2019 FSA Posters

P014: BURN INJURY IN A PATIENT WITH TWIN PREGNANCIES
Catalina Carvajal, DO, Carlos Rodriguez, MD; Kendall Regional Medical Center

Introduction/Background: The perioperative management of the obstetric patient with thermal injuries adds complexity to the anesthetic considerations.  A 33-year-old G1P0 healthy female with twin pregnancies at 25 weeks’ gestation presented after sustaining partial thickness burn to the anterior chest, abdomen and left upper extremity after accidentally spilling boiling water on herself. On exam, the patient had a total body surface (TBSA) 5% with swelling and pain. Vitals were stable, and no inhalational injury was suspected. The pre-operative fetal ultrasound found an estimated fetal age of 25 weeks and 1 day and the biophysical profile for both fetuses was 8 and 8. Patient was evaluated by the burn team and underwent a surgical wound bed prep with application of skin substitute under general anesthesia with pre- and post-operative fetal monitoring. 

Methods: Patient was connected to the standard ASA monitors and adequately pre-oxygenated with 100% oxygen. She underwent rapid sequence induction with succinylcholine 1 mg/kg, propofol 2.5mg/kg and fentanyl 1.5mcg/kg were administered. Patient was intubated using a glidescope while applying cricoid pressure, a grade I view was achieved without difficulty. The choice was made to provide a total intravenous anesthetic (TIVA) and to prevent the use of inhalation agents to avoid hypotension that may interfere with uteroplacental perfusion and reduce the incidence of post-operative nausea and vomiting. Anesthesia was maintained with a propofol and remifentanil infusion. She underwent a surgical wound bed preparation with application of skin substitute to right breast 14 cm x 11cm, left breast 10 cm x 13 cm, abdomen 15 cm x12cm, and left arm 20 cm x 6 cm by the burn/plastic surgery team. Careful monitoring of patient’s hemodynamics was conducted throughout the procedure. Adequate fluid management was provided and warming measures such as increasing operating room temperature, fluid warmer, and forced-air warming blanket were used to maintain normothermia.

Results: Patient and twin fetuses tolerated the anesthesia and procedure well. Patient was extubated at the end of the procedure and a post-operative fetal assessment was obtained. The pain service was consulted to assist in pain control following the debridement and skin substitute placement as patient was complaining of pain and swelling. The pain consult determined pain was characteristic of a combination of neuropathic and nociceptive pain secondary to the inflammation of burns. Patient was placed on scheduled Acetaminophen 650 mg and Percocet 5/325 mg po q4h. For severe pain, Morphine sulfate 1 mg IV was prescribed as needed.

Discussion/Conclusion: The management of burns during pregnancy poses some distinct challenges in the perioperative period. Burn patients have special anesthetic requirements that should be accounted for depending on the TBSA involved such as adequate intravenous fluid management, temperature control, choice of medications, infection control with early and aggressive treatment, and a low threshold for securing the airway. Likewise, pregnancy results in various maternal physiologic changes that alter anesthetic care as well as the need for perioperative fetal monitoring. A multidisciplinary approach must be taken to improve outcomes and minimize the harm caused to both the mother and the developing fetus.