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烧伤患者的麻醉

Authors
Sam R Sharar, MD
Hernando Olivar, MD
Section Editor
Michael Avidan, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA
Translators
王洁, 主治医师

引言

烧伤患者的整个围术期处理可能均需要麻醉医师参与，包括术前气道处理、术中麻醉、术后重症监护以及术后疼痛的处理。本专题将总结烧伤患者麻醉处理的这些方面。烧伤患者处理的其他问题参见其他专题。 (参见“重度烧伤患者的治疗概述”和“成人中重度热烧伤的紧急处理”和“轻度热烧伤的治疗”)

麻醉前会诊：重点考虑因素

烧伤

烧伤范围和严重程度 — 对烧伤区占全身体表面积(total body surface area, TBSA)百分比以及烧伤位置和严重程度的估计至关重要，因为这些因素会影响麻醉处理的诸多方面，包括气道处理、液体管理、药物用法用量，以及温度调节。烧伤面积占TBSA百分比的估算基于Lund-Browder图表(图 1)。重度烧伤被定义为，成人中烧伤面积大于25%TBSA的Ⅱ度烧伤，或10岁以内儿童或40岁以上成年人中烧伤面积大于20%TBSA的Ⅱ度烧伤(表 1)。重度烧伤也包括累及超过10%TBSA的Ⅲ度烧伤。高压电烧伤、烟雾吸入性损伤，以及面部、眼睛、耳、手、足或会阴的烧伤也被界定为重度烧伤。重度烧伤可能会引起严重的生理学及炎性反应，这对随后的住院诊疗有直接影响。 (参见“重度烧伤患者的治疗概述”和“烧伤的分类”)

液体复苏 — 热损伤后的最初48小时是烧伤的“复苏期”或“低潮期”。这期间会发生全身炎症反应，并伴随着因毛细血管通透性增加所致的血浆液体、电解质和蛋白质流失[1-3]。可根据一些公式(如，Parkland公式)进行有效的液体复苏，复苏终点目标是为了实现美国烧伤协会(American Burn Association, ABA)推荐的尿量为0.5-1mL/(kg·h)[4]。过多的静脉输液[如，液体泛滥(fluid creep)]会使患者有发生肺水肿、腹腔间隔室综合征或肢体循环受损的风险。 (参见“成人中重度热烧伤的紧急处理”，关于‘液体复苏’一节)

心血管系统 — 在严重烧伤后即刻的复苏期，患者的心输出量(cardiac output, CO)较低，处于一种“低潮”状态[3,5](参见“重度烧伤的并发症和远期结局”，关于‘心脏衰竭’一节)。由于血管通透性增加诱导的血浆丢失所致的低血容量、心肌对儿茶酚胺反应减弱，冠脉血流量减少引起的心肌缺血，以及加压素水平升高引起的全身血管阻力增加，患者的心输出量相比于基线水平可减少多达60%[6,7]。若液体治疗时初始复苏不足之后又复苏过度，则可导致肺水肿和右心衰竭。

烧伤后72-96小时，在恢复期期间，心血管变化发展至“涨潮”状态。这期间出现的高动力和高代谢反应包括心输出量增加、心动过速、心肌耗氧量增加，以及全身血管阻力降低[3]。

                     

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Literature review current through: 2017-07 . | This topic last updated: 2016-10-11.
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References
Top
  1. Kumar P. Grading of severity of the condition in burn patients by serum protein and albumin/globulin studies. Ann Plast Surg 2010; 65:74.
  2. Kumar P, D'Souza J, Bhaskara KG, Bharadwaj S. Serum protein level in conjunction with serum albumin/globulin ratio as an indicator of severity of changes in capillary permeability. Burns 2003; 29:628.
  3. Bittner EA, Shank E, Woodson L, Martyn JA. Acute and perioperative care of the burn-injured patient. Anesthesiology 2015; 122:448.
  4. Pham TN, Cancio LC, Gibran NS, American Burn Association. American Burn Association practice guidelines burn shock resuscitation. J Burn Care Res 2008; 29:257.
  5. Latenser BA. Critical care of the burn patient: the first 48 hours. Crit Care Med 2009; 37:2819.
  6. Crum RL, Dominic W, Hansbrough JF, et al. Cardiovascular and neurohumoral responses following burn injury. Arch Surg 1990; 125:1065.
  7. MacLennan N, Heimbach DM, Cullen BF. Anesthesia for major thermal injury. Anesthesiology 1998; 89:749.
  8. Lavrentieva A, Palmieri T. Determination of cardiovascular parameters in burn patients using arterial waveform analysis: a review. Burns 2011; 37:196.
  9. Williams FN, Herndon DN, Kulp GA, Jeschke MG. Propranolol decreases cardiac work in a dose-dependent manner in severely burned children. Surgery 2011; 149:231.
  10. Williams FN, Herndon DN, Suman OE, et al. Changes in cardiac physiology after severe burn injury. J Burn Care Res 2011; 32:269.
  11. Palmieri TL. Use of beta-agonists in inhalation injury. J Burn Care Res 2009; 30:156.
  12. Dai NT, Chen TM, Cheng TY, et al. The comparison of early fluid therapy in extensive flame burns between inhalation and noninhalation injuries. Burns 1998; 24:671.
  13. Suzuki M, Aikawa N, Kobayashi K, Higuchi R. Prognostic implications of inhalation injury in burn patients in Tokyo. Burns 2005; 31:331.
  14. Rehberg S, Maybauer MO, Enkhbaatar P, et al. Pathophysiology, management and treatment of smoke inhalation injury. Expert Rev Respir Med 2009; 3:283.
  15. Liffner G, Bak Z, Reske A, Sjöberg F. Inhalation injury assessed by score does not contribute to the development of acute respiratory distress syndrome in burn victims. Burns 2005; 31:263.
  16. Boots RJ, Dulhunty JM, Paratz J, Lipman J. Respiratory Complications in Burns: An Evolving Spectrum of Injury. Clinical Pulmonary Medicine 2009; 16:16.
  17. Jenkins ME, Gottschlich MM, Warden GD. Enteral feeding during operative procedures in thermal injuries. J Burn Care Rehabil 1994; 15:199.
  18. Evans DC, Martindale RG, Kiraly LN, Jones CM. Nutrition optimization prior to surgery. Nutr Clin Pract 2014; 29:10.
  19. Yamashita S, Kaneda K, Han TH. Population pharmacokinetics of a propofol bolus administered in patients with major burns. Burns 2010; 36:1215.
  20. Kaneda K, Han TH. Comparative population pharmacokinetics of fentanyl using non-linear mixed effect modeling: burns vs. non-burns. Burns 2009; 35:790.
  21. Han T, Kim H, Bae J, et al. Neuromuscular pharmacodynamics of rocuronium in patients with major burns. Anesth Analg 2004; 99:386.
  22. Blanchet B, Jullien V, Vinsonneau C, Tod M. Influence of burns on pharmacokinetics and pharmacodynamics of drugs used in the care of burn patients. Clin Pharmacokinet 2008; 47:635.
  23. Lawton G, Dheansa B. The management of major burns – a surgical perspective. Current Anaesthesia & Critical Care 2008; 19:275.
  24. Papini R. Management of burn injuries of various depths. BMJ 2004; 329:158.
  25. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. Available at: http://www.asahq.org/~/media/For%20Members/documents/Standards%20Guidelines%20Stmts/Basic%20Anesthetic%20Monitoring%202011.ashx (Accessed on September 03, 2014).
  26. Etherington L, Saffle J, Cochran A. Use of transesophageal echocardiography in burns:a retrospective review. J Burn Care Res 2010; 31:36.
  27. American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112:1084.
  28. Hostler D, Weaver MD, Ziembicki JA, et al. Admission temperature and survival in patients admitted to burn centers. J Burn Care Res 2013; 34:498.
  29. Reynolds L, Beckmann J, Kurz A. Perioperative complications of hypothermia. Best Pract Res Clin Anaesthesiol 2008; 22:645.
  30. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209.
  31. Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med 2009; 37:S186.
  32. Qadan M, Gardner SA, Vitale DS, et al. Hypothermia and surgery: immunologic mechanisms for current practice. Ann Surg 2009; 250:134.
  33. Watts DD, Trask A, Soeken K, et al. Hypothermic coagulopathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet function, and fibrinolytic activity. J Trauma 1998; 44:846.
  34. Mitrophanov AY, Rosendaal FR, Reifman J. Computational analysis of the effects of reduced temperature on thrombin generation: the contributions of hypothermia to coagulopathy. Anesth Analg 2013; 117:565.
  35. Kaiser HE, Kim CM, Sharar SR, Olivar HP. Advances in Perioperative and Critical Care of the Burn Patient. Advances in Anesthesia 2013; 31:137.
  36. Botts J, Srivastava KA, Matsuda T, Hanumadass ML. Wire Fixation Of Endotracheal Tube For Surgery Of Severe Facial Burns. Annals of Burns and Fire Disasters 1998; 11.
  37. Sorbello M, Frova G. Frova introducer: neither a stylet nor simply an introducer. Anaesthesia 2008; 63:1010.
  38. Gray RM, Rode H. Intra-operative endotracheal tube stabilisation for facial burns. Burns 2010; 36:572.
  39. Shafer SL. Shock values. Anesthesiology 2004; 101:567.
  40. Dennis CJ, Chung KK, Holland SR, et al. Risk factors for hypotension in urgently intubated burn patients. Burns 2012; 38:1181.
  41. Johnson KB, Egan TD, Kern SE, et al. Influence of hemorrhagic shock followed by crystalloid resuscitation on propofol: a pharmacokinetic and pharmacodynamic analysis. Anesthesiology 2004; 101:647.
  42. Pandit JJ. Intravenous anaesthetic agents. Anaesthesia and Intensive Care Medicine 2007; 9:154.
  43. Han TH, Lee JH, Kwak IS, et al. The relationship between bispectral index and targeted propofol concentration is biphasic in patients with major burns. Acta Anaesthesiol Scand 2005; 49:85.
  44. Han TH, Greenblatt DJ, Martyn JA. Propofol clearance and volume of distribution are increased in patients with major burns. J Clin Pharmacol 2009; 49:768.
  45. Das S, Forrest K, Howell S. General anaesthesia in elderly patients with cardiovascular disorders: choice of anaesthetic agent. Drugs Aging 2010; 27:265.
  46. Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet 2009; 374:293.
  47. Lipiner-Friedman D, Sprung CL, Laterre PF, et al. Adrenal function in sepsis: the retrospective Corticus cohort study. Crit Care Med 2007; 35:1012.
  48. Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis*. Crit Care Med 2012; 40:2945.
  49. Lundy JB, Slane ML, Frizzi JD. Acute adrenal insufficiency after a single dose of etomidate. J Intensive Care Med 2007; 22:111.
  50. Komatsu R, You J, Mascha EJ, et al. Anesthetic induction with etomidate, rather than propofol, is associated with increased 30-day mortality and cardiovascular morbidity after noncardiac surgery. Anesth Analg 2013; 117:1329.
  51. McPhee LC, Badawi O, Fraser GL, et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med 2013; 41:774.
  52. Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent? Anaesthesia 2009; 64:532.
  53. McGuinness SK, Wasiak J, Cleland H, et al. A systematic review of ketamine as an analgesic agent in adult burn injuries. Pain Med 2011; 12:1551.
  54. Cancio LC, Cuenca PB, Walker SC, Shepherd JM. Total intravenous anesthesia for major burn surgery. Int J Burns Trauma 2013; 3:108.
  55. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology 2006; 104:158.
  56. Osta WA, El-Osta MA, Pezhman EA, et al. Nicotinic acetylcholine receptor gene expression is altered in burn patients. Anesth Analg 2010; 110:1355.
  57. Martyn J. Clinical pharmacology and drug therapy in the burned patient. Anesthesiology 1986; 65:67.
  58. Han TH, Martyn JA. Onset and effectiveness of rocuronium for rapid onset of paralysis in patients with major burns: priming or large bolus. Br J Anaesth 2009; 102:55.
  59. Marathe PH, Dwersteg JF, Pavlin EG, et al. Effect of thermal injury on the pharmacokinetics and pharmacodynamics of atracurium in humans. Anesthesiology 1989; 70:752.
  60. Capan LM, Miller SM, Gingrich KJ.. Trauma and Burns. In: Clinical Anesthesia, Seventh, Barash PG. (Ed), Lippincott Williams & Wilkins, Philadelphia 2013. p.1522.
  61. Steinvall I, Fredrikson M, Bak Z, Sjoberg F. Incidence of early burn-induced effects on liver function as reflected by the plasma disappearance rate of indocyanine green: a prospective descriptive cohort study. Burns 2012; 38:214.
  62. Holtman JR Jr, Jellish WS. Opioid-induced hyperalgesia and burn pain. J Burn Care Res 2012; 33:692.
  63. Edrich T, Friedrich AD, Eltzschig HK, Felbinger TW. Ketamine for long-term sedation and analgesia of a burn patient. Anesth Analg 2004; 99:893.
  64. Bussolin L, Busoni P, Giorgi L, et al. Tumescent local anesthesia for the surgical treatment of burns and postburn sequelae in pediatric patients. Anesthesiology 2003; 99:1371.
  65. Fujita K, Mishima Y, Iwasawa M, Matsuo K. The practical procedure of tumescent technique in burn surgery for excision of burn eschar. J Burn Care Res 2008; 29:924.
  66. Gümüş N. Tumescent infiltration of lidocaine and adrenaline for burn surgery. Ann Burns Fire Disasters 2011; 24:144.
  67. Hernandez JL, Savetamal A, Crombie RE, et al. Use of continuous local anesthetic infusion in the management of postoperative split-thickness skin graft donor site pain. J Burn Care Res 2013; 34:e257.
  68. Budny PG, Regan PJ, Roberts AH. The estimation of blood loss during burns surgery. Burns 1993; 19:134.
  69. Housinger TA, Lang D, Warden GD. A prospective study of blood loss with excisional therapy in pediatric burn patients. J Trauma 1993; 34:262.
  70. Chohan SS, McArdle F, McClelland DB, et al. Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UK intensive care unit. Vox Sang 2003; 84:211.
  71. American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2006; 105:198.
  72. Palmieri TL, Greenhalgh DG. Blood transfusion in burns: what do we do? J Burn Care Rehabil 2004; 25:71.
  73. Palmieri TL, Greenhalgh DG, Sen S. Prospective comparison of packed red blood cell-to-fresh frozen plasma transfusion ratio of 4: 1 versus 1: 1 during acute massive burn excision. J Trauma Acute Care Surg 2013; 74:76.
  74. Cartotto R, Musgrave MA, Beveridge M, et al. Minimizing blood loss in burn surgery. J Trauma 2000; 49:1034.
  75. O'Mara MS, Hayetian F, Slater H, et al. Results of a protocol of transfusion threshold and surgical technique on transfusion requirements in burn patients. Burns 2005; 31:558.
  76. Papp AA, Uusaro AV, Ruokonen ET. The effects of topical epinephrine on haemodynamics and markers of tissue perfusion in burned and non-burned patients requiring skin grafting. Burns 2009; 35:832.
  77. McQuitty CK, Berman J, Cortiella J, et al. beta-adrenergic desensitization after burn excision not affected by the use of epinephrine to limit blood loss. Anesthesiology 2000; 93:351.
  78. Missavage AE, Bush RL, Kien ND, Reilly DA. The effect of clysed and topical epinephrine on intraoperative catecholamine levels. J Trauma 1998; 45:1074.
  79. Cartotto R, Kadikar N, Musgrave MA, et al. What are the acute cardiovascular effects of subcutaneous and topical epinephrine for hemostasis during burn surgery? J Burn Care Rehabil 2003; 24:297.
  80. Mitchell RT, Funk D, Spiwak R, Logsetty S. Phenylephrine tumescence in split-thickness skin graft donor sites in surgery for burn injury- a concentration finding study. J Burn Care Res 2011; 32:129.
  81. Imai R, Matsumura H, Uchida R, Watanabe K. Perioperative hemodilutional autologous blood transfusion in burn surgery. Injury 2008; 39:57.
  82. Johansson PI, Eriksen K, Nielsen SL, et al. Recombinant FVIIa decreases perioperative blood transfusion requirement in burn patients undergoing excision and skin grafting--results of a single centre pilot study. Burns 2007; 33:435.
  83. Simpson E, Lin Y, Stanworth S, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012; :CD005011.
  84. Asmussen S, Maybauer DM, Fraser JF, et al. Extracorporeal membrane oxygenation in burn and smoke inhalation injury. Burns 2013; 39:429.