Description

• Anesthesia providers are critical members of the multidisciplinary team that is required to treat patients with severe burn injuries, as well as burn reconstruction procedures.
• Severe burns affect every organ system, present multiple medical and psychological challenges, and must be treated with prompt and vigilant care.

Etiology/Risk Factors

• Etiology: Fire/flame (41.6%); scald (31.0%; children are at a higher risk); contact with a hot object (8.8%); electrical (3.8%)
• Circumstances of injury: Home (66%); accident, non-work related (66%); accident, work related (14.6%); accident, recreation (4.8%)

Physiology/Pathophysiology

• Severe inflammation has been implicated with many post-burn complications: Triggers loss of microvascular wall integrity, intravascular plasma and protein depletion, and interstitial edema (peak edema occurs at 24 hours).
• Inhalation injury is direct damage to the upper and lower airways and lungs from heat, smoke, or toxic fume inhalation. Inhalation of carbon monoxide produces carboxyhemoglobin, and inhalation of cyanide fumes causes inhibition of the mitochondrial electron transport chain.

Anesthetic GOALS/GUIDING Principles

• If inhalation injury or airway edema is suspected, secure the airway early before worsening edema makes intubation difficult or impossible.
• Appropriate fluid management, maintenance of normothermia, glucose control, antibiotic prophylaxis, and ventilatory management have been shown to improve outcome in the ICU setting; these efforts should be extended perioperatively by the anesthesia provider.

Symptoms

Symptoms of inhalation injury: Voice change, dysphagia, dyspnea

Treatment History

• Airway management, intravenous access, fluids
• Dialysis in patients with acute kidney injury; early continuous veno-venous hemofiltration may reduce 28-day mortality, acute lung injury severity, and respiratory distress (1).
• Plasma exchange therapy may decrease the inflammatory response; this is still being investigated (2).
• Blood transfusions; patients with comorbidities are more likely to receive blood, especially with small burn injuries (<10% TBSA) (3). However, this may increase infectious complications and mortality. Outcome studies have not provided information on the ideal transfusion paradigm with significant comorbidities.

Medications

• Naltrexone for pruritus may affect intraoperative opioid requirements.
• TPN should be continued perioperatively; patients are hypermetabolic and have increased caloric requirements.
• Sedation for intubated patients
• Narcotics

CONCOMITANT ORGAN DYSFUNCTION

• Cardiovascular: Intravascular volume depletion, decreased systemic vascular resistance, myocardial depression, and deep vein thrombosis
• Pulmonary: Pulmonary edema, impaired gas exchange, reduced chest wall and airway compliance, dysfunctional cilia, respiratory failure, PNA, and ARDS
• Renal: Acute kidney injury
• Hepatic: Congestion, fatty deposition, cholestasis, centrilobular necrosis, and activation of acute phase reactants
• Gastrointestinal: Stress ulcers, decreased motility, ileus, decreased absorption, bacterial translocation, edema, abdominal hypertension, and compartment syndrome
• Musculoskeletal: Acute and chronic wasting, contractures
• Neuroendocrine: Hypermetabolism increases catecholamines and catabolic hormones, oxygen demand, production of carbon dioxide, muscle wastage, and glucose derangements.

Circumstances to delay/Conditions

The need to treat carbon monoxide poisoning with hyperbaric oxygen should be weighed against the need for emergent surgery.

Classifications

• Degrees of burn:
  • First-degree, superficial burn extends into epidermis, blanches, does not blister, and is intensely painful.
  • Second-degree, superficial partial-thickness burn extends into superficial or papillary dermis, blanches, blisters, and is severely painful.
  • Second-degree, deep partial-thickness burn extends into deep or reticular dermis, does not blanch or blister, and is less painful.
  • Third-degree, full-thickness burn extends into subcutaneous tissue or deeper, is dry like leather or white, and is minimally painful.
• Extent of burn:
  • Wallace's Rule of Nine can be used to estimate the %TBSA burned in adults.
  • The Lund–Browder chart can be used to estimate %TBSA in children.
• ABA grading system:
  • Minor burns: <10% TBSA in adults, <5% TBSA in children or elderly patients, <2% full-thickness burn
  • Moderate burn: 10–20% TBSA in adults, 5–10% TBSA in children or elderly patients, 2–5% full-thickness burn; high-voltage burn, circumferential burn, suspected inhalation injury, concomitant medical problems
  • Major burn: >20% TBSA in adults, >10% TBSA in children or elderly, >5% full-thickness burn, high-voltage burn, known inhalation injury; any significant burn to face, eyes, genitalia, joints or significant associated injuries

Bed Acuity

Transfer to a burn center is indicated for: Age <5 years or >60 years; burns to the face, hands, perineum, joints, or other areas of function; >15% TBSA partial-thickness or >5% full-thickness burn; inhalation injury; chemical, high voltage; concomitant trauma.

Medications/Lab Studies/Consults

Severe burn injury is a permanent, life-altering experience for the patient and his or her family and requires a multimodal approach and often long-term support: Pain specialists, rehabilitation medicine specialists, plastic surgeons, psychiatrists, physical therapists, social workers, and financial counselors.

Complications

Pneumonia (3%), urinary tract infection (2%), wound infection (2%), respiratory failure (3%), septicemia (2%), cellulitis (1.5%), renal failure (1%)

• Smoke Inhalation Injury
• Operating Room Fires
• Airway Sires
• Acute Respiratory Distress Syndrome (Ards)

ICD9

949.0 Burn of unspecified site, unspecified degree

ICD10

T30.0 Burn of unspecified body region, unspecified degree

Naola Austin , MD

andreas Grabinsky , MD