Difference between revisions of "Burn wound debridement"

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<nowiki>*</nowiki>These patients have often had multiple prior anesthetics for debridement.  Carefully review previous anesthetic records, while recognizing that anesthetic requirements may increase over time.
  
 
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
 
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
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=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
 
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
  
* Make sure OR is warm
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* Make sure OR is warm, have warming blankets, forced air warming, and/or warmed fluids.
  
 
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
 
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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** BP:  May need arterial line if no suitable location for cuff
 
** BP:  May need arterial line if no suitable location for cuff
 
* Given high degree of insensible losses, important to track fluid status
 
* Given high degree of insensible losses, important to track fluid status
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* Temperature monitoring is critical
  
 
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
 
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
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* Avoid succinycholine outside 24 hours from injury, given risk for fatal hyperkalemia
 
* Avoid succinycholine outside 24 hours from injury, given risk for fatal hyperkalemia
 
** Risk of hyperkalemia can persist for up to 2 years after a burn injury
 
** Risk of hyperkalemia can persist for up to 2 years after a burn injury
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* Airway management can be complicated by burns to head/neck region.
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** Over time, face of neck contractures can cause the airway anatomy to be distorted. 
  
 
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
 
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
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* Largely depends on the site of the burn injury
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* Pay extra careful attention to positioning on burned areas
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* Extra padding on burned areas
  
 
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
 
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
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* Standard maintenance
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* May have developed tolerance to opioids
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* Blood loss can be significant
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** Frequently check Hgb/Hct
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** To minimize blood loss, surgeon may infiltrate with tumescent solution that contains vasoconstrictors.  This may cause systemic inject and fluid overload
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* Carefully monitor temperature
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**
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* Carefully monitor fluid status
  
 
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
 
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

Latest revision as of 17:01, 1 June 2021

Burn wound debridement
Anesthesia type
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative


The management of burn injuries is complex and these wound typically require aggressive debridement. Epidermal burns typically only require supportive therapy, but deeper burns often require more attention. Most deep partial thickness burns are best managed by excising the burnt tissue and grafting skin. Full-thickness burns >1cm2 will almost always require require excision and grafting[1].

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular
Respiratory
Gastrointestinal
Hematologic
Renal
Endocrine
Other

*These patients have often had multiple prior anesthetics for debridement. Carefully review previous anesthetic records, while recognizing that anesthetic requirements may increase over time.

Labs and studies

Operating room setup

  • Make sure OR is warm, have warming blankets, forced air warming, and/or warmed fluids.

Patient preparation and premedication

Regional and neuraxial techniques

  • Use of regional anesthesia may be limited by area of injury and risk of infection

Intraoperative management

Monitoring and access

  • Depending on the extent of the burn, monitoring can be difficult if access to the chest (ECG), arms (BP), and digits (pulse oximeter) is compromised.
    • EKG: If thorax is severely burned, may consider using skin staples attached to crocodile clips
    • Pulse ox: Consider alternative sites (i.e. ears, nose, lip, tongue)
    • BP: May need arterial line if no suitable location for cuff
  • Given high degree of insensible losses, important to track fluid status
  • Temperature monitoring is critical

Induction and airway management

  • Avoid succinycholine outside 24 hours from injury, given risk for fatal hyperkalemia
    • Risk of hyperkalemia can persist for up to 2 years after a burn injury
  • Airway management can be complicated by burns to head/neck region.
    • Over time, face of neck contractures can cause the airway anatomy to be distorted.

Positioning

  • Largely depends on the site of the burn injury
  • Pay extra careful attention to positioning on burned areas
  • Extra padding on burned areas

Maintenance and surgical considerations

  • Standard maintenance
  • May have developed tolerance to opioids
  • Blood loss can be significant
    • Frequently check Hgb/Hct
    • To minimize blood loss, surgeon may infiltrate with tumescent solution that contains vasoconstrictors. This may cause systemic inject and fluid overload
  • Carefully monitor temperature
  • Carefully monitor fluid status

Emergence

Postoperative management

Disposition

Pain management

Potential complications

Procedure variants

Variant 1 Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

  1. Wang, Cynthia (2014-07-17). "Management of Burns and Anesthetic Implications". Anesthesia for Trauma: 291–319. doi:10.1007/978-1-4939-0909-4_14. PMC 7121311.