Anestesia

Current Anaesthesia & Critical Care (2002) 13, 70 ^75

2002 Published by Elsevier Science Ltd.
c
doi:10.1054/cacc.2002.0385, available online at http://www.idealibrary.com on

FOCUS ON: BURNS AND PLASTICS

Anaesthesia for patients with burns injuries
K. Langley and K. Sim

McIndoe Burns Centre, QueenVictoria Hospital NHS Trust, East Grinstead, West Sussex RH19 3DZ, UK

KEYWORDS Summary The safe managementofcomplex burnsinjuriesrequires anunderstanding
burns, general anaesthesia, of the obligatory pathophysiological changes and currenttreatment options.The anaes-
regional anaesthesia, thetic team must have, collectively specialist skillsin resuscitation, airway management,
,
emergency treatment, critical care procedures and care of small children and access to expert advice in the
transportation of patients management of non-burns co-morbidity The experience of treating relatively small
.
numbers of these patients for prolonged periods of time is unusual in anaesthetic prac-
tice. Flexibility is required to tailor anaesthetic practices to ¢t with overall patient man-
agement objectives. Communication skills are necessary for multidisciplinary team
membership and in dealings with patients, relatives and managerial authorities.
Regular commitment to burns anaesthesia is required to acquire and consolidate ex-
pertise in this group of patients. Issues include altered drug e¡ects, monitoring, blood
conservation techniques and choices in £uid therapy and environmental and metabolic
control.
The contribution of anaesthetic personnel to the management of burns patients con-
tinues to evolve. T raditional roles in resuscitation and preparation for transfer, critical
care, pain management, and anaesthesia for burns surgeryremainimportant but anaes-
thetic inputisrequired to in£uence the future direction of acute burns care services, and
to ensure that the training and development needs of current and future specialist per-
sonnel are met.
2002 Published by Elsevier Science Ltd.
c

INTRODUCTION ASSESSMENT
Although a specialist commitment to anaesthesia for The initial hospital assessment of a major burn should fol-
burns patients is the province of a few, all anaesthetic low (advanced trauma life support) ATLS (advanced
personnel should be competent to systematically assess trauma life support) guidelines with a primary survey
burns injuries and manage their transfer to specialist concentrating on the support of the airway, gas exchange
burns facilities. The causes and thus the presentation of and circulation.The secondary survey examines for asso-
burns injuries are diverse, and include £ame burns, ciated trauma sustained during the accident or whilst
scalds, electrical and chemical burns. Minor burns are trying to escape from the scene. Focusing on the burns
commonFin the UK 1% of the population sustains a injury requires:
burn injury each year, 10% of whom require hospital ad-
K An estimation of percentage surface area
mission. Of these only around one in 10 have sustained a
involvement.
life-threatening injury, but the appropriate early man-
K Assessment of depth of burned areas.
agement of the burn wound and its systemic conse-
K Determination of the evidence for inhalational injury.
quences is a key factor in reducing morbidity.
K Vascular or respiratory compromise secondary to
The burns case mix is not representative of the gener-
circumferential burns should be identi¢ed, and
al population. Patients at the extremes of age are more
escharotomy considered.
vulnerable to injury, as are those with pre-existing mor-
K The cornea should always be examined before facial
bidities such as epilepsy and alcoholism.There is an asso-
swelling makes assessment di⁄cult.
ciation with psychiatric illness, and others, including
K All patients with a history of exposure to smoke in
children, su¡er non-accidental injuries.
an enclosed space should be considered at risk of
inhalation injury, even if the initial signs and sym-
Correspondence to: KS. ptoms are unimpressive. Systemic toxicity secondary

0953-7112/02/$-see front matter

ANAESTHESIA FOR PATIENTS WITH BURNS INJURIES 71

to the inhalation of toxic gases such as carbon halation causes progressive cough and dyspnoea and the
monoxide must be recognized and treated. If the production of copious secretions. A low threshold for
history is unclear, then blood should be retained for tracheal intubation and diagnostic ¢bre-optic broncho-
toxicological analysis. scopy is recommended. The early institution of a regime
K The presence of associated injuries complicates of nebulized bicarbonate solution has proven to be bene-
management, and in£uences priority setting and ¢cial in mobilizing secretions and reducing the incidence
referral decisions. of mucous plugging. Other recommended regimes in-
clude nebulized heparin and or N-acetyl cysteine.3
Major burns injuries (over 20% burn surface area in Patients with signi¢cant carboxyhaemoglobin levels
adults) require prompt resuscitation to treat the predict- (over 30%) require high inspired oxygen concentrations
able pathophysiological consequences.1 to reduce the half-life of COHb.The bene¢t of hyperbaric
K Fluid shifts from the circulation are maximal in the oxygen treatment is questionable given the logistic
¢rst 8 h following injury but continue for 24 h. di⁄culties of managing major burns injuries in hyperbaric
K There is generalized tissue oedema proportional to facilities.
the extent of the burn surface area.
K Cardiac output is initially depressed
K Systemic vascular resistance is high. Venous access
The goal of resuscitation is to restore ¢lling pressures Securing central venous access before generalized tissue
and oxygen delivery as e¡ectively as possible. Resuscita- oedema obscures landmarks is preferable. ATLS teaching
tion £uids are transfused to correct hypovolaemia, initi- has reduced the incidence of £uid under-resuscitation;
ally directed by proscriptive formulae, most commonly over-enthusiastic volume loading should be avoided.
the crystalloid-based Parkland regime. An accurate pa-
tient weight is required. Calculating £uid prescriptions
in children needs adjustments from formulae to account Preparation for transfer
for maintenance requirements. The adequacy of transfer equipment and drugs should be
Traditionally, assessment of the adequacy of resuscita- checked. Guidelines for transfer management are widely
tion has depended on simple parameters including heart available.4 All intravascular lines should be ¢rmly secured
rate, blood pressure and urine output. It is increasingly prior to departure. Contingency plans for airway man-
recognized that this approach fails to detect patients agement enroute should be agreed. Emergency intubation
with signi¢cant regional hypoperfusion, and emphasizes whilst in motion is hardly a preferred option, and inevita-
the importance of expedite transfer from the casualty bly a number of patients will undergo tracheal intubation
facility to a specialist centre bed where appropriate and ventilation primarily for transfer. This can cause dif-
haemodynamic monitoring can be arranged. Trend ¢culties in regions where burns intensive care resources
monitoring of £ow-based parameters is increasingly are scarce, but is preferable to a wait and hope policy.
practiced. Tools such as oesophageal Doppler monitor- Prolonged transfers accentuate the requirement to accu-
ing can be used to guide target-based resuscitation. rately measure and deliver resuscitation £uid volumes.
Other less invasive measures of cardiac ¢lling and cardiac Monitoring appropriate to the patient condition should
output including a transpulmonary double-indicator dilu- be available, with a facility to record and print data on
tion technique that computes intrathoracic blood arrival.
volume have been reported.2 Written information accompanying the patient should
Anaesthetic involvement must be sought early for air- include a history of the burn and any associated injuries,
way assessment, help in securing venous access and liai- initial examination details and treatment of the patient
son in the arrangements for patient transfer. since the burn injury, including airway management, £uid
volumes, urine output. If initial surgical escharotomies
were performed these should be charted.
Airway assessment
It is widely acknowledged that patients with serious
Initially, thermal injury to the upper airway causes oede- burn injuries are best managed in specialist burn units.
ma and potential respiratory obstruction. The combina- Early assessment and active intervention to manage the
tion of facial burns, soot around the nose and mouth, and burn wounds can limit the systemic consequences of the
a clear history of entrapment in a closed space dictates injury and speed functional recovery. High standards
active airway management. Inspiratory noise, agitation of resuscitation, surgery and critical care are required,
and tachypnoea combine to indicate impending respira- and early involvement of experienced sta¡ is necessary.
tory obstruction. There are many aspects to be considered to achieve suc-
Inhalation injury develops as a dynamic process; air- cessful outcome in burns injuries; the contribution of
way oedema generally increases over 12^24 h. Smoke in- anaesthetic members of the burns team remains of high

72 CURRENT ANAESTHESIA & CRITICAL CARE

importance for a substantial part of the patient’s hospital Surgery is indicated for full thickness injuries or when
experience. the wound is unlikely to heal within a few weeks. Slower
Areas of in£uence include: healing wounds risk hypertrophic scar and contracture
formation. Tangential excision is commonly practi-
K Anaesthesia for burns surgery. cedFthis is the debridement of progressive amounts of
K Acute pain management. burns tissue until viable tissue is reached.6 This contrasts
K Critical care. with the historical approach in which burns surgeons
Airway, ventilation, haemodynamics waited for eschar to slough o¡, and then grafted skin
TechnicalFline changes, onto granulating tissue. Advances in surgical, anaesthetic
postpyloric feeding tubes. and critical care have made it possible to excise larger
Nutrition and metabolic management areas of deep burns earlier, and close the wound with
Infection controlFdiagnosis of ventilator-associated autologous or cadaveric skin, or a growing range of skin
pneumonia. substitutes. The introduction of prompt burn excision
with early grafting is believed to result in less scar forma-
K Communication. tion and accelerates functional recovery. Hospital stay is
Patient, surgeons, nurses, therapists, relatives decreased for small burns, but it is more di⁄cult to
K Chronic pain, sleep issues. clearly demonstrate reduced length of in-patient stay
for larger burns.
The timing of surgery for burns wound can be classi-
ANAESTHESIA FOR BURNS SURGERY ¢ed as:
The burns theatre environment can be something of an K ImmediateFescharotomy, or injuries associated with
acquired taste. The case mix, sta¡ and patient dynamics the accident.
are complex and the technical aspects are demanding. K EarlyFtangential excision and grafting within 72 h.
Repeated exposure to patients undergoing multiple sur- K IntermediateFtangential excision and grafting
gical episodes demands patience and attention to detail beyond 72 h.
to discern relevant changes in condition. K LateFpost-burn reconstruction.
A dedicated burns theatre facility must be adequately
stocked and resourced. Theatre anaesthetic equipment In moderate size burns (less than 30%), wound closure
and transport monitoring should be compatible with can be achieved in one procedure using partial thickness
that used in the critical care rooms. Stock control in skin grafts from unburned donor sites. In larger burns
theatre will be in£uenced by infection control proce- partial thickness skin grafts are expanded by 3:1or more,
dures, minimizing store of equipment in theatres. Single and cover is augmented by cadaver allograft which may
use patient items are preferred and didactic cleaning remain adherent for more than 10 days before immune
schedules are needed between cases. Inevitably, the rejection ensues.
turnover of patients is reduced.The temptation to share In very large burns where donor sites are limited, al-
resource with general theatre facilities must also consid- ternative approaches include staged excision of the burns
er infection control issues. The location and sta⁄ng of wound with reharvesting of autologous skin donor areas
post-anaesthetic recovery facilities may be problemati- or the use of arti¢cial skin substitutes to provide tem-
cal, particularly for small children. porary cover.
The practical conduct of burns anaesthesia requires Patients requiring later reconstructive burns surgery
£exibility. Surgical episodes have to be seen in the con- need careful assessment. The extent of the surgery may
text of overall patient management. Momentum has not re£ect anaesthetic di⁄culties in venous access and
to be maintained in the recovery process with targets airway management, so adequate time must be allo-
set and progress judged. This philosophy will inform cated. Patients may travel large distances to maintain
attitudes to fasting times, timing of surgery, sedation, continuity with a particular unit, making day-case ar-
weaning and mobilization. rangements di⁄cult.

Surgery Blood conservation techniques
Modern surgical management strategies are directed at Debridement of major burns has the potential for signi¢-
accurately assessing the depth of the burns wound, excis- cant blood loss, and it is prudent to con¢rm that ade-
ing necrotic tissue to limit infection and the extent of the quate cross-matched blood and blood products is
hypermetabolic response, and achieving wound closure, available before induction of anaesthesia. Surgical timing
with the ultimate goal of maximizing functional and cos- and technique in£uences bleeding, and vigilance is neces-
metic recovery.5 sary to assess losses, especially when multiple surgical


teams work at di¡erent sites on the patient. Blood loss the distribution, transformation and excretion of drugs;
has been estimated to range from 200 to 300 ml for each receptor populations are altered, and losses may occur
percent of the body surface area excised and grafted.7,8 through the burn wound. Polypharmacy is usual, and the
Major blood loss can be sudden and surgery may need potential for interactions high. Experienced pharmacy
to be suspended while hypovolaemia is corrected. sta¡ have an important surveillance role.
Naturally, prevention is better than cure, and strate- The acute phase response to severe burns injuries re-
gies to keep blood loss to a minimum are an important sults in early changes in plasma protein levels. Albumin
part of surgical technique.Tourniquets should be used for levels fall and alpha-1 acid glycoprotein levels rise.
all extremity burns. Subcutaneous in¢ltration of the Changes in the drug non-protein bound fraction can al-
operative site using saline with adrenaline 1:1000 000 ter the pharmacological response.
solution ‘to tumescence’ is highly e¡ective.9 A delay of In general, drug pharmacokinetics undergo a biphasic
10 ^15 min before excision enhances the vasoconstrictive response in burns injury. The initial reduction in circulat-
e¡ect. The technique appears to be safe with few and ing blood volume, cardiac output and tissue perfusion,
only transient haemodynamic complications.10 There is a due to blood and £uid loss and increased vascular perme-
surgical learning curve as there is a qualitative change in ability, reduces renal and hepatic blood £ow. This is
the tissue surface at excision, but graft take rates appear restored following the development of the hypermeta-
not to be compromised. Other techniques shown to be bolic phase, usually after 48 h. There may be, however,
useful are the use of temporary pressure dressings, impairment in renal tubular and hepatic function, so in-
topical thrombin sprays, and topical adrenaline soaks. creased drug clearance may not necessarily result.
Blood transfusion practices are in£uenced by risk^ The volume of distribution (Vd) of a drug may be al-
bene¢t analyses of red cell transfusion and the availability tered by changes in protein binding and in extracellular
of alternative plasma volume expanders. £uid volume, resulting from £uid loss, exogenous £uid
Recent attention has concentrated on determining administration, and increased capillary permeability.
objective indications for blood transfusion, with clinical Changes in loading dose may be required if the drug has
experience suggesting that losses of up to 30% circulating a small volume of distribution or a narrow therapeutic
volume can be replaced with crystalloid or colloid solu- range. Total plasma clearance must be considered
tions alone.11 Haemoglobin concentrations above 8 g/l are when considering drug maintenance doses and dosage
considered su⁄cient and there is no evidence that mod- intervals.
erate anaemia impairs wound healing.12,13 A pharmacodynamic explanation has been proposed
The trend away from the use of albumin, fuelled by for the e¡ects of burn injury on the e⁄cacy of muscle
cost issues and controversy around a published meta- relaxants. Burn injury causes proliferation of extrajunc-
analysis of albumin in critical care patients has com- tional acetylcholine receptors (AchR) leading to resis-
pounded the wide variation in £uid prescription tance to non-depolarizing muscle relaxants (NDMR),
practices in the post acute phase burns patient.14 The and hypersensitivity to depolarizing muscle relaxants.17
use of hydroxyethyl starches has spread, with prolonged This e¡ect may occur within a week of the injury, persist
duration of e¡ect and e⁄cient volume expansion seen as for up to a year, and is proportional to the total burns
desirable properties. However, a recent paper has raised surface area.
the possibility that the use of hydroxyethyl starches may Dose requirements for all anaesthetic agents are gen-
increase the risk of acute renal failure in patients with a erally increased in the burns population with their hyper-
septic pro¢le.15 Reports of chronic itch are also of dynamic circulation and hypermetabolic state; MAC
concern in a patient group already at high risk of this values are raised and the duration of action is decreased.
complication. Tolerance to the e¡ects of sedative, analgesic and inotro-
The persisting high-volume £uid exchanges required in pic medication is commonly seen but the range of re-
severe burns injury patients emphasize the need for stu- sponse for individual patients is unpredictable.
dies to better determine optimal £uid regimes in the
post acute phase. Manufacturers dosage recommenda-
tions for new colloid solutions are derived from general
Feeding and fasting
critical care population studiesFtheir relevance in
burns patients is conjectural. Clinically, signi¢cant gastrointestinal dysmotility is com-
mon in the burns population but repeated interruptions
to the feeding regime for surgical procedures delays re-
covery. Consideration should be given to the early insti-
Pharmacology
tution of postpyloric feeding, and intubated patients can
Abnormal drug e¡ects are to be expected in burns pa- be fed throughout surgery. Anaesthetic techniques that
tients.16 The host response to severe burns injuries re- permit early re-institution of feeding regimes postopera-
sults in functional changes in organ systems controlling tively should be preferred, and the development of an-

74 CURRENT ANAESTHESIA & CRITICAL CARE

tagonists to opioid-induced gastrointestinal status may theatre team. Body areas not being operated on should
be of advantage.18 be kept covered, and forced air warming devices used if
The importance of tight glycaemic control in critical practicable. A radiant heater near the patient can be par-
care patients has recently been promoted.19,20 Clear unit ticularly e¡ective at reducing heat loss. Intravenous £uids
feeding protocols contribute to this by reducing the inci- should be warmed.
dence of prolonged interruptions to enteral regimes.

PAIN CONTROL
Monitoring
Burns pain is frequently poorly managed, with poor
During anaesthesia there is a continual requirement to communication, drug side-e¡ects and anxiety and de-
monitor the patient’s physiological state, to con¢rm cor- pression being contributory factors.22 Pain receptors in
rect equipment function, and to avoid patient awareness. residual skin elements are stimulated, and the host re-
Accepted recommendations state that the following sponse sensitizes receptors around the injury sites. Neu-
monitoring devices are essential to the safe conduct of ropathic pain develops secondary to nerve damage,
anaesthesia: pulse oximetry, non-invasive blood pressure abnormalities in nerve regeneration and central nervous
monitor, ECG and capnography.21 The extent to which system reprogramming.
the patient is assessed beyond the minimal standards of In the acute stage, the assessment of pain in the critical
monitoring should be determined by the patient’s medi- care burns patient is di⁄cult as the usual signs including
cal condition and the proposed extent of surgery. hypertension, tachycardia, sweating and agitation are
Speci¢c issues in the burns patient include obscured. The pattern of burns depth or area provides
K Di⁄culties in placement of monitoring equipment. few clues as to pain severity but e¡ective analgesia is im-
portant to prevent the physiological, functional and psy-
The standard sites for placement of ECG electrodes chological consequences of severe or protracted pain.
are often unavailable, and it may be di⁄cult to make the Opioid doses titrated to response remains the main-
gel electrodes adhere to damaged skin. Options to over- stay of therapy, and side-e¡ects must be accepted and
come these di⁄culties include attaching the ECG leads managed. Combination therapy with low-dose ketamine
to surgical staples or steel sutures placed in burned infusions, regular paracetamol and judicious use of non-
areas, or accepting the trace obtained by electrode pla- steroidal in£ammatory agents can be opioid sparing,
cement at distant sites. though NSAID side-e¡ects limit their use.
Even with all limbs burned it can be possible to place a
blood pressure cu¡ and obtain a reliable reading. How- K Sodium and water retention.
ever, for all extensive procedures invasive measurement K Inhibition of renal prostaglandin production.
is indicated, with the bene¢ts of pulse-contour analysis, K Inhibition of platelet aggregation.
and ease of blood sampling. K Small bowel villous atrophy.
K Extensively protein bound, so e¡ects potentiated by
K Access to usual sites hypoproteinaemia.
Pulse oximetry may be unreliable in the presence of Antidepressant therapy should be started early and
carboxyhaemoglobin or in shocked, vasoconstricted pa- may be bene¢cial in improving sleep patterns.
tients or those with peripheral burns. Attachment of Following discharge from critical care regular assess-
probes to central sites, such as ear, nose, lip, or tongue ments of severity (those recorded by the professionals
may be helpful. Access to neck veins for central venous generally correlate poorly with the patient’s own assess-
pressure monitoring may be precluded by burns wounds. ment) are needed, and distinction between background
K Temperature monitoring and procedural pain is important, as di¡erent strategies
are needed for each.
This is manadatory in all but the shortest procedures. Background pain may be present continually. At ¢rst,
The combination of lengthy procedures in cold operating intravenous opioids by infusion or patient-controlled an-
theatres, large exposed areas of body surface, and ad- algesia (PCA), will be needed to control pain. Once feed-
ministration of large volumes of £uids, can lead to ing has been established the enteral route can be used,
marked intraoperative hypothermia. with long acting oral opioids supplemented, as necessary,
Infants below 6 months are unable to shiver and pro- with shorter acting preparations for breakthrough pain.
longed hypothermia risks hypoxia and acidosis through Procedures, including surgery, dressing changes, and
adaptive brown fat metabolism. Infants and children have physiotherapy, may require more intense analgesia. Poor
higher relative evaporative heat loss than adults. management can lead to a high degree of anticipatory an-
The ambient theatre temperature should be warm, xiety for future procedures, lowering pain tolerance, so
above 271C, despite the discomfort this causes to the early failure is poorly tolerated. Bolus alfentanil doses


and patient-controlled propofol techniques have been 9. Robertson R D, Bond P, Wallace B, Shewmake K, Cone J. The tu-
used successfully and recovery times are markedly short- mescent technique to signi¢cantly reduce blood loss during burn
er than conventional practice with oral opioid and surgery. Burns 2001; 27: 835^ 838.
10. Cartotto R, Musgrave M A, Beveridge M, Fish J,Gomez M. Minimiz-
benzodiazepine combinations. Regional anaesthetic ing blood loss in burn surgery. J Trauma 2000; 49:1034 ^1039.
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frustratingly unresponsive to conventional regimes. Ad- administration in critically ill patients: systematic review of
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which are e¡ective in the treatment of sympathetically xyethylstarch and gelatin on renal function in severe sepsis: a multi-
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