The Intra-operative Checklist (from Dr. Tanya's notes)
🔑 Eight recurring concerns for burns surgery
- Difficult monitoring — attaching leads to burnt/grafted skin
- Difficult airway & mask ventilation — cart ready, inhalational induction preferred
- Hypothermia — the dominant intra-op threat
- Prolonged procedure & multiple surgeries → more anaesthetic agent/analgesia
- Special positioning for donor-skin harvest
- Muscle relaxant choice — avoid suxamethonium, NDMR resistance
- Adrenaline-soaked swabs → tachycardia/arrhythmia
- Haemodynamic support & fluid/blood management — major blood loss
Preventing Hypothermia — the Priority
Burns patients lose heat faster than any other surgical patient: a large exposed raw surface, loss of the skin's insulating barrier, huge evaporative & radiant losses, and impaired hypothalamic thermoregulation. Hypothermia worsens coagulopathy, slows drug metabolism and delays reversal.
Aim
- Keep the patient warm — limit heat loss to ≤~1 °C from baseline
- Post as the first case of the day
How
- Warm the theatre to ~28–32 °C
- Forced-air warming & warming mattress; cover unburnt areas
- Fluid & blood warmers; humidified warm gases
- Minimise exposure time; warm skin-prep solutions
Blood Loss & Adrenaline
💉 Major, rapid, hard to measure
- Excision & grafting bleeds briskly from the raw dermis — blood loss is easily underestimated (soaked into drapes/swabs) and can exceed 30 mL/kg.
- Reserve & cross-match blood products pre-operatively; calculate the maximum allowable blood loss (MABL) and transfusion trigger in advance.
- Surgeons use adrenaline-soaked swabs / tumescent adrenaline to reduce bleeding — this can be systemically absorbed → tachycardia and arrhythmias (especially with volatile agents). Communicate and monitor.
- Have vasopressors/inotropes ready — hypotension is common in the event of blood loss.
Monitoring the Burnt Patient
| Monitor | The burns-specific problem |
|---|---|
| SpO₂ | Unreliable in CO poisoning (reads COHb as O₂Hb); probe may not fit burnt digits — try ear/nose |
| ECG | Gel electrodes won't stick to burnt/grafted skin — use skin-staple / subcutaneous needle electrodes clipped with crocodile clips |
| NIBP / IBP | NIBP cuff may not fit; for prolonged cases with large blood loss use invasive arterial (IBP) monitoring |
| Temperature | Core temperature — essential given the hypothermia risk |
| Urine output | Resuscitation endpoint (0.5–1 mL/kg/h) |
| EtCO₂ & TOF | Ventilation; neuromuscular monitoring (dose titration in NDMR resistance) |
Positioning: plan around the location of burns and the donor-skin sites (often thighs/back) — special positioning & careful padding are frequently needed, and the "burnt" and "donor" areas are both surgical fields.