because the gluconate form requires hepatic metabolism to release ionized calcium. Other potential complications of blood transfusion include hemolytic and non-hemolytic transfusion reactions and dilutional thrombocytopenia.

Transfusion-related acute lung injury (TRALI) is defined as a new acute lung injury occurring within 6 hours of transfusion in a patient without additional risk factors for acute lung injury [28]. TRALI is the leading cause of mortality associated with blood transfusion. The greatest risk of TRALI is associated with blood products that contain large amounts of plasma, namely FFP and platelets. As with ARDS, there are no specific therapies for TRALI and management is supportive. It is difficult to recognize TRALI in patients with major burns since there are multiple etiologies for acute lung injury and ARDS in these patients. The risk of TRALI has been reduced by institution of a blood bank policy of minimizing preparation of plasma rich components (e. g. FFP and platelets) from donors who are known to be or are at risk of becoming alloimunized against leukocytes [29].

Postoperative care

Concerns regarding postoperative care of the burn patient are highly variable depending on the patient’s preoperative condition and the intraoperative course. Postoperative physiological condition can be influenced negatively by the presence of inhalation injury and by metabolic, coagulation, and hemodynamic problems associated with hypothermia, massive transfusion, or systemic inflammatory response to debridement of infected tissues. In addition, analgesia and sedation needs of burn patients are often exaggerated in the postoperative period.

The decision to extubate the burn patient postoperatively must take into account potential pulmonary dysfunction due to inhalation injury or intraoperative acute lung injury associated with sepsis or systemic inflammatory response as well as the hemodynamic stability of the patient. Analysis of arterial blood gases provides valuable information regarding pulmonary function and metabolic status prior to extubation. Additionally, airway distortion and obstruction from edema can preclude postoperative

extubation. The degree of airway edema can be estimated by direct inspection using a bronchoscope or laryngoscope.

Monitoring needs during transport to the intensive care unit should be established and equipment assembled early to avoid delays in transportation after surgery is complete. Resuscitation drugs and an easily accessible site for intravenous drug administration should be made available prior to transport of potentially unstable patients.

After transport to the intensive care unit, transfer of care requires a concise report of intraoperative events relative to postoperative care as well as fluids administered and estimated blood loss. Surgical debridement, skin harvesting and grafting are painful procedures. Since poorly controlled pain and anxiety can adversely affect wound healing and psychological outcome it is important that pain and anxiety be adequately treated. Tolerance to morphine often occurs in patients with large burn injuries and may necessitate larger doses or may be associated with hyperalgesia that is poorly controlled with morphine. The use of other analgesics such as methadone, fentanyl or alpha-2 adrenergic agonists have been found to be effective when this occurs [30–31]. Anxiolytic agents are also beneficial in burned patients, especially if prolonged mechanical ventilation is required. Agents such as benzodiazepines, alpha-2 adrenergic agonists and propofol are commonly used to provide anxiolysis.

A chest radiograph may be needed to confirm position of an endotracheal tube or central venous catheter or to rule out complications of central venous cannulation. Since maintenance of body temperature can be challenging during burn surgery and hypothermia is poorly tolerated by burn patients, postoperative temperature should be determined on arrival in the intensive care unit and facilities should be available to treat hypothermia promptly, if it occurs. Blood gas analysis and other laboratory studies should be initiated soon after arrival in the intensive care unit in order to identify any pulmonary or metabolic disturbances that require treatment. Ongoing blood loss can be concealed by bulky burn wound dressings and dilutional coagulopathy can occur after massive transfusion. If ongoing hemorrhage requiring transfusion is suspected, a blood warmer should be used to avoid hypothermia. These

patients should be monitored carefully for hemodynamic instability or significant decrease in hemoglobin that might indicate continued hemorrhage.

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