Specific aspects of perioperative management from anaesthetic point of view

1. Peioperative
Anaesthesia
Management of Burn
Patients
Presented by:
Dr.

2. Structure of the skin

3. Structure of the skin

4. BURN DEPTH

5. Classification of Burn Depth
“First-Degree”
a. Involves injury to epidermal
layer
b. Erythema (pink to red)
c. Skin blanches absence of
blisters
d. Painful with tingling
sensation,
pain is eased by cooling
e. Discomfort lasts 48 hrs
healing occurs 3 to 5 days
f. No scarring; intact skin

6. Classification of Burn Depth
“First-Degree”

7. 2. Superficial partial-thickness burn
a. Involves injury to the epidermis and the superficial
layers of the dermis
b. Large blisters may cover an extensive area
c. Pink to red base and broken epidermis, with wet,
shiny and weeping surface
d. Excruciating Pain
e. Heals in 10 to 21 days
f. Some scarring and minor
pigment changes may occur
2nd degree BURN DEPTH
Superficial partial – thickness burn

8. 2nd degree BURN DEPTH
Superficial partial – thickness burn

9. 3. Deep partial-thickness
burn
a. Involves injury of most
of the dermal layer
b. Pain is reduced
c. Wound surface is red
and dry with white
areas in deeper parts,
no blisters
d. Generally heals in 3-6
weeks
e. Scar formation
2nd degree BURN DEPTH
Deep partial – thickness burn

10. 2nd degree BURN DEPTH
Deep partial – thickness burn

11. Second degree
BURN DEPTH
Superficial partial-thickness:
•Usually quite painful
•Erythematous with blebs and bullae
•Even air motion across skin hurts
Deep partial-thickness:
• Sensation impaired to a variable
degree

12. Second degree
BURN DEPTH

13. Classification of Burn Depth
“Third-degree”
4. Full -thickness burn
a. Involves injury and
destruction of the epidermis
and the dermis, the wound
will not heal by re-
epithelialization and
grafting may be required.
b. Appears dry, hard,
leathery eschar.
c. Appears as a waxy white,
deep red, yellow, brown, or
black.

14. Classification of Burn Depth
“Third-degree”
d. Absence of sensation
because of nerve ending
destruction.
e. Scarring and wound
contractures are likely to
develop without preventive
measures.

18. Classification of Burn Depth
“Fourth-degree”
5. Deep full-thickness burn (subcutaneous)
a. Extends beyond the skin into underlying
fascia and tissues and damage to the muscle,
bone, and tendons occurs.
b. Injured area appears black and sensation
is completely absent.
c. Eschar is hard and inelastic.
d. Healing time takes months and grafts
are required.

19. Severity of burn
1.Minor Burn Injury
2.Moderate Burn Injury
3.Major Burn Injury

20. Minor Burn Injury
Minor Burn Injury
• Second-degree burn of less than
15% total body surface area (TBSA)
in adults;10% TBSA in children.
• Third-degree burn of less than
2% TBSA not involving special care
areas (eyes, ears, face, hands, feet,
perineum, joints).

21. Moderate Burn Injury
Moderate, Uncomplicated
Burn Injury
• Second-degree burns of
15%–25% TBSA in adults or
10%–20% in children
• Third-degree burns of less than
10% TBSA not involving special
care areas.

22. Major Burn Injury
Major Burn Injury
• Second-degree burns exceeding
25% TBSA in adults or
20% in children
• All third-degree burns exceeding 10%
TBSA.
• All burns involving eyes, ears, face,
hands, feet, perineum, joints.
• All inhalation injury, electrical injury.

25. Adult Rule of Nines Chart

26. Child Rule of Nines Chart

27. Infant Rule of Nines Chart

29. Lund & Browder Chart 5yrs - Adult

30. Lund & Browder Chart Infant - 5yrs

31. Berkow Chart

32. Site-specific complications
1. Burns of the head, neck, and chest
are associated with pulmonary
complications.
2. Burns of the face are associated
with corneal abrasion.
3. Burns of the ear are associated with
auricular chondritis.
4. Hands and joints require intensive
therapy to prevent disability.

33. Site-specific complications
5. The perineal area is prone to
autocontamination by urine and feces.
6. Circumferential burns of the
extremities can produce a tourniquet-
like effect and lead to vascular
compromise (compartment syndrome).
7. Circumferential thorax burns lead to
inadequate chest wall expansion and
pulmonary sufficiency.

34. Types of BURN
A. Thermal burns are caused by exposure
to flames, hot liquids, steam, or hot
objects.
B. Chemical burns
1. Burns are caused by tissue contact with
strong acids, alkalis, or organic
compounds.
2. Systemic toxicity from cutaneous
absorption can occur.
3. Deep partial-thickness injuries.

35. Types of BURN
C. Electrical burns
1. Burns are caused by heat generated by
electrical energy as it passes through the
body.
2. Electrical burns result in internal tissue
damage.
3. Cutaneous burns cause muscle and soft
tissue damage that may be extensive,
particularly in high-voltage electric injuries.
4. The voltage, type of current, contact site,
and duration of contact are important to
identify.

36. Types of BURN
5. Alternating current is more dangerous than
direct current because it is associated with
cardiopulmonary arrest, ventricular
fibrillation, tetanic muscle contractions, and
long bone or vertebral fractures.
6. Subcutaneous (Fourth Degree).
D. Radiation burns are caused by exposure to
ultraviolet light, x-rays or radioactivity
(superficial burn = sunburn )

37. INHALATION
INJURIES

39. Smoke inhalation injury
1. Description: Injury results when the victim is
trapped in an enclosed, hot, smoke-filled
space.
2. Assessment:
a. Facial burns
b. Erythema
c. Swelling of oropharynx and nasopharynx
d. Singed nasal hairs
e. Flaring nostrils
f. Stridor, wheezing, and dyspnea
g. Hoarse voice
h. Sooty (carbonaceous) sputum and cough
i. Tachycardia
j. Agitation and anxiety

40. Carbon monoxide poisoning
1. Desciption
a. Carbon monoxide is colorless,
odorless, and tasteless gas that has an
affinity for hemoglobin 200 times than
that of oxygen.
b. Oxygen molecules are displace and
carbon monoxide reversibly binds to
hemoglobin to form carboxyhemoglobin.

41. Carbon monoxide poisoning
c. Tissue hypoxia occurs
Mild: headache, nausea
Moderate: dizziness, confusion,
ataxia, visual changes, pallor
Severe: dysrhythmias, coma, cherry
red buccal membrane, cherry-red cast to
skin.

42. Signs of Carboxyhaemoglobinaemia
COHb levels Symptoms
0-10% Minimal (normal level in heavy smokers)
10-20% Nausea, headache
20-30% Drowsiness, lethargy
30-40% Confusion, agitation
40 -50% Coma, respiratory depression
>50% Death

43. QUESTIONS ?
 What assessment of the patient would you
make?
 Discuss airway assessment,
 The significance of perform SaO2 and other
investigations you would perform (COHb).
 What are the indications for intubations.
 What fluid requirements will patients have ?
 What fluid would you give, when you give,
and why ?
 Discuss analgesia, are burns painful ?
 Where should the patient be looked after ?

44. Step 1: Initial Assessment
Airway: does the patient have a patent airway?
Breathing: is the patient breathing adequately?
Circulation: Is the patient’s circulatory and cardiac
status stable?
Neurological status: EVM
Note: burns do NOT alter mentation—if the
patient is un-alert or disoriented, something else
is going on!
Expose the patient, and treat for
hypothermia

45. Step 2: Determining Burn
Severity
• Burn severity is determined primarily by
assessing the extent of the burn as percentage of
total body surface area, and its depth.
• ‘Partial/full thickness’ and ‘1st/2nd/3rd degree’
are acceptable terminology.
• First and second degree burns are partial
thickness burns
• Third degree burns are full thickness burns

46. 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

47. Fluid Resuscitation
End point Urine output
in adults 0.5-1.0 ml/kg/hour
in children 1.0-1.5 ml/kg/hour

48. Stages of Thermal Injuries
1st Stage –
Edema
2nd Stage –
Diuresis

49. 1st Stage – Edema
First 24 hours
Fluid leak: vascular space  interstitial
space
 osmotic pressure
 capillary permeability
Vasoactive substances released
 interstitial edema and intravascular
hypovolemia occurs

50. 1st Stage – Edema
Burns >30% BSA cause capillary changes in both
burned and non-burned tissue
Burned tissue edema
Direct thermal injury to endothelial cells
and  burn tissue osmolarity
Non-burn tissue edema
Severe hypoproteinemia
Small wound
Edema greatest 8-12 hrs post injury
Large wound
Edema greatest 18-24 hrs post injury

51. 2nd Stage – Diuresis
24-36 hours after burn, fluid and electrolytes
begin to remobilize back into intravascular space
Capillary seal reestablishes
Diuresis occurs due to  GFR in response to 
intravascular volume
May see hypernatremia and hypokalemia
Cardiac output may  200-300% normal
 O2 consumption

52. Effects of Burn
1.Localized Effect
2.Systemic Effect

53. Localized Effect

54. Systemic Effect
Cardiovascular
Blood
Electrolyte, Acid & Base
Respiratory
Endocrine
Immune
Gastrointestinal
Muscles & Skeleton

55. Cardiovascular system
CardioVascular System (first 24 hrs)
Activation of CNS system and catecholamine
release:
Tachycardia
Vasoconstriction
During early phase:
Classic S/S of compensated shock
Dramatic decrease in cardiac output
Volume loss and decreased venous return:
 preload
 cardiac filling pressure
 CVP and PCWP
After 24hrs = increased blood flow to tissues, HTN

56. Immune and hematologic system
Immune System
Alters immune cells ability to function
 killing power of neutrophils
Macrophages and lymphocytes do not
work well
Hematologic System
Destruction of RBCs
Hemoglobinuria
 Hgb level  viscosity
 WBC level
Coagulation altered

57. Endocrine and neurological system
Endocrine System
Massive release of catecholamines, glucagon,
ACTH, ADH, Renin, Angiotensin & Aldosterone.
Hyperglycemia.
Neurological System
 cerebral perfusion
Cerebral edema occurs from Na shifts
Carbon monoxide or associated head injury
may cause neuro changes

58. Respiratory System
Upper airway injury
Involves all of airway to level of true vocal cords.
Initially due to inflammation from heat of inspired
smoke.
Exacerbated by accumulation of excess interstitial
fluid.
Major airway injuries
Involves trachea and bronchi.
Parenchymal injury
Involves entire respiratory tract down to, and
including, alveolar membrane.
Commonly lethal within first few hours after injury
due to profound bronchospasms and hypoxia.

59. Respiratory System
Respiratory System Con’t
0-24hrs
Edema
Obstruction
Carbon Monoxide Poisoning
2-5 Days
May develop ARDS
Signs & Symptoms
Stridor / Hoarseness / Facial burns / Singed
nasal hairs / Carbonaceous sputum / Impaired
level of consciousness
S/S of deteriorating ABGs & increasing respiratory
distress

60. Renal System
Renal System
RBF & GFR
Activation of RAS
Release of ADH
retain water & Na
lose of K, Ca, & Mg
ARF
Acute Tubular Necrosis 2o hemoglobinuria
& myoglobinuria due to hemolysis & tissue
necrosis
Maintain high u/o (2ml/kg/hr) w/ fluids /
osmotic diuretics

61. GI and hepatic System
GI System
Slow peristalsis and possible ileus
 HCL acid secretion from stress
response
Narcotics for pain management further
slow peristalsis
Hepatic System
Decreased hepatic synthesis
Decreased metabolic function

62. Induction Medications
- Burn patients require higher than normal
doses of non depolarizing muscle relaxants
due to altered protein binding and increase
in extrajunctional acetylcholine receptors.

63. Muscle Relaxants
Depolarizers– safe in the 1st 24hrs (after which
hyperkalemia may be a problem up to a year or
the burn is healed)
Non-depolarizers – burn patient’s tend to be
resistant to the effects of non-depolarizing
muscle relaxants
May need 2-5 x’s the normal
dose!!!

64. Common Operations
- Decompression procedures
escharotomies & fasciotomies
- Burn excision & skin grafting
- Reconstruction operations
- Supportive procedures
tracheostomy, gastrostomy,
vascular access

65. Review – Anesthetic Management
Preop Meds
Provide adequate analgesia
Fluids
Establish Adequate Vascular
Access
Consider Invasive
Monitoring
Airway Management
Consider Alternatives to
Direct Laryngoscopy
Awake FOB
Ventilation
Increased minute ventilation
increased metabolic rate
Fluids & Blood
Anticipate rapid, large blood
loss
Parkland Formula
Temperature Regulation
Increase ambient
temperature
Warm IV fluids
Anesthetic Drugs
Include opioids
Consider effects of increased
circulating catecholamines
Muscle Relaxants
Avoid Succinyl
Anticipate resistance to
nondepolarizing muscle
relaxants
Postoperative
Anticipate increased
analgesic requirements

67. THANK YOU