Extubation & Post-op Care
- Awake extubation is preferred — after full return of airway reflexes and complete neuromuscular reversal.
- Delay extubation (elective post-op ventilation) if: significant airway oedema, blood loss > 30 mL/kg, or an extensive/prolonged procedure.
- Post-op essentials: O₂ supplementation, ± nasopharyngeal airway, continued monitoring, haemodynamic & fluid support, active warming and psychological support.
Multimodal Analgesia
Why it is hard
- Severe background + procedural pain; opioid tolerance from repeated surgeries
- Neuropathic component as nerves regenerate
The multimodal plan
- Opioids (expect ↑ requirement) + ketamine (analgesia, anti-hyperalgesia)
- Gabapentinoids (pregabalin/gabapentin) for the neuropathic component
- Regional / peripheral nerve blocks (incl. for donor sites), paracetamol/NSAIDs
- Topical morphine to wound beds; non-pharmacological & psychological support; physiotherapy
Common Mistakes
Giving suxamethonium to a healing burns patient (after 24–48 h) → hyperkalaemic cardiac arrest.
Trusting a "normal" SpO₂ in a fire victim — it cannot detect carboxyhaemoglobin. Give 100% O₂ and check co-oximetry.
Waiting to intubate an inhalation-injury airway — oedema makes a manageable airway impossible within hours.
Underestimating blood loss and heat loss during excision/grafting — no blood reserved, cold theatre, no fluid warmer.
Standard weight-based non-depolariser dosing without TOF monitoring — under-dosing because of resistance.
Viva-Ready Pearls
Parkland: 4 mL × kg × %TBSA Ringer's lactate / 24 h, half in first 8 h — titrate to urine output.
Sux window: safe < 24 h; avoid from ~24–48 h up to ~1–2 years (extrajunctional receptors).
CO half-life: ~4–5 h on air → ~1 h on 100% O₂; SpO₂ is falsely normal.
Lund–Browder is the most accurate TBSA estimate, especially in children.
Warm everything: theatre 28–32 °C, fluids, gases; post the burns list first.
References
- Dr. Tanya Chawla — case notes on Burns (contracture release & grafting) & Acute Burns.
- Miller's Anesthesia — Anesthesia for the Burn-Injured Patient.
- Morgan & Mikhail's Clinical Anesthesiology — Anesthesia for Patients with Burns.
- Stoelting's Anesthesia and Co-Existing Disease — Skin & Musculoskeletal / Burns.
- ATLS & national burn-care guidance — burn resuscitation & inhalation injury.