AIRWAY MANAGEMENT IN POST BURN CONTRACTURE - PowerPoint Presentation

Slide1

AIRWAY MANAGEMENT IN POST BURN CONTRACTURE

Prof Qazi Ehsan Ali

Dept of

Anaesthesiology

JNMedical

College, AMU, Aligarh

Slide2

Airway issues in burns may be

classified into

two distinctive recovery stages:

acute burn injury and

chronic post-burn scar reconstruction.

Each stage involves

different airway issues,

carries different risks, and

requires different evaluation methods and

approach strategies.

Vis a vis the acute burn injury phase, particular attention must be paid to extra- as well as intra-oral soft tissue changes.

For post-burn scar reconstruction, the focus should be on extra-oral scar contracture.

Slide3

Anesthetic considerations peculiar to Post burn Contracture patients

Slide4

1.Difficult airway

2.Use of muscle relaxants

3. Patient positioning

4. IV access

5. Application of monitors

6. Hypothermia

Slide5

important pre operative history before

anaesthesiA

Time of burn and its duration

Types of burn

Loss of consciousness with burn injury

Slide6

IMPORTANT PREOPERATIVE TEST

Serum electrolytes-sodium, potassium

Haemogram

RFT

Chest X ray

ECG

ABG

Slide7

Problems in facial / neck contractures ??

Slide8

1.Reduced mouth opening

2. Restricted neck movements

3. Stiff submandibular space

4.

Scar and contractures in suprasternal area obviates the use of

lightwand

/

cricothyrotomy

/ emergency tracheostomy

5. Larynx may be shifted from midline

6. Ineffective cricoid pressure

7. Application of OELM/ BURP during difficult laryngoscopy and intubation are not possible

Slide9

limited

atlanto

-occipital joint extension,

These patients generally present to the hospital ----for release of contractures.

Airway management in this setting is a challenge to

anaesthesiologist

owing to fixed flexion deformity --------resulting in nonalignment of oral, pharyngeal & laryngeal planes for intubations.

Such patients are usually managed along the awake limb of difficult airway algorithm

Slide10

Thorough

preopera-tive

preparation should be done, including ------

arrangement of difficult airway equipment,

a stylet,

different sizes of facemask,

oral and nasopharyngeal airways,

different sizes

ofendotracheal

tube,

Macintosh and McCoy

laryngoscopeblades

,

a laryngeal mask airway (LMA),

a

Proseal

laryngealmask

airway (PLMA),

an intubating LMA,

a

fibre

-optic bronchoscope and a tracheostomy set.

Slide11

While intubating patients with orofacial burns -----

difficult intubation kit including -------

fibreoptic

bronchoscope must be kept ready in the operating room.

This will help timely management of the airway as well as

prevent any adverse events in the perioperative period.

Slide12

Airway assessment

Examination of head and neck flexion-

extention

movement

Head and neck lateral rotation

MP grade

Perioral wound or contracture

Patency of the nasal passages and for any history of epistaxis.

Mouth opening

Slide13

Sub mandibular space compliance

Length of neck

Thickness of neck

Slide14

‘BONES’

for assessing difficulty at mask ventilation

(Beard, obesity, no teeth, elderly, snorer)

‘LEMON’

for assessing difficulty during laryngoscopy & intubation

(Look externally, examine 3-3-2,MMP, obstruction, neck mobility)

‘RODS’

for assessing difficult placement of SAD

(Restricted mouth opening, obstruction, disrupted upper airway, stiff lung)

‘BANG’

to predict difficult surgical airway

(Bleeding tendency, agitation, neck scarring, growth or vascular abnormalities in region)

Slide15

options for airway management

Awake intubation (nasal/ oral)

Video laryngoscope

ILMA + ETI (if MO> 2 finger)

LMA classic /

Combitube

( if tracheal stenosis suspected secondary to inhalation burns)

Pre-induction neck contracture release under

tumescent local anesthesia

/ ketamine

anaesthesia

Elective tracheostomy /PCT

Slide16

Difficulty in securing ETT

Restricted mouth opening.

Narrow nasal passage.

Stiff submandibular space.

Decreased

oropharyngeal

space.

Distortion in anatomic alignment of Oro-pharynx, pharynx and trachea.

Cervical spine distortion.

Fixed flexion neck deformity.

Inability of

atlanto

-occipital extension.

Slide17

impact of burn on muscle relaxants

Succinyl choline massive release of intracellular K+ dangerous

hyperkalemia

Starts after 1

st

week and last up to 6 months.

NDMR is safer if no predictors of difficult intubation.

Patients with >30% burn area may manifest resistance to NDMR. Due to proliferation of extra

junctional

receptors.

Seen after 1 week and last up to 3-6 months.

Slide18

Preparations for awake

fiberoptic

intubation

Slide19

Psychological preparation of patient.

Procedure and post operative numbness should be explained.

Premedicate

with Inj.

Glycopyrolate

0.2mg IV

Inj. Midazolam 0.02-0.03mg/kg: sedation and amnesia.

Fentanyl 1-2mcg/kg: analgesia for blocks, reduce airway response to manipulation and reduce discomfort and haemodynamic changes to intubation.

Dexmedetomidine

also been used for achieving optimal sedation

Slide20

sedation/analgesia for awake intubation

Judicious titration: don’t give boluses of drugs.

Avoid multiple drugs.

Try to use drugs that have reversal agent.

Slide21

L.A --- awake FOI

Xylocaine most commonly used

3-4mg/kg used via nebulizer

Rest 3-4mg/kg for direct mucosal application, blocks and infiltration some direct through bronchoscope ( spray-as-you-go-technique)

Slide22

Generally not possible

Branch of

vagus

; sensation to epiglottis, arytenoids and vocal cords.

Needle is inserted through the skin on to lateral portion of hyoid bone, walked off inferiorly and advanced through

thyrohyoid

membrane.

Resistance is felt as needle passes through membrane.

2-3 ml of 1%

xylocaine

injected

bylaterally

.

Duration lasts 20-30min with plain and up to 2hrs with adrenaline. So patient can be at increased risk of aspiration until normal function returns.

Superior laryngeal nerve block

Slide23

RECURRENT laryngeal nerve block

If possible

, cricothyroid membrane identified and a 23

guage

needle with 2-3ml 2% xylocaine is advanced until loss of resistance felt.

Placement within trachea is identified with aspiration of air.

Drug is injected rapidly and needle withdrawn.

Vigorous coughing helps spread of drug to under the

volacal

cords and trachea and carina.

Cotton pledges soaked in 4% xylocaine are placed in pyriform fossa, with curved tonsillar forceps, for 2 min.

Slide24

Nebulized

xylocaine

provide satisfactory anaesthesia from nose or mouth to below vocal cords.

For patients above 30kg 5ml of 4%

xylocaine

is safe.

Advantage of nebulized

xylocaine

against direct topical administration is reduced serum

xylocaine

level.

Slide25

“ADD a TSP”

A

dequate explanation of need of procedure

De

congestion of nasal passage using

vasoconstrictors.

D

rying up secretion by using

glycopyrolate

.

To

picalisation

of upper airway by nebulisation,

gargles and local spray.

S

edation and anxiolysis: midazolam and

remifentanyl

Patience, patience and patience

Slide26

Tumescent L.A

Slide27

Described for scar release.

Mixture of 30 ml of 2%

Lidocaine

;

1mg epinephrine (1:1000)

1ml of

hyaluronidase

containing 1500 IU

450ml RL

70-200ml of final mixture is used for release of scar

Targeted tissue become swollen, firm or tumescent and permits procedures to be performed.

Slide28

Tube fixation

The fixation of the ET is a challenge in the burned patient.

The ideal fixation secures the tube safely without additional injury to the tissue of the face and is flexible enough to adjust to

edema

formation.

Suturing the tube to the gums, wiring the tube around a tooth, and circumferential fixation or devices that allow frequent adjustment are examples.

Slide29

The usual forms of adhesive tape are not effective in the burned patient ----- do not adhere adequately ---- even to non burned skin.

Usually,

a soft sling ribbon

is used. It is tied at the back of the head (not the neck), and gauze padding should be added ------- to avoid constriction of soft tissues.

Slide30

concerns about the patient’s body temperature

Massively burned patients with loss of skin have constant evaporation from open surface.

Tend to develop severe intraoperative hypothermia and it is exaggerated by the effects of general anaesthesia

Normothermia for a burned patient is approximately 38.5°C because -------the burned patient develops a resetting of the centrally mediated thermostat

.

Slide31

Maintenance of normothermia is of paramount importance for survival of flap

Hypothermia : hypoxia, bleeding &

haematoma

Active warming starts before the patient is asleep.

The ambient temperature in theatre is raised to about 22–24 degree C.

Heat loses from fresh gas flows and inhalation agents should be taken in to consideration

Slide32

Monitoring in burn patient

Slide33

Applying monitors may be difficult in

pt

with limb and chest wall burns.( Needle ECG electrodes & invasive arterial BP) --------In addition to basic monitoring

Invasive blood pressure monitoring ------

enables safe manipulation of the perfusion pressure &

provides access to blood gas analysis and

haematocrit

estimations. (at the start of the operation and repeated every 2 hours)

Slide34

Urine output --------

another indicator of volume status.

A urine output of 1–2 ml/kg/hour should be maintained intraoperatively and postoperatively

Slide35

The patient is

ventilated

to

normocapnia

.

Hypocapnia ---- ↑ peripheral vascular resistance &↓ cardiac output,

while hypercapnia causes sympathetic stimulation.

If the surgeon uses the microscope for vessel preparation or anastomosis on the chest or abdomen ------ the tidal volume is reduced to minimize movement in and out of the surgeon’s field of vision.

The respiratory rate is then ↑ to maintain minute ventilation.

Slide36

Precautions during

extubation

Use of intraoperative dexamethasone 0.10-0.20 mg/kg iv to reduced airway edema

Fully awaken the prior to

extubation

Wait for complete reversal of NMB

Extubate

over a jet

stylet

Nurse the patients post op. in head up position for 12-24

hr

Keep tracheostomy and TTJV kit ready

Slide37

THANK YOU