Burn Excision Research Articles

Early excision and grafting of face and neck burns in patients over 20 years.

Although excision and grafting of burns has become common and standard, many surgeons have been reluctant to excise and graft face burns. In fact, we could find photographic results at 1 year after grafting of only eight patients in the English literature. We began excision and grafting of face burns in 1979 and presented our first 16 patients in 1986 in this journal. With encouragement from Janzekovic and Jackson, we continued and have now used essentially the same procedure for more than 20 years in approximately 100 patients and, from this large series, are able to present outcomes. From January of 1979 to May of 1999, we performed excision and grafting on 91 patients with deep face burns. Data were recorded and 35-mm photographs were obtained throughout the 20-year period. We reviewed that database and the slide files of these patients. We found 45 patients with complete photographic sets including 1-year follow-up. Since, in our opinion, there is no useful, objective measure of appearance, we decided to simply publish all 45 sets of complete photographs, permitting the reader to subjectively form an opinion of the outcome of this procedure. The results are all shown as "full" face burns and two "partial" face burns. We continue to believe that early excision and grafting is indicated for face burns that will not heal within 3 weeks and that the procedure yields results that permit the burn victims to return to society and minimizes the time off work or out of school.

Early Burn Excision Prevents the Acute Motor Nerve Conduction Deficit in Mice Caused by a Full Thickness Burn

Early Burn Excision Prevents the Acute Motor Nerve Conduction Deficit in Mice Caused by a Full Thickness Burn

Propranolol Is Beneficial in Children With Acute and Severe Burns

Source: Herndon DN, Hart DW, Wolf SE, et al. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med. 2001;345:1223–1229.At the University of Texas Medical Branch, Galveston, 25 children (<18 years of age) with acute, severe burns (more than 40% of the total body surface area) were randomized to receive oral propranolol or placebo for at least 2 weeks. All patients had been resuscitated and had initial excision and grafting within 48 hours of admission and were stabilized for at least 5 days prior to entering the study. The dose of propranolol was adjusted to decrease the resting heart rate by 20% from the patient’s baseline. Resting energy expenditure and skeletal muscle protein kinetics were measured before and 2 weeks after initiation of the study.Patients in each group had similar ages and severity of burn injury. The average dose of propranolol necessary to achieve a 20% decrease in resting heart rate was 1.1 mg/kg every 4 hours. Blood pressure, glucose and temperature did not differ significantly between study groups. Resting energy expenditure (140 kcal/day) and oxygen consumption (25 ml/min) increased in the control group 2 weeks after study initiation. The resting energy expenditure in children who received propranolol decreased (−422 kcal/day, P=.01), as did oxygen consumption (−56 ml/min, P=.002). Children treated with propranolol had net protein synthesis while control patients had net protein breakdown. Children in the 2 treatment groups did not have significant differences in baseline insulin-like growth factor, growth hormone, cortisol, or insulin levels. Changes in these hormone levels during the study did not differ significantly between the treatment groups. The authors conclude that treatment with propranolol attenuates hypermetabolism and reverses muscle-protein catabolism.Hypermetabolism, secondary to catecholamine mediation, is the hallmark of thermal injury.1,2 The resting energy expenditure can be doubled in patients with burns ≥40% of body surface area resulting in muscle loss. This muscle loss can lead to delay in wound healing, graft loss, ventilator dependence, and other complications, with the potential for increased hospital length of stay. The current strategy used to prevent muscle loss is to administer high-protein, high-calorie nutrition, preferably enterally. Sometimes, parenteral nutrition is needed when enteral nutrition is not sufficient or is not tolerated. The administration of large amounts of protein and carbohydrates can be fraught with complications, which include hyperglycemia, diarrhea, and dehydration.Other researchers have demonstrated that the heart rate correlates with resting energy expenditure in adults.3 Decreasing the heart rate by 20% from the patients’ baseline significantly reduced the muscle loss in these patients. This study did not evaluate wound healing, wound complications, or hospital length of stay. However, preventing muscle loss should be beneficial in seriously burned children. It is important to note that the administration of propranolol began after the patients were fully resuscitated and had undergone excision of burns with grafting. Blunting the tachycardic response may mask inadequate resuscitation or early sepsis and, therefore, these patients must be carefully monitored.Using a beta-blocker to reduce metabolic demands in burn patients is ingenious. While propranolol may not be able to be used in all burn patients (eg, asthmatics), this paper should spark interest in further studies to confirm these preliminary findings.

Storage media and temperature maintain normal anatomy of cadaveric human skin for transplantation to full-thickness skin wounds.

Cadaveric human skin provides an optimal temporary cover after early excision of full-thickness burns; however, engraftment is reduced greatly by cryopreservation. Refrigerated skin is generally preferred because of its rapid revascularization, presumably caused by its greater viability. In this study, the effects of storage solutions, temperature, and the changing of the storage media on skin graft anatomy were evaluated as an indicator of graft viability. Split-thickness human skin grafts (0.012-0.015 mm) were retrieved from cadaveric donors and grafted to circumferential, full-thickness skin wounds on athymic mice. After clinical determination of engraftment 3 months after grafting, 6-mm punch biopsy samples of the human skin were harvested and separated into two groups. Biopsy samples were stored in either saline or Eagle's minimal essential medium. Media were not changed or were changed every 3 days. All groups were stored at either 4 degrees C or room temperature (RT). After 5, 10, and 21 days of storage, biopsy samples were grafted onto athymic mice for 20 days. The biopsy grafts were then collected and prepared for histologic scoring on a scale of +4 (normal anatomy) to 0 (no epithelial cells). Significant differences in histologic scores were found by the nonparametric Kruskal-Wallis test followed by Wilcoxon pairwise comparison. Skin stored in media maintained better histologic anatomy than skin in saline, suggesting better maintenance of viability. There was also better preservation of anatomy after storage at RT for 21 days with media changes every 3 days when compared to unchanged media and all conditions at 4 degrees C. These results support the hypothesis that increased availability of nutrients and increased storage temperature maintain higher viability of cadaveric human skin for transplantation to full-thickness cutaneous wounds.

The use of silver coated dressings on donor site wounds: a prospective, controlled matched pair study

Acticoat, a new silver-coated dressing, produces a moist healing environment along with the sustained release of ionic silver for improved microbial control. These properties suggest that Acticoat might be a useful donor site dressing. However, there are no human studies which assess Acticoat for this use. The purpose of this study was to compare the healing of human skin graft donor sites dressed with Acticoat, to the healing of those dressed with Allevyn, an occlusive moist-healing environment material, which is our standard donor site dressing. In burn patients who had undergone burn excision and grafting, identical side-by-side split thickness donor site wound pairs were dressed with Allevyn and Acticoat. Re-epithelialization was directly assessed daily by a single observer from post-operative day 6 onward, and by four independent observers who rated the extent of re-epithelialization by viewing standardized digital images of the wounds that had been obtained on post-operative days 6, 8, 10,and 12. Donor sites were swabbed for bacterial culture on days 3, 6, and 9. Subsequently, each study donor site scar was rated by a blinded observer using the Vancouver Scar Scale at 1, 2, and 3 months. Sixteen paired sites in 15 patients (3 female, 12 male) were studied. Donor sites dressed with Allevyn were >90% re-epithelialized at a mean of 9.1±1.6 days while donor sites dressed with Acticoat required a mean of 14.5±6.7 days to achieve >90% re-epithelialization ( P=0.004). The Allevyn sites had significantly greater estimated re-epithelialization at days 6, 8, 10 and 12 than the Acticoat sites based on the observations of the digital images. There were no significant differences in the incidence of positive bacterial cultures with either dressing at days 3, 6, and 9. Donor sites dressed with Acticoat had significantly worse scars at 1 and 2 months but this difference resolved by 3 months. Our findings do not support the use of Acticoat as a skin graft donor site dressing.

Determinants of blood loss during primary burn excision

Background. Excisional therapy for burn wounds is frequently associated with large operative blood losses. Our objective was to identify patient and operative factors that affect surgical blood loss and determine strategies to minimize hemorrhage. Methods. Data from 92 consecutive pediatric patients with severe burns (>40% total body surface area) were evaluated. Patient demographics, burn characteristics, operative factors, and clinical course variables were correlated with blood loss. Blood loss at the time of initial total burn excision was determined by a standardized, previously validated method. Data were analyzed sequentially and cumulatively through univariate and cross-sectional multivariate linear regression. Results. Demographic factors that correlated with increased blood loss were older age, male sex, and larger body size. Area of full-thickness (third-degree) burn correlated with blood loss, whereas total burn size did not. High wound bacteria counts (derived from quantitative tissue cultures), total wound area excised, and operative time were the strongest predictors of the volume of operative hemorrhage. Blood loss increased with delay to primary burn excision at a maximum at 5 to 12 days after burn injury. Conclusions. Early definitive surgical therapy before extensive bacterial colonization and rapid operative excision is a strategy that may decrease operative hemorrhage and transfusion requirements during burn surgical procedures. (Surgery 2001;130:396-402.)

Antibiotic Prophylaxis for Group A Streptococcal Burn Wound Infection Is Not Necessary

Historically, group A beta-hemolytic streptococci (GAS) burn wound infection has been a major source of morbidity and mortality in burn patients and has prompted the prophylactic administration of antibiotics to children with burns. Wound monitoring, surveillance cultures, and early excision of deep wounds may have changed this. Our objective in this project was to determine the efficacy of routine antibiotic prophylaxis in the era of early excision and closure of deep burn wounds. Two cohorts of burned children were compared: all children admitted during calendar years 1992 through 1994 (group 1) and during calendar years 1995 through 1997 (group 2). All group 1 children received routine GAS antibiotic prophylaxis. Only those group 2 children with documented positive admission or surveillance cultures for GAS were treated. There were 511 children in group 1 and 406 children in group 2. They were well matched for age (4.7 +/- 0.21 years vs. 5.3 +/- 0.26 years, p = 0.06) and burn size (11.0% +/- 0.7% vs. 12.4% +/- 0.8%, p = 0.18). GAS species were recovered at admission or during hospitalization from 11 (2.6%) of group 1 children and 18 (4.4%) of group 2 children (p = 0.05), indicating a marginally higher rate of carriage in group 2. Nevertheless, in group 1 there were three (0.6%) who developed GAS wound infection and in group 2 there were four (0.98%, p = 0.71). The incidence of GAS infection in those patients with positive admission cultures was three (27%) of group 1 and four (22%) of group 2. No child developed fulminant GAS infection. Routine antibiotic prophylaxis of burn wounds in children in not effective in further reducing a low baseline incidence of GAS wound infection if admission screening by culture is used to identify those children who carry the organism and early excision of deep burns is practiced.

Delayed primary excision and grafting of full thickness alkali burns of the hand and forearm

In a prospective study, 15 cases of domestic alkali drain cleaner burns involving the dorsal aspect of the hand and forearm were included. There were ten males and five females. The average age was 27 years and the mean total body surface area burnt was 2%. All patients failed to do immediate water lavage at home and hence all wounds ultimately required excision and grafting. Patients were initially treated with daily silver sulfadiazine dressing on an out-patient basis. Seven to 9 days after injury, patients were admitted to hospital and underwent excision and grafting. On final follow-up, there was excellent return of function, which was assessed using the grip strength of the hand and the range of motion of the wrist and fingers. Cosmetic appearance and texture of the graft were assessed according to a proposed grading system. The cosmetic result was considered satisfactory in 12 patients and poor in three patients. There were no excellent cosmetic results, because of hyperpigmentation of the healed graft. Advantages of delayed primary excision and grafting of full thickness alkali burns of the hand and forearm are discussed.

Recent advances in burn care

The patient with severe burn injuries offers significant challenges to the anesthesiologist. Inhalation injury continues to be the most significant contributor to morbidity and mortality despite recent advances in the techniques of mechanical ventilation and respiratory therapy. Operative procedures are complicated by the presence of severe pulmonary injury, massive blood loss, significant fluid shifts, and hypermetabolism, which alter the pharmacokinetics of many anesthetic agents. Recent advances in nutrition, respiratory support, the early excision of burns, and skin substitutes are improving survival from massive burns and decreasing the resultant disability.

Results of early excision and full-thickness grafting of deep palm burns in children.

The timing and method of treatment of deep palm and finger burns varies widely. Our protocol involves performing full-thickness skin grafts (FTSG) in nonhealing palm burns. We reviewed the functional and cosmetic results after FTSG to the palm. From August 1997 to April 1999, 11 patients (12 palms) underwent excision and FTSG within 2 weeks of injury. A panel of medical and nonmedical professionals evaluated follow-up pictures of the grafts at 1, 2 to 4, and beyond 4 months. Parameters used for evaluation were color match with the unburned skin (1 = no difference to 4 = large difference), graft thickness (1 = flat to 4 = markedly raised), overall appearance (1 = poor to 100 = excellent), and time to maturity. Hand function, as assessed by occupational therapy notes, was also recorded. All 12 grafted palms had a 100% take and healed with minimal scarring. Mean color match scores were 2.4 at 1 month, 1.8 at 2 to 4 months, and 1.6 beyond 4 months. On the graft thickness scale, grafts were given scores of 2.6, 2.2, and 1.9 during the same intervals. The overall appearance was 71 at 1 month, 81 at 2 to 4 months, and 85 beyond 4 months. All grafts except 1 were judged to be mature at 2 to 4 months follow-up. Full passive range of motion was attained in all grafted hands within the period of 2 to 4 months after operation. Early excision and FTSG of deep pediatric palm burns can be performed in the outpatient setting. The grafts have an acceptable color match, are minimally raised, and achieve excellent cosmetic result. The grafts mature within a few months after surgery to allow for rapid return to normal range of motion. FTSG should be considered as a first choice for deep palm burns.

Does burn wound excision after thermal injury attenuate subsequent macrophage hyperactivity and immunosuppression?

Studies have shown that cell mediated immunity is suppressed markedly following thermal injury. Macrophages and the activation of an inflammatory cascade that includes interleukin (IL)-1, IL-6, tumor necrosis factor-alpha (TNFalpha) and PGE2 have been implicated as causative factors. Burn wound excision and grafting is a common clinical practice that decreases patient morbidity and mortality. It is not known, however, if the salutary effects of this procedure are related to modulation of macrophage activity post-burn. Therefore, C57BL/6 female mice were subjected to a third-degree scald burn covering 25% of their total body surface area followed by complete excision and allografting of the injury site at 8, 24, or 72 h post-burn. Splenic macrophage function was assessed 7 days post-burn. Thermal injury without burn excision and grafting significantly increased macrophage TNFalpha, IL-6, nitric oxide, and PGE2 production in response to lipopolysaccharide stimulation, whereas IL-1beta production was not increased. Burn wound excision and grafting normalized TNFalpha production to sham levels, independent of when post-burn the procedure was conducted. In contrast, the elevated production of other inflammatory mediators (IL-1beta, IL-6, nitric oxide, PGE2) post-burn was unaffected by burn wound excision and grafting. Moreover, splenic T-lymphocyte proliferation was also suppressed at 7 days post-burn and was not improved by burn wound excision and grafting. These results, therefore, suggest that the beneficial effects of burn wound excision and grafting are likely to be related to the normalization of macrophage TNFalpha production as well as the maintenance of skin barrier function.

Minimizing blood loss in burn surgery.

Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound outcome in burn surgery. An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds. Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p = 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outcome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%. The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

The fate of the dorsal metacarpal arterial system following thermal injury to the dorsal hand: A Doppler sonographic study.

Hands are involved in over 70% of all serious burns. This study comprised 80 hands in 41 patients with burns of the dorsum of the hand. Eighty percent of the hands in our study had deep partial-thickness and full-thickness burns that had to be grafted. This study was performed to evaluate the patency of the dorsal metacarpal artery (DMCA) system in burn-injured hands. Sixteen hands healed spontaneously; 62 had to be excised and grafted. Doppler mapping of the dorsum of the hand was completed using an 8-MHz probe. Patent vessels were found in a pattern similar to that of a normal population in spontaneously healed and grafted partial-thickness burns. The incidence of dorsal arteries decreased from 100% for the first DMCA to 80% for the DMCA in the fourth web space. In full-thickness burns the correlation of burned hands to normal volunteers was only 80%. It can be concluded from the data that the DMCA system is not damaged by deep partial-thickness burns that are excised and grafted. The DMCA system is still intact in 80% of patients with full-thickness burns. The potential for elevating a DMCA flap is therefore preserved after burn excision and grafting. Preoperative Doppler examinations are recommended before planning the flaps.

Beta-adrenergic desensitization after burn excision not affected by the use of epinephrine to limit blood loss.

Burn patients have impaired myocardial function and decreased beta-adrenergic responsiveness. Further beta-adrenergic dysfunction from systemic absorption of topically administered epinephrine that is given to limit blood loss during burn excision could affect perioperative management. The authors evaluated the effect of topical epinephrine administration to patients during burn excision on the lymphocytic beta-adrenergic response. Fifty-five patients (age, 2-18 yr) with 20-90% body surface area burns received a standardized anesthetic for a burn excision procedure. Lymphocyte samples were taken at baseline and 1 and 3 h after the initial use of epinephrine (n = 43) or thrombin (controls, n = 12). Plasma epinephrine levels were measured by high-performance liquid chromatography. Lymphocyte beta-adrenergic responsiveness was assessed by measuring production of cyclic adenosine monophosphate (cAMP) after stimulation with isoproterenol, prostaglandin E1 (PGE1), and forskolin. beta-adrenergic receptor binding assays using iodopindolol and CGP12177 yielded beta-adrenergic receptor density. Epinephrine levels were elevated at 1 h (P < 0.01) and 3 h (P < 0.01) after epinephrine use but not in control patients. Production of cAMP in lymphocytes 1 h after epinephrine was greater in patients receiving epinephrine than in control patients on stimulation with isoproterenol (P < 0.05) and PGE1 (P < 0.05). Three hours after epinephrine administration, production of cAMP decreased when compared with baseline in both control patients and those receiving epinephrine after stimulation with isoproterenol (P < 0. 05), PGE1(P < 0.05), and forskolin (P < 0.05). Lymphocytic beta-adrenergic receptor content was not changed. Topical epinephrine to limit blood loss during burn excision resulted in significant systemic absorption and increased plasma epinephrine levels. Acute sensitization of the lymphocytic beta-adrenergic cascade was induced by the administration of epinephrine reflected by increased cAMP production after stimulation with isoproterenol and PGE1. The lymphocytic beta-adrenergic cascade exhibited homologous and heterologous desensitization 3 h after the use of epinephrine or thrombin, indicating that epinephrine administration was not a causative factor.

Infections in critically ill pediatric burn patients

Refinement of the surgical approaches to large wounds and improvements in critical care have extended our ability to support children with increasingly severe burns through the physiological trial of staged wound closure. However, as early burn excision and closure decreases the incidence of burn wound infection, the occurrence of other infections has increased. Sepsis remains the single largest killer of children in the burn unit. Knowledge of those infections likely to occur in burned children will facilitate early intervention and decrease mortality. Copyright © 2000 by W.B. Saunders Company

Then and now: treatment volume, wound coverage, lung injury, and antibiotics: a capsule history of burn treatment at mid-century

While there are many ways in which the treatment of burns was improved at mid-century, four seem to lead the list: uid therapy; prompt wound coverage; the nature of lung injury; and infection. Marked improvement in these four realms of burn therapy occurred simultaneously, beginning just before and during World War II, and for a decade afterwards. It was my privilege to be a part of this scene and I relate these stories with a sense of nostalgia and the triumphs of Oliver Cope and his group, while at the same time bowing to the immense advances that have been made by other groups since that time [1±21]. The ®rst of these foci was that of improved understanding of the pathophysiology of burns, the volume and nature of uid dislocations caused by burns, and their treatment, as well as the nature of toxic substances that, superimposed on volume-reduction, caused renal failure. The second advance was a clear de®nition of the importance and methods for expeditious wound closure by burn excision and prompt grafting. Thirdly, was the elucidation of the nature of lung injury in burns, and fourthly, the availability of antibiotics to control infection. All four of these advances became available at or about the time ofWorldWar II.

Early tangential excision and skin grafting of moderate burns is superior to honey dressing: a prospective randomised trial

Methods: In this prospective trial, 50 burn patients were randomised to be treated either with early tangential excision and skin grafting or by the application of honey dressings, with delayed skin grafting as necessary. The 25 patients in the tangential excision (TE) group had burns of 23±4%, 12% of which was full thickness. The honey treated patients (HT), (N=25), had burns of 24±4%, 13% of which was full thickness. Seventeen of the TE patients were operated upon on day 3, the remainder before day 6 post burn. Eleven of the HT patients eventually required skin grafting. Cosmetic and functional results were assessed at 3 months post discharge. Results: In the TE group, the skin grafting take rate was 99±3%. In the HT group, the graft take rate was 74±18% ( P<0.01). The mean percentage of blood volume replaced was 35±12% in TE patients vs. 21±15% in HT patients ( P<0.01). Only one TE patient died due to status asthmaticus, while there were 3 deaths, all from sepsis, in the HT patients. At 3 month follow-up, 92% of the TE patients had good to excellent functional and cosmetic results vs. 55% in HT patients, 3 of whom had significant contractures. Conclusion: Early tangential excision and skin grafting was clearly superior to expectant treatment using topical honey in patients with moderate burns in this randomised, prospective study performed at a General Hospital in the Indian subcontinent. The availability of suitable allogenic blood is a potential problem when TE is employed.

Staged high-dose epinephrine clysis is safe and effective in extensive tangential burn excisions in children

Prodigious blood loss commonly accompanies extensive tangential burn excisions. Staged high-dose epinephrine clysis may facilitate blood conserving excisional burn surgery. Prospective data was collected in 25 consecutive children who underwent tangential excision over the torso of at least 10% of the body surface with staged high dose epinephrine clysis. The children had an average age of 6.3±1.1 years and burn size of 45.7±3.9%. Total operative wound size (excision plus donor site) averaged 21±0.8% of the body surface. Total dose of epinephrine averaged 24.6±2.8 mcg/kg. Based on pre- and postoperative hematocrit and known volume of transfusion, the percent of the total blood volume lost per percent total wound generated averaged 0.98±0.19% of the blood volume per % of the body surface; 18 of the children (72%) required no blood in the perioperative period. There were no complications related to epinephrine use, graft take averaged 98±0.6% and all children survived and have been discharged home in good condition. Due to its rapid metabolism, subcutaneous epinephrine at high doses can be repetitively administered as long as time is allowed for its metabolism to occur. Use of this technique facilitates a marked reduction in blood requirements for these traditionally bloody operations.

Massive transfusion of reconstituted whole blood is well tolerated in pediatric burn surgery.

Massive transfusions can produce cardiovascular instability, metabolic abnormalities, dilutional coagulopathy, and pulmonary dysfunction. They also have been related to a higher incidence of infections. The purpose of this study was to assess the safety of massive transfusion of reconstituted whole blood. Twenty consecutive severely burned pediatric patients underwent near-total burn excision on admission and blood transfusion with reconstituted whole blood. Patients were studied for coagulopathies and postoperative complications related to massive transfusion. Only one patient presented with postoperative bleeding related to acute renal failure. No other complications occurred. There were no septic episodes or pulmonary dysfunction. The amount of massive blood transfusion did not correlate with any laboratory or clinical disturbance. Massive transfusion of reconstituted whole blood in severely burned pediatric patients is safe; it does not compromise hemostasis nor is it associated with an increased rate of septic episodes or pulmonary complications. A prospective randomized clinical trial comparing its effectiveness versus packed red cells is necessary.

Effect of topical and subcutaneous epinephrine in combination with topical thrombin in blood loss during immediate near-total burn wound excision in pediatric burned patients

Bleeding is a major concern during burn wound excision. To evaluate the efficacy of epinephrine to control blood loss, a prospective cohort of 42 pediatric patients were examined. Half of the patients received topical epinephrine to excised wounds and donor sites and subcutaneous epinephrine to scalp donor sites during total burn excision, while the other half did not. Both groups of patients received bovine topical thrombin sprayed at a concentration of 1000 U/ml. Mean blood loss in the epinephrine group was 1090 ml (range 20–4000), with a blood loss of 0.48±0.12 ml/cm 2 excised, while the control group was 1271 ml (range 40–3750) and 0.51±0.15 ml/cm 2. Differences in preoperative and postoperative hematocrits were respectively −3.4±7.8 and −4.6±7.5. The groups were not statistically different in this analysis. Subgroup analysis by age, burn size and time of burn to excision showed no differences. No complications or side effects of the use of the vasopressor solution occurred. In conclusion, no differences in blood loss were found between the groups. The routine use of local epinephrine during total wound excision in combination with topical thrombin in pediatric patients operated within 24 h after the admission may not be necessary. The effect of topical thrombin on blood loss should be analyzed separately.