Postoperative Care for the Burn Patient
Andrew Vardanian
Jeremy Goverman
INTRODUCTION
Burn injuries cause significant morbidity and mortality, often requiring operative intervention. The most common causes of burn injury are fire/flames (43%) and scald injuries (33%). Other causes include contact with hot objects, electrical and chemical burns. The most prevalent age group with burn injuries are those 20 to 60 years of age, accounting for more than 50% of all burn injuries. Advances in burn care have allowed the overall mortality rate to decrease from 3.4% to 2.7% in men and 4.6% to 3.3% over the 10-year period from 2004 to 2013.
Burn patients undergo various operations in three phases of care—acute, subacute, and long term or reconstructive. The most common procedures are debridement (excision) of burn wounds, skin grafting, placement of wound dressings, and venous catheter placement. The specific type of grafting varies from use of autografts, allografts (cadaveric), and xenografts (porcine) depending on depth of burn and institutional protocols. The location of excision and grafting is dependent on the location of the burn injury, and may entail simple application of grafts on large surface areas such as the back or torso, or more detailed insetting as often required with grafting to the hand.
Each phase of burn surgery has important postoperative considerations. Common postoperative complications are reviewed as well as special circumstances in burn care such as chemical burns, electrical injuries, and frostbite.
PHASES OF BURN SURGERY
Burn surgery can be divided into acute, subacute, and long term or reconstructive (see Table 12.1). In the acute setting, the primary goal is survival. Patient survival is paramount, but other important considerations in the acute phase are limb and digit preservation. Border-zone (zone of stasis) tissue that may survive with appropriate resuscitation and burn care reduces the overall amount of burn wound requiring further treatment. The different types of operations that are usually required are decompressive procedures such as escharotomy and fasciotomy, early excision of burn wounds to remove dead tissue (eschar), and skin grafting to restore the integrity of the skin. Other common procedures are central and arterial line placement, enteral feeding tube placement, and bronchoscopy.
In the subacute phase, the initial resuscitation period has ended and primary wound excision and grafting has occurred. The burn surgeon tailors care for ongoing patient and wound care needs. Incompletely debrided wounds and/or areas of graft loss are reexcised. New skin graft donor sites or healed donor sites from prior graft harvests are used to regraft open surfaces. Adjustments are made to joint surfaces and digits that commonly have graft loss in large total body surface area (TBSA) burns. In massive burns (>90% TBSA), cultured epidermal autografts may be utilized in the subacute phase of burn surgery. Other commonly performed procedures include tracheostomy
(percutaneous or open), typically for prolonged intubation, and central line changes as indicated.
(percutaneous or open), typically for prolonged intubation, and central line changes as indicated.
TABLE 12.1 Phases of Burn Surgery | |||||||||||||||
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The long-term or burn reconstructive phase has great diversity in the types of operations and may range from contracture release, split-thickness or full thickness skin grafting, and local tissue rearrangements, to more complex tissue transfer including free-tissue transfer. Because life-threatening injuries have been previously addressed, the purpose of surgery during this phase is to improve functional and aesthetic outcomes.
POSTOPERATIVE CARE: THE ACUTE AND SUBACUTE PHASES OF BURN SURGERY
Decompressive procedures (escharotomy, fasciotomy), burn wound excision (escharectomy), and skin grafting (autografting or allografting) are the main procedures done for the acute burn patient. Escharotomies may be performed at the bedside in the intensive care unit (ICU) with electrocautery, but may also be performed in the operating room. The purpose is to release overlying burned tissue, often in circumferential and large TBSA burns requiring massive fluid resuscitation, to allow tissue decompression and to improve perfusion. The chest and abdomen may be released in this manner to allow improved respiratory dynamics and to decrease abdominal compartment syndrome. Abdominal compartment syndrome may require urgent decompressive laparotomy. Ocular compartment pressure is released with lateral canthotomy. Deep thermal injuries, ischemia-reperfusion injury, edema related to resuscitation, or electrical injuries may also cause fascial compartment syndrome of the extremities. Fasciotomies are commonly performed to release compartments of the hand, forearm, or lower extremity.
Patient Positioning
Burn wound debridement and grafting require proper patient positioning in the operating room in order to maximize surgeon access to the sites of injury. The arms or legs are frequently elevated to allow proper wound debridement or graft harvesting. The patient may need to be placed in prone, lateral, or supine positions at various times during the operation.
Temperature Regulation
Maintenance of core body temperature is important in the postoperative period to prevent worsening coagulopathy and to regulate hypermetabolism, both of which may result in worsening tissue perfusion and metabolic acidosis. Loss of body heat occurs quickly in the burn patient. With loss of the epidermis, the burn patient is unable to properly thermoregulate using cutaneous vasoconstriction. Heat dissipates from the body core to superficial tissues. It is highly important to use warmed fluids and to heat postoperative care rooms to maintain normothermia in the burn patient. Covering the head and extremities may be useful as well as the use of radiant heaters and forced-air warming blankets.
Monitoring and Goal-Directed Therapy
Postoperative care necessitates goal-directed therapy and must be tailored to the specific needs of the individual burn patient. ICU level of care is often necessary with appropriate resuscitation and monitoring of heart rate, blood pressure, mean arterial pressure, body temperature, oxygen saturation, and volumes of fluid input and output. Burn TBSA of 20% causes maximal stimulation of inflammatory mediators, which impairs vascular tone and cardiac function, and results in an exaggerated systemic inflammatory and hypermetabolic response. Vasoactive medications such as α agonists, α/β agonists, and ADH agonists may be necessary to maintain adequate mean arterial pressure. Care must be taken to avoid overresuscitation, which can result in compartment syndrome, progression of burn wound depth, loss of skin grafts, and increased infectious complications.
Postoperative care involves monitoring lab values such as the hemoglobin level, platelet count, INR, and PTT. Bleeding may occur after excision and skin grafting, and blood transfusions may be necessary. An estimate of blood loss within the first 3 days of burn surgery ranges from 0.45 to 0.75 mL/cm2 burn area excised. With large raw, open surface areas, ongoing blood loss may occur in the postoperative period. Hemoglobin levels must be checked to prevent critical anemia. Dressings must be monitored for excessive saturation, which can herald ongoing bleeding.
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