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Unal D, Hazir MS. Review Airway management in pediatric patients with burn contractures of the face and neck. J Burn Care Res 2022; 43:1186-1202. [PMID: 35137105 DOI: 10.1093/jbcr/irac016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Burn injury is a common cause of trauma, non-fatal burn injuries are a leading cause of morbidity, and significant numbers of the victims are children. Scar contracture after burn injury can cause severe functional limitation, pain, aesthetic and psychological problems and patients may present for contracture release and reconstructive surgery. The aim of this systematic review was to identify research relevant to airway management of children with burn contracture of the face and neck with special emphasis on awake airway management and airway anesthesia, and synthesize results that can aid practice. Literature search was performed on Medline, PubMed, Cochrane Library, and Google Scholar with selected keywords. The search was restricted to human subjects of ≤18 year age, there was no language or time restriction and the final search was concluded in July 2021. The review included 41 articles involving airway management of 56 patients in 61 anesthesia episodes. Patients aged between 8 months to 18 years. Mask ventilation and direct laryngoscopy, video laryngoscopy, optical stylet, supraglottic airway, flexible scope intubation and tracheostomy, and extracorporeal membrane oxygenation were the devices and methods used for securing the airway and oxygenation while the patients were awake or after anesthesia induction. Detailed planning and patient preparation are the fundamentals of airway management of pediatric patients with burn contracture of the face and neck, awake airway management with airway anesthesia can be safely used in selected patients, this review provides information for good clinical practice and might serve to improve the care of such children.
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Affiliation(s)
- Dilek Unal
- Department of Anesthesiology and Reanimation, University of Health Sciences Diskapi Yildirim Beyazit Teaching Hospital, Ankara, Turkey
| | - Melis Sumak Hazir
- Department of Anesthesiology and Reanimation, University of Health Sciences Diskapi Yildirim Beyazit Teaching Hospital, Ankara, Turkey
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Berger-Estilita J, Wenzel V, Luedi MM, Riva T. A Primer for Pediatric Emergency Front-of-the-Neck Access. A A Pract 2021; 15:e01444. [PMID: 33821828 PMCID: PMC8083165 DOI: 10.1213/xaa.0000000000001444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 11/05/2022]
Abstract
"Cannot intubate, cannot oxygenate" situations in healthy children are uncommon but are often associated with poor outcomes. Clinical assessment, anticipatory planning, and the use of algorithms can lessen the likelihood of untoward outcomes, but the common final pathway of many algorithms for a difficult pediatric airway involves obtaining emergency tracheal access. The airway practitioner must have the know-how and training needed to invasively secure the airway when confronted with this rare but potentially devastating emergency. We provide practitioners with an overview of pediatric emergency front-of-the-neck access strategies and a structure for their management.
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Affiliation(s)
- Joana Berger-Estilita
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Vivian Wenzel
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus M. Luedi
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Riva
- From the Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Essig GF, Niermeyer WL, Essandoh M, Dewhirst E, Gerlach RM, Gonzalez LS, Chaney MA. Averting Risk of Airway Loss During Surgical Management of Retrosternal Goiters. J Cardiothorac Vasc Anesth 2020; 34:2260-2268. [DOI: 10.1053/j.jvca.2020.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 12/17/2022]
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Jayawardena ADL, Bouhabel S, Sheridan RL, Hartnick CJ. Laryngotracheal Reconstruction in the Pediatric Burn Patient: Surgical Techniques and Decision Making. J Burn Care Res 2020; 41:882-886. [PMID: 32112103 DOI: 10.1093/jbcr/iraa032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The management of laryngotracheal stenosis (LTS) in the pediatric burn patient is complex and requires a multidisciplinary approach. The mainstay of treatment for LTS is laryngotracheal reconstruction (LTR), however, limited reports of burn-specific LTR techniques exist. Here, we provide insight into the initial airway evaluation, surgical decision making, anesthetic challenges, and incision modifications based on our experience in treating patients with this pathology. The initial airway evaluation can be complicated by microstomia, trismus, and neck contractures-the authors recommend treatment of these complications prior to initial airway evaluation to optimize safety. The surgical decision making regarding pursuing single-stage LTR, double-stage LTR, and 1.5-stage LTR can be challenging-the authors recommend 1.5-stage LTR when possible due to the extra safety of rescue tracheostomy and the decreased risk of granuloma, which is especially important in pro-inflammatory burn physiology. Anesthetic challenges include obtaining intravenous access, securing the airway, and intravenous induction-the authors recommend peripherally inserted central catheter when appropriate, utilizing information from the initial airway evaluation to secure the airway, and avoidance of succinylcholine upon induction. Neck and chest incisions are often within the TBSA covered by the burn injury-the authors recommend modifying typical incisions to cover unaffected skin whenever possible in order to limit infection and prevent wound healing complications. Pediatric LTR in the burn patient is challenging, but can be safe when the surgeon is thoughtful in their decision making.
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Affiliation(s)
- Asitha D L Jayawardena
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
| | - Sarah Bouhabel
- Department of Otolaryngology-Head and Neck Surgery, McGill University Health Center, Montréal, Canada
| | | | - Christopher J Hartnick
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston
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Emery MA, Eitan S. Drug-specific differences in the ability of opioids to manage burn pain. Burns 2019; 46:503-513. [PMID: 31859093 DOI: 10.1016/j.burns.2019.03.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 03/04/2019] [Accepted: 03/30/2019] [Indexed: 12/17/2022]
Abstract
Burn injury pain is a significant public health problem. Burn injury treatment has improved tremendously in recent decades. However, an unintended consequence is that a larger number of patients now survive more severe injuries, and face intense pain that is very hard to treat. Although many efforts have been made to find alternative treatments, opioids remain the most effective medication available. Burn patients are frequently prescribed opioids in doses and durations that are significantly higher and longer than standard analgesic dosing guidelines. Despite this, many continue to experience unrelieved pain. They are also placed at a higher risk for developing dependence and opioid use disorder. Burn injury profoundly alters the functional state of the immune system. It also alters the expression levels of receptor, effector, and signaling molecules within the spinal cord's dorsal horn. These alterations could explain the reduced potency of opioids. However, recent studies demonstrate that different opioids signal preferentially via differential signaling pathways. This ligand-specific signaling by different opioids implies that burn injury may reduce the antinociceptive potency of opioids to different degrees, in a drug-specific manner. Indeed, recent findings hint at drug-specific differences in the ability of opioids to manage burn pain early after injury, as well as differences in their ability to prevent or treat the development of chronic and neuropathic pain. Here we review the current state of opioid treatment, as well as new findings that could potentially lead to opioid-based pain management strategies that may be significantly more effective than the current solutions.
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Affiliation(s)
- Michael A Emery
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX 77843, USA; Interdisciplinary Program in Neuroscience, Texas A&M Institute for Neuroscience (TAMIN), USA
| | - Shoshana Eitan
- Behavioral and Cellular Neuroscience, Department of Psychological and Brain Sciences, Texas A&M University, 4235 TAMU, College Station, TX 77843, USA; Interdisciplinary Program in Neuroscience, Texas A&M Institute for Neuroscience (TAMIN), USA.
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Wang L, Xu W, Deng X. Airway management - an extracorporeal 'fifth way'? Anaesthesia 2018. [PMID: 29536525 DOI: 10.1111/anae.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- L Wang
- Plastic Surgery Hospital, Beijing, China
| | - W Xu
- Plastic Surgery Hospital, Beijing, China
| | - X Deng
- Plastic Surgery Hospital, Beijing, China
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7
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Quantifying Risk Factors for Long-Term Sleep Problems After Burn Injury in Young Adults. J Burn Care Res 2017; 38:e510-e520. [PMID: 27003738 PMCID: PMC9968418 DOI: 10.1097/bcr.0000000000000315] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Restorative sleep is an important component of quality of life. Disturbances in sleep after burn injury were reported but all based on uncontrolled or nonstandardized data. The occurrence and the effect of long-term sleep problems in young adult burn survivors have not been well defined. This 5-year (2003-2008) prospective multicenter longitudinal study included adults with burn injuries ages 19 to 30 years who completed the Young Adult Burn Outcome Questionnaire (YABOQ) up to 36 months after injury. The items measured 15 patient-reported outcomes including physical, psychological, and social statuses and symptoms such as itch and pain. Scores of these 15 YABOQ outcome domains were standardized to a mean of 50 and a SD of 10 based on an age-matched nonburned reference group of young adults. Sleep quality was assessed using the item 'How satisfied are you now with your sleep,' rated by a 5-point Likert scale. Patients responding with very and somewhat dissatisfied were classified as having sleep dissatisfaction and the remaining as less or not dissatisfied. The associations between sleep dissatisfaction (yes/no) and YABOQ outcome domains were analyzed longitudinally using mixed-effect generalized linear models, adjusted for %TBSA burned, age, gender, and race. Generalized estimating equations were used to take into account correlated error resulting from repeated surveys on each patient over time. One hundred and fifty-two burn survivors participated in the YABOQ survey at baseline and during the follow-up who had at least one survey with a response to the sleep item. Among them, sleep dissatisfaction was twice as prevalent (76/152, 50%) when compared with the nonburned reference group (29/112, 26%). The likelihood of a burn survivor being dissatisfied with sleep was reduced over time after the burn injury. Sleep dissatisfaction following burns was significantly associated, in a dose-dependent manner, with increasing burn size (P = .001). Better sleep was associated with better outcomes in all domains (P < .05) except Fine Motor Function, and this association was significantly more apparent in the longer term compared with the shorter term with the same domains (P < .05). Dissatisfaction with sleep is highly prevalent following burn injuries in young adults. Lower satisfaction with sleep is associated with poorer scores in nearly all quality of life measures. Satisfaction with sleep should be addressed during the long-term clinical follow-up of young adults with burn injuries. Further research should be undertaken to understand the components of sleep quality that are important to burn survivors and which ones might be modified and tested in future intervention studies.
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Abstract
Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury is characterized by a reduction in cardiac output and increased systemic and pulmonary vascular resistance. Approximately 2 to 5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic endpoints. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia, and altered pharmacology.
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Affiliation(s)
- Edward A Bittner
- From the Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (E.A.B., E.S., J.A.J.M.); Shriners Hospitals for Children®, Boston, Massachusetts (E.A.B., E.S., J.A.J.M.); Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas (L.W.); and Shriners Hospitals for Children®, Galveston, Texas (L.W.)
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Park CD, Lee HK, Yim JY, Kang IH. Anesthetic management for a patient with severe mento-sternal contracture: difficult airway and scarce venous access -A case report-. Korean J Anesthesiol 2013; 64:61-4. [PMID: 23372888 PMCID: PMC3558652 DOI: 10.4097/kjae.2013.64.1.61] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/09/2012] [Accepted: 04/20/2012] [Indexed: 11/25/2022] Open
Abstract
There are many problems in the anesthetic management of patients with scar contracture. In this case, a 41-year-old male with severe scar contracture on his face, neck, anterior chest, and both shoulders underwent surgery for resurfacing with flaps. We tried to awake fiberoptic orotracheal intubation with GlideScope® Video laryngoscope guide after surgical release of contracture under local anesthesia. We report a successful management of a patient with severe burn contracture achieved by combined effort of surgeons and anesthesiologists.
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Affiliation(s)
- Chong-Doo Park
- Department of Anesthesiology and Pain Medicine, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
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Caruso TJ, Janik LS, Fuzaylov G. Airway management of recovered pediatric patients with severe head and neck burns: a review. Paediatr Anaesth 2012; 22:462-8. [PMID: 22260458 DOI: 10.1111/j.1460-9592.2012.03795.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.
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Affiliation(s)
- Thomas J Caruso
- Department of Anesthesia, Critical Care, and Pain Medicine, Shriners Hospital for Children, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Rose AS, Gore MR, Hultman CS, Cairns BA. Contracture related airway obstruction (CRAO) treated successfully with incisional release. Int J Pediatr Otorhinolaryngol 2011; 75:286-8. [PMID: 21163536 DOI: 10.1016/j.ijporl.2010.10.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 10/22/2010] [Accepted: 10/27/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To describe the delayed airway obstruction that can result from anterior cervical burns and report a case of successful decannulation following incisional release and full-thickness skin grafting (FTSG). METHODS Case report from a tertiary care academic children's hospital. RESULTS Direct laryngoscopy demonstrates a significant improvement in the upper airway immediately following an anterior cervical incisional release. The patient was then able to be decannulated on postoperative day 10. CONCLUSIONS Cervical contracture is an important consideration in children with airway obstruction following burns to the upper chest, anterior neck and face, and may be treated successfully with incisional release and FTSG.
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Affiliation(s)
- Austin S Rose
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7070, USA.
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Abstract
Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. With advances in burn care and with the development of experienced multi-disciplinary teams at regionalized burn centers, many children are surviving severe burn injury. As members of the multi-disciplinary care team, anesthesia providers are called upon to care for these critically ill children. These children provide several anesthetic challenges, such as difficult airways, difficult vascular access, fluid and electrolyte imbalances, altered temperature regulation, sepsis, cardiovascular instability, and increased requirements of muscle relaxants and opioids. The anesthesia provider must understand the physiologic derangements that occur with severe burn injury as well as the subsequent anesthetic implications.
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Affiliation(s)
- Gennadiy Fuzaylov
- Department of Anesthesia and Critical Care, Pediatric Anesthesia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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13
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Kim KM. First step to safe anesthesia: Pre-operative prediction of difficult airway. Korean J Anesthesiol 2009; 57:275-276. [DOI: 10.4097/kjae.2009.57.3.275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kye-Min Kim
- Department of Anesthesia and Pain Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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