UCSD Pediatrics Burn Pain Management Site

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Bronchoscopy
Bronchoscopy is frequently performed in our burn unit for both diagnostic and theraputic reasons. Patients with inhalational injury can have severely damaged bronchi with epithelel sloughing. Bronchoscopy can assist with the diagnoses and treatment by removing soot and excessive secretions. Many patients will develope pneumonia and because of paralysis necessary to manage the patient will prevent adequate bronchopulmonary clearance which can be effectively cleared with bronchcsocopy. Finally, upper airway edema and erosions from both tissue edema and direct inhalational injury may necessitate prolonged intubation. Bronchoscopic evaluation in combination with direct laryngoscopy can assist in decision making when considering extubation.

In adults, pre-emptive discussion with the patient in combination with mild sedation and topical anesthesia is often adequte to blunt the noxious stimulus. Children however cannot be made to understand what is happening to them thus will require general anesthesia.
Patient Selection

All patients 15 years or less should have anesthesia for flexible or rigid bronchoscopy
Anesthesia Guidelines

For patients who are intubated and mechanically ventilated, anesthesia can be provided by the bedside nurse using a combination of benzodiazepines and opioids with or without ketamine. The key to providing adequate anesthesia is to have the person providing the care not be involved in other aspects of the procedure. A loading dose of the sedative/analgesic should be given and then be supplemented with additional agents. There should be plenty of extra anesthetic available as patients often rapidly develope tolerance. It is always useful to apply topical anesthesia as well to decrease the general anesthetic dose.

Patients who are not intubated or extremely ill and prone to hypotension or hypoxia should have anesthesia present. To get an anesthesia consult or emergency case scheduled call the OR desk at x-6040.

Agents to consider :

Benzodiazepines:

Midazolam (0.1-0.3 mg/kg IV)

Lorezepam(0.1-0.3 mg/kg)

Opioids

Fentanyl (2-10+ mcg/kg)

Morphine (0.1-0.3+mg/kg)

Dilaudid (0.02-0.2mg/kg)

Sedative Hyonotic

Ketamine (2-5 mg/kg)

Etomidate (0.2-0.4mg/kg)

Propofol (2-5mg/kg)

Sevoflurane or Isoflurane