Adopt a Philosophy of Early Excision and Grafting of Burn Wounds

Adopt a Philosophy of Early Excision and Grafting of Burn Wounds

Jeremy W. Pyle MD

James H. Holmes IV MD

No measure has had a greater effect on the outcome for burn patients than the shift away from conservative management and toward early and aggressive surgical management. In the 1970s, the standard of care for burns was to perform dressing changes with daily debridements, with bacterial collagenase aiding in the thinning of the eschar and the development of granulation tissue. In due time, split-thickness skin grafts (STSG) would be applied, and a take of about 50% was expected. A gradual evolution has produced a new standard of care in terms of both resultant graft take and individual function. A 95% graft take is now the norm. Current practice has evolved around one principle: early excision of wounds and immediate coverage provides extraordinarily better results. No other intervention has reduced burn mortality as much.

Benefits of early excision and grafting include decreased length of stay, reduced costs, less time away from work or school, fewer debridements, fewer infectious wound complications, and reduced mortality. Furthermore, there is evidence to suggest that early excision and grafting leads to less intense complications when they do occur. Aesthetic and functional benefits are related to a less intense inflammatory response in the wound, which is reduced with early removal of eschar and provision of coverage.

What to Do

Timing of early excision and grafting is not exact. Many wounds benefit from 3 to 7 days of conservative management while the tissue in the zone of stasis declares itself as either viable or not. With the exception of wounds over a joint, if the tissue appears able to heal in less than 2 to 3 weeks, surgical management is likely unnecessary. Those wounds that do not require excision have a good vascular supply providing a pink or white and shiny base with rapid capillary refill. These are characteristics of superficial partial-thickness burns, which do well with local wound care and time. When indicated, as in obvious full-thickness burns, excision and grafting should be performed as soon as the patient is stabilized. Ideally, this is within 5 days and certainly within 1 week. Data
suggest that morbidity, length of stay, local infection, and sepsis are more common if wounds needing excision are treated conservatively beyond 1 week.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Adopt a Philosophy of Early Excision and Grafting of Burn Wounds
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