Burn Debridement & Grafting (Acute / Late)
Patient phenotype
Acute burns — first OR within 24-72h for debridement. Patient: hypovolemic, hypermetabolic, possible inhalation injury, hyperkalemia risk. Late grafting weeks-months later: anemia, malnutrition, contracture, opioid tolerance.
Procedure
Excise eschar to viable tissue, harvest split-thickness skin grafts from donor sites, apply to wounds. Significant blood loss (~100-200 mL per 1% TBSA debrided). Multiple staged returns common.
Anesthetic plan
GETA. Massive crystalloid + blood products. Aggressive temperature management (highest hypothermia risk in OR). Multiple OR returns common. Avoid sux > 24h post-burn (hyperkalemic arrest).
Setup
- ·A-line — often through-burn (sterile prep + frequent recheck)
- ·Central line — internal jugular preferred (extremities often burned)
- ·Multiple large-bore PIVs (whatever skin survives)
- ·Type & cross 4-6 units PRBC, FFP, platelets available
- ·Cell saver
- ·Forced air warmer + fluid warmer + ambient temp 80°F+
- ·Foley + UOP > 1 mL/kg/hr target
- ·Albuterol nebulizer (for inhalation injury bronchospasm)
Biggest concerns by phase
Inhalation injury + airway edema
Carbonaceous sputum, facial burns, singed nasal hair, hoarse voice, stridor → inhalation injury. Airway edema progresses 24-48h post-burn. EARLY intubation (don't delay if any sign). Bronchoscopy assesses lower airway. CO toxicity: cherry-red skin not reliable, treat empirically with 100% O₂ if any concern.
Sux contraindicated > 24h post-burn
Up-regulated extrajunctional ACh receptors after 24h → massive K release with sux → hyperkalemic arrest. Use rocuronium 1.2 mg/kg for RSI (with sugammadex backup). Caveat: burn patients also need increased non-depolarizing NMB doses (resistance).
Difficult IV access through burned skin
Plan ahead. IO access acceptable for emergency. Central line via IJ if all extremities burned. Avoid sites with eschar or compromised perfusion.
Massive blood loss + 1:1:1 transfusion
100-200 mL blood loss per 1% TBSA debrided. A 30% TBSA debridement = 3-6 L blood loss. Activate MTP early. Goal: maintain Hgb > 8, INR < 1.5, fibrinogen > 200, platelets > 75. TXA 1g + 1g infusion.
Hypothermia — single biggest threat
Burned skin = no thermoregulation. Open wound + irrigation = catastrophic heat loss. Aggressive prevention: ambient temp 80-85°F, all fluids warmed, all skin covered when not surgical site, BAIR + warming blankets. Below 35°C, coagulation collapses.
ICU intubated — hypermetabolic state, infection, repeat returns
Burn patients have 2-3× normal metabolic rate for weeks. Recurrent infections common (lines, wounds). Multiple OR returns expected (q48-72h for large burns). Direct to ICU intubated. Pain control: high opioid + ketamine + multimodal.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
30% TBSA burn patient, Day 3 post-injury, going for first debridement. ETT in place from initial inhalation injury. Pre-op K is 5.4, last dose roc 6 hours ago. You need an intubation dose for this case. What do you use and why?
What an examiner probes for
- ▹Sux ABSOLUTELY contraindicated > 24h post-burn (hyperkalemic arrest)
- ▹Roc 1.2 mg/kg with sugammadex available
- ▹Anticipate increased dose needs (resistance to non-depolarizing NMB in burn patient)
- ▹Plan for maintenance — sustained NMB likely needed for case
Sources
- Miller's Ch 81 (burns)
- ABA Practice Guidelines
- Sheridan Burn Care
Anatomy reference
Sourced reference images. 4 matches for "skin integumentary".
Browse the full image library →
