DEPARTMENT OF SURGERYPreoperative care of the burn           patient   Amalia Cochran, MD, FACS, FCCM  Associate Professor...
DEPARTMENT OF SURGERYDisclosures• None
DEPARTMENT OF SURGERYObjectives• At the completion of this talk, learners will  be able to:  – Recognize unique challenges...
DEPARTMENT OF SURGERYWhy anesthesia and burns?• Highly-developed, specialized skill sets  – Airway management  – Pulmonary...
DEPARTMENT OF SURGERYChallenges in Burn Anesthetic Management• Compromised airway      •   Positioning• Pulmonary         ...
DEPARTMENT OF SURGERYMajor Preoperative Considerations
DEPARTMENT OF SURGERYPatient Age
DEPARTMENT OF SURGERYBurn Depth, Burn Extent, Burn MechanismBURN CHARACTERISTICS
DEPARTMENT OF SURGERYFirst Degree Burns              • Only damage is to                epidermis              • Red, hype...
DEPARTMENT OF SURGERYSuperficial Partial-Thickness Burns                  • “Superficial 2nd degree”                  • Ep...
DEPARTMENT OF SURGERYDeep Partial-ThicknessBurns          • “Deep 2 degree”                           nd                  ...
DEPARTMENT OF SURGERYFull-Thickness Burns              • “3rd degree”              • Extends to                subcutaneou...
DEPARTMENT OF SURGERYEstimating Burn Size
DEPARTMENT OF SURGERYFlash and Flame burn• 50% of US burns• Flash burns   – More superficial   – Cover more area   – More ...
DEPARTMENT OF SURGERYScald burn• 2nd most common• Mosaic of partial and  full thickness• Immersion scalds  common in “high...
DEPARTMENT OF SURGERYHigh-Voltage electrical burn• 5-7% of burn  admissions• Most common cause of  amputations in burns• A...
DEPARTMENT OF SURGERYChemical burn• 3% of burns; 30% of  burn deaths• Denaturation of  proteins• Irrigation for 30 minutes...
DEPARTMENT OF SURGERYAIRWAY CONSIDERATIONS
DEPARTMENT OF SURGERYWhy inhalation injury matters• Independent risk factor for mortality• Increased fluid requirements du...
DEPARTMENT OF SURGERYSigns and Symptoms- Inhalation Injury• Hoarseness           •   Wheezing• Lacrimation/         •   St...
DEPARTMENT OF SURGERYInitial management• 100% humidified O2• Determine if the patient’s airway is at risk   – Progressive ...
DEPARTMENT OF SURGERYAirway Obstruction• Result of direct  thermal injury• Coupled with edema  from resuscitation of  larg...
DEPARTMENT OF SURGERYSmoke Inhalation injury               • Gold standard for                 diagnosis:                 ...
DEPARTMENT OF SURGERYTreatment of Inhalation Injury                 • Tracheal intubation                   and mechanical...
DEPARTMENT OF SURGERYCarbon monoxide poisoning• Impaired oxygen binding and oxygen carrying  capacity   – Decreased O2 del...
DEPARTMENT OF SURGERYBurn ShockRESUSCITATION
DEPARTMENT OF SURGERYBurn Shock• Complex process of circulatory and microcirculatory  dysfunction• Not entirely remedied b...
DEPARTMENT OF SURGERYMassive edema formation               interstitial pressure              microvascular           ...
DEPARTMENT OF SURGERYEarly CV pathophysiology of burns• Decreased cardiac output• Increased SVR  – Secondary impact of tis...
DEPARTMENT OF SURGERYWho gets formally resuscitated?• Any burn ≥ 10-15% TBSA    – 2nd or 3rd degree only•   All electrical...
DEPARTMENT OF SURGERYFactors that increase fluid requirements•   Delay to resuscitation•   Smoke inhalation injury•   High...
DEPARTMENT OF SURGERYParkland Calculation for Resuscitation   4 mLx Body weight (Kg) x %TBSA   = 24 hour fluid requirement...
DEPARTMENT OF SURGERYSample Calculation• 4 mLx 90 kg x 17%=  6120 mL of LR• 3060 mL in 1st 8  hours (383 mL/hr)• 1530 mL f...
DEPARTMENT OF SURGERYMonitoring Resuscitation•  If the patient is not making enough urine, he’s not   getting enough fluid...
DEPARTMENT OF SURGERYMetabolic derangements and           burns
DEPARTMENT OF SURGERYMetabolic response to major burn
DEPARTMENT OF SURGERYCV pathophysiology of hypermetabolism•   Chronic inflammatory state•   Hyperdynamic circulation•   Hy...
DEPARTMENT OF SURGERYBURN THERMOREGULATION
DEPARTMENT OF SURGERYPoikilothermia• Loss of cutaneous  vasoconstriction• Evaporative  temperature loss• Magnified by abla...
DEPARTMENT OF SURGERYALTERATIONS IN DRUGMETABOLISM
DEPARTMENT OF SURGERYAcute/ Resuscitation Phase• Decreased renal and hepatic blood flow  => decreased clearance of many ag...
DEPARTMENT OF SURGERYHyperdynamic phase• Increased renal and hepatic blood flow =>  increased clearance of many agents• De...
DEPARTMENT OF SURGERYHyperdynamic phase• Increased Vd• May also have losses directly from  wounds• ?Impairment of hepatic ...
DEPARTMENT OF SURGERYSummary of drugmetabolism• Altered pharmacodynamics and pharmacokinetics  – Clearance may be increase...
DEPARTMENT OF SURGERYTake-home message?
DEPARTMENT OF SURGERYBurn patients are challenging!• Difficulties in airway management and  vascular access• Progression f...
DEPARTMENT OF SURGERYThank you!
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Cochran anesthesia postgrad 2013

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My talk on burns from the 2013 Updates in Anesthesia Course

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Cochran anesthesia postgrad 2013

  1. 1. DEPARTMENT OF SURGERYPreoperative care of the burn patient Amalia Cochran, MD, FACS, FCCM Associate Professor, University of Utah Department of Surgery Burn Center at the University of Utah
  2. 2. DEPARTMENT OF SURGERYDisclosures• None
  3. 3. DEPARTMENT OF SURGERYObjectives• At the completion of this talk, learners will be able to: – Recognize unique challenges in burn anesthetic management – Respond to major preoperative considerations in burn patients – Describe special pharmacologic considerations in burn care
  4. 4. DEPARTMENT OF SURGERYWhy anesthesia and burns?• Highly-developed, specialized skill sets – Airway management – Pulmonary care – Fluid and electrolyte management – Vascular access – Pharmacologic support of circulation
  5. 5. DEPARTMENT OF SURGERYChallenges in Burn Anesthetic Management• Compromised airway • Positioning• Pulmonary • Edema insufficiency • Dysrhythmias• Altered mental status • Impaired temperature• Associated injuries regulation• Difficult vascular • Altered drug access responses• Rapid blood loss • Renal insufficiency• Impaired tissue • Immunosuppression perfusion • Infection/sepsis
  6. 6. DEPARTMENT OF SURGERYMajor Preoperative Considerations
  7. 7. DEPARTMENT OF SURGERYPatient Age
  8. 8. DEPARTMENT OF SURGERYBurn Depth, Burn Extent, Burn MechanismBURN CHARACTERISTICS
  9. 9. DEPARTMENT OF SURGERYFirst Degree Burns • Only damage is to epidermis • Red, hyperemic • Uncomfortable • DOES NOT COUNT FOR BURN SIZE CALCULATIONS
  10. 10. DEPARTMENT OF SURGERYSuperficial Partial-Thickness Burns • “Superficial 2nd degree” • Epidermis and papillary (superficial) dermis are damaged • Blistering • Moist, pink, blanch with pressure • Quite painful
  11. 11. DEPARTMENT OF SURGERYDeep Partial-ThicknessBurns • “Deep 2 degree” nd • Epidermis, papillary dermis, various depths of reticular dermis • Pink-white, somewhat dry appearance • Less painful, but more slow to heal
  12. 12. DEPARTMENT OF SURGERYFull-Thickness Burns • “3rd degree” • Extends to subcutaneous tissues • Does not heal spontaneously* • Appear charred with thrombosed vessels • Little or no pain • High infection potential
  13. 13. DEPARTMENT OF SURGERYEstimating Burn Size
  14. 14. DEPARTMENT OF SURGERYFlash and Flame burn• 50% of US burns• Flash burns – More superficial – Cover more area – More airway risk• Flame burns – Deeper into dermis – Increased risk of inhalation injury/ CO
  15. 15. DEPARTMENT OF SURGERYScald burn• 2nd most common• Mosaic of partial and full thickness• Immersion scalds common in “high risk” groups• Association with NAT in children
  16. 16. DEPARTMENT OF SURGERYHigh-Voltage electrical burn• 5-7% of burn admissions• Most common cause of amputations in burns• Arrhythmias• Renal damage• Concomitant trauma• Compartment syndrome
  17. 17. DEPARTMENT OF SURGERYChemical burn• 3% of burns; 30% of burn deaths• Denaturation of proteins• Irrigation for 30 minutes to 2 hours – Risk of hypothermia• “Traditional” ABCs• Acid-base imbalance
  18. 18. DEPARTMENT OF SURGERYAIRWAY CONSIDERATIONS
  19. 19. DEPARTMENT OF SURGERYWhy inhalation injury matters• Independent risk factor for mortality• Increased fluid requirements during resuscitation – Up to 50% higher• Medium-term consequences: – Impaired gas exchange – Pneumonia – ARDS/ SIRS/ MSOF
  20. 20. DEPARTMENT OF SURGERYSigns and Symptoms- Inhalation Injury• Hoarseness • Wheezing• Lacrimation/ • Stridor Conjunctivitis • Bronchorrhea• Brassy cough • Dyspnea• Carbonaceous • Anxiety sputum • Disorientation• Facial burns • Obtundation/ Coma• Singed nasal hairs
  21. 21. DEPARTMENT OF SURGERYInitial management• 100% humidified O2• Determine if the patient’s airway is at risk – Progressive edema? – Smoke inhalation injury?• Intubation is NEVER the wrong answer if concerned about airway safety!
  22. 22. DEPARTMENT OF SURGERYAirway Obstruction• Result of direct thermal injury• Coupled with edema from resuscitation of large burn• Puts airway at VERY high risk – Can easily be lost if not intubated early
  23. 23. DEPARTMENT OF SURGERYSmoke Inhalation injury • Gold standard for diagnosis: Fiberopticbroncoscopy • Usually minimal initial physiologic and anatomic manifestations • 3-4 days later- impaired oxygenation, decreased compliance
  24. 24. DEPARTMENT OF SURGERYTreatment of Inhalation Injury • Tracheal intubation and mechanical ventilation • Aggressive pulmonary toilet • Percussive ventilation • RT protocols to mobilize debris and secretions • Lung protective ventilation strategies
  25. 25. DEPARTMENT OF SURGERYCarbon monoxide poisoning• Impaired oxygen binding and oxygen carrying capacity – Decreased O2 delivery due to curve shift• Clinical features: Headache, nausea, altered mental status• Pulse oximetry is normal – Requires carboxyhemoglobin level• Best treatment: 100% O2 – Evidence does not support hyperbaric
  26. 26. DEPARTMENT OF SURGERYBurn ShockRESUSCITATION
  27. 27. DEPARTMENT OF SURGERYBurn Shock• Complex process of circulatory and microcirculatory dysfunction• Not entirely remedied by fluid resuscitation• Result of tissue damage, hypovolemia, and inflammatory mediators
  28. 28. DEPARTMENT OF SURGERYMassive edema formation   interstitial pressure  microvascular permeability   capillary hydrostatic pressure   intravascular oncotic pressure   (relative) interstitial oncotic pressure
  29. 29. DEPARTMENT OF SURGERYEarly CV pathophysiology of burns• Decreased cardiac output• Increased SVR – Secondary impact of tissue/ organ ischemia• Myocardial dysfunction (commonly)
  30. 30. DEPARTMENT OF SURGERYWho gets formally resuscitated?• Any burn ≥ 10-15% TBSA – 2nd or 3rd degree only• All electrical, chemical, inhalation injuries• All multiple traumas• Extremes of age• When in doubt- start fluid resuscitation
  31. 31. DEPARTMENT OF SURGERYFactors that increase fluid requirements• Delay to resuscitation• Smoke inhalation injury• High voltage electrical injury• Increased 3rd degree/ full-thickness• Associated soft tissue injuries – Burn/ trauma• Methamphetamines
  32. 32. DEPARTMENT OF SURGERYParkland Calculation for Resuscitation 4 mLx Body weight (Kg) x %TBSA = 24 hour fluid requirements with Lactated Ringers 1/2 in the first 8 hours 1/2 over the next 16 hours Adjust according to urine output
  33. 33. DEPARTMENT OF SURGERYSample Calculation• 4 mLx 90 kg x 17%= 6120 mL of LR• 3060 mL in 1st 8 hours (383 mL/hr)• 1530 mL for next 16 hours (191 mL/ hr)• Remember- these estimates are a starting point!
  34. 34. DEPARTMENT OF SURGERYMonitoring Resuscitation• If the patient is not making enough urine, he’s not getting enough fluid! – Increase the fluid rate, usually by 10% – PLEASE don’t give diuretics!• Goals: Adults: 30-50 mL/hr Children: 1 mL/kg/hrMyoglobinuria/hemoglobinuria: Goal is twice normal urine output• If the patient is making excessive urine, LR rate may be reduced
  35. 35. DEPARTMENT OF SURGERYMetabolic derangements and burns
  36. 36. DEPARTMENT OF SURGERYMetabolic response to major burn
  37. 37. DEPARTMENT OF SURGERYCV pathophysiology of hypermetabolism• Chronic inflammatory state• Hyperdynamic circulation• Hypotension• Tachycardia• Decreased SVR• Increased cardiac output
  38. 38. DEPARTMENT OF SURGERYBURN THERMOREGULATION
  39. 39. DEPARTMENT OF SURGERYPoikilothermia• Loss of cutaneous vasoconstriction• Evaporative temperature loss• Magnified by ablative effects of general anesthesia
  40. 40. DEPARTMENT OF SURGERYALTERATIONS IN DRUGMETABOLISM
  41. 41. DEPARTMENT OF SURGERYAcute/ Resuscitation Phase• Decreased renal and hepatic blood flow => decreased clearance of many agents• Decreased CO => increased alveolar accumulation – May augment inhaled anesthetic agent effects
  42. 42. DEPARTMENT OF SURGERYHyperdynamic phase• Increased renal and hepatic blood flow => increased clearance of many agents• Decreased albumin – Increased unbound fraction of acidic or neutral drugs (diazepam)• Increased α-acid glycoprotein – Decreased unbound fraction of basic drugs (propofol)
  43. 43. DEPARTMENT OF SURGERYHyperdynamic phase• Increased Vd• May also have losses directly from wounds• ?Impairment of hepatic enzymes – May result in decreased clearance even with increased blood flow
  44. 44. DEPARTMENT OF SURGERYSummary of drugmetabolism• Altered pharmacodynamics and pharmacokinetics – Clearance may be increased or decreased• Use of serum drug levels may be helpful – Antibiotics – Enoxaparin
  45. 45. DEPARTMENT OF SURGERYTake-home message?
  46. 46. DEPARTMENT OF SURGERYBurn patients are challenging!• Difficulties in airway management and vascular access• Progression from shock to hypermetabolism during first 48 hours post-injury• Requirement for a full team approach to care
  47. 47. DEPARTMENT OF SURGERYThank you!

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