Current Anaesthesia & Critical Care (2002) 13, 70^75�c 2002 Publishedby Elsevier Science Ltd.doi:10.1054/cacc.2002.0385, available online at http://www.idealibrary.com on

FOCUSON:BURNSANDPLASTICS

Anaesthesia for patients with burns injuriesK.Langley and K. Sim

McIndoe Burns Centre,QueenVictoria Hospital NHS Trust, East Grinstead,West Sussex RH19 3DZ,UK

KEYWORDSburns, general anaesthesia,regional anaesthesia,emergency treatment,transportation of patients

Summary The safemanagementofcomplexburnsinjuriesrequires anunderstandingof the obligatorypathophysiological changes and currenttreatmentoptions.The anaes-thetic teammusthave, collectively, specialist skills inresuscitation, airwaymanagement,critical care procedures and care of small children and access to expert advice in themanagement of non-burns co-morbidity. The experience of treating relatively smallnumbers of these patients for prolonged periods of time is unusual in anaesthetic prac-tice.Flexibility is required to tailor anaesthetic practices to ¢t with overallpatientman-agement objectives. Communication skills are necessary for multidisciplinary teammembership and in dealingswith patients, relatives andmanagerial authorities.Regular commitmentto burns anaesthesia is required to acquire and consolidate ex-

pertise in this group of patients. Issues include altered drug e¡ects, monitoring, bloodconservation techniques and choices in £uid therapy and environmental andmetaboliccontrol.The contribution of anaesthetic personnel to themanagementof burnspatients con-

tinues to evolve.Traditional roles in resuscitation and preparation for transfer, criticalcare, painmanagement, andanaesthesia forburns surgeryremainimportantbut anaes-thetic inputisrequiredtoin£uencethe future directionof acuteburnscare services, andto ensure thatthe training and development needs of current and future specialist per-sonnel aremet.�c 2002 Publishedby Elsevier Science Ltd.

INTRODUCTIONAlthough a specialist commitment to anaesthesia forburns patients is the province of a few, all anaestheticpersonnel should be competent to systematically assessburns injuries and manage their transfer to specialistburns facilities. The causes and thus the presentation ofburns injuries are diverse, and include £ame burns,scalds, electrical and chemical burns. Minor burns arecommonFin the UK 1% of the population sustains aburn injury each year, 10% of whom require hospital ad-mission.Of these only around one in10 have sustained alife-threatening injury, but the appropriate early man-agement of the burn wound and its systemic conse-quences is a key factor in reducingmorbidity.Theburns casemix is notrepresentative of the gener-

al population. Patients at the extremes of age are morevulnerable to injury, as are thosewith pre-existing mor-bidities such as epilepsy and alcoholism.There is an asso-ciation with psychiatric illness, and others, includingchildren, su¡er non-accidental injuries.

0953-7112/02/$-see frontmatter

Correspondence to: KS.

ASSESSMENTThe initialhospital assessmentof amajor burn should fol-low (advanced trauma life support) ATLS (advancedtrauma life support) guidelines with a primary surveyconcentratingon the supportof the airway, gas exchangeand circulation.The secondary surveyexamines for asso-ciated trauma sustained during the accident or whilsttrying to escape from the scene. Focusing on the burnsinjury requires:

K An estimation of percentage surface areainvolvement.

K Assessment of depth of burned areas.K Determination of the evidence for inhalational injury.K Vascular or respiratory compromise secondary tocircumferential burns should be identi¢ed, andescharotomy considered.

K The cornea should always be examined before facialswellingmakes assessment di⁄cult.

K All patients with a history of exposure to smoke inan enclosed space should be considered at risk ofinhalation injury, even if the initial signs and sym-ptoms are unimpressive. Systemic toxicity secondary

ANAESTHESIAFORPATIENTSWITHBURNS INJURIES 71

to the inhalation of toxic gases such as carbonmonoxide must be recognized and treated. If thehistory is unclear, then blood should be retained fortoxicological analysis.

K The presence of associated injuries complicatesmanagement, and in£uences priority setting andreferral decisions.

Major burns injuries (over 20% burn surface area inadults) requirepromptresuscitation to treat the predict-able pathophysiological consequences.1

K Fluid shifts from the circulation are maximal in the¢rst 8h following injury but continue for 24h.

K There is generalized tissue oedema proportional tothe extent of the burn surface area.

K Cardiac output is initially depressedK Systemic vascular resistance is high.

The goal of resuscitation is to restore ¢lling pressuresand oxygen delivery as e¡ectively as possible. Resuscita-tion £uids are transfused to correct hypovolaemia, initi-ally directed by proscriptive formulae, most commonlythe crystalloid-based Parkland regime. An accurate pa-tient weight is required. Calculating £uid prescriptionsin children needs adjustments from formulae to accountformaintenance requirements.Traditionally, assessment of the adequacy of resuscita-

tion has depended on simple parameters including heartrate, blood pressure and urine output. It is increasinglyrecognized that this approach fails to detect patientswith signi¢cant regional hypoperfusion, and emphasizesthe importance of expedite transfer from the casualtyfacility to a specialist centre bed where appropriatehaemodynamic monitoring can be arranged. Trendmonitoring of £ow-based parameters is increasinglypracticed. Tools such as oesophageal Doppler monitor-ing can be used to guide target-based resuscitation.Other less invasivemeasures of cardiac ¢lling and cardiacoutput including a transpulmonary double-indicator dilu-tion technique that computes intrathoracic bloodvolume have been reported.2

Anaesthetic involvementmust be sought early for air-way assessment, help in securing venous access and liai-son in the arrangements for patient transfer.

Airway assessment

Initially, thermal injury to the upper airway causes oede-ma and potential respiratory obstruction.The combina-tion of facialburns, soot around thenose andmouth, anda clear history of entrapment in a closed space dictatesactive airway management. Inspiratory noise, agitationand tachypnoea combine to indicate impending respira-tory obstruction.Inhalation injury develops as a dynamic process; air-

way oedema generally increases over12^24h. Smoke in-

halation causes progressive cough and dyspnoea and theproduction of copious secretions. A low threshold fortracheal intubation and diagnostic ¢bre-optic broncho-scopy is recommended.The early institution of a regimeof nebulizedbicarbonate solution has proven to bebene-¢cial in mobilizing secretions and reducing the incidenceof mucous plugging. Other recommended regimes in-clude nebulized heparin and orN-acetyl cysteine.3

Patients with signi¢cant carboxyhaemoglobin levels(over 30%) require high inspired oxygen concentrationsto reduce thehalf-life ofCOHb.Thebene¢tof hyperbaricoxygen treatment is questionable given the logisticdi⁄culties ofmanagingmajorburns injuries inhyperbaricfacilities.

Venous access

Securing central venous access before generalized tissueoedema obscures landmarks is preferable. ATLS teachinghas reduced the incidence of £uid under-resuscitation;over-enthusiastic volume loading should be avoided.

Preparation for transfer

The adequacyof transfer equipment anddrugs shouldbechecked.Guidelines for transfer management arewidelyavailable.4 All intravascular lines shouldbe ¢rmly securedprior to departure. Contingency plans for airway man-agementenroute shouldbe agreed.Emergency intubationwhilst inmotion is hardly a preferred option, and inevita-bly a number of patientswill undergo tracheal intubationand ventilation primarily for transfer.This can cause dif-¢culties in regions where burns intensive care resourcesare scarce, but is preferable to a wait and hope policy.Prolonged transfers accentuate therequirement to accu-rately measure and deliver resuscitation £uid volumes.Monitoring appropriate to the patient condition shouldbe available, with a facility to record and print data onarrival.Written information accompanying the patient should

include a history of the burn and any associated injuries,initial examination details and treatment of the patientsince the burn injury, including airwaymanagement, £uidvolumes, urine output. If initial surgical escharotomieswere performed these should be charted.It is widely acknowledged that patients with serious

burn injuries are best managed in specialist burn units.Early assessment and active intervention to manage theburnwounds can limit the systemic consequences of theinjury and speed functional recovery. High standardsof resuscitation, surgery and critical care are required,and early involvement of experienced sta¡ is necessary.There aremany aspects to be considered to achieve suc-cessful outcome in burns injuries; the contribution ofanaesthetic members of the burns team remains of high

72 CURRENT ANAESTHESIA & CRITICALCARE

importance for a substantial partof thepatient’s hospitalexperience.Areas of in£uence include:

K Anaesthesia for burns surgery.K Acute painmanagement.K Critical care.Airway, ventilation, haemodynamicsTechnicalFline changes,

postpyloric feeding tubes.Nutrition andmetabolic managementInfection controlFdiagnosis of ventilator-associated

pneumonia.

K Communication.Patient, surgeons, nurses, therapists, relatives

K Chronic pain, sleep issues.

ANAESTHESIAFORBURNSSURGERYThe burns theatre environment can be something of anacquired taste.The case mix, sta¡ and patient dynamicsare complex and the technical aspects are demanding.Repeated exposure to patients undergoing multiple sur-gical episodes demands patience and attention to detailto discern relevant changes in condition.A dedicated burns theatre facility must be adequately

stocked and resourced. Theatre anaesthetic equipmentand transport monitoring should be compatible withthat used in the critical care rooms. Stock control intheatre will be in£uenced by infection control proce-dures, minimizing store of equipment in theatres. Singleuse patient items are preferred and didactic cleaningschedules are needed between cases. Inevitably, theturnover of patients is reduced.The temptation to shareresourcewith general theatre facilitiesmust also consid-er infection control issues. The location and sta⁄ng ofpost-anaesthetic recovery facilities may be problemati-cal, particularly for small children.The practical conduct of burns anaesthesia requires

£exibility. Surgical episodes have to be seen in the con-text of overall patient management. Momentum hasto be maintained in the recovery process with targetsset and progress judged. This philosophy will informattitudes to fasting times, timing of surgery, sedation,weaning andmobilization.

Surgery

Modern surgical management strategies are directed ataccurately assessing the depth of theburnswound, excis-ingnecrotic tissue to limit infection and the extentof thehypermetabolic response, and achieving wound closure,with the ultimate goal of maximizing functional and cos-metic recovery.5

Surgery is indicated for full thickness injuries or whenthewound is unlikely to heal within a few weeks. Slowerhealing wounds risk hypertrophic scar and contractureformation. Tangential excision is commonly practi-cedFthis is the debridement of progressive amounts ofburns tissue until viable tissue is reached.6 This contrastswith the historical approach in which burns surgeonswaited for eschar to slough o¡, and then grafted skinonto granulating tissue. Advances in surgical, anaestheticand critical care have made it possible to excise largerareas of deep burns earlier, and close the wound withautologous or cadaveric skin, or a growing range of skinsubstitutes. The introduction of prompt burn excisionwith earlygrafting is believed to result in less scar forma-tion and accelerates functional recovery.Hospital stay isdecreased for small burns, but it is more di⁄cult toclearly demonstrate reduced length of in-patient stayfor larger burns.The timing of surgery for burns wound can be classi-

¢ed as:

K ImmediateFescharotomy, or injuries associatedwiththe accident.

K EarlyFtangential excision and grafting within 72h.K IntermediateFtangential excision and graftingbeyond 72h.

K LateFpost-burn reconstruction.

Inmoderate size burns (less than 30%), wound closurecan be achieved in one procedure using partial thicknessskin grafts from unburned donor sites. In larger burnspartial thickness skin grafts are expandedby 3:1ormore,and cover is augmented by cadaver allograft which mayremain adherent for more than 10 days before immunerejection ensues.In very large burns where donor sites are limited, al-

ternative approaches include stagedexcision of theburnswoundwith reharvesting of autologous skin donor areasor the use of arti¢cial skin substitutes to provide tem-porary cover.Patients requiring later reconstructive burns surgery

need careful assessment.The extent of the surgery maynot re£ect anaesthetic di⁄culties in venous access andairway management, so adequate time must be allo-cated. Patients may travel large distances to maintaincontinuity with a particular unit, making day-case ar-rangements di⁄cult.

Blood conservation techniques

Debridementofmajor burns has the potential for signi¢-cant blood loss, and it is prudent to con¢rm that ade-quate cross-matched blood and blood products isavailable before induction of anaesthesia. Surgical timingand technique in£uences bleeding, and vigilance is neces-sary to assess losses, especially when multiple surgical

ANAESTHESIAFORPATIENTSWITHBURNS INJURIES 73

teams work at di¡erent sites on the patient. Blood losshas been estimated to range from 200 to 300ml for eachpercent of the body surface area excised and grafted.7,8

Major blood loss can be sudden and surgery may needto be suspendedwhile hypovolaemia is corrected.Naturally, prevention is better than cure, and strate-

gies to keep blood loss to a minimum are an importantpartof surgical technique.Tourniquets shouldbeused forall extremity burns. Subcutaneous in¢ltration of theoperative site using saline with adrenaline 1:1000 000solution ‘to tumescence’ is highly e¡ective.9 A delay of10^15min before excision enhances the vasoconstrictivee¡ect. The technique appears to be safe with few andonly transient haemodynamic complications.10 There is asurgical learning curve as there is a qualitative change inthe tissue surface at excision, but graft take rates appearnot to be compromised.Other techniques shown to beuseful are the use of temporary pressure dressings,topical thrombin sprays, and topical adrenaline soaks.Blood transfusion practices are in£uenced by risk^

bene¢t analyses of red cell transfusion and the availabilityof alternative plasma volume expanders.Recent attention has concentrated on determining

objective indications for blood transfusion, with clinicalexperience suggesting that losses of up to 30%circulatingvolume can be replaced with crystalloid or colloid solu-tions alone.11Haemoglobin concentrations above 8g/l areconsidered su⁄cient and there is no evidence that mod-erate anaemia impairs wound healing.12,13

The trend away from the use of albumin, fuelled bycost issues and controversy around a published meta-analysis of albumin in critical care patients has com-pounded the wide variation in £uid prescriptionpractices in the post acute phase burns patient.14 Theuse of hydroxyethyl starches has spread, with prolongedduration of e¡ect and e⁄cient volume expansion seen asdesirable properties.However, a recent paper has raisedthe possibility that the use of hydroxyethyl starchesmayincrease the risk of acute renal failure in patients with aseptic pro¢le.15 Reports of chronic itch are also ofconcern in a patient group already at high risk of thiscomplication.Thepersistinghigh-volume £uid exchangesrequired in

severe burns injury patients emphasize the need for stu-dies to better determine optimal £uid regimes in thepost acute phase. Manufacturers dosage recommenda-tions for new colloid solutions are derived from generalcritical care population studiesFtheir relevance inburns patients is conjectural.

Pharmacology

Abnormal drug e¡ects are to be expected in burns pa-tients.16 The host response to severe burns injuries re-sults in functional changes in organ systems controlling

the distribution, transformation and excretion of drugs;receptor populations are altered, and losses may occurthrough the burn wound. Polypharmacy is usual, and thepotential for interactions high. Experienced pharmacysta¡ have an important surveillance role.The acute phase response to severe burns injuries re-

sults in early changes in plasma protein levels. Albuminlevels fall and alpha-1 acid glycoprotein levels rise.Changes in the drug non-protein bound fraction can al-ter the pharmacological response.In general, drug pharmacokinetics undergo a biphasic

response in burns injury.The initial reduction in circulat-ing blood volume, cardiac output and tissue perfusion,due to blood and £uid loss and increasedvascularperme-ability, reduces renal and hepatic blood £ow. This isrestored following the development of the hypermeta-bolic phase, usually after 48h. There may be, however,impairment in renal tubular and hepatic function, so in-creased drug clearancemay not necessarily result.The volume of distribution (Vd) of a drug may be al-

tered by changes in protein binding and in extracellular£uid volume, resulting from £uid loss, exogenous £uidadministration, and increased capillary permeability.Changes in loading dosemay be required if the drug hasa small volume of distribution or a narrow therapeuticrange. Total plasma clearance must be consideredwhen considering drug maintenance doses and dosageintervals.A pharmacodynamic explanation has been proposed

for the e¡ects of burn injury on the e⁄cacy of musclerelaxants. Burn injury causes proliferation of extrajunc-tional acetylcholine receptors (AchR) leading to resis-tance to non-depolarizing muscle relaxants (NDMR),and hypersensitivity to depolarizing muscle relaxants.17

This e¡ectmay occur within aweekof the injury, persistfor up to a year, and is proportional to the total burnssurface area.Dose requirements for all anaesthetic agents are gen-

erally increased in theburns populationwith their hyper-dynamic circulation and hypermetabolic state; MACvalues are raised and the duration of action is decreased.Tolerance to the e¡ects of sedative, analgesic and inotro-pic medication is commonly seen but the range of re-sponse for individual patients is unpredictable.

Feeding and fasting

Clinically, signi¢cant gastrointestinal dysmotility is com-mon in the burns population but repeated interruptionsto the feeding regime for surgical procedures delays re-covery.Consideration should be given to the early insti-tution of postpyloric feeding, and intubated patients canbe fed throughout surgery. Anaesthetic techniques thatpermitearlyre-institution of feedingregimespostopera-tively should be preferred, and the development of an-

74 CURRENT ANAESTHESIA & CRITICALCARE

tagonists to opioid-induced gastrointestinal status maybe of advantage.18

The importance of tight glycaemic control in criticalcare patients has recently been promoted.19,20 Clear unitfeeding protocols contribute to this by reducing the inci-dence of prolonged interruptions to enteral regimes.

Monitoring

During anaesthesia there is a continual requirement tomonitor the patient’s physiological state, to con¢rm cor-rect equipment function, and to avoidpatient awareness.Accepted recommendations state that the followingmonitoring devices are essential to the safe conduct ofanaesthesia: pulse oximetry, non-invasivebloodpressuremonitor, ECG and capnography.21 The extent to whichthe patient is assessed beyond the minimal standards ofmonitoring should be determined by the patient’s medi-cal condition and the proposed extent of surgery.Speci¢c issues in the burns patient include

K Di⁄culties in placement of monitoring equipment.

The standard sites for placement of ECG electrodesare often unavailable, and itmay be di⁄cult to make thegel electrodes adhere to damaged skin.Options to over-come these di⁄culties include attaching the ECG leadsto surgical staples or steel sutures placed in burnedareas, or accepting the trace obtained by electrode pla-cement at distant sites.Evenwith all limbs burned it can be possible to place a

blood pressure cu¡ and obtain a reliable reading. How-ever, for all extensive procedures invasive measurementis indicated, with the bene¢ts of pulse-contour analysis,and ease of blood sampling.

K Access to usual sites

Pulse oximetry may be unreliable in the presence ofcarboxyhaemoglobin or in shocked, vasoconstricted pa-tients or those with peripheral burns. Attachment ofprobes to central sites, such as ear, nose, lip, or tonguemay be helpful. Access to neck veins for central venouspressuremonitoringmaybe precludedbyburnswounds.

K Temperaturemonitoring

This is manadatory in all but the shortest procedures.The combination of lengthyprocedures in cold operatingtheatres, large exposed areas of body surface, and ad-ministration of large volumes of £uids, can lead tomarked intraoperative hypothermia.Infants below 6 months are unable to shiver and pro-

longed hypothermia risks hypoxia and acidosis throughadaptivebrown fatmetabolism. Infants and children havehigher relative evaporative heat loss than adults.The ambient theatre temperature should be warm,

above 271C, despite the discomfort this causes to the

theatre team. Body areas not being operated on shouldbe kept covered, and forced air warming devices used ifpracticable. Aradiantheater near thepatientcanbepar-ticularly e¡ective atreducingheat loss. Intravenous £uidsshould bewarmed.

PAINCONTROLBurns pain is frequently poorly managed, with poorcommunication, drug side-e¡ects and anxiety and de-pression being contributory factors.22 Pain receptors inresidual skin elements are stimulated, and the host re-sponse sensitizes receptors around the injury sites. Neu-ropathic pain develops secondary to nerve damage,abnormalities in nerve regeneration and central nervoussystem reprogramming.In the acute stage, the assessmentofpain in the critical

care burns patient is di⁄cult as the usual signs includinghypertension, tachycardia, sweating and agitation areobscured. The pattern of burns depth or area providesfew clues as to pain severity but e¡ective analgesia is im-portant to prevent the physiological, functional and psy-chological consequences of severe or protracted pain.Opioid doses titrated to response remains the main-

stay of therapy, and side-e¡ects must be accepted andmanaged.Combination therapy with low-dose ketamineinfusions, regular paracetamol and judicious use of non-steroidal in£ammatory agents can be opioid sparing,though NSAID side-e¡ects limit their use.

K Sodium andwater retention.K Inhibition of renal prostaglandin production.K Inhibition of platelet aggregation.K Small bowel villous atrophy.K Extensively protein bound, so e¡ects potentiated byhypoproteinaemia.

Antidepressant therapy should be started early andmay be bene¢cial in improving sleep patterns.Following discharge from critical care regular assess-

ments of severity (those recorded by the professionalsgenerally correlate poorly with the patient’s own assess-ment) are needed, and distinction between backgroundand procedural pain is important, as di¡erent strategiesare needed for each.Background pain may be present continually. At ¢rst,

intravenous opioids by infusion or patient-controlled an-algesia (PCA), will be needed to control pain.Once feed-ing has been established the enteral route can be used,with long acting oral opioids supplemented, as necessary,with shorter acting preparations for breakthrough pain.Procedures, including surgery, dressing changes, and

physiotherapy, may requiremore intense analgesia. Poormanagementcan lead to a highdegree of anticipatory an-xiety for future procedures, lowering pain tolerance, soearly failure is poorly tolerated. Bolus alfentanil doses

ANAESTHESIAFORPATIENTSWITHBURNS INJURIES 75

and patient-controlled propofol techniques have beenused successfully andrecovery times aremarkedly short-er than conventional practice with oral opioid andbenzodiazepine combinations. Regional anaesthetictechniquesmay be available, depending on the burns dis-tribution but topical local anaesthetic application hasproven disappointing in our hands, with variable e¡ect.Prolonged pain can develop co-incident to the healing

process and tissue regeneration, associated with itchingand tingling. The chronic pain state that emerges oftenhas multiple, often unclear origins of pain, and can befrustratingly unresponsive to conventional regimes. Ad-juvant therapies include clonidine, and anticonvulsantswhich are e¡ective in the treatment of sympatheticallymaintained pain.23 Psychological therapies to boostcoping strategies and aid relaxation bene¢t manypatients.

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FURTHERREADING

MacLennanN,HeimbachDM,CullenBF. Anesthesia formajor thermalinjury. Anesthesiology1998; 89: 749^770.