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Innovation and clinical specialities: burns
AIDS should be treated in the same manner with similar outcomes
expected. Further research is needed to understand the effect of
HIV on immunosuppression in its early stages of disease.
Surgical management
After hemodynamic stabilization, a burned patient’s priority of
treatment shifts to ‘burn-wound-management’ 46 . Preoperatively,
several factors can pose a challenge to surgical patient care. In
the developing world, many of the burns present late, already
infected, or the poor general health of the patients makes them
unfit for anesthesia. In addition, blood loss can be significant in
burn wound excision, especially since inflamed and infected
wounds tend to bleed more during tangential excision. Thus, burn
surgery can be dangerous in high risk patients where blood
transfusion facilities are not readily available.
The options for the surgical management of burns includes early
tangential excision and grafting for deep dermal burns and
delayed escharectomy skin grafting for full thickness skin loss 47 .
Tangential excision describes the sequential and layered excisions
of devitalized tissues to a vital bed, generally recognized by
punctuate bleeding. An inadequately excised wound is more likely
to become infected and is unsuitable for graft take, necessitating
further surgery. 19 The use of tumescence (discussed below) is
good for decreasing blood loss from the burn site; however it
makes judgment of adequacy of excision and of hemostasis more
difficult. It can decrease blood loss to a minimal amount. Adequate
debridement must instead be determined by tissue quality, and
not by punctuate bleeding.
The exact timing for wound excision is debatable. It is often
suggested that burn wounds should be excised and grafted if they
are not expected to heal within 21 days of injury. This is especially
true for key functional and esthetic locations such as the hands
and face. 19 The decision to perform extensive excisions in a single
setting versus staged procedures is dependent upon the
hemodynamic stability of the patient, the availability of resources,
and the coordination of all parties involved in the care of the
patient. 19 Conservative treatment of burn wounds, with silver
sulfadiazine, followed by serial excision of the burn wound is
currently the standard of care in many burn centres throughout the
world. Burns are excised in areas of as much as 20% TBSA in one
operative setting, and performing the entire excision of the burn
wound in 10 days post-injury is the goal. All full-thickness burns
can be excised first, so that deep dermal and indeterminate depth
wounds are addressed later, preventing excision of potentially
viable tissue. Early excision and grafting is the treatment of choice
to potentially reduce scar contractures and hypopigmentation 47 .
The disadvantages to serial excision are that the patient needs to
return many times to the operative room, so that episodes of
bacterial translocation, bacteremia, and cardiovascular instability
are repeated. Other disadvantages include exaggerated blood
losses, prolongation of the hypermetabolic response, and
increased risk of infection and sepsis from remaining eschar in
which bacteria proliferate.
Near-total wound excision has been advocated as an alternative
to serial debridement in massive burns. In near-total excision, all
full-thickness and partial-thickness burns are excised within 24
hours of admission, and the excised wounds are covered with
autografts and skin substitutes are used if the burn exceeds the
donor-site supply. Areas of the face are normally not excised in the
first operation. Near-total burn excision has dramatically improved
survival in massive burns 18 . However, it has been postulated that
the surgical trauma of immediate burn wound excision, especially
given the hemodynamic instability of burn patients during the first
72 h after the injury, may aggravate the inflammatory and catabolic
responses, leading to potentially fatal postoperative
complications. 18,47 It should be clear that near-total wound excision
is only meant for massive burns, and allograft/autograft/xenograft
must be available for coverage, or the wounds would only have
been converted to full thickness open wounds.
General surgical principles
The intent of burn wound operations is twofold: to remove
devitalized tissue and restore skin continuity. For this process to
take place and for the skin graft to take, four things are required:
✚ A viable wound bed.
✚ No accumulation of fluid between the graft and the wound
bed.
✚ No shear stresses on the wound.
✚ Avoidance of massive micro-organism proliferation.
Surgical debridement is performed using a Goulian blade for small
areas or those with multiple irregular contours (e.g., hand or knee)
and a Watson or Humby blade for larger areas. Inexpensive
alternatives have been proposed for harvesting and debriding
blades 48 . Burned tissue is excised tangentially and sequentially
until the wound has been excised down to healthy dermis, fat,
muscle, peritenon, or periosteum. The wound may then be
covered with an autograft, allograft, or synthetic skin substitute.
Graft depth should be adjusted in pediatric and geriatric
populations for their thinner reticular dermis layer. If using a
powered dermatome, it should be set at less than 10/1000th
inch. The meshing pattern used for wound closure depends on
burn surface area and donor site availability. Meshing of the skin
graft has several advantages, including expanding the square
centimeters of coverage, allowing for drainage of fluid from under
the graft, and allowing for placement of the graft over contoured
areas, such as the knee or ankle. The disadvantage of the meshed
skin graft includes a permanent weave-like appearance of the
healed scar site, and increased contraction. 17
Many authors have described innovative methods for
performing skin grafting in resource-poor settings 49 . With minimal
financial resources, using readily available modified household or
industrial materials a surgeon is able to sharpen the Humby knife
48, 50
and use a pizza cutter for meshing grafts.
Methods of optimizing hemostasis and minimizing blood losses
include meticulous attention to maintaining the patient’s core body
temperature (operating in a warm environment, isolating surgical
fields, warming intravenous fluids, warming humidified air circuits
for anesthesia), the use of cautery, the application of topical
epinephrine solutions or topical thrombin solutions, injecting dilute
epinephrine tumescent solution below the eschar, and the use of
topical fibrin sealants.
The use of tumescence and tourniquet in burn excision
significantly reduces intraoperative blood loss and facilitates
accurate wound excision. Epinephrine is diluted in saline to a
concentration of 1:500,000 (2mg/l) and large volumes are injected
beneath the wound to be excised. Use a concentration of
1:1,000,000 for children. The edges of the wound are scored with
Hospital and Healthcare Innovation Book 2009/2010 61