Burn Excision Research Articles

Candida infection in massively burned patients.

Immunosuppressed burned patients receiving antibiotics for suppression of bacterial infection are ideal hosts for opportunistic fungi. Massive excision of burns with autograft and homograft coverage has radically changed the course of disease. Three hundred ninety-three patients were admitted to the Shriners Burns Institute, of whom 125 patients had fungus cultured during their hospitalization and 42 patients subsequently developed involvement of three or more organs. Twenty-one of the 42 patients developed Candida septicemia requiring amphotericin B or flucytosine therapy. The mean third-degree burn in patients with Candida septicemia was 65% total body surface area compared to three-organ involvement/no clinical sepsis at 38% mean third-degree burn. Patients developing candidemia did so during the first week postburn and 7 days after excision therapy. It is hypothesized that massive burns with immunosuppression are further suppressed by repeated surgical intervention, anesthesia, and perioperative use of broad-spectrum antibiotics, further predisposing these patients to early development of Candida septicemia. With early recognition of burn wound invasion by routine biopsies, wound swabs, and early amphotericin therapy, the mortality has been reduced to 14% compared to 60-90% reported in other series.

Burns to the elderly: a reappraisal

Admissions to the McIndoe burns unit over the period 1975 to 1984 were reviewed and 123 patients over the age of sixty-five were studied in detail. Comparison with standardised mortality curves showed no difference in survival rates, but review of individual cases suggests that regular examination of elderly patients could shorten admission times and reduce the mortality by encouraging prompt identification and treatment of medical complications. Patients with burns of greater than 5% of surface area should be resuscitated with intravenous fluids as this age group is very susceptible to hypotensive renal damage. Excision of burns on or before the fifth day resulted in longer admissions and increased the number of procedures per patient. Disagreement in the recent literature on this point suggests the need for a randomised, controlled trial of early excision in the elderly patient.

Face burn reconstruction—does early excision and autografting improve aesthetic appearance?

Despite improvements in functional rehabilitation secondary to better control of scar and contractures, aesthetic rehabilitation of the extensively burned face has remained a difficult problem. This study was undertaken to evaluate both technique and aesthetic results of early excision and split thickness autografting (STAG) of full skin thickness face burns. Twenty-five patients with full skin thickness face burns were operated on between days 4 and 14 post-burn. Thirteen patients had excision and STAG in one stage. Twelve patients had a two-stage procedure-excision and coverage with a biological dressing followed 24–72 h later by STAG. Seven of these patients had a pressure dressing in the form of a silicone face mask applied at the second stage. Early cosmetic results were encouraging in all patients. Twenty-five per cent of patients later required either contracture release or skin resurfacing. Preliminary results are encouraging and warrant evaluation by surgeons at other centres. When early excision of full skin thickness face burns is undertaken, cautious optimism as to the ultimate aesthetic result, both by the surgeon and the patient, is advisable.

Early Burn Excision and Grafting

The current state of knowledge and experience with early burn wound closure leads to some conclusions that are proved and others that are suggested. The issues that are proved include the following: Small (less than 20 per cent TBSA) full-thickness burns and indeterminate (deep partial-thickness versus full-thickness) burns, if treated by an experienced surgeon, can be excised safely and grafted with a decrease in hospital stay, cost to the patient, and time away from work or school. Early excision and grafting dramatically decreases the number of painful ward debridements required by all patients. Patients with burns between 20 and 40 per cent TBSA appear to have fewer infectious wound complications and a shortened hospital stay if treated with early excision and grafting. In addition to the above conclusions, about which there is little disagreement, there are other suggestive data and clinical impressions that do not yet have "hard data" to support them. These issues include the following: Scarring is less in wounds closed early, leading to better appearance and the need for fewer reconstructive procedures. There presently is not a good measure of "cosmetic appearance," and comparative studies await an acceptable scale to measure results. Mortality from wound infection is less in patients with major burns. Because wounds exceeding the donor sites cannot be closed permanently and completely until donor sites can be reharvested, proof will come only when a durable permanent cover can be applied in a timely fashion. Data now suggest that mortality has decreased, but none of the studies has been conclusive. Mortality from other complications of major burns may decrease with early excision and grafting. Decreasing stress, hypermetabolism, and decreasing the overall bacterial load of such patients enables them to resist other complications better. The only present data supporting this conclusion, however, come from animal studies. The current state of the art suggests that small, deep burns can be excised and grafted by general or plastic surgeons in community hospitals as long as they are interested in the procedure and the hospital has the proper support facilities. Burns of cosmetically or functionally important areas (face, hands, feet, and joints) should be excised by someone with a special interest in burns, and burns in excess of 10 per cent TBSA should be excised only in facilities with excellent support facilities, including an experienced anesthesiologist, trained nursing personnel, good critical-care facilities, and a safe blood bank.

The effect of triglycyl-lysine-vasopressin (terlipressin INN, Glypressin) on skin blood flow, measured with laser Doppler flowmetry, thermography and plethysmography. A dose-response study.

Triglycyl-lysine-vasopressin (TGLVP) has been shown to reduce blood loss in connection with early excision of experimentally induced burns in pigs. In order to determine an appropriate dosage of TGLVP in patients with burns, a dose-response study was undertaken. TGLVP was administered intravenously in various doses to healthy volunteers, and skin blood flow was measured with laser Doppler flowmetry, thermography and plethysmography. Blood pressure, heart rate and electrocardiac activity were monitored as well as serum and urine changes. The doses of 5, 10 and 20 micrograms TGLVP/kg b.wt. caused statistically significant reduction of skin blood flow; minimal values were 35, 26 and 25% of predrug values for the three doses, respectively. Thermography and plethysmography were less sensitive for detecting effects of TGLVP than laser Doppler flowmetry. Minor effects on blood pressure and heart rate were recorded after TGLVP, but no disturbances in electrocardiac activity. Urinalyses revealed an antidiuretic action of TGLVP. The study supports earlier findings and suggests a dose level of TGLVP for the use in excision of burns.

Caustic Burns from Contact with Wet Cement

Cement is a widely used mixture in construction. A corrosive alkali, calcium hydroxide, is liberated as water is added to the lime present in the cement mixture. Skin contact for prolonged periods produces deep chemical burns with thick eschar formation. Five cases of chemical burns to the lower extremities following contact with the cement mixture are presented. When full-thickness burns were present, long periods of hospitalization were necessary for eschar separation prior to skin grafting. Early excision of full-thickness caustic burns with immediate skin grafting diminished the length of hospitalization and returned the patient to work sooner. (JAMA1985;254:528-529)

The effect of immediate v delayed burn wound excision on pulmonary function

Pulmonary dysfunction has been reported as a complication of burn wound excision. It remains undetermined as to the degree of lung injury and whether this is caused by bacteria or by inflammatory mediators released during excision of the wound. We produced a 15% full thickness burn in 19 sheep and completely excised the would under general anesthesia immediately postburn or at days 4 and 5 or days 7 and 8. Pulmonary parameters measured were of dynamic lung compliance, C DYN PaO 2 /FiO 2 , pulmonary artery pressure (Ppa), and burn lymph, venous, and aortic TxB 2 . There was a transient increase in wound lymph and plasma TxB 2 during immediate excision, increasing from a preburn value of 200 and 220 ± 50 pg/mL, to 950 ± 210 and 800 ± 180 pg/mL, respectively. However, pulmonary parameters remained unchanged. Animals excised at four or five days (n = 7) demonstrated a transient (one- to two-hour) decrease in C DYN and an increase in Ppa, as well as an increase of TxB 2 in plasma and burn lymph. Two of seven demonstrated a more protracted decrease in compliance and gas exchange postexcision, corresponding with a more protracted increase in plasma TxB 2 . Animals excised at 7 to 8 days (n = 7) demonstrated a similar increase in TxB 2 in lymph and plasma and a similar transient lung dysfunction. Three of seven demonstrated more pronounced pulmonary changes. Four out of five sheep from both excision periods demonstrating more severe lung dysfunction and increased TxB 2 levels had wound quantitative cultures greater than 10 7 bacteria/g. However, four of nine sheep with only a transient lung response also had increased bacterial contents but only modest increases in TxB 2 . We conclude that the pulmonary changes seen with delayed burn excision are only modest in degree and are the result of wound mediator release, rather than the direct effect of wound bacterial content.

Quantitative assessment of burn injury in porcine skin with high-frequency ultrasonic imaging.

Early excision and grafting of full thickness burns has been shown to decrease morbidity and mortality. Errors made in assessing acute burn depth are common and result in prolonged hospitalization in expectant healing of full-thickness burns and in unnecessary excision and grafting of potentially regenerative partial-thickness burns. High-frequency ultrasonic imaging may be a noninvasive, convenient means of quantitating burn depth. A depth analysis system for imaging burned skin was developed using a high-frequency 18.5 MHz (nominal 25 MHz) pulse-echo ultrasound system with a longitudinal resolution of 86 mu. Five adult mini-swine (15 kg) were burned with a temperature-(190 degrees C) and pressure-controlled (236 g/cm2) burning iron. A series of burn durations (1-45 seconds) was used to inflict partial- and full-thickness burns of various depths. Ultrasonic scans of the acutely excised burns were performed across the lateral margin of the burn, including adjacent normal skin to serve as control. Direct histologic comparison was made with each scan plane. Average burn and normal skin depth measurements were made by independent observers for 34 scans and corresponding histologic sections. A significant correlation was achieved between burn depth and percent burn (burn depth/adjacent normal skin depth) as measured by ultrasound and histology (R = 0.90, t = 11.2, P less than .001).

Circumferential burns to the fingers associated with gold and platinum rings

Two patients sustained circumferential burns to the fingers associated with metal rings. The first case was caused by molten zinc and was treated by early burn excision and split skin grafting, while the second case was an electrical burn caused by a car battery and was treated conservatively.

Temporary wound closure after burn excision.

Temporary wound closure after burn excision.

Excision and grafting of large burns: operation length not related to increased morbidity.

In order to study the relation between length of operation and postoperative morbidity in patients with burns greater than 30% TBSA a retrospective review was done. Seven categories of morbidity were chosen and points assigned for significant change from the preoperative state. There were no intraoperative or immediate postoperative deaths. The overall morbidity was 19%. The eventual mortality was 19%. There was no correlation between length of operation and postoperative morbidity.

Selective aggressive burn excision for high mortality subgroups.

Traditional teaching recommends major burn procedures be limited to successive 20% total body surface area (TBSA) excision and grafting procedures. This format theoretically reduces the surgical stress and limits the transfusion requirements to a level reasonably tolerated by patients. We have treated 14 patients with thermal burns involving greater than 30% TBSA. These patients underwent excisions ranging from 30 to 70% TBSA at the initial operative escharectomy. Tangential and fascial excisions were employed, depending upon the depth of injury, and autografts and/or allografts were utilized for wound closure. The results of this technique yielded an overall 71% survival. Time from burn to last autograft and hospital stay tended to be shortened or unchanged when compared to national averages. This series demonstrates the feasibility of performing early major escharectomy in a selected burn population without apparent increased surgical risk compared to patients treated by conventional staged excision. Although burn wound sepsis and mortality appeared favorably affected by this technique, the small population size was unsuitable for adequate statistical analysis.

Early excision of major burns in children: Effect on morbidity and mortality

The advantage of early excision and grafting in the treatment of limited full-thickness burns has been clearly established. The goal of the present study was to evaluate the role of early burn wound excision in major pediatric burns. Of the 470 pediatric burn admissions between 1979 and 1984 that were reviewed, 53 patients met the criteria of deep second or third degree burns greater than 25% total body surface area (TBSA). Of these, 20 had burn wound excision within 7 days (Early) and 33 had delayed excision and grafting (Late). The Early group, despite having greater transfusion requirements (69.4 v 36.2 cc/kg), had shorter hospital stays (35.3 v 49.1 d, P less than 0.05), fewer metabolic complications (20% v 79%, P less than 0.001), and less burn wound contamination (55% v 90%, P less than 0.01) than the Late group. Mortality was lower in the Early group (0% v 12%), but this was not statistically significant. Early excision and grafting are therefore recommended in the care of major burns in children.

Caustic Burns From Contact With Wet Cement

Cement is a widely used mixture in construction. A corrosive alkali, calcium hydroxide, is liberated as water is added to the lime present in the cement mixture. Skin contact for prolonged periods produces deep chemical burns with thick eschar formation. Five cases of chemical burns to the lower extremities following contact with the cement mixture are presented. When full-thickness burns were present, long periods of hospitalization were necessary for eschar separation prior to skin grafting. Early excision of full-thickness caustic burns with immediate skin grafting diminished the length of hospitalization and returned the patient to work sooner.

Results of early excision and grafting in hand burns

A total of 658 admissions to the Burns Unit at the Royal Brisbane Hospital were reviewed over a 4-year period. During this time, 73 hand burns were treated. The policies of the Burns Unit regarding hand burns are detailed; and, where possible, early excision and grafting is performed. The results of these hand burns are discussed and indicate minimal requirements for reconstructive surgery. The most common reconstructive surgery needed was for web space release in 10 patients and excision of hypertrophic scar in 2 patients. It is concluded that early excision and grafting of hand burns is safe and practical, and combined with adequate splinting, exercise and pressure garments, gives good results and lessens hospital stay in patients with relatively small injuries. The duration of stay in hospital in patients with large burns is not due to the treatment of their hand burns, but to their overall large body surface area burnt.

The tangential excision of extensive or deep burns

This report contains our experience gained over 13 years of the tangential excision of burned tissue in 627 patients. We have discussed the indications for and timing of tangential excision, methods of determining the margin between viable and non-viable tissue using histological studies in some patients and the problem of wound coverage after tangential excision.

Immediate excision and skin graft of a friction burn in a replanted thumb with a note on its usefulness and indications

A case is presented in which an area of friction burn was excised from the dorsum of a replanted thumb and the wound closed with a split-skin graft. In our experience successful revascularisation of similar injuries has often been followed by progressive venous failure. It is suggested that this technique, by decompressing the tissues, may prevent stagnation and propagation of thrombus, protect the interpositional graft and avoid subsequent venous failure with loss of the replanted digit.

Effect of early burn excision and grafting on pulmonary function.

The effects of early burn excision and grafting on pulmonary function were measured. Blood gases, PaO2/FIO2, and dynamic lung compliance were measured before, during, and after 70 procedures in 37 patients with major body burns, 22 of whom also had significant superimposed impairment in lung function. Excisions were carried out 24 to 48 hours and again 5 to 7 days postburn, only in hemodynamically stable patients in whom ventilation could be safely maintained to, from, and in the operating room. We noted no instances of increased pulmonary dysfunction which were not rapidly reversible in the postoperative period. A modest transient decrease in lung compliance and oxygen exchange, as well as an increase in PaCO2, was seen which we attributed to a discontinuation of PEEP (positive end expiratory pressure) and underestimation of needed minute ventilation intraoperatively and during transport. This was in large part corrected in the latter part of the study period. Seven patients, mean age 67 years, were included in the series. All patients did well. We conclude that if proper precautions are made, early excision can be safely performed in patients with altered lung function.

Early or late excision of hand burns

In intestinal mucosa of fed adult rats, cytochrome P-450 content and activity of benzpyrene hydroxylase and p-nitroanisole O-demethylase are highest in the upper small intestine and progressively decrease toward the terminal ileum. Among the mucosal cell populations, mature villous tip cells contain 6 to 10 times more cytochrome P-450 and drug-metabolizing activity per mg microsomal protein than epithelial crypt cells. On restriction of dietary iron intake for 48 hr, cytochrome P-450 content and drug-metabolizing enzyme activity of villous tip cells decrease to 42% and 13% of control values, but are restored within 24 hr by oral iron supplementation. These findings suggest that intestinal drug metabolism is localized primarily in upper villous cells of duodenal mucosa, that cytochrome P-450 is synthesized in maturing epithelial cells as they migrate to the top of the mucosal villus and that this process is critically dependent on dietary (luminal) iron.

Triglycyl-lysine-vasopressin or lysine-vasopressin in early excision of burns. An experimental study comparing the effects on blood loss, hemodynamics and renal function.

Twelve piglets were submitted to a third degree burn covering one third of total body surface area under general anesthesia. Fluid treatment was given in amounts corresponding to 2.4 ml/kg/% burn/24 h, and hemodynamics and renal function were monitored for 24 h. Regional blood flows were determined with the aid of the radioactive microsphere technique before burn, 5 and 24 h after burn respectively. One group was treated with triglycyl-lysine-vasopressin (TGLVP) as bolus injections and the other with lysine-vasopressin (LVP) in infusion. Both groups were submitted to excision of the burned tissues after 5 h. Total blood loss was 39 +/- 9 g in the TGLVP group and 51 +/- 7 g in the LVP group (n.s.). TGLVP changed the distribution of cardiac output (CO) more than LVP did, leading to smaller blood flows to the splanchnic organs, skin and carcass while the perfusion of the brain, heart, liver and kidneys was similar after 5 h. The burn caused a 30% decrease of CO in both groups. After the first TGLVP injection there was a small further decrease in CO but after excision there were similar recoveries of CO in both groups. After 24 h the CO redistribution remained during LVP infusion, but those effects had almost vanished in the TGLVP group. Total diuresis and the glomerular filtration rate tended to be larger during LVP treatment but there was no significant difference in serum creatinine after 24 h. Thus both drugs decrease blood loss during early excision and they seem to have similar effects on circulation and renal function.(ABSTRACT TRUNCATED AT 250 WORDS)