The management of thermally injured patients is challenging. Effective treatment is mandatory at the scene of the accident, in the resuscitation bay, the operating room (OR), and the intensive care unit (ICU). Anesthesiologists trained in resuscitation, intraoperative management, and postoperative support are essential members of the burn patient management care team. As our surgical colleagues concentrate on surgical diagnosis and therapy, the anesthesiologist must also provide anesthesia and preserve vital organ functions. Severe burn injuries, defined as burns exceeding 40% of total body surface area (TBSA), occur in approximately 35,000 patients annually. In 15 to 30% of fire victims, smoke inhalation and carbon monoxide intoxication complicate the burn injury. Risk factors associated with mortality include: • Age greater than 60 years • More than 40% of body surface area (BSA) burned • Presence of inhalation injury Mortality can be predicted as 0.3%, 3%, 33%, or approximately 90%, depending on whether zero, one, two, or three of these risk factors are present, respectively. Pathophysiology A thorough knowledge of the pathophysiologic changes that accompany burn injuries facilitates anesthetic management during the three phases of burn injury: 1. Early resuscitation 2. Debridement and grafting 3. Reconstructive phases The pathophysiology of thermal injury is related to the initial distribution of heat within the skin. Most burns involve only the epidermis (first-degree burns) or portions of the dermis (second-degree burns), but, with prolonged exposure, burns may involve the entire dermis (third-degree burns) or extend beneath into fat, muscle, and bone. Burn injuries induce a systemic hypermetabolic response, resulting in inflammation, immune system compromise, catabolism, and endocrine dysfunction. Early excision and grafting have been demonstrated to reduce inflammation and decrease the risks of infection, wound sepsis, and multi-organ failure.
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