kifaru

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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
 

UTSouthwestern

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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
 

GasPundit

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UT, awesome post. To me, this is the difference between being a practitioner (of anything) and a consultant. I mean, you could try to use a rather standard anesthetic, but it would be sloppy and you'd risk a bad outcome.
 

DrQuinn

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Is sux truly contraindicated in an immediate burn? I've done some quick searching and found that within the first 4-6 hours after the burn injury, its ok to use succhinylcholine, the real danger is within day 1-4. I've spoken with burn attendings and they only have anecdotal evidence.

Q
 

UTSouthwestern

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QuinnNSU said:
Is sux truly contraindicated in an immediate burn? I've done some quick searching and found that within the first 4-6 hours after the burn injury, its ok to use succhinylcholine, the real danger is within day 1-4. I've spoken with burn attendings and they only have anecdotal evidence.

Q
The problem lies in the timing of the use of sux from the burn event and the variability you will encounter in different age groups and among patients with differing severity of burns. Unless you absolutely need to use it because of a probable difficult airway, a non-depolarizer is probably the safer choice.

You are, however, correct about what is generally considered to be a safe window of opportunity as has been published previously on this topic.
 

2ndyear

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I met Dr. Papadakos at the U of R interview. He is a pretty big name in burns, just proving once again that anesthesia can lead to some pretty cool directions. I just love the physiology in burns, wacky. That and you get to just pound the fluid which is a nice change from MICU. I did a burn rotation in med school and I could see myself enjoying this field in the future. Here's Papadakos' page:
http://web.anes.rochester.edu/testsite-php/content/Faculty-ppapadak.php
 

Dr. J?

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Has anyone determined the length of time for which succinylcholine is contradindicated in a pt post-burn injury?

I am curious b/c I was told by an attending (from a NYC hospital whose name I cannot recall) that I was at risk for severe hyperkalemia if given succ d/t my PMx of a significant electrical burn when I was 12 (I am now a much older 2nd yr med student). She even mentioned that I should consider wearing a medical alert bracelet.

I was polite to her when she told me this (we were sharing dinner at a Japanese steak house), but thought she was totally full of $hit at the time (since it had been every bit of 15 yrs ago since my accident and I assumed my physiology would have returned to baseline). I attempted to search for articles on the subject when I returned from the conference, but could only find a few from the 1960-70's era which seemed to say the contraindication only lasted for a few months.

I would be interested in any comments y'all have about this, thanks.
 

UTSouthwestern

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Dr. J? said:
Has anyone determined the length of time for which succinylcholine is contradindicated in a pt post-burn injury?

I am curious b/c I was told by an attending (from a NYC hospital whose name I cannot recall) that I was at risk for severe hyperkalemia if given succ d/t my PMx of a significant electrical burn when I was 12 (I am now a much older 2nd yr med student). She even mentioned that I should consider wearing a medical alert bracelet.

I was polite to her when she told me this (we were sharing dinner at a Japanese steak house), but thought she was totally full of $hit at the time (since it had been every bit of 15 yrs ago since my accident and I assumed my physiology would have returned to baseline). I attempted to search for articles on the subject when I returned from the conference, but could only find a few from the 1960-70's era which seemed to say the contraindication only lasted for a few months.

I would be interested in any comments y'all have about this, thanks.
Fifteen years after the fact places you in no risk for hyperkalemia with sux. Unless you have a neuromuscular disease or suffered some type of paralysis from your injuries, you should be OK.