Anesthetic Technique & Management: Anesthetic Technique & Management Preop Meds Provide adequate analgesia Fluids Establish Adequate Vascular Access Multiple large bore IV’s Consider Invasive Monitoring Airway Management Early intubation Consider Alternatives to Direct Laryngoscopy Awake FOB Airway management: Airway management Intervention and treatment: the 4 P’s Patency Protect Pulmonary toilet Positive pressure Intubate with the largest ETT possible Improves management of secretions Minimizes risk of ETT obstruction Decreases resistance to gas flow Allows for FOB studies Anesthetic Technique & Management: Anesthetic Technique & Management Standard and invasive monitors placed early Needle electrodes Ventilation Increased minute ventilation increased metabolic rate Fluids & Blood Anticipate rapid, large blood loss Evaluate coagulation status Temperature Regulation Increase ambient temperature Warm IV fluids Anesthetic Technique & Management: Anesthetic Technique & Management Anesthetic Drugs Include opioids Consider effects of increased circulating catecholamines Muscle Relaxants Anectine safe in the 1 st 24hrs after which AVOID; hyperkalemia may be a problem up to a year or the burn is healed Pseudocholinestarase levels decrease 5-6 days after burn and can last for several months Anticipate resistance to nondepolarizing muscle relaxants (>30% BSA) May need 2-5 x’s the normal dose!!! Occurs ~ 1 week post injury and peaks 5-6 weeks post burn Management cont’d: Management cont’d Varied drug responses Albumin concentration decreased after 48 hours albumin-bound drugs (such as benzos and anticonvulsants) have an increased free fraction and prolonged effect Cardiovascular support Ketamine for dressing changes and escharotomies Postoperative Anticipate increased analgesic requirements General Concerns: General Concerns Compromised Airway Hypovolemia Compromised Vascular Access Interaction of Anesthetic Agents Pain Fluid Resuscitation: Fluid Resuscitation Parkland formula 4cc X weight X % burn ½ volume in first 8 hours Second ½ over last 16 hours Brooke formula 2cc X weight X % burn ½ volume in first 8 hours Second ½ over last 16 hours Daily maintenance fluids D5W Colloids may be given 2 nd day 0-30%: no colloid 30-50%: 0.3 ml/kg/BSA burn/24* 50-70%: 0.4 ml/kg/BSA burn/24* 70-100%: 0.5 ml/kg/BSA burn/24* Rule of Nines: Rule of Nines Size of burn estimation to assess total BSA burned Body divided into regions that represent 9% or multiples of 9% of total BSA Adults: head/neck 9%; arms/hands 9% each extremity; thighs/legs 18% each extremity; anterior/posterior trunk 18% each side; perineum 1% Children calculated slightly different due to large head Size of hand roughly equal to 1% BSA Rule of Nines Burn Chart: Rule of Nines Burn Chart Child: For every year of age >1yr up to 10yr, decrease head surface area by 1% and increase each leg by 0.5% Three phases of burn injury: Resuscitative phase : Three phases of burn injury: Resuscitative phase First 24 hours Includes airway management and treating any circulatory and associated injuries Suspicion of upper and lower airway injury is increased with singed eyebrows/eyelashes and black soot around nose and mouth Fluid resuscitation: Fluid resuscitation Parkland formula 4ml/kg LR per percent BSA burned ½ given over first 8 hours Rest over next 16 hours In addition to maintenance Brooke formula 3ml/kg per percent BSA burned ½ over first 8 hours Rest over next 16 hours Myoglobinuria : Myoglobinuria Occurs following rhabdomyolisis and hemoglobinuria due to hemolysis; affects renal blood flow via damage to renal parenchyma FFP may protect renal function since it contains haptoglobin, which binds free hemoglobin Aggressive fluid resuscitation Maintenance of urine output with osmotic diuretics and sodium bicarb to protect kidneys Debridement and grafting phase: Debridement and grafting phase Multiple skin debridements Escharotomies Amputations Grafts Tracheotomies May still be hemodynamically unstable in this phase Common Operations: Common Operations Decompression procedures Escharotomies & fasciotomies Burn excision & skin grafting Reconstruction operations Supportive procedures Tracheostomy, gastrostomy/feeding jejunostomy, vascular access Nutrition is vitally important Escharotomy: Escharotomy A surgical incision of the eschar and superficial fascia in order to permit the cut edges to separate and restore blood flow to unburned tissue distal to the eschar. Eschar: nonviable, inelastic skin destroyed by thermal damage Early excision is KEY in preventing neurovascular constriction of extremities or ventilatory compromise Circumferential burns (impede ventilation) Compartment syndrome (impede perfusion) Can be performed at the bedside / ED. Fasciotomy: Fasciotomy The fascia is thin connective tissue covering, or separating, the muscles and internal organs of the body. Usually done by a surgeon under general or regional anesthesia. An incision is made in the skin, and a small area of fascia is removed where it will best relieve pressure. Then the incision is closed. Skin grafting: Skin grafting Superficial, partial thickness burns may be treated with daily dressings, local wound care, and topical antibiotics until epithelialization Temporary coverage with allograft or xenograft may decrease pain and need for daily dressings Deep, partial thickness burns have better functional outcome with early and aggressive debridement and grafting Reduces pain, number of operations, mortality, blood loss, and length off hospital stay Full thickness burns treated by removal of devitalized tissue (debridement) and grafting with autologous skin grafts Skin grafting: Skin grafting Reconstructive phase: Reconstructive phase May continue for rest of life Release of contractures Multiple plastic surgery Common long-term disabilities affecting burn patients: Common long-term disabilities affecting burn patients Disabilities affecting the skin and soft tissue: Hypertrophic scars Susceptibility to minor trauma, chemicals, or cold Dry skin Contractures Itching and neuropathic pain Alopecia Chronic open wounds Skin cancers Orthopedic disabilities: Amputations Contractures Heterotopic ossification Osteoporosis Long-term complications of critical care after burns: Deep-vein thrombosis Venous insufficiency, or varicose veins Tracheal stenosis, vocal cord disorders, or swallowing disorders Renal or adrenal dysfunction Hepatobiliary or pancreatic disease Cardiovascular disease Reactive airway disease or bronchial polyps References: References American Burn Association website. Accessed January 17, 2012, http://www.ameriburn.org/resources_factsheet.php Hettiaratchy, S. & Papini, R. (2004). Initial management of a major burn II: assessment and resuscitation. British Medicine Journal, 329:101–103. Nagelhout, J.J. & Plaus, K.L. 4 th edition. Saunders Publishing, 2009. Excellent website: www.burnsurgery.com Thank you to colleagues at Shriner’s, Hamot, and Shock Trauma for slides/pictures used in this presentation.