Acute Burn Surgery Research Articles

Postoperative hypothermia is associated with reduced length of stay in adult acute burn survivors

BackgroundThe hypermetabolic response after a burn predisposes patients to hypothermia due to dysfunction of thermoregulation. Traditionally, hypothermia is avoided actively in burn care due to reported complications associated with low body temperature. The likelihood of hypothermia with acute burn surgery is compounded by general anesthesia, exposure of wound areas and prolonged operation times. However, we find limited studies exploring the effects of perioperative hypothermia on length of stay in the adult burn population. ObjectiveTo determine associations between postoperative hypothermia and hospital length of stay in adult burns patients. MethodThis retrospective cohort study involved patients admitted to the State Adult Burn Unit in Western Australia between 1st January 2015 to 28th February 2021. All adults who underwent surgery for acute burn, and had postoperative recovery room body temperature recorded, were included in the study. In this study, we defined normothermia as >36.5C and hypothermia as < 36.0 °C with mild, moderate, and severe hypothermia being 35.0–35.9 °C, 34.0–34.9 °C and < 34.0 °C, respectively. Patients with hyperthermia were excluded. Multivariable general linear models explored if hypothermia was independently associated with length of stay. ResultsAmong 1486 adult patients, 1338 (90%) were normothermic postoperatively, with temperatures >36.0C. We included 148 (10%) patients with hypothermia (temperature <36.0 °C) postoperatively. Most burns in the study population were minor: 96% had burns < 15% TBSA. Data modelling demonstrated that hypothermia was associated with a shorter length of hospital stay (coefficient = −0.129, p = 0.041). ConclusionIn adult acute burn patients, postoperative hypothermia was associated with reduced length of stay after surgery. The positive results of this study indicate that a review of the core temperature targets with acute burn surgery, and timing of burn patient cooling practices in general is warranted.

Efficacy and Complications Associated with Acellular Dermal Substitute Use in the Treatment of Acute Burns: A Systematic Review and Meta-Analysis

Over several decades, skin substitutes have become an essential tool in acute burn surgery, particularly in major burns, where scarce donor tissues can limit the availability of autografts. This systematic review aimed to assess the efficacy, complication rates, and long-term outcomes of acellular dermal substitutes in acute burns and compare these to conventional skin grafting methods of coverage. A search of PubMed, Web of Science, and CENTRAL for appropriate randomized controlled trials (RCTs), non-randomized trials, and observational studies was conducted. Following screening, nine RCTs and seven observational studies fulfilled our inclusion and exclusion criteria. Our primary outcomes, which were graft take and incidence of infection, found no significant difference between the substitute and control procedures in a meta-analysis (p = 0.37 and p = 0.87, respectively). For our secondary outcomes, the studies were analyzed via narrative synthesis, which reported variable rates of graft loss and duration of acute hospital stay, from which definitive conclusions could not be drawn due to the heterogeneity in reporting. Despite a high risk of bias in the included studies, the evidence reviewed suggests that the treatment of an acute burn with a substitute may improve scar quality when compared to conventional grafting. This review therefore suggests that acellular dermal substitutes offer a viable method for staging the closure of deep partial- and full-thickness acute burns, although more robust RCTs with less heterogeneity are needed to support these conclusions.

584 Where Are They Now? - A Single-Center Survey of Burn Surgery Fellow Graduates

IntroductionBurn surgery encompasses different surgical disciplines such as general surgery, trauma, surgical critical care and plastic surgery. Those who apply to burn fellowship also have various interests. This study’s purpose was to discern the various career paths of burn fellowship graduates. It also investigated the frequency of specific chosen specialties and workplace settings. The results of the study could be used to modify current clinical burn fellowship curriculum.MethodsA survey was created using an internet tool and emailed to graduates of the clinical burn fellowship program from an American Burn Association verified burn center. The survey was sent to graduates of the last 10 years (2010-2020). The questions inquired about surgical field of work, board certification, additional training experience, work setting, and time since fellowship graduation. The participants’ responses were recorded anonymously to account for biases. The quantitative data was then collected for each question, and the data was calculated into percentages.ResultsOf the possible 17 fellows who graduated in the past ten years, 11 responded to our survey (64.7%). The most common surgical field pursued after the fellowship was plastic surgery with 5 graduates (45.5%). The following three fields all had 2 graduates each: burn surgery (burn/trauma), general surgery and wound care (18.2%). Almost all of the participants had completed additional training: 6 in plastic surgery (54.5%), and 4 in surgical critical care (36.4%). The work settings were primarily academic institutions (45.5%), followed by office-based practices (35.4%), ambulatory surgery centers (9.1%), and community hospitals (9.1%). Of the participants, 4 are board-certified in their chosen field, and 5 are board-eligible. Only 3 graduates are affiliated with a burn center.ConclusionsThe results of the study indicate the interests and career choices of previous burn fellows. This information can be used to modify burn fellowship curriculums to the needs and future career paths of the fellows. Traditional clinical burn fellowship programs emphasize burn critical care and acute burn surgery. Since some of the graduates are interested in plastic surgery, burn reconstruction could be added to the current curriculum. Plastic surgery faculty members could also serve as mentors to the fellows.

801 Topical hemostatic agents in burn surgery: a systematic review

IntroductionAcute burn surgery (tangential excision and grafting) has long been associated with significant intra-operative bleeding over large surface areas, where in adults approximately 200-250 mL of blood loss would be expected per %TBSA excised and grafted using traditional methods. Several techniques were introduced to limit bleeding, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery.MethodsA systematic review was performed by two independent reviewers using PubMed, Scopus, and Web of Science databases from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in acute burn surgery (excision and/or grafting). Animal studies and review articles were excluded. Data was extracted on the topical agent(s) used, their dosage, mode of delivery, hemostasis outcomes (if measured), and complications (if reported).ResultsThe search identified 1982 non-duplicate citations, of which 134 underwent full text review, and 49 met inclusion criteria. Papers were grouped whether they compared (n=11, 22%), described (n=21, 43%) or secondarily described (n=17, 35%) topical hemostatic agents. Several authors (n=22, 45%) described topical hemostatics as part of a protocol that included other methods of blood conservation (tourniquet, tumescent infiltration, etc). In total, 31 studies incorporated a vasoconstrictor agent (epinephrine, phenylephrine, vasopressin), and 30 studies incorporated a procoagulant agent (thrombin, fibrin). Four studies incorporated other agents (hydrogen peroxide, tranexamic acid and collagen). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1,000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/mL. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III to V.ConclusionsA multitude of topical hemostatic agents have been reported in the burn literature, with a wide range of dosages and modes of deliveries, as well as protocolization with other blood conservation techniques to limit blood loss during surgery. Determining the optimal topical hemostatic agent is limited by low quality data and challenges with consistent reporting of intra-operative blood loss and other clinically meaningful outcomes.

587 Ambient temperatures in the burn operating room: A QI initiative

IntroductionPatients with burn injuries are particularly susceptible to perioperative hypothermia, which is associated with a range of complications, including infection, bleeding and delayed wound healing. Raising the operating room (OR) ambient temperature is an important strategy to prevent hypothermia, but we were uncertain about how strictly we do this. The purpose of this study was to determine the ambient OR temperatures during acute burn surgery as the first step of a quality improvement initiative to ensure we are maintaining a warm OR environment.MethodsBetween 1/3/2020 and 28/2/2021, ambient temperatures during surgery in the burn OR of an ABA-verified burn center were recorded every 15 minutes. Temperatures were measured using a wall-mounted smart sensor, transmitted to a mobile smartphone application via Bluetooth. All patients undergoing acute burn excision and closure procedures lasting > 2 hours were included in the study. Hypothermia was defined as a core temperature < 36°C.ResultsOf the 119 patients, the majority were male (n=86; 72.3%), the mean age was 49.8 years (range 18-89) and the mean total body surface area (TBSA) was 15.8% (range 1-62%). They underwent 261 operations (mean 2.2 cases per patient; range 1-15) with a mean duration of 211.1 minutes (range 120-468 minutes). Sixty-two patients underwent 1 surgery, and 31 had 2 surgeries. Eight patients (6.7%) died. Thirty-three patients (27.7%) were hypothermic at the end of 43 cases (16.5%).The mean ambient temperature was 24.8oC (range 18.7oC to 29.6oC). Hypothermic patients (n= 33 patients, 43 cases), did not differ significantly in age or operative duration from non- hypothermic patients (n= 86 patients, 218 cases) but did have significantly larger %TBSA burns [32.3 vs 24.8 (p= 0.02)]. Hypothermic cases experienced significantly lower ambient temperatures at the start of surgery (p=0.007), and mean temperature during surgery (p=0.009), and tended to experience a lower ambient temperature at the end of surgery (24.5 C vs 25.1 °C , p= 0.06). [Table]ConclusionsWe have identified that the ambient temperature in our burn OR is lower than desirable and that this is directly related to development of hypothermia. These results now indicate that a QI intervention (stricter attention and manoeuvers to ensuring a warm operating room at the start and during surgery) is required.

Tranexamic acid reduced blood transfusions in acute burn surgery: A retrospective case-controlled trial

ObjectiveEarly excision and grafting of burn wounds are key for reducing prevalence of infection and sepsis. However, it is associated with massive blood loss and patients frequently require large numbers of blood transfusions. This study aimed to evaluate the effect of tranexamic acid (TXA) on blood transfusion requirements in acute burn surgery. MethodsPatients admitted to the burn intensive care unit between January 2018 and May 2021 and received TXA before first surgery for wound excision and grafting were matched in a 1:2 ratio to patients that did not receive TXA (confounders age,sex,total body surface area (TBSA) burned). Primary endpoint of the analysis was the total number of transfused units of red blood cells (RBC) intra- and postoperatively up to 48 h. Fresh frozen plasma (FFP) and platelets were evaluated. Endpoints were compared between groups using van Elteren tests adjusting for strata variable age, gender, TBSA. ResultsTwenty-six TXA patients were matched with 52 control patients resulting in similar distributions of gender (77.9%(TXA)vs. 82.7%(control) males, p=0.542), age (51.7±21.3vs.48.3 ±17.4years,p = 0.459) and %TBSA burned (33.5%(IQR34)vs. 38.5% (IQR 30.5),p = 1.000). TXA group received significantly less RBC units intraoperatively (2.5(IQR 2.0)vs.4.0 units (IQR4.0), p = 0.038) and in total (4.0(IQR3.0)vs.6.0(IQR4.0),p = 0.017). TXA patients also received less blood products in general (RBC, FFP, platelets) in each period and in total. We found no significant difference in length of stay (24.0(IQR26.0)vs.33.0 days (IQR 0.5),p = 0.367) or mortality (15.4%vs.21.2%, p = 0.542). DiscussionThis study shows that necessity for blood transfusions in acute burn surgery may be reduced significantly by administration of TXA perioperatively. Randomized-controlled trials are needed to prove these findings.

Safety and Cost-Effectiveness of Outpatient Surgery in Acute Burn Care.

Outpatient burn surgery is increasingly used in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our center's experience. This was a single-center, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split-thickness skin graft or dermal regenerative template from January 2010 to December 2018. Patient demographics, comorbidities, burn etiologies, operative data, and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation. One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (interquartile range) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, comorbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8170 per patient from inpatient costs. Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

Implementation and Validation of Free Flaps in Acute and Reconstructive Burn Care.

Microsurgical free flap reconstruction in acute burn care offers the option of reconstructing even challenging defects in a single stage procedure. Due to altered rheological and hemodynamic conditions in severely burned patients, it bears the risk of a higher complication rate compared to microsurgical reconstruction in other patients. To avoid failure, appropriate indications for free flap reconstruction should be reviewed thoroughly. Several aspects concerning timing of the procedure, individual flap choice, selection and preparation of the recipient vessels, and perioperative measures must be considered. Respecting these specific conditions, a low complication rate, comparable to those seen in microsurgical reconstruction of other traumatic limb defects, can be observed. Hence, the free flap procedure in acute burn care is a relatively safe and reliable tool in the armamentarium of acute burn surgery. In reconstructive burn care, microsurgical tissue transfer is routinely used to treat scar contractures. Due to the more robust perioperative condition of patients, even lower rates of complication are seen in microsurgical reconstruction.

57 Safety and Cost Effectiveness of Outpatient Surgery in Acute Burn Care

Abstract Introduction Outpatient burn surgery is increasingly utilized for delivery of acute burn care. Reports of its safety and efficacy are limited. The purpose of our study was to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our centre’s experience. Methods This was a single centre, retrospective cohort study of consecutive patients who underwent outpatient acute burn surgery requiring split thickness skin graft or dermal regenerative template from January 2010 - December 2018. Patients with insufficient follow up to evaluate operative site healing were excluded. Patient demographics, comorbidities, burn etiologies, operative data and postoperative care were reviewed. The primary outcome is complication involving major graft loss requiring reoperation. Results 165 patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. The number of annual outpatient procedures increased 48% from 23 to 34 cases over the 9-year period. The mean grafted total body surface area was 1.0 ± 0.9%. Rate of major graft loss requiring reoperation was 5.2% (9/172). Greater than 95% graft take was achieved in 80.9% of patients. Age, sex, co-morbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rate. Outpatient burn surgery model was estimated to save CA$7,875 per patient from inpatient costs. This extrapolates to a total of over CA$1.36 million in savings over the 9-year study period. Conclusions Acute burn care at our centre is increasingly being delivered through an outpatient day surgery model. Our demonstration of its safety and considerable cost savings is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

An Experimental Simulation of Heat Effects on Cognition and Workload of Surgical Team Members.

To isolate heat exposure as a cause of cognitive impairment and increased subjective workload in burns surgical teams. Raising ambient temperature of the operating room can improve burns patient outcomes, but risks increased cognitive impairment and workload of surgical team members. Prior research indicates ambient heat exposure depletes physiological and cognitive resources, but these findings have not been studied in the context of burns surgical teams. Seventeen surgical team members completed 2 surgery simulations of similar complexities in a hot and in a normothermic operating room. During each simulation, participants completed multiple cognitive tests to assess cognitive functioning and the SURG-TLX to self-assess workload. Order effects, core body temperature changes due to menstruation, and circadian rhythms were controlled for in the experimental design. Descriptive statistics, correlations, and mixed ANOVAs were performed to assess relationships between ambient heat exposure with cognitive functioning and perceived workload. Heat had a main effect on executive functioning and verbal reasoning. Duration of heat exposure (heat ∗ time) increased response times and negatively impacted executive functioning, spatial planning, and mental rotation. Perceived workload was higher in the hot condition. We provide causal evidence that over time, heat exposure impairs cognitive speed and accuracy, and increases subjective workload. We recommend building on this study to drive best-practices for acute burns surgery and design work to enable burns teams to maintain their cognitive stamina, lower their workload, and improve outcomes for patients and surgeons.

Hydrosurgical debridement versus conventional surgical debridement for acute partial-thickness burns.

Burn injuries are the fourth most common traumatic injury, causing an estimated 180,000 deaths annually worldwide. Superficial burns can be managed with dressings alone, but deeper burns or those that fail to heal promptly are usually treated surgically. Acute burns surgery aims to debride burnt skin until healthy tissue is reached, at which point skin grafts or temporising dressings are applied. Conventional debridement is performed with an angled blade, tangentially shaving burned tissue until healthy tissue is encountered. Hydrosurgery, an alternative to conventional blade debridement, simultaneously debrides, irrigates, and removes tissue with the aim of minimising damage to uninjured tissue. Despite the increasing use of hydrosurgery, its efficacy and the risk of adverse events following surgery for burns is unclear. To assess the effects of hydrosurgical debridement and skin grafting versus conventional surgical debridement and skin grafting for the treatment of acute partial-thickness burns. In December 2019 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We included randomised controlled trials (RCTs) that enrolled people of any age with acute partial-thickness burn injury and assessed the use of hydrosurgery. Two review authors independently performed study selection, data extraction, 'Risk of bias' assessment, and GRADE assessment of the certainty of the evidence. One RCT met the inclusion criteria of this review. The study sample size was 61 paediatric participants with acute partial-thickness burns of 3% to 4% total burn surface area. Participants were randomised to hydrosurgery or conventional debridement. There may be little or no difference in mean time to complete healing (mean difference (MD) 0.00 days, 95% confidence interval (CI) -6.25 to 6.25) or postoperative infection risk (risk ratio 1.33, 95% CI 0.57 to 3.11). These results are based on very low-certainty evidence, which was downgraded twice for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in operative time between hydrosurgery and conventional debridement (MD 0.2 minutes, 95% CI -12.2 to 12.6); again, the certainty of the evidence is very low, downgraded once for risk of bias, once for indirectness, and once for imprecision. There may be little or no difference in scar outcomes at six months. Health-related quality of life, resource use, and other adverse outcomes were not reported. This review contains one randomised trial of hydrosurgery versus conventional debridement in a paediatric population with low percentage of total body surface area burn injuries. Based on the available trial data, there may be little or no difference between hydrosurgery and conventional debridement in terms of time to complete healing, postoperative infection, operative time, and scar outcomes at six months. These results are based on very low-certainty evidence. Further research evaluating these outcomes as well ashealth-related quality of life, resource use, and other adverse event outcomes is required.

A quality improvement project incorporating preoperative warming to prevent perioperative hypothermia in major burns

BackgroundPatients with extensive burn injuries are susceptible to a host of accompanying adverse effects should they develop perioperative hypothermia, which occurs in up to ¼ of all major burn cases. This quality improvement project aimed to reduce the incidence of perioperative hypothermia to below 10% of cases in patients with major burn (Total Body Surface Area [TBSA] >15%), within a one year period. MethodsA baseline diagnostic phase was undertaken to provide a greater understanding of the incidence, natural history and risk factors of perioperative hypothermia. We also reviewed and reinforced intraoperative measures in current use, including preemptive adjustment of the ambient temperature, underbody warming mattress use, warming blanket application over areas not operated, regular temperature monitoring, and discussion at the WHO surgical checklist. Preoperative forced air warming with a ‘Bair Hugger’™ was identified as a sound change initiative, a strategy applied to good effect in other surgical settings. The primary outcome measure was the percentage of cases of perioperative hypothermia (<36°C), utilizing a time series design for the period between 1 November 2016 and 31 October 2017. Results53 patients with burn greater than 15% TBSA were admitted over the one year period. Of these, 40 patients required 127 operative procedures. Their mean age was 48.23 years, their mean TBSA was 27.65% (range 15–75%), and their mean length of hospital stay was 31.2 days. After the introduction of pre-warming, the proportion of cases of inadvertent hypothermia reduced to 13.77% (n=14/102), with special cause variation, from 24% (n=6/25) in the baseline data collection period. The final temperature correlated with the lowest temperature recorded in only 32% of cases. Based on stakeholder feedback and consensus from the literature, an algorithm was developed which forms the basis for a medical directive for preoperative warming for eligible patients. No significant balancing measures were identified, nor any undue costs incurred. DiscussionThe inevitable drop in temperature is ameliorated by sound perioperative practices, rather than just intraoperative ones. This initiative demonstrated the potential benefits of, and motivates for, the broad application of preoperative warming in the context of major acute burn surgery. Further investigations include PDSA cycles to determine whether the duration or degree of intraoperative hypothermia is more virulent. To consolidate the pre-warming initiative, we have introduced a standard order within our admission order sets to include preoperative warming for all eligible patients.

The impact of operative time and hypothermia in acute burn surgery

BackgroundProlonged operative time and intraoperative hypothermia are known to have deleterious effects on surgical outcomes. Although millions of burn injuries undergo operative treatment globally every year, there remains a paucity of evidence to guide perioperative practice in burn surgery. This study evaluated associations between hypothermia and operative time on post-operative complications in acute burn surgery. MethodA historical cohort study from January 1, 2006 to October 31, 2015 was completed at an American Burn Association verified burn centre. 1111 consecutive patients undergoing acute burn surgery were included, and 2171 surgeries were analyzed.Primary outcomes included post-operative complications, defined a priori as either infectious or noninfectious. Statistical analysis was undertaken using a modified Poisson model for relative risk, adjusted for total body surface area, inhalation injury, co-morbidities, substance abuse, and age. ResultsThe mean operative time was 4.4h (SD 3.7–4.7h; range 0.58–11h), and 18.6% of patients became hypothermic intra-operatively. Operative time was independently associated with the incidence of hypothermia (p<0.05), and both infectious (RR1.5; 1.2–1.9, p<0.0004) and non-infectious complications (RR2.3; 1.3–4.1, p<0.0066). In patients with major burns (TBSA≥20%), hypothermia predisposed to infectious (RR1.3; 1.1–1.5, p<0.0017) and non-infectious complications (RR1.7; 1.2–2.5; p<0.0049). Risk stratification revealed that hypothermic patients with major burns undergoing prolonged surgery had an increased risk of both infectious (RR1.4; 1.1–1.7, p<0.0068) and non-infectious complications (RR1.8; 1.1–3.0, p<0.0132) when compared with those without these risk factors. ConclusionsPatients who undergo prolonged surgeries and become hypothermic are more likely to develop complications. We therefore advocate for diligent adherence to strategies to prevent hypothermia and recommend limiting operative time in clinical circumstances where intraoperative measures are unlikely to adequately prevent hypothermia.

Isolated APTT prolongation-not always a bleeding risk in acute paediatric burns surgery.

Isolated APTT prolongation-not always a bleeding risk in acute paediatric burns surgery.

Safety and efficacy of excision and direct closure in acute burns surgery: Outcome analysis in a prospective series of 100 patients and a survey of UK burns surgeons’ attitudes

Many burns surgeons avoid excision and direct closure of acute burns owing to concerns over wound dehiscence, scarring and infection. There is no evidence in the literature to support this practice. We present outcomes of a prospective series of 100 patients who underwent excision and direct closure of 138 burns over a 2-year period, along with results from a survey sent to 33 senior burns surgeons to gauge attitudes towards direct closure in burns surgery. 47% of survey respondents never perform direct closure. Dehiscence was cited as the most common concern, followed by hypertrophic scarring (HTS). In our cohort, the superficial dehiscence rate was 12% and the HTS rate was 16%, with no scarring contractures. Patients with healing time greater than 14 days were more likely to develop HTS (p=0.008), as were those with wound dehiscence (p=0.014). Patients undergoing part-grafting in addition to direct closure took significantly longer to heal than those undergoing direct closure alone (p=0.0002), with the donor site or graft delaying healing in the majority. Excision and direct closure of acute burn wounds avoids donor site morbidity and has an acceptable complication rate. It is a safe and effective treatment for full thickness burns in selected cases.

Is the length of time in acute burn surgery associated with poorer outcomes?

BackgroundAcute wound closure surgery improves outcomes, after burn particularly mortality, but also imposes physiological stress on the patient. The duration of surgery is associated with adverse outcomes in other populations. This study aimed to examine if extended acute burn surgery duration was associated with poorer in-hospital outcomes. MethodsThis retrospective cohort study included adult burn patients who required a single wound closure surgery at Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to assess the influence of patient and injury factors on surgery duration and length of stay (LOS). ResultsSurgery duration independently increased LOS (incidence rate ratio [IRR]=1.004, p<0.001). This translates to a predicted 13% increase in LOS for a 30min increase in surgery ‘knife to skin’ time. Total body surface area (TBSA) was identified as a significant predictor of surgery duration (IRR=1.047, p<0.001), estimating that a 10% TBSA increase results in a 59% increase in surgery duration. ConclusionThe results show that surgery duration is associated with LOS after adjusting for size of burn and other factors. The study justifies the need to explore strategies to reduce acute burn surgery duration.

Integra Artificial Skin ® for burn scar revision in adolescents and children

Integra Artificial Skin ®, a biosynthetic dermal template, is well established in acute burn surgery. The aim of the study was to determine the role of Integra in the surgical treatment of postburn scars in a younger population. Between March 1998 and November 2004, 17 patients ( n = 17; mean age = 13.15 years) underwent complete excision of hypertrophic scars or keloids (1–4% TBSA; extremities = 47%, head/neck = 35%, trunk = 18%) with subsequent implantation of Integra for defect closure. Split thickness skin grafting (STSG) of the Integra-derived neodermis was performed 3 weeks after the first operation. Scar excision and primary Integra implantation was successful in all but one patient (94%) who (6%) needed reimplantation once. Integra's mean take rate was 99.7% for all primarily successful patients. Complications occurred in three patients (18%), including minor problems without long-term consequences in 12% (seroma formation), and major problems in 6% (hematoma formation). Take rate of STSG ranged from 50% to 100% (mean 94%). Functional and cosmetic long-term outcome showed results scored “excellent” in 53%, “good” in 36%, and “fair” in 11%. Comparison of pre- and postoperative findings revealed a significant functional improvement in all and a considerable cosmetic improvement in all but two patients. These results suggest that Integra is a valid new treatment modality for extensive burn scar revision in younger patients.