BJA Education, xxx(xxx): xxx (xxxx)

doi: 10.1016/j.bjae.2022.01.001
Advance Access Publication Date: XXX

Matrix codes: 1B04,

1D01, 1D02, 2A02,
3A10, 3C00, 3H00

Major burns: part 2. Anaesthesia, intensive care and

pain management
C. McGovern1,2, K. Puxty1,2 and L. Paton1,*
1
Glasgow Royal Infirmary, Glasgow, UK and 2University of Glasgow, Glasgow, UK
*Corresponding author: [email protected]

Keywords: anaesthesia; burns; critical care; pain

Learning objectives Key points

By reading this article you should be able to:
Involvement of the multidisciplinary burns team

Describe the main challenges of caring for a pa- is vital for the care of patients with major burns.
tient with major burns in the operating theatre or
Thermoregulation, blood loss and coagulopathy
ICU. are key considerations for the anaesthetist during

Explain the ways for optimising intravenous fluid surgery for major burns.
therapy to avoid under- and over-resuscitation.
The Parkland formula should be used to guide

Outline how to recognise and manage infectious resuscitation and fluids titrated to urine output,
complications in patients with major burns. haemodynamic and laboratory variables.

Illustrate the pharmacological and non-
Human albumin solution, given in addition to
pharmacological techniques available to miti- crystalloids, may reduce fluid requirements.
gate the hypermetabolic response to burn injury.
The hypermetabolic response to major burns can
be attenuated by early excision, appropriate
nutrition and specific pharmacotherapy.
As a result of improvements in the care of patients with major
burns, increasing numbers of patients are surviving more
may have profound physiological, psychological, functional
severe injuries.1 Many require a protracted stay in intensive
and social problems.
care, numerous operative interventions and comprehensive
The initial assessment and treatment of patients with
rehabilitation. Engagement of a multidisciplinary burns team
major burns has been covered in a recent accompanying
is necessary to help maximise quality of life for survivors who
article.2 This article focuses on the ongoing care of an adult
patient with a major burn of more than 15% total body surface
area (TBSA) in both the operating theatre and the ICU. Previ-
ous articles in this journal describe the management of major
Christopher McGovern MRCEM FRCA FFICM is a specialty trainee burns in paediatric patients and smoke inhalation.3,4
in anaesthesia and intensive care medicine and a clinical research
fellow at the University of Glasgow.
Anaesthesia and burn surgery
Kathryn Puxty MD MRCP FRCA FFICM is a consultant in anaes-
Since the 1940s it has been recognised that early excision of
thesia and intensive care at Glasgow Royal Infirmary. She is an
burn eschar improves mortality.5 This is likely to result from
honorary clinical associate professor at the University of Glasgow
removal of necrotic tissue that can both fuel the intense in-
and a CSO career research fellow.
flammatory response and act as a culture medium for path-
Lia Paton BMedSci (Hons) FRCA FFICM is a consultant in anaes- ogens. Patients often undergo surgical excision of burnt tissue
thesia and intensive care and lead clinician for burns intensive care in the first day or two after the injury. Some patients with full
at Glasgow Royal Infirmary, a tertiary referral centre for burns in thickness burns will require more immediate decompressive
Scotland. She is also chair of the Care of Burns in Scotland (COBIS) surgery such as escharotomy or fasciotomy. However, many
data group.

Accepted: 8 January 2022

© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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Major burns, part 2

will undergo multiple subsequent operations including tem- may also be difficult, and suitable sites for i.v. access and
porising cadaveric autografts, xenografts (such as pig skin) or direct arterial monitoring may be limited.
synthetic dermal substitutes until skin coverage with auto- It is mandatory to monitor the patient’s core temperature.
grafts is possible (using unburned patient donor skin). Later Methods to minimise heat loss include minimising exposure,
elective surgical procedures are frequently required to help using forced air warmers and heat lamps, humidifying
restore function and improve cosmesis. anaesthetic gases, infusing warmed i.v. fluids and maintain-
ing an ambient temperature in theatre of 28e33 C.
Care should be taken to assess a patient’s ventilatory re-
Location of surgery quirements preoperatively and lung protective ventilation
Burns surgery should be carried out in a dedicated burns should be continued throughout the intraoperative period.
operating theatre, ideally in close proximity to intensive care Patients who have also suffered an inhalation injury may have
facilities. Theatre personnel should have appropriate training, increased requirements for oxygen and PEEP. For these pa-
experience and access to specialist equipment. It is vital that tients, it is particularly important to avoid alveolar der-
the theatre can be appropriately warmed in order to reduce ecruitment with the loss of PEEP during transfer to a transport
heat loss. Procedures such as dressing changes may be carried or theatre ventilator. As the hypermetabolic response suffered
out under sedation led by an anaesthetist, but all the neces- by patients with burns leads to increased oxygen consump-
sary resources to convert to general anaesthesia should be tion and carbon dioxide production, higher than expected
immediately available. oxygen concentrations and minute volumes may be required.
Blood loss can be as much as 3.4% of total blood volume for
each per cent TBSA excised.6 Bleeding risks are increased in
Preoperative assessment patients with infected burn tissue, deeper thickness burns
and by prolonged operative time. Bleeding risks may be
Assessment of a patient for burn surgery should include
reduced by using limb tourniquets on extremity burns, topical
knowledge of the extent of the burn, associated injuries and
adrenaline or compression bandages. The use of near-patient
details of the planned surgery, including positioning needed
coagulation studies such as thromboelastography may be
and estimated blood loss. Coagulopathy may be present,
superior to standard laboratory-based tests in detecting
driven by endothelial injury and the inflammatory cascade,
coagulation abnormalities and may be of value to direct blood
often exacerbated by secondary infection. Its extent can vary
product use intraoperatively.7
from subclinical changes to fulminant disseminated intra-
vascular coagulation (DIC). Therefore, the need for blood
products should be anticipated early.
Given the large volumes of i.v. fluids often required and the General vs regional anaesthesia
potential for associated renal injury, a thorough assessment Most patients with major burn injuries will require general
of circulating volume status and electrolyte abnormalities anaesthesia for surgical interventions. However, regional
should also be made. Nutritional support should generally be anaesthesia, either alone or in combination with general
continued throughout the operative period in patients who anaesthesia, may be suitable. Careful evaluation is required
have been mechanically ventilated before surgery, and fasting before performing neuraxial anaesthesia because of the
times kept to a minimum in those requiring airway increased incidence of coagulopathy and infection in this
intervention. patient group.
Airway assessment should include clinical examination
and a careful review of previous anaesthetics. Although me-
chanical ventilation may have already been established Intensive care management
before transfer to the operating theatre, particular care is
required to prevent accidental extubation, especially in pa- Fluid management
tients with airway burns or inhalation injuries. Formation of a Appropriate resuscitation with fluids is critical in the first
tracheostomy may be indicated for various reasons and is 24e48 h after a burn injury. Under-resuscitation may lead to
commonly required for patients with complex facial burns in impaired tissue perfusion, end organ damage and extension
order to maintain skin health around the mouth and nose. In of burn depth. However, giving excessive fluids is also harm-
addition, although burns involving the face or neck may not ful; risks include electrolyte disturbances such as hypona-
present any airway difficulties initially, subsequent contrac- traemia, exacerbation of tissue oedema, pulmonary and
tures may severely limit neck extension and mouth opening. cerebral oedema, and abdominal and limb compartment
Advanced techniques such as awake fibreoptic intubation syndromes.
may be indicated. A difficult airway trolley with equipment for The Parkland formula remains the most commonly used
emergency front of neck access should always be immediately tool to calculate fluid requirements. Concerns have been
available. raised that it may overestimate the volume needed, prompt-
ing bodies such as the American Burn Association to recom-
mend less than 4 ml kg1 TBSA1.8 However, we advocate
Intraoperative management
using 4 ml kg1 TBSA1 for initial calculations and then per-
Monitoring can prove challenging. Electrocardiogram elec- forming regular clinical reviews to permit escalation or de-
trodes sometimes require sutures or skin clips for reliable escalation of fluid input based on individual patient physi-
contact. Pulse oximetry and blood pressure cuff positioning ology, as opposed to rigidly adhering to any one formula.

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 Major burns, part 2

Use Parkland formula (2-4 ml kg–1 TBSA–1)

for initial fluid rates using ACTUAL body Calculate urine output targets using
weight IDEAL body weight

Fluid challenge 250 ml balanced

crystalloid up to 3x h–1. Consider
< 0.5 ml kg–1 h–1 noradrenaline if hypotensive.
Increase baseline fluid rate by 10%. *

CHECK
HOURLY 0.5-1 ml kg–1 h–1 Continue current fluid rate
URINE
VOLUMES

Use ml kg–1 of
IDEAL body 1-2 ml kg–1 h–1 REDUCE fluid rate by 10%
weight

>2 ml kg–1 h–1 REDUCE fluid rate by 25%

*Persisting low urine output may be due to problem other than under-resuscitation.
Reassess patient using:
• Peripheral perfusion, mean arterial pressure, pulse pressure variation
• Blood lactate, haematocrit, base excess
• Cardiac output monitor
• Measure intra-abdominal pressures

At 12 h after injury, if fluid volumes will exceed 6 ml kg–1 TBSA–1 consider

“Colloid Rescue”:
Replace ONE THIRD of crystalloid regimen with 4.5% human albumin solution

Fig 1 Resuscitation protocol for resuscitation with i.v. fluids in the adult patient with burns (adapted with permission from Care of burns in Scotland [COBIS]).

Goal-directed fluid therapy therapy. The additional use of cardiac output monitoring to
The most common and easy method of ensuring appropriate guide fluid delivery in patients with major burns has
fluid resuscitation is by targeting an hourly urine output of demonstrated improvements in cardiac output, oxygen de-
0.5e1 ml kg1 ideal body weight. Failure to meet this target livery and organ dysfunction, but a mortality benefit has not
should prompt reassessment and adjustment of fluid delivery been identified.9
as detailed in Figure 1.
However, an inadequate urine output is not always caused
Choice of fluid
by volume depletion. Renal failure from acute tubular necrosis
or rhabdomyolysis can result in oliguria, as can increased Balanced crystalloids such as Hartmann’s solution are the
anti-diuretic hormone release in response to injury. Other mainstay of fluid resuscitation in major burn injuries. Their
causes such as vasoplegia, low cardiac output and abdominal use, when compared with 0.9% saline, has been demonstrated
compartment syndrome should also be considered. to reduce the incidence of significant electrolyte disturbances
Conversely, urine volumes in excess of targeted values should such as hyperchloraemic metabolic acidosis.10 The use of
prompt a reduction in the volumes of fluids given, mitigating colloids such as human albumin solution in combination with
against the phenomenon of ‘fluid creep’, whereby more fluid crystalloids may reduce overall fluid volume requirements,
than required is given. mitigate against ‘fluid creep’ and lessen increases in intra-
Peripheral perfusion, serum lactate, acidebase balance abdominal pressures compared with crystalloids alone.9 We
and haematocrit should also be used to help guide fluid recommend the addition of 4.5% human albumin solution if

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Major burns, part 2

Table 1 Formulae to calculate daily caloric requirements (kcal day1) in patients with burn injuries. TBSA, total body surface area.

Formula Calculation (kcal day¡1) Comments

HarriseBenedict Men: 66.5 þ 13.75 (weight in kg) þ 5 Multiplied by factor determined by burn
(height in cm) e 6.76 (age in yrs) size:
Women: 66 þ 9.56 (weight in kg) þ 1.85 <20% TBSA 1.5
(height in cm) e 4.68 (age in yrs) 20e40% TBSA 1.6
>40% TBSA 1.7

Toronto e4343 þ 10.5 (%TBSA) þ 0.23 (caloric Can be adjusted by activity factor:
intake in last 24 h) þ 0.84 (Harris Confined to bed: 1.2
eBenedict unadjusted) þ 114 (temp in  C) Minimal ambulation: 1.3
e 4.5 (days after injury) Moderate activity: 1.4

Curreri 25 (weight in kg) þ 40 (%TBSA) Can overestimate caloric needs

Hangang 867.542e5.546 (age in yrs) þ 13.297 Adjusted for each post-burn day (PBD)
(weight in kg) þ 4.879 (% TBSA) e 9.844 and if mechanically ventilated (V¼1 if
(PBD) þ 500.612 (V) ventilated, V¼0 if not)

fluid resuscitation volumes in the first 24 h are projected to be of stay, improve wound healing and reduce wound in-
greater than 6 ml kg1 %TBSA1 (Fig. 1). This technique of fections.14 The British Burn Association (BBA) national stan-
‘colloid rescue’ should be continued until 48 h after the burn dards state15:
injury.
(i) Enteral nutrition should be started as soon as possible in
major burns, ideally within 6e12 h after the injury.
Thermoregulation (ii) Total body weight loss should not exceed 10% of the pa-
tient’s weight at admission.
Major burn injuries are associated with thermodysregulation,
with an initial propensity to hypothermia driven by heat and
fluid loss from the burn wounds themselves. Steps to reduce Route of nutrition
heat loss during the initial stages of resuscitation are detailed As with most critically ill patients, the enteral route is
in Part 1.2 The principles of maintaining an adequate core preferred. Postpyloric feeding may be required if gastric stasis
temperature in the operating theatre also apply to the inten- is present and impairing calorie delivery. Postpyloric feeding
sive care environment. may also help reduce the risk of aspiration, especially in pa-
Most patients with major burns will subsequently develop tients requiring multiple interventions under general anaes-
a raised core temperature. This reflects altering of the hypo- thesia. Parenteral nutrition is rarely required, but when used,
thalamic setpoint for thermoregulation by pyrogens such as caution should be exercised because of the associated risks
interleukin-1 (IL-1) and tumour necrosis factor.11,12 More including infection, overfeeding and erratic blood glucose
profound hyperthermia, with temperatures exceeding 40 C, control.
can occasionally occur and may lead to multiorgan failure.
Steps to address potentially harmful hyperthermia should be Caloric requirements
taken in patients with a core temperature above 39.5 C. The aim of nutritional support in patients with major burns is
Techniques include debulking dressings, giving antipyretics to meet the substantially increased caloric requirements in
such as paracetamol, applying ice to non-burned areas, infu- these patients while avoiding harmful overfeeding. The
sion of cooled i.v. fluids, and irrigating the bladder and complications of overfeeding include hyperglycaemia,
stomach with cold fluids. More invasive approaches such as hypertriglyceridaemia, hepatic steatosis, hypercapnoea and
intravascular heat exchange catheters or extracorporeal cir- prolonged duration of mechanical ventilation.14 Various
cuits may also need to be considered. methods have been used to assess caloric needs. The most
accurate method is indirect calorimetry, but this remains
mainly a research tool. In lieu of this, various formulae have
Nutrition
been devised to guide clinicians (Table 1).14,16 Such formulae
Basal metabolic rate can increase significantly after a burn may under- or overestimate requirements at different times
injury, more than doubling in patients with burns >40% during a patient’s admission. Given the complexities of
TBSA.13 If not addressed, this can result in loss of lean body providing optimum nutritional support, specialist input from
mass, immune compromise and impaired healing. There is a a dietician within the burns team is essential.
direct correlation between loss of lean body mass and adverse
events, including infectious complications and death.14 Macronutrients
The three main macronutrients e carbohydrates, proteins and
Timing of nutritional support lipids e provide substrates for adenosine triphosphate (ATP)
Starting enteral nutrition in the hours immediately after biosynthesis, wound repair, immune function and mainte-
injury has been shown to have beneficial effects on stress nance of lean body mass. Carbohydrates are generally the
hormones, improve gut integrity, reduce intensive care length preferred energy source, preventing a reliance on muscle

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 Major burns, part 2

proteolysis. However, relying solely on carbohydrates to meet

caloric needs would result in hyperglycaemia caused by Table 2 Long-term effects of burn injuries.25
glucose delivery exceeding the rate at which it can be used. A
relative insulin resistance, commonly observed in critically ill Organ system Effects
patients, may also exacerbate hyperglycaemia. Glucose
Immune Increased incidence of respiratory
should be limited to 55% of total energy requirements and infections (influenza, pneumonia)
hyperglycaemia managed with supplemental insulin as Increased hospital admissions
required.16 with infective diseases
Excessive lipid delivery can result in accumulation in the Increased mortality from
liver and impaired immune function.14 Therefore, lipids infections
should account for no more than 30% of energy delivered,
Cardiovascular Increased risk of ischaemic heart
although some centres recommend a maximum of 15%.14,16 disease, hypertension, heart
Given the potentially high sedation requirements of these failure and stroke
patients, the lipid content of propofol should also be accoun- Reduced exercise tolerance
ted for. Myocardial fibrosis
Protein plays a crucial role in wound repair and mainte-
Gastrointestinal Increased risk of disease of
nance of lean body mass. Increasing protein intake to supra-
alimentary tract, gallbladder,
physiological values does not prevent catabolism of existing biliary tract and pancreas
protein stores but does prevent a negative nitrogen balance Increased hospital admissions
and improve protein synthesis. Protein should be delivered at with diabetes mellitus
1.5e2 g kg1 day1 in adults. This often requires protein-
enriched feeds prescribed under the guidance of a dietetic Musculoskeletal Increased fracture risk
Joint pain and stiffness
team.16
Reduced mobility
Increased hospital admissions
with musculoskeletal disorders
Micronutrients
Reserves of trace elements including copper, selenium, zinc Central Nervous Increased hospital admissions
and vitamins B, C, D and E may become depleted because of with epilepsy, migraine and nerve
the intense inflammatory response, exudative losses and problems
haemodilution resulting from resuscitation with i.v. fluids.17
Micronutrients are essential for antioxidant defences, Miscellaneous Increased all-cause mortality
Increased cancer risk (perhaps
wound healing and immune function. Adequate supplemen-
worse in females)
tation often requires supraphysiological doses to be given,
often parenterally because enteral absorption may be
limited.16 Early replacement of these elements may reduce
infectious complications, improve wound healing and reduce
intensive care length of stay.17 (iv) Thrombocytopenia <100109 L1 (>3 days after initial
resuscitation)
(v) Hyperglycaemia >11.1 mmol L1 or insulin infusion dose
Infection requirement >7 units h1
(vi) Intolerance of enteral feed
The loss of skin, the primary barrier to infection, coupled with
relative immunosuppression in patients with major burns With such difficulty in relying on clinical signs and tradi-
lead to an increased risk of infectious complications. In- tional biomarkers such as C-reactive protein (CRP), other
fections are an important contributor to the high morbidity markers such as procalcitonin (PCT) may have better
and mortality rates after major burns, accounting for an discriminatory capacity in diagnosing sepsis in patients with
estimated 42e65% of deaths after burn injury.18 major burns.20 There is also increasing interest in the use of
genomic variants, cytokine profiles and epigenetic markers.21
Patients with infections should be treated with appropriate
Burn wound colonisation and infection antibiotics, ideally as advised by the medical microbiology
Patients can become colonised with multiple, often resistant, team and based on colonising organisms. Surgical debride-
organisms.18 Such colonisation occurs with low bacterial ment may be required. Patients with a delayed presentation or
concentrations on the surface of wounds, without surround- delayed excision of burn wounds are at highest risk of infec-
ing erythema or cellulitis. In contrast, invasive wound infec- tive complications.
tion is characterised by cellulitis of surrounding healthy
tissue, extension of existing burn depth, eschar separation or
Common pathogens
necrosis. Patients may develop worsening pyrexia or raised
The most common pathogens, particularly early in the
inflammatory markers, but this can be difficult to distinguish
admission, are Gram-positive bacteria such as Staphylococcus
from the inflammatory response after burns. Consequently,
aureus, Streptococcus and Enterococcus species. Gram-negative
specific criteria for the diagnosis of sepsis in patients with
bacteria such as Pseudomonas aeruginosa can translocate
burns have been proposed19:
from the gastrointestinal tract or the environment and thrive
(i) Temperature >39 C or <36.5 C in the moist environment of a burn wound. Infections from
(ii) Heart rate >110 beats min1 Pseudomonas will have a typically green/yellow colour and foul
(iii) Ventilatory frequency >25 bpm (or minute ventilation smell and can lead to invasive infection with necrosis. Other
>12 L min1 if invasively ventilated) Gram-negative pathogens including Acinetobacter, Escherichia

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Major burns, part 2

coli and Klebsiella can also cause invasive infections. Multi- for use in women and children. Oxandrolone has been used
resistant strains of pathogens including P. aeruginosa, Acine- from around Day 5 after burns, at a dose of 10 mg enterally
tobacter species and vancomycin-resistant Enterococcus (VRE) twice daily in patients with 30% TBSA burns, to minimise
are an increasing concern. Recognised risk factors include the weight loss, improve urinary nitrogen balance, increase
use of broad-spectrum antibiotics, colonisation at hospital muscle strength and reduce healing time. Some studies have
admission, need for escharotomy, prolonged hospital or shown benefits such as reduced ICU and hospital duration of
intensive care stay and multiple surgical procedures.22 Fungal stay, maintained lean body mass and improved whole body
colonisation and invasive fungal infections are also significant mass.29 Adverse events include hepatic injury with increased
problems. Fungal wound infection is independently associ- liver transaminases, renal injury and skin complications such
ated with increased mortality.23 Candida albicans is the most as cellulitis.
common pathogen, although Aspergillus and non-albicans
Candida such as Candida tropicalis and Candida krusei are
becoming more common.22 Regular clinical review and sam-
Pain management
pling of wounds and other potential sources of colonisation The pain experienced from a burn injury can be excruciating
and infection should guide antimicrobial therapy. and is often difficult to manage. Some studies suggest higher
pain scores during hospital admission are associated with
Toxic shock syndromes poorer long-term outcomes such as increased mental health
Toxin-producing strains of S. aureus can cause toxic shock problems.30 Given the complexities and challenges of effective
syndrome (TSS). Streptococcal toxic shock syndrome (STSS), pain management, a specialist pain service should be an in-
caused by group A Streptococcus, has a similar presentation. In tegral part of the burns team.15
addition to the non-specific clinical signs suggestive of
infection described previously, patients with TSS or STSS may Types of pain
also exhibit a diffuse macular rash, vomiting and diarrhoea,
thrombocytopenia, lymphopenia and deranged liver function Although the burn injury is usually the most significant source
tests. In addition to standard management of infections, an- of pain, there are many other causes. These include pain from
tibiotics that directly reduce exotoxin production, such as associated injuries, tracheal tubes, invasive lines and cathe-
clindamycin and linezolid, should be considered. The use of ters, skin autograft donor sites, pressure areas and in-
i.v. immunoglobulin has also been reported.24 terventions including position changes. Clinicians should
adopt a structured approach to management of acute burns
pain, addressing the three main types of pain: background,
Hypermetabolic and inflammatory response breakthrough and procedural pain.
Although changes in the metabolic and inflammatory
response are most pronounced in the acute phase, some Background pain
changes can persist for several years after a burn injury has Patients will experience a degree of persistent pain after a
healed.25 Changes include: burn injury and multimodal analgesia should be prescribed to
maintain adequate control. Infusions should be titrated to a
(i) Increased resting energy expenditure
targeted effect, maximising clinical benefit while avoiding
(ii) Increased serum and urine cortisol and catecholamines
unwanted adverse effects. Multiple methods for pain assess-
(iii) Increased cytokines including IL-6, IL-8 and granulocyte
ment exist including the VAS, designed for cooperative and
colony-stimulating factor (G-CSF)
communicative patients, and the Critical Care Pain Observa-
These persisting metabolic, inflammatory and immune tion Tool (CPOT) for use in the ICU.31 Non-pharmacological
changes can result in an increased risk of developing later measures such as appropriate dressings, comfortable posi-
problems (Table 2).26 Appropriate skin closure, nutritional tioning, cutaneous stimulation, acupuncture and techniques
support and analgesia are fundamental to mitigating this such as cognitive behavioural therapy and music therapy may
response. Several therapies have been proposed, some of also help alleviate this form of pain.
which are discussed further.
Breakthrough pain
Beta-blockers Breakthrough pain occurs on top of well-controlled back-
Beta-adrenergic blockade with drugs, such as propranolol, ground pain, either as an exacerbation of background pain or
suppress the catabolic effects of a burn by reducing energy originating from another source. This can be evoked, spon-
expenditure, limiting insulin resistance, preventing muscle taneous, predictable or unpredictable. It can be managed with
wasting and acting as anti-inflammatory agents. However, boluses of rapid-acting agents, increases in the rate of opioid
they must be used with caution in intensive care because of infusions or, if predictable, anticipatory doses of longer-acting
the risk of cardiovascular instability. A recent systematic re- agents.
view of the use of beta-blockers in patients with major burns
showed no benefit in terms of mortality, length of hospital Procedural pain
stay or incidence of sepsis.27 However, other studies have Procedural interventions include dressing changes and mobi-
demonstrated improved wound healing and reduced muscle lisation. Analgesic interventions should be timed appropri-
catabolism.28 ately to gain the maximum benefit from the agent being used.
Appropriate agents include opioid boluses, inhaled agents
Oxandrolone including nitrous oxide and methoxyflurane or analgosedative
Oxandrolone is an androgen receptor agonist, which stimu- agents such as ketamine. Other non-pharmacological
lates protein synthesis and muscle growth with much less methods may be beneficial, including hypnosis, virtual reality
virilising activity than testosterone, making it more suitable systems and other distraction techniques.

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 Major burns, part 2

Pharmacological management in survivors of major burn injuries, regardless of whether or

not they were managed in the ICU. Patients with major burns
Opioids
often have a prolonged hospital admission, numerous inva-
Opioids remain the mainstay of pain management in burn
sive procedures, multiple risk factors for developing delirium
injuries. The choice of opioid and method of delivery will
and significant pain issues. Furthermore, the event causing
depend on local preferences and patient factors including
the burn injury is frequently distressing.
renal function and conscious level. Patient-controlled anal-
Psychological support staff should form part of the multi-
gesia (PCA) is commonly used but relies on a conscious and
disciplinary team. Routine psychological assessment is
alert patient. Patients with significant burn injuries often
advised and robust care pathways should be in place in order
require large doses of opioids. Adverse effects include ileus,
to provide help and support to burn victims and their families.
respiratory depression, delirium, hypotension and potentially
This should include access to support groups, charities,
dependence. Because of this, a multimodal analgesic
websites and opportunities for peer support.15 Early psycho-
approach incorporating advice from a pain specialist is
social screening may help identify patients at the highest risk
advised.
of developing problems after burn injury, allowing prompt
intervention to address the psychological, emotional and so-
Non-steroidal anti-inflammatory drugs
cial challenges these patients may face.
Non-steroidal anti-inflammatory drugs such as ibuprofen and
diclofenac are infrequently used in critically ill patients
because of the potential risks of gastrointestinal haemorrhage Conclusions
and renal impairment. Although they may be of benefit in
As a result of vast improvements in burn care in recent de-
selected patients, they should be used with caution.
cades, clinicians are now responsible for managing patients
who have suffered burn injuries of increasing severity and
Ketamine
complexity. It is challenging to provide high-quality anaes-
Ketamine is an N-methyl-D-aspartate (NMDA) receptor
thetic and intensive care. These patients often require
antagonist with potent analgesic effects. Ketamine can be
numerous and complex surgical interventions. Areas that
given as an i.v. infusion, often to reduce opioid requirements,
require special focus include airway management, manage-
or in sedative or anaesthetic doses for painful interventions.
ment of blood and fluid loss, thermoregulation and over-
Ketamine may also have a role in preventing the development
coming monitoring difficulties. Patients who have suffered
of neuropathic pain and has been shown to reduce secondary
major burns are also at high risk of infection, excessive
hyperalgesia and ‘wind-up’ phenomenon in healthy
catabolism, significant pain and psychological distress, all of
volunteers.32
which are associated with adverse long-term consequences.
Managing this myriad of complex issues requires expert input
Gabapentinoids from a wide multidisciplinary team.
Gabapentin and pregabalin have been used in the manage-
ment of burn pain and pruritus, both acutely and in those who
develop chronic symptoms. The evidence suggesting benefit Acknowledgements
from these drugs is mainly from observational studies, which
The authors thank Drs Martin Hughes and Richard Cowan of
demonstrated improved pain scores and reduced opioid con-
Glasgow Royal Infirmary and Jamie Nimmo at Care of Burns in
sumption.33 However, given the increasing evidence of harm
Scotland (COBIS) for permission to reproduce the i.v. fluids
from dependence, abuse and overdose, they should be used
protocol, and Katrina Dalgarno, specialist dietician in inten-
with caution, especially in patients with a history of alcohol or
sive care and surgery, for guidance in writing the section on
drug misuse.34
nutrition.

Dexmedetomidine
Dexmedetomidine is a highly selective a2 receptor agonist Declaration of interests
with both analgesic and sedative effects. It can be used in the
The authors declare that they have no conflicts of interest.
ICU as part of an analgosedative regimen, in combination
general anaesthesia, as a sedative for painful procedures and
also as an adjunct in PCA. Common adverse effects of dex- MCQs
medetomidine are bradycardia and hypotension. As recent
studies have highlighted the risk of pyrexia associated with The associated MCQs (to support CME/CPD activity) will be
dexmedetomidine use, caution is advised in the context of accessible at www.bjaed.org/cme/home by subscribers to BJA
hypermetabolism after burns.35 Education.

Psychological sequelae of burn injuries References

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Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en febrero 23, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
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239e43 1118e28

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Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en febrero 23, 2022. Para
uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.