 Introduction

 Cause Of Burn
 Pathophysiology Of Burn Injury
 Burn Severity
 Management

 Anaesthetic Considerations
 Long-term Considerations
 Burn injuries contribute significantly to the global burden of disease and remain
a leading cause of worldwide morbidity.
 From a global perspective, more than 8 000 000 new cases of burns occur
annually.
 More than 95% of burn deaths occurring in low- and middle-income countries.
 Consequences of burn injury are dictated by the severity of tissue damage.
 Management ranging from simple first aid management to intensive and
specialised interventions
 Anaesthetic management of patients suffering from burn injury is complex.
 Anaesthetic management is focusing on fluid resuscitation, airway
management, analgesia and infection control.
 A burn injury can have multiple aetiologies.
 Most aetiologies occur as a result of direct skin contact with a chemical,
heat, electrical, friction or radiation source.
 causing damage to superficial tissues.
 The specific mechanism and extent of burn injury can strongly influence
prognosis.
 Inhalation injury occurs in 20% of burn injuries.
 Inhalation injury arises from inhalation of smoke components that damage
oropharyngeal and pulmonary airway structures.
 inhalation injury is with higher mortality due to sequalae.
Acute
 Immediate localised effects as well as systemic effects.
 Can be improved though early intervention.
 The local area undergoes cell death.
 Exposed injured nerve endings (extremely painful ).
 Inflammatory mediators eg. Histamine, which may initiate a systemic response.
 Burns more the 25% (TBSA) risk of systemic inflammatory response.
 Ebb phase’, (lead to shock.)
 In first 48 hours due to systemic response
 low peripheral vascular resistance, decreased CO.
 Early management and rapid fluid resuscitation can reduce tissue damage.
 Plateau phase’ occurs for a number of days.
 Hyperdynamic circulation.
 Increased oxygen and glucose consumption.
Long term
 Result in chronic pain and have a negative impact on quality of life.
 The chronic pain in burn injury is multifactorial.
 Prolonged intense nociceptive pain arising from damaged tissues
 Neuropathic pain arising from nerve fibres damage and inflammation.
 Injured tissues as well as donor tissues can be affected.
 Dressing are required to minimise infection and promote healing.
 Repeated painful dressing can prolong pain.
 Chronic pain include scarring that interferes with musculoskeletal function, as
well as psychological sequelae.
 Physical disfiguration and potential loss of livelihood.
 Pain management of burns requires specialised care to minimise long-term
sequelae.
 Burn injuries are classified according to depth :
1. The epidermis alone (first degree).
2. Dermis and epidermis (second degree or partial thickness) .
3. Epidermis, dermis and hypodermis (third degree or full thickness).
 Full-thickness burns require significant intervention in the form of surgical
debridement, full excision and grafting.
 Early excision and grafting, within 3 days of injury, has led to significant reduction
in mortality .
 Patient age, TBSA involved, depth and mechanism of burn as well as specific
body areas affected are considered in burn severity.
 Superficial burns, are not counted in calculations of TBSA involvement.
 There is no consensus classification for what constitutes a major burn.
 Burns that may need specialist intervention.
RESUSCITATION (A,B,C….)

A-Airway
major burn injury often require immediate challenging airway management.
airway status can evolve rapidly after burn injury .
airway management in early stage before it becomes more difficult to manage.
Airway management can be complicated by limitation in mouth opening, airway
and facial oedema and difficulties interpreting airway anatomy.
All airway management Techniques should be consider .
indication for intubation or tracheostomy should be for cases of current or evolving
impairment of airway patency.
Clinical signs include airway swelling, soot contamination of airway secretions,
increasing work of breathing, hoarseness,stridor, dysphagia……..
This emphasises the importance of continued clinical assessment and early
intervention should airway signs show a clear pattern of deterioration.
B-Breathing
 Pulmonary complications, (pulmonary oedema) a major cause of mortality
 Symptoms include wheezing, hoarseness, bronchorrhoea and excessive sputum
production together with tachypnoea and low oxygen saturations.
 Pulmonary oedema after burn injury can arise from 2 mechanisms:
1-Direct irritation by heat, smoke or chemicals.
2- Part of a (SIRS).
 Patients may require oxygen therapy, controlled ventilation.
C-Circulation/Fluid Resuscitation
 Bleeding from wounds, evaporative losses and systemic responses can lead to
impaired organ perfusion after burn injury.
 burn shock presents as marked hypoperfusion and hypovolemia occurring
within the first 24 hours necessitating aggressive fluid resuscitation.
 Inadequate fluid resuscitation results in worsening burn injury and mortality.
 Burn shock is most common cause of death from severe burn in the first week.
 Various formulas have been devised to provide estimates of both rate and
volume of fluid resuscitation
 These formulas are best used in the context of full assessment of vital sign
patterns, urine output and cardiac filling pressures and trending creatinine.
 crystalloid is an accepted form of therapy for volume loss after burn injury,
 Colloid may a part of a restrictive fluid strategy.
Monitoring
Depending on the site of burn injury, intraoperative monitoring of patients
with burn injuries can be difficult.
Pulse oximetry may not function on fingers or toes, with alternative sites
such as the nose, ear or tongue often needing to be used instead.
Rarely,arterial blood gases might have to be used to estimate oxygenation
level.
Temperature probes are essential.
Noninvasive blood pressure measurement is possible if the cuff can be
applied to non-burnt areas.
 invasive blood pressure monitoring may required.
ECG may be difficult to obtain as the adhesive may not stick to burnt
tissues.
Options for ECG monitoring include needle electrodes or skin staples.
Airway Considerations
Patients with burns are often transferred intubated and ventilated from intensive
care or high-dependency unit facilities.
Care must be taken to transfer patients to theatre without incident and to
maintain existing ventilation therapies.
Patients who are not intubated may present all the challenges and may require
strategies to manage difficult intubation scenarios.
Suxamethonium may be safely used in burn patients in the first 48 hours.
After 48 hrs hyperkalaemic response may exaggerated.
Analgesia
Analgesia for severe burn injuries can be challenging to manage.
Opioid remain the mainstay of analgesia in severe burn injury.
 In many cases, high-dose infusions of opioids and sedatives are
commenced to aid endotracheal tube tolerance.
opioid tolerance, leading to higher opioid requirement.
Specialist pain management is desirable in these patients,.
Strategies such as opioid rotation, introduction of opioid-sparing nalgesic
strategies and careful opioid de-escalation.
Opioid-sparing agents include ketamine and lignocaine infusion as well as
non-opioid analgesia is often added to existing opioid
Therapy to facilitate conscious sedation.
Nonpharmacologic therapies aid dressing changes, particularly in the
paediatric burn population
Vascular Access
Since significant fluid shifts and volume losses occur in this
vascular access is crucial but may also present special challenges.
Invasive monitoring and large-bore venous lines are essential as burn patients
have large, exposed surface areas leading to unexpectedly high losses.
Such access can facilitate rapid fluid resuscitation, provide access and
monitoring and inotropic support.
Lines should be sited in areas that are not in the surgical field.
Suturing and ties rather than standard vascular access adhesive dressings may
be needed.
The use of ultrasound to visualise arteries and veins may be required to guide
placement.
Nutrition and Thermoregulation
Adequate nutritional support is essential in severe burn management.
burns exceeding 40%TBSA experience doubling of their basal metabolic rate.
The enteral route is preferred to facilitate postpyloric feeding to avoid effects of
associated gastric stasis.
If regular oral feeding is not possible, nasogastric or total parental nutrition
options must be explored,
 Insufficient nutrition has been correlated with increased mortality.
Monitoring of temperature in patients with severe burns can be challenging, but
is vital for detecting thermo-dysregulation.
Severe hypothermia due to heat and fluid loss and profound hyperthermia, can
lead to multiorgan failure.
Hyperthermia can be a sign of altered hypothalamic thermal setpoint, a sign of
an infectious complication or transfusion reaction.
All episodes of hyperthermia must be investigated appropriately.
Pharmacologic Considerations
Patients with significant burn injuries have altered pharmacodynamic and
in pharmacokinetics.
These patho-physiological changes mean that careful titration and
monitoring of commonly used anaesthetic drugs may be required.
Burn injury–related changes cause proliferation of extrajunctional
acetylcholine receptors.
This release more potassium into the extracellular space, predisposing to
life-threatening hyperkalaemia when suxamethonium is used.
This risk appears to be greatest in patients more than 48 hours after and
for up to 1 year pos-tinjury
 Non-depolarising neuromuscular blocking agents (NMBAs) may also have
altered pharmacodynamics in burn patients,(multifactorial.)
Pharmacologic Considerations
 Plasma protein concentration and binding capabilities may be drastically altered
after severe burn injury.
 Significant hypoalbuminemia can occur due to protein-rich fluid loss and
decreased hepatic synthesis.
 In addition, alpha 1-acid glycoprotein (AAG)concentrations can increase as part
of the inflammatory response .
 These can affect protein bound anaesthetic and analgesic drugs.
 Drugs bound to albumin may be present in a higher free concentration.
 Pharmacodynamic changes may also arise as a result of continued exposure to
opioid therapy.
Improved resuscitation management and surgical techniques
have led to improved mortality rates following severe burn
injury.
Despite this, survivable burn injuries can create long-term
issues that can significantly affect quality of life.
Approximately 1 of every 3 patients develops at least 1
contracture following a burn injury, which can limit mobility.
These contractures can require further surgeries many months
after the original injury and cause additional scarring as well as
contribute to chronic pain.
Careful consideration must be given to airway management,
muscle relaxant choice as well as positioning during surgery in
these patients.