Department: BSc.

Anesthesia 2nd year

Module title: course. Anesthesia for general surgay

Group 2two assignment

S\N NAME IDNO
1. Abdullah Yusuf Lisho 1893\16
2. Mohamed Ahmed Hasaan 1903\16
3. Hasan Adow Maow 1899\16
4. Hassen Abdale Osman 1900\16
5. Ahmed Marehan Aresi 1896\16
Anesthesia Management for Burn Patients
Definition of a Burn:
A burn is an injury to the skin or other tissues caused by heat, chemicals, electricity, radiation,
or friction. Burns cause varying degrees of tissue damage, depending on the source, intensity,
and duration of exposure. Burns are classified based on the depth and severity of the tissue
damage.

Classification of Burns:
1. First-Degree Burns (Superficial Burns):
Affect: Only the outer layer of the skin (epidermis).

Symptoms: Redness, minor inflammation, or swelling, pain, and dry skin without blisters.

Healing Time: Generally heals within a few days to a week, with no scarring.

Example: Mild sunburn.

2. Second-Degree Burns (Partial-Thickness

Burns):
Affect: Both the outer layer (epidermis) and the underlying layer (dermis).

Symptoms: Redness, blisters, severe pain, and possible swelling. The skin may appear wet or
moist.

Healing Time: Typically heals within 2-3 weeks, with possible scarring or pigmentation changes.

Example: Burns from hot liquids.

3. Third-Degree Burns (Full-Thickness Burns)
Affect: Extend through the epidermis and dermis, potentially damaging deeper tissues like fat,
muscle, or bone.

Symptoms: White, blackened, or charred skin. Numbness due to nerve damage. The skin may
appear leathery.

Healing Time: Requires medical intervention and often leads to scarring. Skin grafts may be
needed for healing.

Example: Burns from fire, prolonged exposure to hot objects, or electricity.

4. Fourth Degree Burns

Affect: Extend beyond the skin into deeper tissues such as muscles, tendons, and bones.

Symptoms: Blackened, charred appearance with no sensation due to destruction of nerve

endings.

Healing Time: Requires surgical intervention, amputation may be necessary, and extensive
rehabilitation is often required.

Example: Severe electrical burns.

Each burn type requires different levels of medical treatment depending on the severity and
extent of tissue damage.

Causes of Burns:
1. Thermal Burns
Caused by contact with hot objects, such as flames, hot liquids (scalds), steam, or hot surfaces.

2. Chemical Burns:

Result from exposure to corrosive chemicals such as acids, alkalis, or solvents that damage the
skin and tissues.

3. Electrical Burns:

Occur when electricity passes through the body, causing tissue damage along the path of the
current. These burns often affect deeper tissues, including muscles and nerves.
4. Radiation Burns:

Caused by prolonged exposure to radiation, such as sunburn from UV rays or radiation therapy
for cancer treatment.

5. Friction Burns:

Occur due to abrasion of the skin against rough surfaces, generating heat through friction.
Examples include road rash from a fall.

6. Cold Burns (Frostbite)

Occur when the skin and underlying tissues freeze, typically due to prolonged exposure to cold
temperatures.

Complications of Burns:
1. Infection:

Burn wounds can become infected, leading to localized or systemic infections like sepsis. The
skin barrier is damaged, allowing bacteria to enter.

2. Shock:

Severe burns can lead to hypovolemic shock, where the body loses a large amount of fluid due to
damaged blood vessels, causing a dangerous drop in blood pressure.

3. Scarring:

Burns, especially deep ones, often heal with scarring, which can be thick (hypertrophic) or
contracture scars that limit mobility in joints and other areas.

4. Respiratory Issues:

Inhalation of smoke, chemicals, or superheated air can cause respiratory complications such as
airway obstruction, bronchospasm, or pulmonary edema.

5. Fluid and Electrolyte Imbalance:

Severe burns can cause massive fluid loss, leading to dehydration and imbalances in electrolytes
like sodium and potassium, which are critical for organ function.

6. Organ Damage:
Severe burns, particularly electrical burns, can cause internal damage to muscles, nerves, and
organs. Prolonged burn injuries can also lead to multi-organ failure.

7. Heat Loss and Hypothermia:

The skin plays a role in temperature regulation, and large burns can cause loss of body heat,
increasing the risk of hypothermia.

8. Psychological Effects:

Burn survivors may experience long-term psychological trauma, including depression, anxiety,
post-traumatic stress disorder (PTSD), and body image issues.

9. Contractures:

Scar tissue can cause the skin to tighten and contract, limiting movement of joints or other body
parts, often requiring surgery or rehabilitation.

10. Chronic Pain:

Burn injuries can result in persistent pain due to nerve damage, requiring long-term pain
management strategies.

Assessment of Burn Area:

Burn area assessment is crucial in determining the severity of the burn and guiding treatment.
The total body surface area (TBSA) affected by the burn is typically calculated, and there are
several methods used to estimate this:

1. Rule of Nines:

This method divides the body into regions, each representing approximately 9% (or multiples of
9%) of the total body surface area.

Adults:

Head and neck: 9%

Each arm: 9%

Each leg: 18%

Front of the torso: 18%

Back of the torso: 18%

Genitalia (perineum): 1%

This method is quick and commonly used in emergency settings, but less accurate for children
due to different body proportions.

2. Lund and Browder Chart:

This method is more accurate than the Rule of Nines, especially for children, as it adjusts for age
and the changing proportions of body parts as a person grows.

Each body part is assigned a percentage of TBSA that varies by age group. For example, infants
have a proportionally larger head compared to their body, which is reflected in the chart.

This method is detailed and is often used in clinical settings to assess burn severity for both
adults and children.

3. Palmar Method (Rule of Palm):

The patient’s palm (excluding fingers) is approximately 1% of their TBSA. This method is used
for estimating the area of small, irregular burns.

It’s a quick and easy method to assess smaller burns in the field or emergency situations.

Steps in Burn Area Assessment:

1. Identify the Burn Depth:

Determine if the burn is first, second, third, or fourth degree, as the depth will guide treatment.

2. Determine TBSA:

Use the Rule of Nines, Lund and Browder Chart, or the Palmar method to estimate the
percentage of the body affected by the burn.

3. Consider the Location:

Burns to critical areas like the face, hands, feet, genitalia, or major joints may require specialized
care, regardless of size.

4. Evaluate Additional Factors:

Consider other factors such as inhalation injury, chemical exposure, or electrical burns, which
can complicate the situation even if the TBSA is small.
5. Use of Imaging and Measurement Tools:

In specialized settings, laser scanning, digital imaging, or other technologies may be used to
more precisely measure burn areas.

Importance of Burn Area Assessment:

Fluid Resuscitation: The extent of the burn area helps in determining fluid needs, especially in
burns covering more than 20% of TBSA.

Surgical Decisions: Larger burns may require early surgical intervention such as excision or
grafting.

Prognosis: The larger the burn area, the higher the risk of complications such as infection, shock,
and organ failure.

Peri-operative Assessment and Optimization of Burn Patients:

Burn patients present unique challenges in the peri-operative period due to the complexity of
their injuries, fluid loss, potential for infection, and altered physiology. Effective peri-operative
assessment and optimization are critical to improving outcomes, especially in cases requiring
surgery such as debridement, skin grafting, or reconstruction.

Pre-operative Assessment:
1. Comprehensive History and Physical Examination:

Burn Etiology and Extent: Assess the cause (thermal, chemical, electrical) and total body surface
area (TBSA) affected using methods like the Rule of Nines or Lund and Browder chart.

Burn Depth: Determine whether the burns are superficial (first-degree), partial-thickness
(second-degree), or full-thickness (third-degree) to assess the need for surgery.

Airway Assessment: Critical for facial burns, smoke inhalation, or thermal injury to the airway.
Signs like hoarseness, stridor, or soot in the mouth may indicate airway compromise.

Inhalation Injury: Suspected in patients with burns in enclosed spaces, facial burns, or singed
nasal hair. Pulmonary function tests and arterial blood gas (ABG) analysis may be necessary.

Fluid Resuscitation Status: Burns greater than 20% TBSA require aggressive fluid resuscitation
(Parkland formula). Monitor fluid balance, urine output, and signs of shock.
Infection Assessment: Look for signs of infection, as burn wounds are prone to bacterial
colonization, and sepsis can develop. Wound cultures may be necessary.

Nutritional Status: Burn patients often have increased metabolic demands. Pre-operative
assessment of nutritional status is critical, and supplementation may be needed.

Comorbidities: Evaluate existing medical conditions such as diabetes, hypertension, and renal or
cardiac disease, which can affect surgical planning and anesthesia.

2. Airway Management:

Potential Difficult Airway: Anticipate airway complications due to edema from burns involving
the face, neck, or oropharynx. Pre-emptive intubation may be needed if there’s concern for
airway swelling.

Inhalation Injury: Assess for carbon monoxide poisoning or cyanide toxicity in fire-related
burns. Treatment with 100% oxygen or hyperbaric oxygen may be necessary.

3. Cardiovascular Assessment:

Hemodynamic Stability: Hypovolemia and shock from fluid loss are common in large burns.
Ensure fluid resuscitation is optimized, and monitor blood pressure, heart rate, and urine output.

Electrolyte Imbalances: Burns can lead to hyperkalemia, hypokalemia, and hypernatremia. Pre-
operatively correct any imbalances to reduce the risk of cardiac arrhythmias during surgery.

4. Renal Function:

Acute Kidney Injury (AKI): Due to fluid shifts and rhabdomyolysis (especially in electrical
burns), evaluate renal function (creatinine, blood urea nitrogen) and ensure adequate hydration.

Urine Output Monitoring: Maintain urine output >0.5-1 mL/kg/h to ensure proper renal
perfusion.

5. Respiratory Assessment:

Lung Function: Evaluate for any restrictive changes in lung function, especially in patients with
extensive chest burns or inhalation injuries.

Oxygenation: ABG and pulse oximetry should be used to assess oxygenation and ventilation
status. Consider bronchoscopy to assess the extent of airway burns.
6. Infection Control:

Wound Infections: Burn wounds are highly susceptible to bacterial infections. Assess for signs of
local infection or sepsis. Pre-operative wound cultures and antibiotics may be indicated.

Tetanus Prophylaxis: Ensure that tetanus immunization status is up-to-date, especially in burns
involving dirt or environmental contaminants.

Intra-operative Management:
1. Anesthesia Considerations:

Airway Management: Early intubation should be considered in cases with suspected airway
edema. Fiberoptic intubation may be needed for difficult airways.

Ventilation: Patients with inhalation injury may require advanced ventilatory support. High
PEEP or lung-protective strategies might be required for patients with acute respiratory distress
syndrome (ARDS).

Anesthetic Agents: Use agents that minimize cardiovascular depression, especially in

hypovolemic patients. Burn patients may have altered pharmacokinetics, requiring adjustments
in dosing.

2. Fluid Management:

Fluid Resuscitation: Continued administration of fluids is essential during surgery. Adjust fluid
administration based on blood loss, urine output, and central venous pressure (CVP) monitoring.

Colloid vs. Crystalloid: After initial resuscitation with crystalloids (e.g., lactated Ringer’s),
colloids (e.g., albumin) may be added to maintain plasma oncotic pressure.

3. Blood Loss Management:

Hemostasis: Burn surgeries such as debridement and grafting can result in significant blood loss.
Prepare for blood transfusion if necessary.

Coagulopathy: Extensive burns can cause coagulopathy, requiring monitoring and correction
during surgery with fresh frozen plasma, platelets, or clotting factors.

4. Temperature Regulation:

Prevent Hypothermia: Burn patients are prone to hypothermia due to impaired thermoregulation
from skin loss. Use warming blankets, warmed IV fluids, and heated operating rooms to prevent
this.
Post-operative Optimization:
1. Pain Management:

Multimodal Analgesia: Use a combination of opioids, NSAIDs, and regional anesthesia

techniques to manage post-operative pain. Burns are highly painful, and effective pain
management is essential for recovery.

Psychological Support: Address psychological trauma, anxiety, and depression which are
common in burn patients.

2. Infection Prevention:

Wound Care: Continue with meticulous wound care, dressing changes, and the use of topical
antimicrobials (e.g., silver sulfadiazine). Consider systemic antibiotics if there is a high risk of
infection.

Sepsis Monitoring: Monitor for signs of sepsis, particularly in large burns, with close monitoring
of vital signs, laboratory markers, and wound cultures.

3. Nutritional Support:

Enteral Nutrition: Early enteral feeding is recommended in burn patients to meet the increased
metabolic demands and support healing. Total parenteral nutrition (TPN) may be considered if
enteral feeding is not feasible.

4. Rehabilitation and Physiotherapy:

Prevent Contractures: Early physical therapy and splinting are crucial to prevent contractures and
improve long-term functional outcomes, particularly in burns involving joints.

Psychological Counseling: Post-operative psychological support is essential for burn patients,

who may suffer from post-traumatic stress disorder (PTSD), depression, or body image issues.

5. Close Monitoring of Organ Function:

Renal and Cardiac Monitoring: Continue to monitor renal function and cardiovascular status, as
fluid shifts and electrolyte imbalances can persist after surgery.
Effective Fluid Management of a Burn Patient:
Fluid management is a critical aspect of care in burn patients, particularly in the first 24 to 48
hours following the injury. Burns cause significant fluid shifts, resulting in hypovolemia,
electrolyte imbalances, and shock. The goal of fluid management is to maintain adequate
perfusion to vital organs, prevent burn shock, and avoid complications from over- or under-
resuscitation.

Key Principles of Fluid Management:

1. Early Fluid Resuscitation:

Burns involving more than 15-20% of the total body surface area (TBSA) require fluid
resuscitation due to capillary leakage and fluid loss.

The first 24 hours post-burn is the most critical period for fluid management, as significant
plasma leakage occurs during this time.

2. Types of Fluids:

Crystalloids (e.g., Lactated Ringer’s): Most commonly used in the initial stages of resuscitation
due to their ability to replenish extracellular fluid.

Colloids (e.g., albumin): May be introduced after 24 hours to maintain oncotic pressure and
prevent edema formation. Typically added in the second phase of resuscitation after capillary
integrity improves.

Blood Products: If there is significant blood loss or hemolysis, packed red blood cells (PRBCs)
may be required.

Fluid Resuscitation Formulas:

Several formulas are used to estimate the volume of fluid needed for burn patients, with
adjustments based on individual response. The most commonly used formula is the Parkland
Formula.

1. Parkland Formula:

Formula: 4 mL of Lactated Ringer’s x Body Weight (kg) x % TBSA burned

Half of the calculated fluid volume is given over the first 8 hours from the time of the burn
injury, and the remaining half is administered over the following 16 hours.
Example:

For a 70 kg patient with 40% TBSA burns:

Fluid requirement in 24 hours = 4 mL × 70 kg × 40 = 11,200 mL.

Administer 5,600 mL in the first 8 hours and 5,600 mL in the next 16 hours.

2. Modified Brooke Formula:

Similar to the Parkland formula but uses 2 mL/kg/%TBSA.

This approach may reduce the risk of fluid overload while still providing adequate resuscitation.

3. Colloid Administration:

After 24 hours, colloids may be used in conjunction with crystalloids to maintain intravascular
volume and reduce edema. The standard recommendation is to add 0.3–0.5 mL/kg/%TBSA
using colloids (such as albumin) after the initial 24-hour period.

Monitoring Fluid Resuscitation:

The effectiveness of fluid resuscitation should be monitored closely using various clinical and
biochemical parameters. These include:

1. Urine Output:

Target Urine Output:

Adults: 0.5-1 mL/kg/hour.

Children: 1-1.5 mL/kg/hour.

Adequate urine output is a key indicator of appropriate fluid resuscitation and renal perfusion.

2. Vital Signs:

Monitor blood pressure, heart rate, and mean arterial pressure (MAP). Hypotension and
tachycardia may indicate under-resuscitation, while hypertension and pulmonary edema may
suggest over-resuscitation.

3. Central Venous Pressure (CVP):

Used in severe cases to assess the patient’s volume status. A CVP of 8-12 mmHg is generally
considered optimal.
4. Lactate Levels:

Elevated lactate levels may indicate inadequate tissue perfusion and are used as a marker for the
adequacy of resuscitation. Lactate clearance should occur with effective fluid management.

5. Hemodynamics:

Invasive monitoring may be necessary for critically ill burn patients, particularly in cases of large
burns or those with inhalation injury.

6. Electrolytes:

Regularly check and correct electrolyte imbalances, especially sodium, potassium, and calcium,
which may be altered due to fluid shifts, resuscitation, and cell injury.

Complications of Fluid Resuscitation:

1. Under-Resuscitation:

Leads to hypovolemic shock, decreased organ perfusion, acute kidney injury (AKI), and
metabolic acidosis.

Signs include decreased urine output, hypotension, tachycardia, and lactic acidosis.

2. Over-Resuscitation (Fluid Overload):

Excessive fluids can cause pulmonary edema, abdominal compartment syndrome, or extremity
compartment syndrome.

Signs include increased respiratory effort, difficulty oxygenating, decreased urine output (despite
increased fluid administration), and increasing abdominal or extremity pressures.

3. Electrolyte Imbalances:

Hyperkalemia: May occur due to cellular damage from burns or inadequate renal excretion.

Hyponatremia: Caused by excessive free water resuscitation or dilution of electrolytes.

4. Edema:

Massive fluid shifts can cause widespread tissue edema, affecting respiratory function (especially
in circumferential chest burns) and necessitating escharotomies.
Special Considerations:
1. Children:

Children have a higher surface area-to-body mass ratio and may require different fluid
resuscitation strategies. The Parkland formula is commonly used but adjusted based on weight
and TBSA.

2. Inhalation Injury:

Patients with inhalation injuries may require additional fluid due to increased capillary
permeability and systemic inflammatory response.

3. Electrical Burns:

These patients may require more fluids than calculated due to the risk of deep tissue injury and
rhabdomyolysis. Monitor for signs of myoglobinuria, and increase fluid administration to
maintain urine output of 1.0-1.5 mL/kg/h.

4. Escharotomy and Fasciotomy:

In patients with circumferential burns, escharotomies may be needed to relieve pressure and
restore circulation in affected limbs or the chest.

Best Choice of Anesthetic Agents and Overall

Anesthesia Considerations in Burn Patients:
Anesthesia for burn patients requires careful planning due to altered physiology, increased risk of
complications, and changes in pharmacokinetics. The choice of anesthetic agents and overall
considerations must focus on maintaining hemodynamic stability, ensuring proper airway
management, and managing pain while addressing the unique challenges posed by burn injuries.

Key Anesthesia Considerations in Burn Patients:

1. Airway Management:

Difficult Airway: Burns involving the face, neck, or airway may lead to airway edema, which
can complicate intubation. Early airway assessment and securing the airway are crucial,
especially if there's suspicion of inhalation injury.
Inhalation Injury: Burn patients exposed to smoke or chemicals may have inhalation injuries that
complicate ventilation. Preoperative bronchoscopy and arterial blood gas (ABG) analysis can
help assess airway damage.

Airway Edema: Edema may worsen over time, so if the patient is stable and there is concern
about airway patency, early intubation should be considered.

Fiberoptic Intubation: In difficult airway situations, fiberoptic bronchoscopy may be necessary to

secure the airway.

2. Hemodynamic Stability:

Hypovolemia: Due to significant fluid shifts and evaporative loss, burn patients often present
with hypovolemia and may require fluid resuscitation before anesthesia induction. Monitor
central venous pressure (CVP), urine output, and blood pressure.

Hyperdynamic Circulation: Burn patients, especially those in the recovery phase, can develop a
hyperdynamic circulation with increased heart rate and cardiac output, requiring careful choice
of anesthetic agents.

3. Altered Pharmacokinetics:

Burn injuries, especially those over 30% of TBSA, alter drug distribution, metabolism, and
excretion. Increased volume of distribution, altered protein binding, and changes in hepatic and
renal function can affect anesthetic drug clearance.

Increased Metabolic Rate: The hypermetabolic state in burn patients can lead to increased dosing
requirements for many anesthetic agents.

4. Hyperkalemia Risk:

Avoid succinylcholine after the first 24 hours post-burn. Succinylcholine can cause life-
threatening hyperkalemia due to upregulation of acetylcholine receptors in burn patients. This
risk remains for months to years after the burn injury.

Use non-depolarizing muscle relaxants instead, such as rocuronium or vecuronium, as they do

not cause hyperkalemia.
Best Choice of Anesthetic Agents:
1. Intravenous Induction Agents:

Etomidate: A good choice in burn patients with unstable hemodynamics, as it provides

cardiovascular stability with minimal effects on blood pressure and heart rate.

Ketamine: A preferred agent in burn patients due to its sympathomimetic properties, which help
maintain blood pressure in hypovolemic patients. Ketamine also provides analgesia and is less
likely to depress respiratory drive, making it an excellent choice for burn trauma cases.

Propofol: Used cautiously in stable patients, but it can cause significant hypotension, particularly
in hypovolemic patients, so it may not be ideal for patients with severe burns or hemodynamic
instability.

Midazolam: Provides sedation and amnesia but has limited hemodynamic effects. It can be
useful for burn procedures but should be used with caution in critically ill patients due to
potential respiratory depression.

2. Inhalational Agents:

Sevoflurane or Isoflurane: These agents are typically used for maintenance of anesthesia and are
well-tolerated in burn patients. They provide reliable depth of anesthesia but may cause
hypotension, which requires careful titration in hypovolemic patients.

Nitrous Oxide: Generally avoided in burn patients, especially those with inhalation injury, as it
can expand in air-filled spaces and worsen respiratory function in patients with compromised
lungs.

3. Muscle Relaxants:

Non-depolarizing Neuromuscular Blockers: Rocuronium and vecuronium are the preferred

muscle relaxants in burn patients to avoid hyperkalemia associated with succinylcholine. Doses
may need to be increased due to the upregulation of acetylcholine receptors in burn patients.

Cisatracurium: Another alternative non-depolarizing agent, cisatracurium, is useful in patients

with renal or hepatic impairment, as it is metabolized via Hoffman elimination.

4. Analgesia:

Opioids: Burn patients experience intense pain, and opioids such as fentanyl, morphine, and
hydromorphone are commonly used for pain control during surgery. However, they should be
titrated carefully to avoid respiratory depression, especially in patients with inhalation injury.
Multimodal Analgesia: Consider using a combination of opioids, ketamine, acetaminophen, and
NSAIDs (if renal function allows) to minimize opioid requirements.

Regional Anesthesia: When appropriate, regional techniques such as nerve blocks or epidural
anesthesia can provide excellent pain control, reduce opioid requirements, and improve
outcomes. However, regional anesthesia should be avoided in areas near the burn or if the patient
is coagulopathic.

5. Antibiotics and Infection Control:

Burn patients are at high risk for infection, and prophylactic antibiotics may be administered
based on wound cultures or clinical suspicion. Proper sterile technique and infection control
measures are essential in the operating room.

Peri-operative Monitoring:
1. Invasive Hemodynamic Monitoring:

Arterial Line: Provides continuous blood pressure monitoring and allows for frequent blood gas
and electrolyte sampling, which is important in large burns.

Central Venous Catheter (CVC): Useful for monitoring central venous pressure (CVP) and
administering vasoactive medications if needed.

2. Urine Output:

Maintain a urine output of 0.5-1 mL/kg/hour in adults to ensure adequate renal perfusion and
guide fluid therapy.

3. Blood Gas and Electrolyte Monitoring:

Regular monitoring of ABGs is essential, particularly in patients with inhalation injuries or fluid
resuscitation. Monitor electrolytes frequently to manage imbalances like hyperkalemia,
hyponatremia, or hypocalcemia.

4. Temperature Regulation:

Burn patients are at high risk for hypothermia due to skin loss and exposure. Warming devices,
heated IV fluids, and maintaining a warm operating room environment are critical to avoid
hypothermia.
Post-operative Considerations:
1. Pain Management:

Opioid Therapy: Continue adequate pain control post-operatively with titrated opioid infusions
or patient-controlled analgesia (PCA).

Adjunctive Agents: Non-opioid analgesics (e.g., acetaminophen, NSAIDs) or adjuncts like

gabapentin for neuropathic pain may be beneficial.

Regional Anesthesia: If regional anesthesia was used, ensure proper transition to systemic pain
management after block resolution.

2. Fluid Management:

Continue close monitoring of fluid balance post-operatively to avoid fluid overload, which can
lead to pulmonary edema or compartment syndrome.

3. Respiratory Care:

Patients with inhalation injury or those who required mechanical ventilation during surgery
should be carefully monitored in the post-operative period, with weaning as tolerated.

4. Nutritional Support:

Post-operative nutritional support is essential for burn patients due to their hypermetabolic state.
Enteral feeding should be resumed as early as possible.

Thank you.