kifaru said:
Question for those in the know;
how would you go about providing anesthesia for a patient who is 3 months s/p burn injury to the face and upper extremities. What are the unique challenges posed by burn patients?
Kifaru
I have a 100 slide power point lecture on anesthesia and burns. Three months out makes most of it easier as the physiology of the patient has largely returned to baseline, including the increased hepatic flow and increased volume of distribution that makes dosing of your meds a little more challenging.
As always, airway issues remain (neck ROM, OP axis alignment, oral diameter, scar tissue in the airway, decreased airway caliber, etc.) and blood loss from surgical manipulation/repair of a burn scar area greater than 16 days out from the event should be estimated to be around 0.5 to 0.75 cc/cm2 unless infected -> 1 to 1.25 cc/cm2).
Psychological issues and pain management issues are likely other issues that will have to be dealt with and regional should be considered when applicable.
Issues more pertinent for the recently burned patient include:
Hypermetabolic state
Insulin resistance/Hyperglycemia
Increased oxygen demands
Carbon monoxide toxicity
Inhalational injury
Poor thermoregulation
Decreased protein binding
Increased rate of surface fluid loss
Increased renal blood flow
Increased VD
Increased cardiac output
Increased muscular Ach receptors
Down-regulated beta receptors
Decreased plasma acetylcholinesterase
Thiopental - Increased dose needed
Opiods - In acute phase of burn they may have exagerated responses, but later response is attenuated
Muscle relaxants
Succinycholine is contraindicated
Non depolarizers have an attenuated response (Enhanced renal elimination, loss of drug through the burn wound, increased protein binding especially alpha-1 acid glycoprotein, and upregulated, but nonfunctional acetylcholine receptors) except for Mivacurium (decreased plasma acetylcholinesterase concentration increases DOA of Miv)
Volatile agents - MAC is usually increased