Balancing Risk and Benefit of Neuraxial Anesthesia in a Post Lung Transplant Burn Patient

Introduction

• Burn patients can be hemodynamically unstable, have compromised

ventilation, and are at high risk for infections.

• Regional anesthesia (RA) has proven useful in post-op analgesia (1),

burn donor graft site management, and decreasing ICU duration (2).

• RA techniques are limited by coagulopathy, local anesthetic systemic

toxicity or infection, though risk of meningeal infection after neuraxial

is rare, even in the bacteremic patient (3).

• RA as a primary surgical anesthetic could be considered in critical,

nonintubated patients for preservation of ventilation, slow titration,

and an improved post-surgical period

Case Presentation

A 68-year-old male patient presented with 23% TBSA severe burns to the

face, groin, buttocks, and lower extremities undergoing NEXOBRID®

(anacaulase-bcdb) debridement therapy to BLE. PMHx included atrial

fibrillation on Eliquis, CHF with reduced ejection fraction, complete heart

block s/p pacemaker, bilateral lung transplant on immunosuppression and

CKD. Hospital course complicated by volume overload, acute-on-chronic

kidney injury, pneumonia, and escalating non-invasive ventilatory support.

A multidisciplinary meeting between the burn, pulmonology, transplant and

acute pain services determined that RA was safer than GA to preserve

ventilation. Performed lumbar epidural catheter under aseptic precautions

after ensuring a normal coagulation profile. Patient tolerated the procedure

well following maintenance of the blockade using titrated boluses of

bupivacaine 0.25% along with vasopressor support. The epidural catheter

was removed the next day, less than 24 hours after insertion.

Discussion

• Treatment of burn patients is complicated by frequent surgical

operations, inhalation injury, pneumonia, and long durations of

mechanical ventilation (4).

• This patient had additional considerations due to previous lung

transplantation, as negative pressure ventilation is preferred over

positive pressure to prevent ventilation induced lung injury, enhance

recovery and limit respiratory complications related to the duration of

mechanical ventilation (5).

• Also on antibiotics with a potential for systemic infection, considered a

relative contraindication for neuraxial anesthesia – why balancing risks

vs. benefits of regional anesthesia needs a multidisciplinary approach.

• To date there is limited evidence showing the use of RA in lung

transplant burn patients.