Anestesia en quemados/Anesthesia and burns

TIVA para cirugía mayor de quemaduras


Total intravenous anesthesia for major burn surgery.
Cancio LC, Cuenca PB, Walker SC, Shepherd JM.
U.S. Army Institute of Surgical Research Fort Sam Houston, Texas, USA.
Int J Burns Trauma. 2013 Apr 18;3(2):108-14. Print 2013.
Abstract
Total intravenous anesthesia (TIVA) is frequently used for major operations requiring general anesthesia in critically ill burn patients. We reviewed our experience with this approach. METHODS: During a 22-month period, 547 major burn surgeries were performed in this center's operating room and were staffed by full-time burn anesthesiologists. The records of all 123 TIVA cases were reviewed; 112 records were complete and were included. For comparison, 75 cases were selected at random from a total of 414 non-TIVA general anesthetics. Some patients had more than one operation during the study: as appropriate for the analysis in question, each operation or each patient was entered as an individual case. For inter-patient analysis, exposure to 1 or more TIVAs was used to categorize a patient as member of the TIVA group.
RESULTS: Excision and grafting comprised 78.2% of the operations. 14 TIVA regimens were used, employing combinations of 4 i.v. drugs: ketamine (K, 91 cases); i.v. methadone (M, 62); fentanyl (F, 58); and propofol (P, 21). The most common regimens were KM (34 cases); KF (26); KMF (16); and K alone (8). Doses used often exceeded those used in non-burn patients. TIVA was preferred for those patients who were more critically ill prior to surgery, with a higher ASA score (3.87 vs. 3.11). Consistent with this, inhalation injury (26.7 vs. 1.6%), burn size (TBSA, 36.3 vs. 15.8%), and full-thickness burn size (FULL, 19.8 vs. 6.5%) were higher in TIVA than in non-TIVA patients. Despite this, intraoperative pressor use was as common in TIVA as in non-TIVA cases (23.9 vs. 22.7%). CONCLUSIONS: TIVA was used in patients whose inhalation injury rate and TBSA were greater than those of non-TIVA patients. TIVA cases were not associated with increased hemodynamic instability. TIVA is a viable approach to general anesthesia in critically ill burn patients.
KEYWORDS: Total intravenous anesthesia (TIVA), burn, surgery
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636662/pdf/ijbt0003-0108.pdf



Manejo de la vía aérea en pacientes con cicatrices contráctiles postquemaduras mentoesternal y periorales


Managing difficult airway in patients with post-burn mentosternal and circumoral scar contractures
Tae-Hyung Han, Hana Teissler, Richard J Han, Joshua D Gaines, and Tho Qynh Nguyen
Int J Burns Trauma. 2012; 2(2): 80-85.
Abstract
Securing the airway is a crucial aspect during reconstructive surgeries of patients with extensive post-burn mentosternal scar contractures; however, the American Society of Anesthesiologists Difficult Airway Management Algorithm recommendation of initial direct laryngoscopy may not be appropriate for these complicated patients. Consequently, there is a significant risk for failure of intubation and airway emergency. We suggest that initial attempts at securing the airway be made with indirect laryngoscopy. Many airway techniques have been effectively used in burn patients, but the role of awake blind or fiberoptic bronchoscopy, although well established in the non-burn population, has yet to be evaluated in burn patients. We report a case series of successful management of difficult airways with fiberoptic bronchoscopy in patients with varying degrees of post-burn head and neck scar contractures.
Keywords: Burn airway, neck contracture, fiberoptic bronchoscopy, laryngeal mask airway

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462526/



Infiltración tumescente de lidocaína y adrenalina para cirugía de quemados

Tumescent infiltration of lidocaine and adrenaline for burn surgery.
Gümüs N.
Plastic, Reconstructive and Aesthetic Surgery Department, Cumhuriyet University Medical Faculty, Sivas, Turkeya.
Ann Burns Fire Disasters. 2011 Sep 30;24(3):144-8.
Abstract
Tumescent infiltration is a widely used type of regional anaesthesia for cutaneous surgery. This technique makes it possible to administer high doses of lidocaine and adrenaline within the safety limits, leading to reduction in pain and bleeding during the operation. In this study, tumescent infiltration of lidocaine and adrenaline was used in routine procedures of burn surgery such as escharectomy, debridement, tangential excision, and skin grafting. In 17 patients with scald and flame burns, tumescent infiltration was performed prior to surgical procedures under either general anaesthesia or intravenous sedation. After 15 minutes, escharectomy, debridement of necrotic tissues, tangential excision of the burned skin, removal of the granulation tissue, and harvesting of the skin graft were performed. No complications occurred. All vital signs remained within safety limits during the operations. Haemorrhage was minimal and the operations were thus performed easily and rapidly. During removal of granulation tissue, very little blood loss occurred so that both the excision of granulation tissue and skin grafting were accomplished rapidly because of the minimal need of severe haemostasis. The duration of surgery was considerably reduced. No haematoma or bruising developed after surgery. No blood transfusions were required as the decline in haematocrit levels was not more than 3%. Postoperative analgesia was excellent for the first 8 h, eliminating the need of additional measures. Tumescent infiltration of adrenaline and lidocaine is a simple, effective and safe technique which facilitates anaesthesia in large areas of the burned body surface and leads to less bleeding and easy surgical dissection and hydrodissection, allowing fast, easy and painless burn surgery.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3293232/pdf/Ann-Burns-and-Fire-Disasters-24-144.pdf




Atentamente
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org