Anesthesia for Burn Patients

There have been a lot of strides in burn care in recent decades so that most people survive even severe burns.  Attention has now been moved away from survival to making patients more comfortable as they heal from a major trauma.  Anesthesia is the art of keeping the patient comfortable during the often several surgeries and multiple dressing changes that need to take place as part of the healing process.

The treatment of burn patients requires a multidisciplinary team of surgeons, nutritionists, internists, respiratory therapy providers, nurses, rehabilitation providers and anesthesiologists.  The anesthesiologists and anesthetists become the experts in gaining vascular access, airway management, lung care and support of the body through fluid and electrolyte management along with their primary expertise in alleviating pain and altering consciousness during surgery.

There are a number of challenges the anesthesia team faces when dealing with a burn patient around surgery.  Some of these include:
  • Lung problems/insufficiency
  • Airway compromise
  • Other injuries
  • Changed mental status
  • Rapid blood loss
  • Limited IV access
  • Low hemoglobin
  • Swelling
  • Heart arrhythmias
  • Poor temperature regulation
  • Kidney problems
  • Poor immune system
  • Infection or sepsis
Evaluation before Surgery

People with severe burns are at their most resilient to withstand surgery shortly after being resuscitated from their burn.  As time goes on, factors surrounding the burn cause the patient’s health to deteriorate so it is important to do the necessary surgery within a narrow window of the best health possible.

Anesthesiologists must look at the following things before bringing the patient to the operating room for surgery.  They need to look at the age of the patient as older people tend to need special care during surgery.  They need to know the extent of the burn so as to gauge the amount of fluid the patient will need in surgery.  The need to know the type of burn and whether or not there has been a lung injury.

When did the burn occur and was the patient adequately resuscitated from the injury?  Are there other injuries or other underlying conditions?

The size of the burn matters when it comes to anesthesia.  Large burns set up inflammatory responses that affect the function of all the body organs, including the liver and kidneys.  If burns are deep, there will be more blood loss in surgery as well as more fluid loss.  Blood products might be immediately necessary to make up for the loss incurred during debridement surgery.

The airway must be clear and be able to pass an endotracheal tube during surgery.  The lungs may be damaged due to smoke inhalation and the anesthesiologist needs to be prepared for these injuries.  Sometimes, using an endotracheal tube unnecessarily because of suspected lung damage is dangerous because it can further inflame upper airway tissues.  The anesthesiologist must weigh these factors in the management of the perioperative patient.

The burn can severely affect circulation.  Shock can develop from poor cardiac output and increased resistance of the blood flow in the arteries.  The tissues don’t get enough circulation.  Fluid shifts from the bloodstream to the lymph tissue and body tissues.  Severe burns can suppress the function of the heart, further contributing to shock development.  The patient may need large volumes of fluid by IV in order to make up for fluid shifts and fluid loss.
 
Resuscitation by the anesthetist begins with giving enough fluids and ends with making sure the patient is getting enough oxygen.  Usually, giving fluids like IV Lactated Ringer’s solution are all that is necessary but some patients will need blood products or protein-containing fluid as well.  More fluid is needed if the patient has the following situations:
  • Delayed resuscitation
  • Lung injury
  • Crushing injury
  • Other injuries/trauma
  • Large full-thickness burns

Patients tend to have a lot of swelling around and in the burned area and this is fluid that needs to be replaced back into the bloodstream so the individual doesn’t suffer from shock.  Doctors need to follow the amount of urine put out by the kidneys in order to gauge whether or not the fluid resuscitation is adequate.  If not enough urine is being put out, the patient isn’t getting enough fluid.
 
Severe burns can cause the kidneys to fail, which further complicates matters.
 
Anesthesiologists must adjust the amount of medication given depending on the burn circumstances.  The kidneys don’t function  well in severe burns so that less medication for the patient is given if the patient  is more sensitive to succinylcholine because a patient  can die of complications of too much of the muscle relaxant during anesthesia.

In the Operating Room

The anesthesiologist is responsible for the patient’s wellbeing in the operating room.  The airway must be extremely secure with an endotracheal tube and might have to be secured while the patient is lying on his or her stomach.  This requires special care during intubation and turning the patient onto his or her stomach.  Special ways of tying the endotracheal tube in place need to be employed so it doesn’t become dislodged during the surgery.  The tube may need to be passed through the nose instead of the mouth.

Even with large surface areas of the body covered in burns, the patient needs to be monitored effectively during surgery.  Means to measure arterial oxygen saturation, blood pressure and body temperature need to be established and maintained during the operation.  Sometimes, peripheral IVs are not possible and the patient will need a central venous catheter instead.  Other times, the IV must be placed directly through burned tissue.  Arterial blood catheters might need to be in place so that the oxygenation of blood and blood pressure inside the arteries can be continually monitored.

As far as anesthetic agents go, sometimes less often used medications like ketamine may need to be used as this is a drug that can induce anesthesia, maintain anesthesia and does not always require that the patient be on a ventilator.  It can even be given intramuscularly for patients who do not have good IV access or who are uncooperative during preparation for surgery.  If an endotracheal tube is present, the patient can have the usual inhaled anesthetic agents during the surgical procedure.  Opioids like morphine can be given before, during and after surgery for pain control.

Blood transfusions may need to be given during surgery.  Most experts believe that there should be blood transfusions if the hemoglobin has dropped to the 6-10 g/dl range.  Patients with heart or lung problems need more blood transfusions at a higher hemoglobin concentration than normal patients.  Ideally blood should be given as the blood is being lost during surgery and not after the patient’s blood pressure and blood volume have already been diminished.

There are complications to giving too much blood.  The blood can become too thin from a lack of platelets in the transfused blood so that excess bleeding occurs.  Citrate, used to preserve blood, can reach toxic levels.  Potassium shifts can occur which can cause heart arrhythmias.  The patient can become too cold if large amounts of cold blood products are given.  The lungs can also fill with fluid if large amounts of blood are necessary.  Blood transfusions increase the risk of infection

In summary, anesthetic management of burn patients is complex and tricky.  Many things factor into the way the patient is managed and how much fluid, oxygen, blood and medications are given.  An anesthesiologist caring for burn patients  must understand the complexities of burns and burn care in order to maintain the person’s vital signs before, during and after surgery. 

A serious burn is a catastrophe. Anyone who has a serious burn thru the negligence of another should contact an experienced catastrophic injury lawyer.
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