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Anesthesia for burn patients

Sam R Sharar, MD
Hernando Olivar, MD
Section Editor
Michael Avidan, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA


Anesthesia providers may be involved in the management of burn patients throughout the perioperative period, including preoperative airway management, intraoperative anesthetic care, postoperative intensive care, and management of postoperative pain. This topic reviews these aspects of the anesthetic management of burn patients. Other issues in the management of burn patients are reviewed separately. (See "Overview of the management of the severely burned patient" and "Emergency care of moderate and severe thermal burns in adults" and "Treatment of minor thermal burns".)


Burn injury

Burn extent and severity — An estimate of the percent total body surface area (TBSA) burned and the location and severity of the burn is essential since these factors affect many aspects of anesthetic care, including airway management, fluid management, drug dosing, and temperature regulation. Calculation of TBSA is based on the Lund-Browder chart (figure 1). A major burn injury is a partial-thickness burn greater than 25 percent TBSA in adults, or greater than 20 percent in children younger than 10 years old or adults older than 40 years old (table 1). Major burn injury is also defined as full-thickness burns involving more than 10 percent TBSA. High-voltage burns, smoke inhalation injury, and burns to the face, eyes, ears, hands, feet, or perineum are also defined as major burns. Major burns may cause an intense physiologic and inflammatory response that has a direct impact on the subsequent hospital course. The ABA recommends that second-degree or greater burns to face, hands, feet, perineum, and major joints should be referred to a certified burn center. The reason besides cosmetic implications (face) is that these areas have a complex anatomy and inadequate management of burn injuries could result in important functional derangements. In addition, patient with burns to the face might have airway involvement or smoke inhalation. (See "Overview of the management of the severely burned patient" and "Classification of burn injury".)

Fluid resuscitation — The first 48 hours after the thermal insult is the “resuscitative phase” or “ebb phase” of the burn injury. A systemic inflammatory response occurs during this period, with loss of plasma fluid, electrolytes, and proteins due to increased capillary permeability [1-3]. Effective fluid resuscitation is guided by formulas (eg, Parkland formula) targeted to achieve the American Burn Association (ABA)-recommended urinary output (UO) of 0.5 to 1 mL/kg per hour as the resuscitative endpoint [4]. Excessive intravenous fluid administration (eg, “fluid creep”) can put the patient at risk of developing pulmonary edema, abdominal compartment syndrome, or compromised circulation of extremities. (See "Emergency care of moderate and severe thermal burns in adults", section on 'Fluid resuscitation'.)

Cardiovascular — Cardiac output (CO) is low, in an “ebb” state, during the resuscitative phase immediately following a severe burn [3,5] (see "Complications and long-term outcomes of a severe burn", section on 'Cardiac failure'). CO is reduced up to 60 percent from baseline due to hypovolemia from permeability-induced plasma loss, reduced myocardial response to catecholamines, increased systemic vascular resistance due to elevated vasopressin levels, and possible myocardial ischemia due to decreased coronary blood flow [6,7]. Initial under-resuscitation with fluid therapy, followed by over-resuscitation, leads to pulmonary edema and right heart failure.

At 72 to 96 hours postburn, during the recovery phase, cardiovascular changes evolve into a “flow” phase. The hyperdynamic and hypermetabolic responses during this phase include increased CO, tachycardia, increased myocardial oxygen consumption, and decreased systemic vascular resistance [3].

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Literature review current through: Nov 2017. | This topic last updated: Oct 17, 2017.
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