Anesthesia for Burn Patients

I. INTRODUCTION

Thermal injury produces predictable pathophysiologic responses. These responses

must be considered when formulating a plan of management of anesthesia

for a burn patient. Airway management, circulatory stabilization, and pulmonary

support are essential.

II. PULMONARY CONSIDERATIONS are primarily related to inhalation

injury

A. RISK FACTORS

1. Burns sustained in closed space

2. Burns from petroleum products

3. Head trauma

4. Impaired mental status

B. INHALATION INJURY is a serious comorbidity in burned patients

1. In the absence of a cutaneous burn, the mortality rate of patients

with:

Inhalation injury is less than 10%. With a burn, the mortality rate of

such patients doubles.

The injury is the result of toxic chemical products of combustion

a. Plastics: Hydrogen cyanide poisons mitochondrial cytochrome oxidase,

causing tissue asphyxia.

b. Cotton and synthetic fibers: Aldehydes damage respiratory mucosa

and impair ciliary function.

c. Wood: This and other carbon-containing compounds can produce

carbon monoxide (see below).

C. THREE DISTINCT MANIFESTATIONS OF INHALATION INJURY

1. Carbon Monoxide (CO) Intoxication

COHb, % signs and symptoms

0-10 none (angina possible in patients with CAD)

10-20 slight headache, exercise-induced angina, dyspnea on vigorous exertion

20-30 throbbing headache, dyspnea on moderate exertion

30-40 severe headache, N/V, weakness, visual complaints, impaired judgment

40-50 syncope, tachycardia, tachypnea, dyspnea at rest

50-60 coma, convulsions, Cheyne-Stokes respirations

>70 death

a. Carboxyhemoglobin level should be determined by ABG. CO binds

well to hemoglobin so that oxygen cannot be transported, causing

hypoxemia; there is also a leftward shift of the oxyhemoglobin dissociation

curve. Carboxyhemoglobin absorbs light at the same

wavelength as oxyhemoglobin (660 nm) so pulse oximetry readings

may be unaffected or even falsely elevated.

b. The elimination halftime of carbon monoxide is 4 h and can be

reduced to 40 minutes with administration of 100% oxygen, which

is the mainstay of treatment of CO intoxication.

2. Upper Airway (Inhalation) Injury is rarely an immediate cause of

hypoxemia as onset is usually delayed 24-36 h postburn.

a. Signs and symptoms

1) Inflammation of oropharyngeal mucosa.

2) Facial burns and singed nasal hair.

3)Hoarseness, stridor, wheezing, rales.

4)Unexplained hypoxemia.

5)Carbonaceous sputum production is the most specific sign.

6) Even in the absence of the above, certain details in the patient

history can be suspicious for inhalation injury; for example, a

patient may have been trapped in a smoke-filled room.

b. Evaluation

1)Chest x-ray is insensitive.

2) Fiberoptic bronchoscopy

a) Signs of injury include mucosal erythema, edema, blisters, ulcers,

hemorrhage, and soot particles.

b)Bronchoscopy is typically performed by the anesthesiologist

if patient is undergoing surgery. Endotracheal intubation can

also be performed over bronchoscope.

c. If there is a reasonable suspicion of upper airway injury, endotracheal

intubation should be done early, because delayed intubation

will be difficult to achieve once upper airway edema has developed,

leading to a potentially fatal hypoxemia.

1)Awake direct laryngoscopy has the advantage of requiring little

equipment, but requires a great amount of patient cooperation.

Furthermore, this technique does not allow visual assessment

of the trachea for evidence of inhalation injury.

2) Cricothyrotomy in experienced hands is an effective airway management

technique, but is probably best reserved as a last resort.

3) Fiberoptic bronchoscopy affords the physician a means to visually

assess the upper airway as well as intubate the trachea.

a)Whenever possible, bronchoscopy is performed with the patient

breathing spontaneously.

b) Sedation with agents such as morphine, midazolam, and/or

ketamine should be provided (refer to Pain Management for

recommended dosages).

c) Suggested method for awake fiberoptic nasotracheal intubation.

• Monitoring should minimally include pulse oximetry,

blood pressure, heart rate, and respiratory rate.

• Administration of the antisialagogue, glycopyrrolate, 5

mg/kg IV, optimizes visualization; sedation as mentioned

previously.

• Select the appropriate sized endotracheal tube (for children,

tube size = [age+16] /4), and a lubricated bronchoscope

that will fit through the ETT.

• Supplies should include suction, phenylephrine 0.25% topical

nasal drops, rubber nasal airways of varying sizes, lubricant

(e.g., lidocaine, Surgilube), extra ETT connectors

that will fit into the nasal airways, three 5 ml syringes of

saline flush, and three 5 cc syringes of lidocaine, 2% (max.

4 mg/kg).

• The nasal route is chosen over oral because it is better tolerated

by awake patients and there is less angulation for

passage of the bronchoscope to the glottis.

• All patients should receive 100% oxygen during the

procedure.

• After topicalization of both nares, a nasal airway is inserted

into the nare not to be intubated. An ETT connector is inserted

into the airway, so that the oxygen source can be attached

to it, allowing the patient to receive 100% oxygen

without interfering with the bronchoscopy.

• The ETT is inserted into the free nare to just above the glottis.

The bronchoscope is then inserted through the ETT.

• When the glottis is visualized, 2% lidocaine is sprayed onto

the vocal cords via the bronchoscope sideport.

• The bronchoscope may then be gently passed through the

vocal cords to the level of the carina, at which point the

ETT may be advanced.

4. Pulmonary Parenchymal Injury appears to be the result of secondary

changes in the bronchial and pulmonary vasculature. With the exception

of steam, direct thermal injury very rarely occurs below the

vocal cords.

a. Mechanisms of such injury probably include inflammatory mediators

like complement, interleukins, and cytokines. The inflammatory

response may be secondary to the original burn injury or

superimposed sepsis.

b. The clinical picture of the patient with a secondary lung injury

manifests as respiratory failure from the adult respiratory distress

syndrome.

c. If a inhalation injury is present the incidence of respiratory failure

in the burned patient increases from 5-73%.

III. CARDIOVASCULAR CONSIDERATIONS

A. HYPOVOLEMIA is related primarily to the loss of plasma and interstitial

fluid through burned skin and abnormally permeable vasculature.

1. Blood volume decreases and edema forms most rapidly during the

first 8 h postburn.

2. Hourly urine output with a Foley catheter is the most readily available

index of volume replacement. Adults: 0.5-1 cc/kg/h; kids:

1-2 cc/kg/h.

3. Hematocrit is a poor indicator of volume status.

B. HEMODYNAMIC PARAMETERS

1. Cardiac output: CO is decreased during the initial burn period. Contractility

is reduced, probably secondary to inflammatory mediators

as well as an attenuated response to catecholamines. After the first

24-48 h, the circulatory system enters a hyperdynamic state, where

heart rate and blood pressure are increased. CO is usually twice

normal.

2. Systemic vascular resistance: Coincident with the initial decrease in

CO, SVR is increased. SVR is markedly low during the hyperdynamic

state.

IV. ADDITIONAL PHYSIOLOGIC CONSIDERATIONS

A. HYPERMETABOLISM increases with the extent of the burn injury

1. Probably secondary to inflammatory mediators

2. Calories tend to be diverted away from wound healing; it is therefore

recommended to begin enteral nutrition as soon as possible.

3. Hypermetabolism increases production of CO2 and consumption

of O2.

4. Below-normal ambient temperatures increase metabolic rate; a warm

operating room is mandatory.

B. HEMATOLOGIC

1. Red blood cells have a shortened half-life, but maintain their normal

oxygen-carrying capacity.

2. Disseminated intravascular coagulation is the most extreme form of

coagulopathy encountered in burned patients—fortunately, it is rare.

After the acute burn period, prophylaxis for deep venous thrombosis

should be employed, as there is a significant decrease in levels of proteins

C and S, as well as antithrombin III.

C. RENAL FUNCTION varies with the time since the original burn injury.

1. Etiologies of early renal insufficiency in burned patients

a. hypovolemia

b. mediators of vasoconstriction, including catecholamines and the

renin-angiotensin system

c. myoglobin, nephrotoxic medications

2. During the hyperdynamic state, glomerular filtration rate is elevated.

Certain drugs may be cleared more rapidly than expected, leading to

lower than desired serum drug levels. Tubular resorptive function,

however, may be diminished. Predicting accurate drug doses in individual

patients is therefore difficult and best managed by measuring

serum drug levels (e.g., aminoglycosides) or titrating a drug to the

desired effect.

PHARMACOKINETICS AND PHARMACODYNAMICS IN BURN

PATIENTS

I. GENERAL CONSIDERATIONS

A. INCREASED extracellular volume and volume of distribution.

B. ALTERATIONS in plasma protein composition, especially

hypoalbuminemia and increased levels of acute phase proteins.

C. THE CONCLUSION then is that normal doses of anesthetic medications

may result excessively high or low active, unbound amount of drug.

II. MUSCLE RELAXANTS

A. DEPOLARIZING AGENTS—SUCCINYLCHOLINE

1. Marked hyperkalemia severe enough to cause cardiac arrest is possible

if succinylcholine is used in burn patients

2. Although there is some controversy regarding the postburn interval

during which succinylcholine is contraindicated, it is reasonable to

completely avoid the use of succinylcholine in burn patients.

B. NONDEPOLARIZING AGENTS

1. Reduced sensitivity of these agents in burn patients is felt to be secondary

to postburn proliferation of extrajunctional nicotinic acetylcholine

receptors.

2. Therefore, increased doses of nondepolarizing agents may be required;

however, unless required to facilitate mechanical ventilation, their use

is unnecessary in burn patients.

III. SEDATIVES AND ANALGESICS

A. ALTHOUGH burn patients clearly require increased doses of sedatives

and analgesics, pharmacokinetics cannot completely explain this

phenomenon.

B. THE DOSES of sedatives and analgesics must be titrated to effect; but

the following serves as a useful starting point:

Agent Recommended Dosages

morphine sulfate 0.03-0.1 mg/kg IV

midazolam 0.03-0.1 mg/kg IV

scopolomine 0.4-1 mg po or 0.2-0.6 mg IV/IM

propofol 0.5-1 mg/kg IV

ketamine 0.5-1 mg/kg IV or 2.5-5 mg/kg IM

PREOPERATIVE ANESTHETIC ASSESSMENT OF BURN PATIENTS

I. HISTORY

A. CHARACTERISTICS OF THE BURN INJURY

1. Time of injury must be known as blood loss varies not only with

local infections but also with the time elapsed since the occurrence of

the burn:

Surgical Procedure Predicted Blood Loss

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1-3 days since burn injury 0.70 ml/cm2 burn area

> 4 days since burn injury 0.90 ml/cm2 burn area

infected burn wounds 1.0-1.25 ml/cm2 burn area

2. Environment in which the injury occurred has both hemodynamic

and pulmonary implications, e.g., a person trapped in an enclosed,

smoke-filled room is likely to have an inhalation injury, with a subsequent

need for airway protection and increased fluid requirements.

3. Burn source will determine the extent of injury.

a. Electrical injuries may produce far more tissue destruction than is

visually apparent, leading to myoglobinemia, myoglobinuria, and

possible pigment nephropathy (acute renal failure).

b. Chemical burns may have systemic toxicity (e.g., hydrogen cyanide),

or cause pulmonary damage by unsuspected inhalation of

fumes (e.g., sulfuric acid).

B. CHARACTERISTICS OF THE PATIENT

1. Age can have profound implications for long-term prognosis as well

as the individual’s ability to compensate for the physiologic stresses

associated with a burn injury. In general, the extremes in age (i.e., the

very young, very old), tend to be the most critically ill for a given

burn injury.

2. Coexisting medical problems

II. PHYSICAL EXAMINATION

A. CHECK FOR HEAD AND NECK BURNS, SINGED NASAL HAIRS,

HOARSENESS, as these are signs that supraglottic edema may develop

or is already present.

B. CARBONACEOUS SPUTUM, WHEEZES, OR DIMINISHED BREATH SOUNDS

are signs of possible inhalation injury.

C. ABDOMINAL DISTENSION may indicate an ileus, which increases the

risk of aspiration of gastric contents during anesthetic induction.

D. SEARCH for sites suitable for placement of invasive lines and other

monitoring equipment.

III. LABORATORY AND RADIOGRAPHIC EVALUATION

A. COMPLETE BLOOD COUNT (CBC)

B. ARTERIAL BLOOD GAS, particularly for burns >30% TBSA and in

suspected inhalation injury. Remember that pulse oximetry

measurements are unaffected even in patients hypoxic from carbon

monoxide intoxication.

C. CHEST RADIOGRAPH should be obtained in any burn >30% TBSA and

in suspected inhalation injury. Evidence of ARDS, infiltrates, or

effusions is sought to anticipate potential problems with

intraoperative oxygenation.

IV. PREOPERATIVE ORDERS

A. ADULTS

1. NPO after midnight—make certain that a maintenance rate of intravenous

fluids is administered during fasting.

2. Premedications will depend on the patient’s preoperative condition—

e.g., patients who are already intubated with continuous sedation

probably do not require premedication. If premedications are indicated:

a. Midazolam (Versed) 2-5 mg IV on call to the operating room.

b. Glycopyrrolate (Robinul) 0.2 mg IV, on call to the operating room,

is useful if fiberoptic bronchoscopy is planned.

3. Type and cross blood components based on predicted blood loss.

B. CHILDREN

1. NPO after midnight (0400 for infants), with maintenance intravenous

fluids during fasting.

2. Premedications are generally recommended for children to lessen the

anxiety of surgery and being separated from parents.

a. Acetaminophen (Tylenol) 15 mg/kg po up to 1000 mg on call to

the operating room.

b. Midazolam (Versed) 0.5 mg/kg po up to 20 mg on call to the operating

room.

c. Scopolomine 0.4-1.0 mg po, on call to the operating room, is not

only useful as an antisialagogue, but is also an effective and inexpensive

sedative in children.

3. Type and cross whole blood based on predicted blood loss.

V. INTRAMUSCULAR KETAMINE ADMINISTRATION IN CHILDREN

A. INTRAMUSCULAR MEDICATIONS, as a routine form of analgesia and

sedation, produce highly unpredictable drug plasma levels and are

therefore best avoided. For children, IM injections can be physically

and psychologically traumatic (“needlephobia”).

B. INTRAMUSCULAR KETAMINE, however, is useful as a premedication and

for brief procedures where intravenous access is unavailable (e.g.,

outpatient facial moulage sessions).

C. BIOJECTTM NEEDLE-FREE MEDICATION INJECTOR can be used to inject

a local anesthetic prior to injecting ketamine with a standard needle

or inject ketamine directly.

D. SELECTING THE CORRECT BIOJECTTM SYRINGE

Patient weight (kg) Injection site Syringe

Less than or equal to 7 thigh/gluteal brown/#3

Greater than 7, less than 23 deltoid brown/#3

Greater than 7, less than 23 thigh/gluteal blue/#4

Greater than 23 deltoid blue/#4

E. RECOMMENDED DOSING

1. Local anesthesia–NaHCO3, 0.1 ml and lidocaine (2%), 0.9 ml.

2. Ketamine–1-2 mg/kg IM on transport to OR; 5-10 mg/kg IM for procedures

outside of the operating suite (e.g., facial moulage)

INTRAOPERATIVE MONITORING

I. INTRAOPERATIVE MONITORING of a burned patient is comparable

to that of any critically ill patient undergoing major surgery.

II. MINIMUM STANDARDS of the American Society of Anesthesiologists.

A. THE CONTINUOUS PRESENCE OF A QUALIFIED ANESTHETIST

B. CONTINUOUS FIO2 MEASUREMENT

C. PULSE OXIMETRY

D. VENTILATORY MONITORS

1. Observing chest excursion, auscultation of breath sounds.

2. End-tidal carbon dioxide analysis.

3. Disconnect alarms during mechanical ventilation.

E. CONTINUOUS ELECTROCARDIOGRAPHY—either with standard adhesive

gel electrodes or staples/alligator clips

F. ARTERIAL BLOOD PRESSURE AND HEART RATE determination at least

every five minutes.

G. CONTINUOUS BODY TEMPERATURE MEASUREMENT (nasopharyngeal,

esophageal, axillary, rectal, urinary bladder)

III. ADDITIONAL MONITORING MODALITIES

A. CARDIOVASCULAR MONITORING can be supplemented if detection of

sudden hemodynamic alterations is required.

1. An arterial line can provide a beat-to-beat record of BP and provide

access to obtain repeated blood samples for ABGs and other tests.

2. A central venous line, in otherwise healthy patients, can correlate

directionally and quantitatively with changes in LVEDP.

3. Pulmonary arterial catheters, however, better estimate the determinants

of cardiac output in critically ill patients, and also allow calculation

of DO2, VO2, and numerous other hemodynamic parameters.

PA catheter complications must be weighed against benefits of invasive

Monitoring

Recommended sites for placement of CVP and PA catheters (most to least desirable)

Left Subclavian Vein

Right Subclavian Vein

Right Internal Jugular Vein

Femoral Veins

4. All lines should be rewired three days after insertion and new sites

found six days after the original insertion.

B. FOLEY CATHETER

IV. GUIDELINES FOR INSERTION OF CENTRAL VENOUS AND

INTRAARTERIAL CATHETERS

A. CHOOSING THE APPROPRIATE SIZE CENTRAL VENOUS CATHETER

Age or Size Catheter Size

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> 4 years old 6 French

> 50 kg with expected large blood loss 8 French

B. CHOOSING THE APPROPRIATE SIZE ARTERIAL CATHETER

Size Artery Catheter Size and Length

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> 5 kg Radial 3 French/5 cm

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Ø 5 kg Femoral 3 French/8 cm

INDUCTION AND MAINTENANCE OF ANESTHESIA IN BURN

PATIENTS

I. GENERAL ANESTHESIA IS THE TECHNIQUE OF CHOICE IN

ACUTELY BURNED PATIENTS

A. INDUCTION

1. Evaluation of the airway plays a key role in the technique to be used.

a. In patients with facial burns who do not have airway obstruction,

consider awake intubation.

b. If inhalation injury is suspected, awake fiberoptic intubation is recommended,

usually by the nasal route, which is better tolerated.

2. Preoperative hemodynamics will determine the induction agent(s)

selected. The following list is not all-inclusive—one goal of any anesthetic

technique for acutely burned patients is to maintain hemodynamic

stability.

a. Ketamine

1)Has sympathomimetic properties, and not only increases heart

rate and blood pressure, but also preserves hypoxic and hypercapnic

ventilatory drive and reduces airway resistance.

2) In critically ill patients with no intrinsic sympathetic reserve,

ketamine can act as a myocardial depressant.

3) It is the only nonopioid induction agent that is analgesic.

4) The unpleasant hallucinations experienced postoperatively can

be attenuated with midazolam.

b. Propofol

1)Has the advantage of being an antiemetic and having a rapid

and thorough elimination.

2)Compared to ketamine, propofol at induction doses produces

apnea and hypotension.

c. Volatile Agents

1)Mask induction with nitrous oxide and halothane/ isoflurane is

typically used in pediatric patients who have intravenous access

prior to surgery.

2)Volatile anesthetics all produce dose-dependent myocardial depression

and vasodilatation.

3)Hypoxic pulmonary vasoconstriction is blunted, and can result

in detrimental ventilation/perfusion mismatching.

4) Despite the above concerns, unlike the altered pharmacokinetics

and dynamics of IV agents, volatile anesthetics tend to have

more predictable wash-in and washout times.

d. Opioids

1) In general, the intraoperative use of opioids is not advised, especially

with the availability of the ketamine and its analgesic

properties. If used, MSO4 to a maximum of 0.1 mg/kg IV may

reduce the amount of volatile agent(s) required.

B. MUSCLE RELAXANTS

1. Succinylcholine is well-known to cause hyperkalemia, and can lead

to cardiac arrest if the preoperative K > 5.0.

a. The greatest risk of hyperkalemia appears to be between 10 and 50

days postburn.

b. These zones, however, are poorly defined.

c. The safest recommendation is to avoid the use of succinylcholine

in burn patients.

2. Nondepolarizing relaxants are acceptable for muscle relaxation in

burn patients, although higher doses than in other patients are

required.

3. With the exception of patients who need facilitation of mechanical

ventilation, the routine use of muscle relaxants in acutely burned patients

is unnecessary and therefore not recommended.

C. ANESTHESIA is typically maintained with any of the previously

mentioned induction agents along with nitrous oxide and oxygen.

D. TYPICAL ANESTHETIC TECHNIQUES FOR ACUTELY BURNED PATIENTS

1. Adults should preferably have intravenous access prior to induction

of anesthesia.

a. In a hemodynamically stable patient, propofol can be followed by

mask induction with isoflurane to allow endotracheal intubation.

Anesthesia would be maintained with oxygen, nitrous oxide and

isoflurane.

b. In an unstable patient, induction may be done with ketamine and

topical lidocaine on the vocal cords prior to intubation. Oxygen,

nitrous oxide, and ketamine would be the maintenance agents.

2. Children should also have intravenous access prior to induction of

anesthesia, but often initial induction with a volatile agent to permit

placement of an intravenous catheter may be necessary.

a. Induction techniques in children with intravenous access are essentially

identical to those for adults. Inhalation induction, as previously

described, is a frequently used technique in children.

PAIN MANAGEMENT

I. PATIENT DISCOMFORT is an obvious result of untreated pain, but it

can also lead to subsequent noncompliance with other therapies, as well

as a distrust of the managing physician(s).

II. ADVERSE PHYSIOLOGIC CONSEQUENCES OF PAIN

Organ System Clinical Effect

Respiratory

increased skeletal muscle tension hypoxemia, hypercapnia

decreased total lung compliance ventilation-perfusion mismatching

atelectasis, pneumonia

Cardiovascular

increased myocardial work dysrhythmias, angina, myocardial infarction,

congestive heart failure

Endocrine

increased ACTH protein catabolism, lipolysis

increased cortisol hyperglycemia

increased glucagon

increased epinephrine

decreased insulin

decreased testosterone decreased protein anabolism

decreased insulin

increased aldosterone salt and water retention

increased antidiuretic hormone

increased cortisol congestive heart failure

increased catecholamines vasoconstriction

increased angiotensin II increased myocardial contractility

increased heart rate

Coagulation

increased platelet adhesion increased incidence of thromboembolism

diminished fibrinolysis

activation of coagulation cascade

Immunologic

lymphopenia decreased immune function

depression of reticuloendothelial system

leukocytosis

reduced killer T-cell cytotoxicity

Gastrointestinal

increased sphincter tone ileus

decreased smooth muscle tone

Genitourinary

increased sphincter tone urinary retention

decreased smooth muscle tone

III. BECAUSE PAIN FROM BURNS CAN BE CONSTANT, continuous

therapeutic levels of analgesia must be maintained. The severity of burn

pain justifies the use of intravenous narcotics and sedative/hypnotic

agents. As in other aspects of burn management, the concept of titrating

therapy to desired effect is practiced.

A. ADULTS (UNIVERSITY OF TEXAS—BLOCKER BURN UNIT)

1. Morphine sulfate (MSO4) may be effective in doses as little as 1 mg or

as large as 15 mg. The extent of the burn injury and other comorbidities

(e.g., an intubated/mechanically ventilated patient) will determine

the most effective dose and frequency of administration.

2. Midazolam (Versed), although lacking analgesic properties, complements

narcotics, especially during dressing changes and for intubated

patients. Doses in the range of 0.025-0.1 mg/kg are effective and should

be in small (0.5-1 mg) increments.

B. CHILDREN (SHRINERS BURN INSTITUTE, GALVESTON) A comprehensive

written protocol is available at SBI, and the following summarizes the

salient points:

1. If the patient complains of pain, then the patient has pain.

2. Background analgesia All patients receive acetaminophen, 15 mg/kg

po q4h.

a. (Patient > 3 years old) If more background analgesia is required,

then give MSO4, 0.3 mg/kg po q4h.

b. (Patient <>

then give MSO4, 0.1 mg/kg po q4h or 0.03 mg/kg IV q4h.

Procedure/Event Recommended Therapies (in

(may be used for both adults and children) order of preference)

Dressing changes and staple removal (pretub) 1. MSO4, 0.3 mg/kg po and Versed, 0.5

mg/kg po

2. MSO4, 0.03 mg/kg IV and Versed

0.03 mg/kg IV

3. ketamine, 0.5-2 mg/kg IV*

4. propofol, 0.5-1 mg/kg IV*

5. nitrous oxide, 50%, by patientcontrolled

face mask*

Rehabilitation therapy 1. MSO4, 0.1-0.3 mg/kg po

2. MSO4, 0.03 mg/kg IV.

Immediate 24 h postoperative period 1. MSO4, 0.3 mg/kg po and Versed, 0.5

mg/kg po q3-4h or alternate each

every 3-4h

2. MSO4, 0.03 mg/kg IV and Versed

0.03 mg/kg IV q2-4h or alternate

each every 2-4h

3. or patients > 5 years, morphine

patient-controlled analgesia (PCA)-

continuous infusions are not

recommended (see attached

guidelines)

Postoperative period for reconstructive 1. Vicodin (hydrocodone 5 mg/

surgery patients acetaminophen 500 mg†

2. Lortab elixir (5 ml contains

hydrocodone

2.5 mg/acetaminophen 167 mg) †

*Anesthesiology team should be notified †hydrocodone, 0.1-0.2 mg/kg po q4-6h

Patient-controlled analgesia-suggested pediatric guidelines

PCA Parameters MSO4, 1 mg/ml

PCA dose 0.05 mg/kg

Lockout interval 6-15 minutes

4-h Limit 0.2-0.3 mg/kg