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Anesthetic management of a parturient with severe burns and diffuse lung injury
Abstract Number: F3C-5
Abstract Type: Case Report/Case Series
Thermal injuries in pregnancy present unique challenges for anesthetic care as guidelines for management are lacking. In parturients with 25-50% total body surface area (TBSA) burns, mortality rates approach 63%. Here we present a case report of the successful anesthetic management of cesarean delivery in a parturient with severe burns complicated by diffuse lung injury, acute kidney injury, and metabolic acidosis.
A 38 year old woman with unknown medical history was transferred from an outside hospital to the burn unit with 40-50% TBSA burns (lower torso, bilateral upper and lower extremities) after an apartment fire. The patient had been intubated prior to arrival. Initial carboxyhemoglobin was 20% and bedside bronchoscopy showed large amounts of soot extending past carina. Chest x-ray demonstrated bilateral interstitial opacities suggestive of diffuse lung injury. Fetal ultrasound revealed an approximate 27 week gestational age and a normal heart rate. Central venous access and arterial line were obtained and intravenous volume resuscitation was initiated using the Parkland formula. In spite of aggressive volume resuscitation, the patient developed acute kidney injury with serum creatinine peaking at 5.3 mg/dl, as well as a worsening metabolic acidosis requiring a sodium acetate infusion. A multidisciplinary team convened to discuss treatment options. The burn surgeons suggested early eschar debridement and skin grafting to expedite wound healing as a delay would significantly increase maternal mortality. The obstetric and neonatal teams agreed that the metabolic burden of multiple surgeries would negatively impact fetal well-being so the decision was made to proceed with early cesarean delivery to hasten maternal recovery. A total intravenous general anesthetic with mechanical ventilation was utilized intraoperatively. A standard oxytocin infusion was sufficient for obtaining good uterine tone. The patient had a stable intraoperative course and was subsequently transported back to ICU intubated and sedated. Two days later, the patient underwent debridement and skin grafting followed by two more successful burn surgeries over the course of the month.
This case highlights the importance of a multidisciplinary approach in the care of the pregnant burn patient. Initial treatment will focus on airway stabilization and aggressive volume resuscitation. The physiologic changes of pregnancy may influence treatment techniques. For instance, the Parkland formula may underestimate fluid requirements for the pregnant patient. In addition, medication choice may have to be modified depending on the patient’s condition. Use of specific uterotonics such as carboprost should be avoided in patients with acute lung injury and the dosing of magnesium sulfate normally used for neuroprotection of the fetus should be altered in the setting of renal insufficiency.
J Clin Anesth. 2013 Nov;25(7):582-6.
Anaesthesia. 2003 Sep;58(9):931-2.