Topics to be discussed………………..

1. Topics to be discussed……………….. • Rehabilative management • Specific Burns • Anaesthesia during surgical management of burn sequelae • Postoperative management Dr Chittaranjan Joshi www.anaesthesia.co.inanaesthesia.co.in@gmail.com

2. The rehabilitative management • Acute phase. Prevention of: - articular limitations - muscle or tendon contractures - breathing complications - oedema • Post-acute phase. Aims: - recovery of muscular tone trophism - return of patient to normal overall condition - restoration of patient’s autonomy in shortest time possible • Chronic phase (sequelae). Aims: - scar prevention - treatment of orthopaedic sequelae - treatment of neurological sequelae - return of patient to social environment, family, and working life

3. Various procedures of kinesitherapy • Assisted active mobilisation • Active mobilization • Mobilization against resistance • Dynamic proprioceptive re-education • Stretching • Postural sequences • Recommencement of standing (orthostatism) • Re-education for the recommencement of walking • Splinting

4. Exercises Bandaging is applied - in the acute phase, to prevent oedema - after skin grafting - In burns in the course of healing - during the chronic phase Massotherapy Manual lymphatic drainage Physical therapy - Ultrasounds: 3Hz, intensity 1.5 W/m2 - TENS - Vacuum therapy

5. Respiratory Burns Smoke inhalation should be suspected if Explosion in closed environment Flame burns to the face Shoot in mouth or nostrils Hoarse and stridor Early Intubation may be required Blood Carboxy Hb level : Extent of injury

6. Electrical Burn • Most are flash burns • Flash may reach 40000c • Don’t occur by electrical conduction • Low tension burn-small but full thickness • High tension burn-entry and exit wound • Current passes through the path of least resistance • Extent of tissue destrn-underestimated • High tension burns-arrhythmias • Myonecrosis and myoglobinuria

7. The Degree of Tissue Injury is Dependent on: Voltage of the source Amperage of current passing through the tissues Resistance of tissue traversed by current Duration of contact Pathway of the current

9. Treatment • Moist dressing • Cooling cream • Antiphlogistics • Topical Corticosteroids

10. Chemical Burn

11. Chemical burn 3 factors determine the severity • Type of chemical and its concentration • Temperature • Contact time • Acid burns may penetrate deeply down to the bone • Alkali can cause deep dermal or full thickness burn

12. Treatment • At scene, cool the tar with cool water. • Removal of the tar is best done using an emulsifying agent such as Tween 80 found in neosporin ointment. Neosporin applications, using a closed dressing, will soften the tar so it can be gently removed. An alternative agent but less effective is SSD to soften the tar. • Wound management is that for a deep burn with SSD usually followed by surgery. • Calcium gluconate

13. Burns in pregnant patient • maternal outcome unaffected by pregnancy • fetal outcome • <20% BSA burn: no effect • >30% BSA burn: increased risk of preterm labour • >40% BSA burn: high risk of fetal death • >50% BSA burn: consider elective cesarean section if fetus is still viable • initial resuscitation unchanged

14. Anaesthesia for burn patient • Escharotomy

16. TEF after burn British Journal of Anaesthesia 2005 94(1):132-134

17. Anaesthesia for burn patient • Release of burn contracture

20. Problems • Difficult airway management • Inadequate resuscitated patient • Difficulty in establishing IV access • Hyperkalemic response to scoline • Resistance to non-depolarizing muscle relaxant • Significant blood and plasma loss • Patient positioning • Hypothermia • Postoperative analgesia

21. Preop. assessment • Emphasis on the following: - extent & site of burn - extent & site of proposed surgery - Volume status - Airway, ease of intubation - Associated injury - Evidence of infection • Review latest I(x), correct abnormalities, GXM for blood and plasma • Premedication in suitable patient

22. Intraop management • Prepare for difficult intubation if the burn area involved head and neck region • Means to reduce heat loss: - warming blanket - blood warmers - humidifiers • Monitors: - ECG, BP, SpO2, ETCO2, CVP, urine output - maybe difficult to place because of the burn area involved - Invasive BP may be indicated if the surgery is extensive and there is no suitable site for placement of sphygmomanometer cuff

23. Altered pharmacokinetics • Volume of distribution increases for water soluble drugs (resistance to non-depolarizing agents occurs.) • Increased extracellular fluid: intracellular fluid ratio • Albumin falls - less protein binding • Increased metabolic rate / temperature leading to altered half life

24. Induction agents • Thiopental requirements are increased in children for more than 1 year after burn injuries • Significant when burned area is more than 15% BSA • No change in pharmacology of propofol Anesth Analg. 2003 Sep;97(3):839-42. Anesth Analg 1985;64:1156-60

25. Opioids • The foremost cause of inadequate pain relief in burn patient is undermedication J Burn Care Rehabil 1995; 16:365-371 • Strong opioids could be used much more effectively in burn patients, and their dosage reduced by co-administering drugs that block nociceptive or inflammatory afferent input, glutamate release, and/or activation of NMDA receptors Anaesthesia: Biological Foundations.Philadelphia: Lippincott-Raven, 1997 • finding of opioid receptors on peripheral nerve terminals in inflammatory states such as thermal injuries suggests that the peripheral administration of opioids may decrease burn painN Engl J Med 1995; 332:1685-1690

26. Opioids….. • Dose requirement of opioids in burn patient is increased ↓ altered pharmacokinetics or altered pharmacodynamics ????? • Moreover, the functioning of the body's endogenous system of endorphins may alter the response to exogenous opioids.

27. Succinylcholine • succinylcholine should not be used beyond 24 h after a burn injury Anesthesiology 1998; 89:49-70 • there are no reports in the literature of succinylcholine-induced hyperkalemia in humans occurring within 1 week after a burn injury • The upregulation of acetylcholine receptors (AChRs) after burns occurs at sites immediately beneath and distant from the burn J Appl Physiol 1988; 65:1745-51 • a positive correlation between AChR number and the intensity of the hyperkalemia after succinylcholine has been confirmed and occurs as early as 72 h after burn Anesthesiology 1996; 84:384-91 • succinylcholine is probably safe up to 48 h after burn injury, but it may be wise to avoid it beyond that period Anesthesiology: Volume 91(1) July 1999 pp 321-322

28. NDMRs • 3 fold increase in dose requirement of NDMRs Anesthesiology 1986;65:67-75 • 30% or more of the body must be burned to produce resistance to NDMRs. • manifests about 10days after burn injury, peaking at 40 days, and declining after about 60days. Anesth Analg1982;61:614-7 • Proliferation of extrajunctional AChRs and increased level of glycoproteins are responsible Am. J. Nurs., 85:30-45, 1985 Anesthesiology 1983;59:561-4

29. NDMRs • 1.2 mg/kg dose of rocuronium provides good intubating conditions with a faster onset time compared with a dose of 0.9 mg/kg. Anesth Analg 2004;99:386-392 • dose of vecuronium must be titrated to achieve effective muscular paralysis: the correcting factor is 1.3 for a BSA under 20%, 1.9 for a BSA between 20 and 40%, 2.5 for a BSA between 40 and 60%, and 2.9 for a BSA above 60%. Ann Fr Anesth Reanim. 1996;15(2):135-41 • Increases in acetylcholine receptors (AChRs) at the muscle membrane, induced by burn injury, have been associated with resistance to atracurium Anesthesiology. 83(2):309-315, August 1995

30. Intraop management… 4. Choice of anaesthetic agent (i) Induction agent - Thiopentone 4mg/kg - Ketamine 2mg/kg : good analgesics effect : maintains BP in hypovolaemic pt – Propofol 2mg/kg : no analgesics effect : cause hypotension : good recovery (ii) Volatile agent - Isoflurane is agent of choice - Halothane is not suitable as it’s rare possibility of halothane hepatitis - sevoflurane should be used in burns surgery as a routine anaesthetic.Acta, vol. 44 - 2002

31. (iii) Muscle relaxant - SCOLINE should be avoided because of the hyperkalemic response - Large doses of non-depolarizing muscle relaxants may be required due to altered protein binding and an increase extrajunctional acetylcholine receptor which bind non- depolarizing drug without causing neuromuscular effect

32. 5. Provide adequate analgesia using IV morphine or pethidine or fentanyl 6. Minimize heat loss to reduce incident of post-op shivering 7. Close monitoring of haemodynamic status 8. Replace blood early 9. There should be close communication between surgeon and the anaesthetist

33. Post-op management • The following aspect should be taken care: - oxygen therapy - analgesia - temperature: radiant heater, warming blanket - fluid and blood transfusion

34. Postoperative pain • aggressive analgesia is critical to avert the cycle of pain, anxiety, and more pain and to minimize adverse psychological effects of pain commonly encountered in burn patients J Pain Symptom Manage 1995; 10:446-455 • to improve analgesic efficacy and reduce drug side effects in postoperative patients, preemptive/multimodal analgesia uses two or more drugs with different mechanisms of action (e.g., local anesthetics, nonsteroidal anti-inflammatory drugs [NSAIDs], and opioids) applied before, during, and after surgery to different targets (at the periphery or centrally), along with nonpharmacological techniques to reduce stress and anxiety Drugs 1999; 58:793-797

35. Postoperative pain………… • Strong opioids could be used much more effectively in burn patients, and their dosage (as well as side effects) reduced by co-administering drugs that block nociceptive or inflammatory afferent input, glutamate release, and/or activation of NMDA receptors In: Biebuyck JF, et al. (Eds). Anaesthesia: Biological Foundations. philadelphia:Lippincott-Raven, 1997. • acetaminophen or NSAIDs with opioids could be a basic treatment for burn pain J Burn Care Rehabil 1998; 19:151-159 • Traditional NSAIDs are not recommended in burn patients who undergo extensive excision and grafting procedures because their antiplatelet effects may increase blood loss

36. Postoperative pain………… • Newer NSAIDs, the cyclooxygenase-2 (COX-2) inhibitors, offer analgesia with few side effects, including minimal inhibition of platelet function Lancet 1999; 80:121-125. • effects of COX-2 inhibitors on wound healing remain to be demonstrated • These drugs could be introduced early during treatment to reduce peripheral and central sensitization, decrease opioid requirements, and reduce side effects.

37. Postoperative pain………… • The finding of opioid receptors on peripheral nerve terminals in inflammatory states such as thermal injuries suggests that the peripheral administration of opioids may decrease burn pain . N Engl J Med 1995; 332:1685-1690 • NMDA-receptor antagonism may offer specific advantages in treating post-burn hyperalgesia and lessening opioid dose escalation Drugs 1998; 55:1-4 • The opioid-sparing actions seen with ketamine combinations could reduce opioid-related adverse effects, including the hyperalgesia sometimes seen with high opioid doses Pain 1999; 82:111-125.

38. Neuraxial blockade • Epidural bupivacaine + morphine – effective in relief of pain and improve circulation Rev Esp Anesthiol Reanim 1989, sep-oct;39(5),288-90 • Epidural morphine reduces incidence of hyperalgesia in burn patient Pain 1994 Nov;59 (2): 261-71

39. The management of burn patient can be extremely difficult and requires a planned multi- disciplinary approach in which anaesthesiologists should assume a leading role

40. Thank You www.anaesthesia.co.inanaesthesia.co.in@gmail.com