The anesthetic management of the severely burned patient.

The anesthetic management of patients with major burns must be based on pathophysiological knowledge of the disease. In the immediate post-burn period hemodynamic changes are of major importance. Because in severe cases any of the determinants of cardiac output can be implicated in these changes, precise physiological measurements are required. Arterial pressure, urinary output, central venous pressure and right heart catheterization can help in choosing the appropriate intervention. The metabolic response to the injury is initially protective, providing enough substrate, but later will lead to extreme levels of catabolism which can impair wound healing and immunological response. The anesthesiologist can decrease that response by providing calories, adequate room temperature, a reduction of the NPO period to the minimum necessary, and avoiding stress situations. Respiratory injury can either affect the upper airway or produce the picture of ARF, which may require special treatment before, during and after surgery. Several technical problems are usually present in the anesthetic management of these patients: 1) difficult airway, 2) scarce venous access, 3) no places available for monitoring, 4) drug dependency, 5) multiple anesthetics, 6) tendency to hypothermia, 7) inaccurate estimation of blood loss, 8) hyperkalemia after succinylcholine administration, and 9) systemic effect of topical medications.