Browse the corpus

Anesthetic management of the patient with burns can be complex due to various pathophysiological and hemodynamic changes following a burn comprising greater than 20% total body surface area. The patient with severe burns poses added challenges of airway management, fluid resuscitation, and vascular access due to direct trauma to the skin and soft tissue structures. This activity reviews and highlights the critical components necessary for the anesthetic management of a patient with severe burns, emphasizing the inter-professional team in evaluation and treatment. Objectives: Explain how the pathophysiologic changes associated with burns alter anesthetic management. Identify the ideal approach to an airway complicated by significant thermal injury to supraglottic structures. Utilize the Parkland formula for fluid resuscitation after a severe burn and the parameters by which fluid resuscitation should be guided. Collaborate with the interprofessional team to optimize the care of a patient with burns and provide anesthesia management. Access free multiple choice questions on this topic.

Almost half a million people seek medical care annually due to burn injuries. The anesthesiologist plays a critical role in managing complicated cases involving airway management, hemodynamic support, intravascular access, thermoregulation, and pulmonary support. The airway of a severely burned patient can quickly become compromised with traditional means of anesthesia and requires special attention to ensure adequate ventilation. When treating patients with burns, the complex pathophysiologic changes pose challenges in performing intraoperative fluid resuscitation, selecting appropriate induction drugs, and determining optimal ventilation strategies. The anesthesiologist plays a critical role in optimizing the care of these patients.[1][2]

Infection Severe burns can weaken the immune system due to increased cytokine inflammatory markers, leading to a greater risk of infection. Wounds quickly become colonized with gram-positive organisms like Staphylococcus aureus and Staphylococcus epidermis. Over several days, intestinal microbes such as Pseudomonas aeruginosa and Escherichia coli colonize the wounds. Systemic antibiotic therapy is not necessarily warranted for these microbe colonizations perioperatively, although thorough wound cleansing with soap, water, normal saline, and/or chlorhexidine is advisable. Topical antibiotic therapy should be suitable for the perioperative period in the early phases of a burn. A conversation between the surgeon and anesthesiologist can minimize the overuse of antibiotics in this subset of patients.[18][19][20]

Approximately 500,000 people present to the emergency department each year with a burn, but most of these patients do not require critical care.[1] When critical care is required, minutes count as a difficult airway can quickly advance to a "can't ventilate, can't intubate" situation with the swelling that occurs during the hours after a severe burn injury. The anesthesiologist can play an important role in managing these cases with their vast knowledge of physiology, pharmacology, airway management skills, and critical care skills. However, it is only through effective communication and coordination among all patient's interprofessional care team members that the patient can have the best chance at a favorable outcome. Severely burned patients are a complex population that requires a multidisciplinary approach to their medical care. This population of patients can have multifaceted problems, including complicated airways, smoke inhalation injuries, and a unique approach to hemodynamic optimization considering the pathophysiology of burns. Optimizing the care of this complex population may require interdisciplinary collaboration and a myriad of services. A retrospective study involving a Difficult Airway Response Team (DART) composed of anesthesiologists, otolaryngologists, and trauma surgeons as a multidisciplinary approach to difficult airways found that a team-based approach was able to secure the airway more often without the need for an emergency cricothyrotomy in a statistically significant manner.[21] Applying a multidisciplinary approach to a burn patient with a difficult airway can lead to a safer and less harmful method of securing the airway.

A retrospective study involving a Difficult Airway Response Team (DART) composed of anesthesiologists, otolaryngologists, and trauma surgeons as a multidisciplinary approach to difficult airways found that a team-based approach was able to secure the airway more often without the need for an emergency cricothyrotomy in a statistically significant manner.[21] Applying a multidisciplinary approach to a burn patient with a difficult airway can lead to a safer and less harmful method of securing the airway. The Parkland Formula is a valuable tool for estimating the necessary amount of fluid resuscitation for a burn patient. However, relying solely on this number for calculating the administration of isotonic fluid can be prone to human errors. Accidentally forgetting to include fluid volumes from intravenous medications is a common issue. Burn patients must receive the correct amount of fluid resuscitation as too little fluid is associated with increased morbidity and mortality. Too much fluid is associated with fluid creep, which can lead to higher rates of infection and intubation.[1][2] A retrospective review of burn patients found that patients actually receive much higher volumes of fluid than estimated by the Parkland Formula to properly fluid resuscitate a burn patient.[22] Effective team communication can help prevent fluid creep and its associated issues. Nursing staff plays a crucial role in ensuring accurate intake and output recording and can provide essential feedback to physicians and advanced practice clinicians when significant volumes of medications, such as antibiotics, sedation, and electrolyte replacement, are being infused. These fluid volumes are often overlooked when calculating fluid resuscitation goals, making the nursing staff's vigilance and communication vital for effective patient care. The anesthesiologist and critical care physician collaborate with the surgeons to make adjustments in fluid delivery so surgical sites or respiratory function are not compromised. Effective communication among team members is key to improving outcomes for this complex subset of patients without the need to alter the currently available therapies.