Anesthesia for the Pediatric Burn

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Anesthesia for the Pediatric Burn

• Mark Ansermino
• British Columbias Childrens Hospital

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Airway

• Ensure clear airway
• Suspect inhalation injury if
• fire in confined space
• soot in nostrils/ sputum/ mouth
• singed nasal/ facial hair
• burns on face/ tongue/ pharynx
• stridor or hoarseness

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Breathing

• Artificial ventilation if required
• Always administer O2
• Carbon Monoxide poisoning if
• inhalation injury
• fire in confined space
• altered consciousness
• If in doubt intubate!!

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Circulation

• Intravenous fluid if
• gt15 adult
• gt10 child
• No compromise with IV access
• Ringers lactate solution
• Calculate volume from time of injury

Weight(kg) X Burn area() every hour
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Parkland formula
8 hours
16 hours
2mls / kg / burn
2mls / kg / burn
4mls / kg / burn
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Increased Fluid Requirements

• Children lt 20kg
• Inhalation Injury
• Delayed Resuscitation
• Flame/ Petrol Burns
• Other trauma

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Excessive fluid BAD

• Abdominal compartment syndrome
• Extremity compartment syndrome
• Pulmonary edema
• Tissue edema

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First Aid

• cool vs warm

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Carbon Monoxide
Hb
HbCO
CO

• Confined space - ? LOC - inhalation injury
• 200X gt affinity than oxygen
• also myoglobin, cytochromes
• Rx O2

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Concurrent Injury

• History of injury
• Exclude
• Head injury
• Spinal injury
• Internal injury
• Fractures

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Concurrent Disease

• History of pre-existing condition
• Medications
• History of mechanism of burn

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Analgesia

• Avoid IMI injections!!!
• Intravenous titration
• Ketamine 0.5mg/kg ivi (2mg/kg imi)
• Morphine 0.2mg/kg every 5 mins
• Cover wound
• Keep warm

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End Points of Resuscitation

• Vital signs
• Urine output
• Peripheral perfusion (? temp)
• Base deficit - lactate - ?Hb
• CVP - PCWP
• CO/CI - oxygen delivery
• Gastric mucosal pH

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LA50 in relation to age
TBSA()
Age(Y)
Based on ABA Registry Data 1991-1993
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TBSA for 50 mortality
TBSA()
Age(y)
Galveston Burn Unit
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Burn injury is a multi-system disease

• Cardiovascular System
• Respiratory System
• Central Nervous System
• Haematological System
• Immune System
• Renal System
• Metabolic Systems
• Endocrine Systems

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• Early burn wound excision significantly reduces
  blood loss. (Desai MH. Ann Surg 1990 211
  753-62.)
• Primary excision of the burn wound.
• Improved survival with early excision in major
  burns
• (Still JM, Jr., Law EJ. Clin Plast Surg 2000
  27(1)23-28.)

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Cut it off!!

• Rapid resuscitation
• Thermal stabilization
• Remove stimulus for systemic response
• Cover open wound

How soon ?? 1 or 12 or 24 hrs
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Burn Wound Management

• Topical agents
• Early wound excision
• Early wound closure
• Autologous graft
• Allogenic skin
• Autologous keratinocytes
• Skin substitutes

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Inhalational Injury
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Mortality after Smoke Inhalation

• without a burn lt 10
• with a burn 30 - 50
• total mortality lt 10
• with inhalation injury 30 - 40

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Airway Burns
DIRECT LUNG INJURY
vs
SYSTEMIC EFFECTS
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Airway Burns

• Upper airway burns
• Lower airway burns
• Trachea
• Bronchi
• Alveoli
• External airway burns

Any combination
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Upper Airway Burns

• May be cause of immediate death
• May cause total airway obstruction
• Onset may be delayed
• Control airway early !!

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Airway Burns - Aetiology

• Heat injury
• Smoke particles superheated
• Smoke particles irritants
• Toxic fumes acrolein, HCN, NO2 ,.
• Blast injury
• Bronchial obstruction
• Systemic response (24-48hrs)
• Carbon monoxide poisoning

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Diagnosis of Airway Burns - Clinical

• Burned in enclosed space
• Stridor or hoarseness
• Burns to face, lips, tongue, mouth, pharynx or
  nasal mucosa
• Soot in sputum, nose, mouth
• Dyspnoea, confusion, decreased consciousness

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Diagnosis of Airway Burns - Investigations

• Evidence of hypoxemia
• SpO2
• ABG
• Carboxyhemoglobin
• CXR
• Xenon ventilation scan
• Bronchoscopy
• Mucosal histology
• Human placental alkaline phosphatase (hPLAP)

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CHAHGES AFTER LOWER AIRWAY BURN INJURY
Inflammatory Mediators Thomboxanes, Cytokines,
Prostoglandins
Immune Dysfunction
Hypermetabolism
Ciliary loss
Capillary leak (oedema)
Burn Injury
Oedema
Alveolar injury
Surfactant loss
Myocardial Dysfunction
Renal Dysfunction
LUNG INJURY
V/Q mismatch
Burn Shock
? perfusion of burn wound
Pneumonia
Sepsis
Obstruction
MSOF
? perfusion of gut
Hypoxia
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Treatment of Airway Burns

• Adequate oxygenation
• Secure airway
• 100 O2
• Adequate fluid resuscitation
• Avoid secondary lung injury
• Good airway toilet
• ? Antibiotics ? Heparin ?Lavage
• Beware associated cerebral injury!

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Treatment of Airway Burns Whats New?

• Pressure controlled ventilation
• High frequency ventilation
• Percussive ventilation
• Nitric Oxide
• Partial liquid ventilation
• Surfactant replacement
• ECMO

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Nebulised heparin/ acetylcysteine

• Reduction in mortality in paediatric patients
  with inhalation injury with nebulised heparin/
  acetylcysteine.
• Desai et al. J Burns Care Rehabil 19 210-112.

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Toxic Scald Syndrome

• Small Child Small Burn
• Sick Child

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Toxic shock syndrome

• Fever
• Pyrexia
• Macular rash
• Hypotension
• Hypoxemia
• Low WBC
• Low platelets
• MSOF

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Treatment of Toxic Shock

• Supportive
• Remove source burn
• Globulin
• FFP
• Antibiotics?

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Potential Treatments of Systemic Response

• B blockers
• Oxandrolone
• Thromboxane synthetase inhibitors
• Free radical scavengers
• Antioxidants
• Protease inhibitors
• CD 18 leukocyte adherence antibodies
• Topical protein kinase inhibitor
• Does anything really work??

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Infection and Immunity

• Infection is commonest cause of death following
  burn injury.
• Immunity is depressed by systemic response and
  many interventions.
• Multi - resistant organisms are common.
• Early wound closure essential

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Burn Infection

• All burn patients are infected and
  immunocompromised
• Bacterial surveillance Vs empirical treatment
• Initial Gve replaced with G-ve then fungi
• ? burn size ? systemic infection
• Nosocomial infection common

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Nutritional Support

• Severe hypermetabolic state
• TPN BAD
• Measure REE
• Early Enteral nutrition
• Direct Jejunal feeding
• Metabolic modulators
• Micronutrients