Burn Excision Research Articles

Survival and Wound Contraction of Full-Thickness Skin Grafts are Associated With the Degree of Tissue Edema of the Graft Bed in Immediate Excision and Early Wound Excision and Grafting in a Rabbit Model

The objective of this study was to evaluate the survival of skin grafts on graft beds of immediate excision and early wound excision at various time periods after burns and to establish the appropriate timing of burn excision and grafting in a rabbit model. Eight groups of male Japanese white rabbits (n = 5 per group) were established. Animals of all groups were given a 5 x 10-cm full-thickness burn on their shaved back and received the autografting 3, 6, 12, 18, 24, 48, and 72 hours and 5 days after receiving burns, respectively. Weekly skin-graft evaluation was performed for 5 weeks after grafting by measurement of the secondary skin graft contracture (in size) and the survival area of grafts, with use of computerized planimetry. In addition, relative quantitative analysis of exudation on the burned wound was evaluated. Our results indicated that the exudate-related graft loss and graft contracture varied according to the timing of wound excision. The wound contractures of the grafts were maximal in both the 18-hour and 24-hour groups at 2, 3, 4, and 5 weeks after grafting. The 18-hour and 24-hour groups exhibited significantly greater graft loss than the 72-hour and 5-day groups (P < .05). An apparent increase in the amount of exudation on the graft bed was shown in the 18- and 24-hour groups vs the other groups (P < .05). A reverse correlation was detected between the survival area of the skin graft and the degree of exudation of the graft bed. In conclusion, the survival area and secondary contraction of skin grafts are associated with the degree of tissue edema of the graft bed in immediate excision and early excision in the rabbit model. The adverse affect of edema leakage on the graft bed for skin graft survival was shown. We believe that immediate excision or early wound excision and grafting performed within 12 hours after burn or 48 hours later should be considered in the rabbit model.

The recliner position: A new operating position for burn surgery

Correct positioning of a patient provides the necessary exposure for a surgeon to gain access to complicated burn wounds and therefore can become an essential aspect in determining the procedure’s eventual success. Excision and grafting of burns to the anterior and posterior portions of the shoulder pose special problems stemming from the difficulty in obtaining complete surgical exposure of the entire burn wound with the patient in one position. Thus, excision of circumferential burns of the upper torso often needs to be performed in stages, or necessitates turning the patient intraoperatively with the attendant potential complications. We describe a new position for patients who have sustained deep burns to both anterior and posterior aspects of the upper torso. This technique allows for complete access to the shoulders, and if necessary, the posterior neck.

Predictive model for intra-operative blood loss at initial excision and grafting in adult burn patients

McMullin, Neil R. MD; Wang, Jingjing MS; Wolf, Steven MD; Holcomb, John MD; Wade, Charlie PhD Author Information

Soft Tissue Coverage of the Knee Joint Following Burns

Full-thickness burns around the knee joint are usually associated with exposure of bone, tendon or ligaments. Following excision of the deep burns, there is no viable wound bed to which skin grafts can be applied. Although vacuum-assisted closure has been used to encourage granulation tissue, exposure of the tendons and ligaments following excision usually requires muscle flaps or fasciocutaneous flaps.

The recliner position: Modified operating position for burn surgery

Introduction: Excision and grafting of burns to the shoulders pose special problems stemming from the difficulty in obtaining surgical access to the entire burn wound with the patient in one position. We describe a positioning technique, which allows access to circumferential burns of the shoulders and posterior portions of the neck. Observation: Access to burns to the shoulders for excision and grafting usually requires the need to turn the patient from the supine to the prone position intraoperatively, with the potential complications associated with re-positioning. These include, but are not limited to, prolonged anesthesia time, risks of shearing the skin grafts and bleeding under the grafts. We describe the recliner position, which provides surgical access to these types of wounds and permits the excision and grafting in one operation. In addition to improved exposure of the surgical site, potential advantages of this position include a reduction of bleeding due to lowered venous pressures and improved pulmonary function due to the redistribution of blood flow to the lower and better ventilated lung segments. Conclusion: The recliner position, when used to excise and graft burns to the shoulders and posterior portions of the neck, removes the necessity to reposition the patient, thereby reducing intra-operative time and complications associated with conventional position.

Meta-analysis of early excision of burns

Aims This meta-analysis sought to establish if early excision and grafting is better or equivalent to the conservative treatment of burns in both children and adults with minor or major burns. The outcomes of interest are mortality, wound healing time, duration of sepsis, operating hours, complications of surgery, length of hospital stay, blood transfusion requirements and long term morbidity like joint contractures and hypertrophic scarring. Methods We searched MEDLINE (1966–July 2004), EMBASE (1980–August 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) with the keywords ‘early excision’ and ‘burns’. This yielded 441 articles of which 15 were randomized controlled trials. Only six trials met the inclusion criteria. Results There was a significant reduction in mortality with early excision of burns when compared with traditional treatment only in patients without inhalational injury (RR 0.36, 95% CI 0.20 to 0.65). The blood transfusion requirement is significantly higher in the early excision group but the length of hospital stay was significantly shorter (WMD −8.89, 95% CI −14.28 to −3.50). There was no conclusive evidence on the difference between the two groups in terms of duration of sepsis, wound healing time and skin graft take. Conclusion Early excision of burns is beneficial in reducing mortality (in patients without inhalational injury), length of hospital stay. The only drawback is the greater volume of blood loss.

The Use of Hydrogen Peroxide for Achieving Dermal Hemostasis After Burn Excision in a Patient with Platelet Dysfunction

As a topical hemostatic agent, hydrogen peroxide (3%) has been applied to tangential excisions of burn patients. Hydrogen peroxide provides an adjunct to topical epinephrine for hemostasis and clinically has been most useful in patients with known platelet dysfunction. Hydrogen peroxide should be irrigated from the wound bed before the placement of skin grafting because of its potential to inhibit wound healing. In our experience, hydrogen peroxide (3%) soaks have not resulted in complications related to corrosive damage, oxygen gas formation, or lipid peroxidation that are associated with high concentrations of hydrogen peroxide (30%). We also have experienced excellent skin graft take at the wound bed after using hydrogen peroxide.

Early Excision of a Full-Thickness Burn Prevents Peripheral Nerve Conduction Deficits in Mice

A full-thickness 20 percent body surface area burn in mice produces a significant decrease in tibial motor nerve conduction velocity within 6 hours of the burn and in sensory conduction velocity within 7 days. This suggests that cutaneous burn injury produces a systemic response that affects peripheral motor and sensory nerve function at a distance from the burn site. The authors tested the hypothesis that burn wound excision either 30 minutes or 3 hours after burn would prevent neuropathy. A 20 percent body surface area third-degree burn was applied to the backs of anesthetized mice using procedures that followed National Institutes of Health guidelines. Motor nerve conduction velocity and sensory conduction velocity were determined in intact, anesthetized mice by percutaneous nerve stimulation. Burn wounds were excised and closed at 30 minutes or 3 hours after burn. Motor nerve conduction velocity and sensory conduction velocity were measured before burn and 1, 3, 7, 14, and 21 days after a burn or sham procedure. The number of circulating neutrophils and serum concentrations of tumor necrosis factor-alpha, nitrite, and electrolytes were also determined in each group. Motor nerve conduction velocity and sensory conduction velocity in the 30-minute excision (n = 10) and sham group (n = 5) were not significantly different. Motor nerve conduction velocity and sensory conduction velocity in the nonexcised group (n = 10) and 3-hour excision group (n = 10) were significantly decreased. Serum tumor necrosis factor-alpha concentration was elevated 6 hours after burn in nonexcised animals (n = 9) and in 3-hour excision mice (n = 8) but was not significantly different in the sham (n = 8) and the 30-minute excision group (n = 7). The authors conclude that burn wound excision at 30 minutes but not at 3 hours prevents the nerve conduction deficits measured in mice with 20 percent body surface area burns. The cellular basis of burn-induced neuropathy is unknown, but nitric oxide and tumor necrosis factor alpha-alpha appear to play a role.

The Versajet??? Water Dissector: A New Tool for Tangential Excision

Goulian and Watson knives work well for tangential burn excision on large flat areas. They do not work well in small areas and in areas with a three-dimensional structure. The Versajet Hydrosurgery System (Smith and Nephew, Key Largo, FL) is a new waterjet-powered surgical tool designed for wound excision. The small size of the cutting nozzle and the ability to easily maneuver the water dissector into small spaces makes it a potentially useful tool for excision of burns of the eyelids, digits and web spaces. The Versajet Hydrosurgery System contains a power console that propels saline through a handheld cutting device. This stream of pressurized saline functions as a knife. We have used the Versajet for burn excision in 44 patients. Although there is a learning curve for both surgeons using and operating room staff setting up the device, the Versajet provides a relatively facile method for excision of challenging aesthetic and functional areas.

화상 및 창상에 대한 자근.치자 복합제제의 경피 흡수 및 치료효과

Research was undertaken to compare the pharmacological activity of Lithospermi radix (LR) reported as an oriental medicine for classical uses. LR contains naphthoquinone pigments : shikonin, acetylshikonin, isobutylshikonin, etc. LR is used for the treatment of excision wound, burn, eczema, blister, scarlatina and septicemia as antifebrile, antidotic and antiphlogistic. Gardeniae fructus (GF) has been used for the treatment to jaundice, hepatic disease, anti-inflammatory and analgesic effects, and it contains crocin, geniposide and its derivatives. The therapeutic effects of burn and excision wound healing from LR & GF hydrogel with (GLN) were investigated. To evaluate the therapeutic value of various hydrogels, thermal burn model and excision wound mouse model were used. The burn and wound reduction rate and therapeutic period were measured to calculate the healing extent after 5 experiments. The 2nd degree burn was prepared on hairless mouse back skin and dressing with collagen. The burn and wound reduction rate of GLN hydrogel treated group decreased more rapidly than that of other gel group in animal model. Furthermore therapeutic periods of GLN hydrogel treated group was shorter than that of other gel group. In anti-inflammatory test, GLN hydrogel treated group decreased edema rapidly than that of other gel group. These results suggest that the GLN hydrogel treatment has an therapeutic effect on burn and excision wound healing.

Results of a protocol of transfusion threshold and surgical technique on transfusion requirements in burn patients

Introduction: Blood loss and high rates of transfusion in burn centers remains an area of ongoing concern. Blood use brings the risk of infection, adverse reaction, and immunosuppression. Methods: A protocol to reduce blood loss and blood use was implemented. Analysis included 3-year periods before and after institution of the protocol. All patients were transfused for a hemoglobin below 8.0 gm/dL. Results: Operations per admission did not change during the two time periods (0.78 in each). Overall units transfused per operation decreased from 1.56 ± 0.06 to 1.25 ± 0.14 units after instituting the protocol ( p < 0.05). Also, units transfused per admission decreased from 1.21 ± 0.15 to 0.96 ± 0.06 units of blood ( p < 0.05). This was noticed particularly in burns of less than 20% surface area, declining from 386 to 46 units after protocol institution, from 0.37 to 0.04 units per admission, and from 0.79 to 0.08 units per operation in this group of smallest burns. There was no change noted in the larger burns. Conclusions: This study suggests that a defined protocol of hemostasis, technique, and transfusion trigger should be implemented in the process of burn excision and grafting. This will help especially those patients with the smallest burns, essentially eliminating transfusion need in that group.

Use of the Mayfield Horseshoe Headrest for Management of Burns of the Neck

Proper positioning of a patient facilitates access and decreases frustration during surgical debridement of circumferential burns of the neck. The Mayfield swivel horseshoe headrest (Integra, USA) provides cranial support in either the supine or prone position for excision and skin grafting of the circumferential burns of the neck. This headrest can also be used during reconstruction of the neck.

Establishing transfusion needs in burn patients

Background Despite blood-conservation techniques, hemorrhage during burn excision remains substantial. It is difficult to predict the blood loss that will occur per operation and how many units the patient will require during surgery. This may result in high cross-match-to-transfusion ratios (CMTRs). Methods A retrospective chart review from 2001 to 2003 was performed. All adult patients with >20% total body surface area burns who underwent surgery were included in the study. Variables examined were centimeters excised, estimated blood loss, packed red blood cells transfused during surgery, preoperative and postoperative hematocrit, and CMTR. Results There were 273 operations. The average estimated blood loss was 820 mL, and; the median posttransfusion hematocrit was 27. Based on the area excised and units transfused, a ratio of packed red blood cells/cm excised was determined. A total of 1.78 U blood were transfused/1000 cm 2 excised to keep hematocrit between 25 and 31; P = 0.02. Conclusions Estimation of excision area can predict transfusion need, which at our institution yields a low CMTR.

Milk bottle burns.

In recent years numerous infants have been treated at Stoke Mandeville Hospital's Burns' Unit for scalds sustained in accidents that occurred during the preparation of warm milk. These were significant burns affecting young children with susceptibly thin skin that often resulted in the injured child requiring a long stay in hospital. Frequently, formal intravenous fluid resuscitation was required as was burn excision and skin grafting. We recommend the use of milk bottle warmer to avoid all the hazards associated with use of different techniques of warming milk bottle.

Skin and skin substitutes in burn management

Early burn excision has reduced the mortality from major burns. This practice presents the problem of wound coverage after excision, since the availability of autologous donor sites is limited in very large burns. This article reviews the methods available for covering burn wounds. Methods of expanding autologous skin are discussed as well as techniques using allogeneic tissue and xenograft. Newer synthetic skin substitutes have become an important advance and are also described. Cultured skin replacements are also discussed along with their shortfalls. The treatment of a patient with major burns may require the use of many different skin substitutes, as none is entirely satisfactory on its own.

A prospective double blind randomized study comparing the need for blood transfusion with terlipressin or a placebo during early excision and grafting of burns

Introduction: Early excision and skin grafting has become the standard of good burn management, but it is associated with major blood loss. Aim: To determine the haemostatic effect of terlipressin compared with placebo. Material and methods: Fifty-one patients with burns of 10–20% total body surface area had early excision and split skin grafting of deep burns. The surface area of the burn wound and of the healed graft were measured by planimetry. The patients were randomly allocated to medication, either terlipressin or placebo. Blood loss and number of transfused units of blood were recorded. Results: Twenty-one patients received terlipressin, 13 received terlipressin late (cross-over) and 17 received placebo. Six out of 21 patients exposed to terlipressin were transfused with eleven units of packed red blood cells. Seven out of 13 patients crossed over from placebo to terlipressin (late terlipressin) were transfused with 17 units of blood. Eight out of 17 patients exposed to the placebo were transfused with 22 units of blood ( P<0.05). Graft healing was 1055±609 cm 2 out of 1452±811 cm 2 in terlipressin and 914±633 cm 2 out of 1288±720 cm 2 in the placebo group (n.s.). Conclusion: Terlipressin reduced the need for blood transfusion by a factor of 2.5 compared to a placebo without impairment of graft healing.

Laser Doppler imaging determines need for excision and grafting in advance of clinical judgment: a prospective blinded trial

Introduction: Clinicians’ judgment as to which burns require excision and grafting remains one aspect of burn care without objective measurements. This study presents a prospective, blinded trial to assess decision to operate by laser Doppler imaging (numerical criteria) versus the clinical judgment of an experienced burn surgeon. Methods: A number of 23 patients were enrolled in this prospective trial and 41 representative wounds of indeterminate depth were selected for observation. Daily determination of need to operate (burn depth) was made by a single burn surgeon. Laser Doppler imager (LDI) scans of the same wounds were simultaneously obtained, and not revealed to the clinician. Data analysis compared quickness of decision to operate by LDI to the clinician’s judgment. Concurrence of decisions by either method was compared. Results: A total of 23 patients and 41 wounds were analyzed. LDI and the surgeon agreed in determination of wound depth 56% of the time (23/41, P=0.031). Biopsy confirmation was obtained for 21 wounds. The surgeon’s determination of burn depth was accurate in 71.4% of wounds biopsied (15/21). When the LDI scan median flux indicated need for excision, it was 100% accurate (7/7). When both the surgeon and the LDI were correct in assessing wound depth, LDI would have saved median number of 2 days (minimum=0, maximum=4). Conclusion: LDI allowed for earlier, objective determination of need to operate. Concurrence with clinical judgment in this blinded study was excellent. LDI should be seen as an effective aid to clinical judgment when contemplating excision of burns with indeterminate depth.

Effects of early excision and aggressive enteral feeding on hypermetabolism, catabolism, and sepsis after severe burn.

Severe burn induces a systemic hypermetabolic response, which includes increased energy expenditure, protein catabolism, and diminished immunity. We hypothesized that early burn excision and aggressive enteral feeding diminish hypermetabolism. Forty-six burned children were enrolled into a cohort analytic study. Cohorts were segregated according to time from burn to transfer to our institution for excision, grafting, and nutritional support. No subject had undergone wound excision or continuous nutritional support before transfer. Resting energy expenditure, skeletal muscle protein kinetics, the degree of bacterial colonization from quantitative cultures, and the incidence of burn sepsis were measured as outcome variables. Early, aggressive treatment did not decrease energy expenditure; however, it did markedly attenuate muscle protein catabolism when compared with delay in aggressive treatment. Wound colonization and sepsis were diminished in the early treatment group as well. Early excision and concurrent aggressive feeding attenuate muscle catabolism and improve infectious outcomes after burn.

The use of tourniquets in the excision of unexsanguinated extremity burn wounds

Purpose: Tangential excision of burns is complicated by blood loss. Tourniquet use decreases blood loss, but adequacy of excision has been questioned. An attempt was made to assess the value of not exsanguinating the limb prior to tourniquet inflation to improve visualization of bleeding points and subsequent engraftment. Methods: Eleven excisions of bilateral extremity wounds were performed. One limb was excised without the benefit of a tourniquet, the other with tourniquet but without exsanguination. Tangential excision was performed, hemostasis achieved, and blood loss quantified. Engraftment of skin was assessed at first dressing change and at initial follow-up after discharge. Results: Area of burn was the same, 4.8% with tourniquet, 5.1% without ( P=0.38). Overall blood loss was less with tourniquet control, 100–259 cm 3 ( P=0.002); as was blood loss per area, 0.19–0.58 cc/cm 2 ( P=0.04). Graft take was similar, 98.2% early and 98.1% later with tourniquet, with 98.2 and 96.8% take without ( P>0.1). Conclusions: Tourniquet use in the unexsanquinated extremity reduced blood loss without affecting engraftment.

The effect of prolonged euglycemic hyperinsulinemia on lean body mass after severe burn

Background. The hypermetabolic response to burn increases protein catabolism. Euglycemic hyperinsu-linemia with exogenous insulin maintains muscle protein by continued stimulation of net protein synthesis. Our aim was to determine the effect of euglycemic hyperinsulinemia over the entire hospitalization on muscle anabolism by investigating lean body mass (LBM) as the primary endpoint. Methods. Eighteen subjects between the ages of 2 and 18 with burns of more than 40% were prospectively randomized into 2 groups, a control (n = 9) and a treatment group (n = 9). The treatment group was given continuous intravenous insulin at a rate of at least 1.5 μU/kg/min to maintain serum glucose levels between 100 to 140 mg/dL. Treatment was instituted 24 to 48 hours after arrival and continued until the patient's injury was 95% healed. All patients received continuous enteral feeding. Patients underwent body composition studies by dual-energy x-ray absorptiometry (DEXA) scan on postoperative day 6 after initial burn excision and when 95% healed. Results. Nutritional intakes were not different between groups. In the control, subjects continued catabolism resulted in peripheral muscle wasting and centripetal obesity with diminished truncal LBM. The treatment group had improvement in lean body mass (P =.004) and bone mass (P =.025). The treatment group also had less peripheral muscle wasting with overall increases in upper/lower extremity LBM (P =.005). Hospital length of stay in days per percent of total body surface area burned was decreased in the insulin group (control = 1.03 ± 0.1 vs 0.7 ± 0.9 for insulin patients; P <.05). Conclusions. Euglycemic hyperinsulinemia throughout the hospital course mitigates muscle catabolism and preserves lean body mass. (Surgery 2002;132:341-7.)