What is the targeted Urine output for an adult that thought the fire needed a bit more lighter fluid?

How about the kid that got doused across the way from the fire? 

How would the targeted Urine output change if they both got struck by a bolt of lightening instead?

1) Adults: 0.5/kg/hr

2) Kids < 30 kg:  1 ml/kg/hr

3) High voltage electrical injury= 1-1.5 kg/hr in adults and kids.   (need to wash the myoglobin through)

True or False:

1) Burn pts have a decreased caloric requirement

2) Burn pts are often insulin resistant and hyperglycemic

3) Burn pts should be kept NPO for gut rest at least 5 days after the event.

1) False: Caloric requirements increase.  In a pt. w/ 40% burns the increase can be as much as 132%  There is typically an erosion of muscle d/t catabolic state. 

2) True

3) False:  NPO status should be kept to a minimum.  NPO status can result in a catabolic state.

If I have a confirmed Dobhoff feeding tube in the jejunum how long can enteral feedingsc continue prior to start of surgery? 

What if I am not sure about the feeding tube placement and I need to induce the patient?

1) Up until time of surgery

2) place an OG tube and empty stomach when in doubt.

These are nasty little buggers that develop in the duodenal mucosa after a burn.  They occur when there is a hyper perfusion and subsequent sloughing of the duodenal mucosa.

(Geez- and you thought lactose intolerance was bad)

In General, burn pts exhibit a ____1____ in albumin and _____2_______ in alpha 1 acid glycoprotein (AAG)

3) How does this affect the volume of distribution of drugs?

1) Decrease

2) Increase

3) Pharmacological effects are due primarily to free, unbound drugs.  Therefore if the drug binds to albumin (ie: benzos, salicylic acid, phenytoin) there is more drug available.  Conversely less drug is available if it binds to AAG (ie: lidocaine, meperdine, propranolol)

True or False:

1) Volume of distribution may be inc. or dec. based on the fluid status/shifting and degree of protein binding.

2)  An increase in blood flow to  the kidney and liver decreases the metabolism of some drugs

1) true

2) False: an increase in blood flow to kidneys and liver will generally increase the metabolism of free drugs.

There is no way around this laundry list. 

Therefore:  For Debridement and Grafting what is important to know as an anesthetist?

(8 things)

1) What is the TBSA burned?

2) when was the initial burn injury?  (Determines fluid status/ ooziness/ leakiness)

3) Has the pt. been to the OR before?

4) How much debridement/ grafting is planned?

5) Where are the burn sites?  Where are the donor sites (Need to plan to avoid hypothermia as best as possible)

6) History and Lab work (H+H, Protein level, Type and Cross?)

7) Where are your lines?  (Are they adequate?  Where are they going to be debriding? )

8) Where can you monitor your vital signs? (Gayle talked about those pin thingys you stick in the skin for ECG)

Since heat loss is a major concern and can occur quickly in burn pts, what should we do about it? 

1) Heat the room to > 28 degrees C  (Get a good scrim sweat going)

2) Use warming devices (IVF, BAER HUGGER)

3) Bag the pt or areas of pt if necessary

4) Ask OR team to cover areas that they are not working on

5)  Monitor temp centrally (esophageal)

1) You have a very fast OR team and a lot of debriding that is getting done.  What are you concerned with?

2) Why would you be somewhat concerned when the OR team is putting gauze on the pt after the debridement?

3) How much blood loss can I expect during a debridement?   Are blood loss calculations accurate?

1) Bleeding- Lots of it. 

2) Vasoconstrictor soaked gauze can increase BP and therefore may increase blood loss.  Can also increase the pts risk for MI or arrhythmias.  (Some places use thrombin soaked gauze)

3) 200-400 ml per 1% TBSA debrided

(Gayle says to T&C for 4-6 Units prior to debridement)

True or False:

1) Ketamine is often used in the Burn Unit and is an acceptable choice for a pt. who is hemodynamically unstable. 

2) Within the first 24 hours following a burn there is a decrease in the number of post junctional acetylcholine receptors. 

3) If you give succinylcholine to a burn victim afer the first 24 hours of injury you could kill them, if you will. 

4) Non-depolarizing muscle relaxants are safe to use however the dose required for effect is usually higher and must occur more often.

1) True (According to Gayle's notes)

2) False.  Post junctional acetylcholine receptors proliferate like jackrabbits.

3) True.  It has been associated with significant rises in serum potassium

4) True.

When does debridement need to stop? 

1) Core body temp < 35

2) Blood loss of >10 units

3) Coagulopathy has developed

4) > 2-3 hours in the OR

5) >20% of TBSA has been debrided.

Slide 35, BALLS!:

True or False:

1) This slide seems like an afterthought

2) Burn pts have an increase in narcotic requirements presumably d/t the activation of the endogenous opioid pathways during stress induced analgesia.

3) Intubated pts. are extubated after debridement

4) Debridement is a VERY painful procedure

5)Narcotics may be a useful adjunct in a pt. with hemodynamic instability.

All of these are True-  Except for #3. Have a nice day. 

Love,

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