Absorption of
the ketamine (IM) may be delayed in burns resulting in a slower than
normal recovery.
The use of ketamine has been described under Techniques of anaesthesia in
Chapter 14. Ketamine is useful for debridement and grafting of facial
burns, where the use of a mask is impossible. It is also useful for the
division of neck contractures prior to intubation. The burned patient with
neck contractures and therefore possible airway obstruction will have to be
treated with special care. This is discussed under anaesthesia in the presence
of respiratory obstruction in Chapter 8 (The Airway and its maintenance).

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