What is the recommended approach to anesthesia for burn patients?

Anesthesia for Burn Patients

Multimodal analgesia with titrated intravenous ketamine combined with short-acting opioids forms the cornerstone of anesthesia for burn patients, with all medications carefully titrated using validated pain assessment scales to account for the altered pharmacokinetics caused by hypermetabolism and capillary leakage. 1

Pain Management Strategy

Pharmacological Approach

Primary analgesic regimen:

• Titrated IV ketamine should be combined with other analgesics for severe burn-induced pain, as it effectively reduces morphine consumption and maintains spontaneous breathing during procedures 1, 2
• Short-acting opioids (fentanyl, methadone) are the preferred opioid agents for burn-induced pain and dressing changes 1
• All analgesic medications must be titrated based on validated comfort and analgesia assessment scales to prevent under- and overdosing 1

Critical pharmacokinetic consideration:

• Burn injuries trigger inflammation, hypermetabolism, and capillary leakage leading to hypovolemia, which increases the risk of adverse effects from analgesics and sedatives 1
• Drug titration is essential because burn patients demonstrate altered pharmacokinetic and pharmacodynamic responses due to altered hemodynamics, protein binding, increased extracellular fluid volume, and possible changes in glomerular filtration 3

Anesthetic Options by Clinical Context

For dressing changes and wound care:

• Short-acting opioids combined with ketamine are the best drugs for managing burn-induced pain during brief procedures 1
• Inhaled nitrous oxide can be useful, especially when no intravenous access is available 1
• For highly painful injuries or procedures, general anesthesia is an effective option 1
• Burn wound care should be performed in a clean environment and will mostly require deep analgesia or general anesthesia 1

For major burn surgery:

• Total intravenous anesthesia (TIVA) is a viable approach for critically ill burn patients undergoing major operations 4
• Common TIVA regimens include ketamine-methadone, ketamine-fentanyl, or ketamine-methadone-fentanyl combinations, with doses often exceeding those used in non-burn patients 4
• TIVA is not associated with increased hemodynamic instability despite being used in more critically ill patients 4

Adjunctive Therapies

Non-pharmacological techniques:

• Virtual reality or hypnosis techniques may reduce pain intensity and patient anxiety when the patient is stable and conditions permit 1
• Cooling limited burned surfaces (TBSA <20% in adults, <10% in children) in the absence of shock can improve pain control and limit burn deepening 1, 5
• Covering burns with fatty substances (e.g., Vaseline and dressings) may improve pain control 1

Regional anesthesia:

• Locoregional anesthesia techniques may be used in burn patients when applicable 1

Critical Safety Considerations

Airway Management

• At least one individual capable of establishing a patent airway and positive pressure ventilation must always be present whenever analgo-sedation is administered 3
• Ketamine allows patients to maintain spontaneous breathing, which is particularly important during procedures where patients are continuously turned 3

Monitoring Requirements

• Oxygen should be routinely delivered during sedation 3
• Blood pressure and continuous ECG monitoring should be carried out whenever possible, even during bathing or other procedures 3
• Continuous pulse oximetry is essential 3

Neuromuscular Blockade

• If rocuronium is used for rapid-sequence induction, doses up to 1.2 mg/kg may be required to overcome resistance and provide good intubating conditions in burn patients 6
• Onset time is prolonged in burned patients (86 seconds vs. 57 seconds with 1.2 mg/kg), but recovery profiles are significantly shorter 6

Common Pitfalls to Avoid

Medication dosing errors:

• Alpha-2 receptor agonists (e.g., dexmedetomidine) should be avoided in the acute phase due to their hemodynamic effects 1
• Insufficient evidence exists for lidocaine use in burn patients 1
• Standard dosing may be inadequate due to altered pharmacokinetics—titrate to effect rather than using fixed doses 1, 3

Procedural safety:

• Sedative and analgesic agents should always be administered by designated trained practitioners, not by the person performing the procedure 3
• Resuscitation must be well-conducted before wound care, as wound dressing is not a priority over hemodynamic stability 1

Pain assessment:

• Written protocols for pain management and regular assessment should be used 1
• Failure to recognize and treat pain adequately may result in post-traumatic stress disorder, major depression, or delirium 3