Reduced blood loss during burn surgery

The purpose of this study was to investigate the use of subcutaneous injection of burn wounds and skin graft donor sites with an adrenaline-saline solution to reduce blood loss during burn surgery. This retrospective study reviewed the requirements of blood products in 30 randomly selected adult patients with more than 10% body area burned, who had at least one burn operation at a university regional burn center, between January 1991 and June 1997. Patients were matched by age and percent body area burned and stratified according to the surgical technique in two groups. In Group 1, 15 patients received the modified tumescent surgical technique: subcutaneous injection of adrenaline (1 part/million in warm saline solution) into the subcutaneous tissue of the donor sites for autologous skin graft and areas of burn eschar to be excised, combined with pneumatic tourniquets in extremities and saline-adrenaline soaked nonadherent pads. In Group 2, 15 patients received the traditional surgical technique: soaked gauze compresses with an adrenaline-thrombin solution (1 ml of 1:1,000 adrenaline, thrombin 10,000 units, and 1 L of normal saline). Outcome measures, transfusion of blood products, operating time and complications between the two patient groups were analyzed using the Wilcoxon 2-sample test. The two patient groups were not different by age (40.4 +/- 19.4 vs 38.9 +/- 17.9), percent total body area burned (27.6 +/- 15.4 vs 32.8 +/- 13.4), or percent full thickness burn (7.0 +/- 8.5 vs 11.5 +/- 8.5). The modified tumescent surgical technique significantly reduced mean total blood units transfused per patient (7.9 +/- 11.5 vs 15.7 +/- 12.9 units; P = .031), and the mean blood units transfused intraoperatively per patient (4.7 +/- 7.8 vs 8.9 +/- 8.0 units; P = .026). The modified tumescent surgical technique significantly reduced the intraoperative and total blood transfusion requirements in our thermally injured patients.     

Emergent burn care

The estimated 32,600,000 fires that occur annually in the United States produce over 300,000 injuries and 7,500 deaths. Ten percent of hospitalized burn victims die as a direct result of the burn. Initial evaluation and management of the burn patient are critical. The history should include the burn source, time of injury, burn environment, and combustible products. The burn size is best estimated by the Lund and Browder chart, and the burn depth is determined by clinical criteria. Pulmonary involvement and circumferential thoracic or extremity burns require detection and aggressive treatment to maintain organ viability. Hospitalization is usually necessary for adults with burns larger than 10% of the total body surface area (TBSA) or children with burns larger than 5% of TBSA. Major burns, those of 25% or more of TBSA or of 10% or more of full thickness, should be considered for treatment at a burn center, as well as children or elderly victims with burns of greater than 10% TBSA. Lactated Ringer's solution, infused at 4 ml/kg/% TBSA, is generally advocated for initial fluid restoration. After the acute phase (48 hours), replacement of evaporative and hypermetabolic fluid loss is necessary. These losses may constitute 3 to 5 liters per day for a 40% to 70% TBSA burn. Blood transfusion is often required because of persistent loss of red blood cells (8% per day for about ten days). Many electrolyte abnormalities may occur in the first two weeks. Pulmonary injury commonly is lethal. Circumoral burns, oropharyngeal burns, and carbonaceous sputum are indicative of inhalation injury, but arterial blood gas determinations, fiberoptic bronchoscopy, and xenon lung scans are useful for confirming the diagnosis. Humidified oxygen, intubation, positive-pressure ventilation, and pulmonary toilet are the mainstays of therapy for inhalation injury. Wound care is initially directed at preservation of vital function by escharotomy, if restrictive eschar impairs ventilatory or circulatory function. Antibacterial agents may be applied to the burn, but invasive sepsis, defined as greater than 10(5) organisms per gram of tissue with invasion of subjacent viable tissue, requires systemic antibiotic therapy. Wound debridement is done by daily hydrotherapy, tangential excision, chemicals, primary excision, and grafting, tailoring the technique to the individual burn.(ABSTRACT TRUNCATED AT 400 WORDS)     

Reducing the need for intubation in plastic surgery

Many plastic surgery procedures that have traditionally been performed under general endotracheal anesthesia may safely be undertaken using a ketamine-based intravenous sedation technique. General endotracheal anesthesia has many drawbacks, including lack of patient acceptance. Ketamine-based intravenous sedation technique includes the following steps: 1. The patient is placed in a dissociated state using sedative and narcotic agents accompanied by a subanesthetic dose (0.5 mg/kg) of ketamine. 2. A dilute local anesthetic solution (0.25% lidocaine with 1:2,000,000 epinephrine) is infiltrated into the involved tissues to provide anesthesia and hemostasis. 3. The patient is maintained in a tranquil state throughout the procedure by periodic titration of additional doses of sedative and narcotic agents. Advantages of the technique include reducing the need for intubation and its associated hazards, dramatically decreased blood loss due to use of dilute epinephrine solution, reduced recovery time, ability of patients to respond to commands during surgery, avoidance of positioning injuries and increased rapport between patient, surgeon and anesthetist. Disadvantages include respiratory depression and potential for hypoxia. Dissociative intravenous sedation combined with dilute local anesthetic provides a useful addition to the anesthetist's armamentarium.     

Reconstruction of the oral commissure after an electrical burn

A burn of the oral commissure is one of the most common types of electrical injury in children. To minimize postoperative wound contracture in late reconstructive surgery, a functional reconstruction that combines excision of the burn scar with lateral advancement of the orbicularis oris muscle, re-creation of the modiolus labii, and reestablishment of vermilion continuity has been developed. Functional restoration of the labial musculature to the preinjury position with re-creation of the modiolus labii and reestablishment of vermilion continuity appears to significantly decrease the amount of postoperative wound contracture (p less than 0.025).     

Tourniquet and subcutaneous epinephrine reduce blood loss during burn excision and immediate autografting

Blood loss has been reduced using both tourniquets and epinephrine-injected subeschar during burn wound excision. This study quantified and compared blood loss in extremities distal to an inflated tourniquet with that after subeschar infusion of 1:1,000,000 epinephrine in saline into the trunk or proximal extremities. Tangential excision of eschar to viable dermis or fat was followed by immediate application of meshed autograft. Blood loss was calculated by determining the difference of preoperative and postoperative hemoglobin values and the volume of whole blood administered between these. With tourniquets for limbs, 2.07 +/- 0.34% of circulating blood volume per 1% body surface excised was lost; whereas after epinephrine injection 3.42 +/- 0.39% of blood volume per 1% body surface excised was lost (P < 0.05). Both methods effectively reduced blood loss when compared with excision followed by delayed autograft application. Where there was a choice the tourniquet was more effective.     

Noncontact electrosurgical grounding is useful in burn surgery

Grounding patients with large burns to facilitate the use of electrocautery devices during surgery is commonly difficult because of the paucity of available grounding sites. The Mega 2000 Patient Return Electrode System (Megadyne Medical Products, Draper, UT) is an electrode designed to provide electrical return to facilitate function of electrocautery devices without direct patient contact. It accomplishes this by having a very large surface area (720 square inches) in the form of a reusable pad placed on the operating table that is covered by an impermeable drape and clean sheet beneath the patient. We used this noncontact device in 25 operations of 17 children with large burns and limited availability of traditional grounding sites. The patients had an average age of 8.8 + 4.6 years (range, 14 months-14 years), average burn size of 55 + 33% of the body surface (range, 10-95%), and average weight of 33.0 + 17.9 kg (range, 9-75 kg). Operations included 22 excision and grafting operations, an axillary release, a neck release, and bilateral groin releases. The device functioned well in all cases. There were no cutaneous burns observed. No additional traditional devices required placement. We found the device useful in burn surgery in those cases where there is a paucity of traditional grounding sites available.     

Glucose metabolism in children during the first day after burn injury.

Plasma and blood metabolites were measured in 31 children over the first day after burn injury. In 14 of them blood glucose peaked, rising within 1-4h to 10-20 mmol/l and then falling, by 4-8 h, to 5-10 mmol/l. Usually the peak value preceded treatment and the fall occurred during infusion of dextrose-saline. Peak incidence was independent of burn severity. There was no evidence of similar peaks in children or adults with other injuries, or in 8 adults with burn injuries; through high glucose levels have been reported in children with head injuries. Lactate, non-esterified fatty acids, insulin, cortisol, epinephrine and norepinephrine were also measured. Values in the first 4 h were similar to those reported in adults with other injuries, except for lactate, which rose less in the children. Unexpectedly, the hyperglycemia in the children with burns was poorly related to epinephrine concentration at all times to 24h. Insulin resistance probably developed within the first hour or two; but from 8 h did not seem to depend on synergism between epinephrine and cortisol.     

酮咯酸氨丁三醇对烧伤患者镇痛效应及麻醉深度的影响

目的探讨酮咯酸氨丁三醇对烧伤患者镇痛效应及麻醉深度的影响。方法将50例美国麻醉医师协会（ASA）I～Ⅱ级择期行烧伤植皮手术患者随机分为2组,每组25例。实验组静脉推注酮咯酸氨丁三醇30mg,对照组输注生理盐水,记录不同时点的脑电双频指数（BIS）、平均动脉压（MAP）及心率（HR）。术中以异丙酚和瑞芬太尼靶控输注（TCI）维持麻醉,调节异丙酚血浆靶控浓度（Ct）,维持BIS稳定。结果麻醉剂诱导后,2组患者的HR及MAP均无显著性改变,但BIS均显著下降;给予药物后,实验组BIS继续下降。HR显著下降,MAP略有下降,而对照组上述指标均无明显变化。分别给予酮咯酸氨丁三醇和生理盐水后,实验组患者HR、MAP和BIS均显著低于对照组,差异有统计学意义;实验组异丙酚用量及苏醒期间咽喉疼痛、烦躁发生率均显著低于对照组,差异有统计学意义,而2组麻醉时间、呼吸恢复时间、睁眼时间及拔管时间比较,差异无统计学意义。结论酮咯酸氨丁三醇在不影响患者术后苏醒状态的情况下可产生明显镇痛效应,减少术中TCI异丙酚用量及不良反应的发生。     

Major thermal burn as a result of intraoperative heating blanket use.

A 72-year-old woman sustained a 30% full-thickness total body surface area burn as a result of a malfunction in a heating blanket during coronary artery bypass surgery. Early burn wound excision and wound closure with skin grafts were performed. The patient experienced wide swings in systolic blood pressure. She was treated with antibiotics and received maximal mechanical support. However, cardiac collapse occurred, and the patient died on the tenth day after burn injury. Previous case reports have discussed only minor burns that resulted from heating blanket use. The magnitude of this injury and the death that resulted from it highlight the importance of preoperative and intraoperative equipment checks and careful intraoperative core temperature monitoring.     

Determination of burn depth with noncontact ultrasonography

Early excision and grafting is the current treatment of choice for deep dermal and full-thickness burn wounds that will not heal spontaneously within 3 weeks. The time needed for the burn wound to heal is estimated with clinical assessment of the burn depth; this is often an inaccurate method. Therefore we have developed a new and unique noncontact ultrasonographic method to estimate burn depth. This study was designed to determine the practical utility and accuracy of noncontact ultrasonography for the assessment of burn depth. Seventy-eight burn sites and 42 normal skin sites (control sites) of 15 patients (age, 18-63 years) with burns of 2% to 35% total body surface area were evaluated. The burn sites were scanned with a prototype noncontact ultrasonographic system 1 and 3 days after the burn injuries. The probe was held 1 inch from the skin, and the time spent on each site was approximately 5 minutes. The ultrasonographic results were interpreted by an investigator who was blinded to the clinical findings. Clinical assessment of the burn wounds was made on the same days by 2 experienced physicians who were blinded to the results of the ultrasonography. The investigators were asked to categorize the burn wounds into those that would heal within 3 weeks and those that would not. With this method, we were able to visualize the epidermis, dermis, and dermal-fat interface in normal skin. The destruction of the dermal-fat interface was interpreted as a deep burn, which would not heal within 3 weeks. The overall accuracy of the noncontact ultrasonography in the prediction of which burn wounds would heal within 3 weeks was 96%. The results of this study show that noncontact ultrasonography will allow for the rapid evaluation of burn depth with high accuracy, without contacting the patient, and without causing pain or discomfort.     

Cultured epidermal autograft and the treatment of the massive burn injury.

As a rule, adult and pediatric patients with thermal injuries that involve more than 90% total body surface area (TBSA) burn have poor prognoses. Even for patients who are 5 to 34 years old with a 70% TBSA burn, the mortality rate is 80%. Lack of autologous donor skin, which is essential for permanent wound closure, is the major problem. Recent advances in growth of cultured epidermal autograft (CEA) have allowed closure of full- and partial-thickness burns; in approximately 3 weeks, a 2 cm2 biopsy specimen will produce enough CEA to cover a pediatric patient. Since 1989, we have used this product on nine patients; the average age was 39, and the average TBSA burn was 70% (range, 44% to 93%). We report our approach to use of CEA in six of these patients, including topical applications of 1% silver sulfadiazine and excision of full- and deep partial-thickness wounds within 2 weeks of injury. Temporary closure was achieved with cadaver allograft. "Take" of the allograft forecasted take of CEA. The total operative time of CEA placement was decreased by a two-step technique that obviates repeating debridement: the technique consists of debriding and grafting with allograft, then removing it at the time of CEA placement. CEA take is best on early granulation tissue or freshly excised wounds. Early excision of burn eschar, temporary wound closure with cadaveric allograft and Biobrane (Winthrop Pharmaceuticals, Wound Care Div., Fountain Valley, Calif.), and permanent closure with CEA may improve survival rates among patients with massive burn wounds. CEA is a tremendous asset to the management of massive burn injuries.     

What are the acute cardiovascular effects of subcutaneous and topical epinephrine for hemostasis during burn surgery?

Although subcutaneous and topical epinephrine are widely used for hemostasis during burn surgery, the acute systemic cardiovascular effects of the epinephrine are neither well documented nor completely understood. The purpose of this work was to prospectively study the acute cardiovascular responses to epinephrine (epi) administered subcutaneously and topically during burn surgery. Consecutive patients who received subcutaneous and topical epi during burn surgery were monitored prior to the administration of epi, at 2-minute intervals during subcutaneous epi infiltration, and then after epi infiltration (during which time, topical epi was applied). This period of monitoring lasted up to 20 minutes and was referred to as an epinephrine event (EE). A total of 100 EEs from 38 operations in 24 patients (mean +/- SD: age 43 +/- 16 years, mean % TBSA burn 23 +/- 17%) were studied. The mean dose of subcutaneous epi was 30 +/- 30 microg/kg. Although all patients received topical epi, it was impossible to document the topical dose. There was no significant increase in heart rate from baseline, and no arrhythmias occurred. Mean arterial pressure (MAP) did acutely increase significantly by 17.0 +/- 14.1% from baseline (P =.009) and increased more than 10% from baseline in 64/100 EEs. However, the increase in MAP was independent of the dose of epi (r =.053). The increase in MAP was not clinically significant, did not require intervention, and did not appear to be related to the type of wound that received epi (donor site vs burn wound), or the depth of anesthesia, analgesia, or sedation. On the basis of these findings, the use of subcutaneous and topical epi appears to be safe and produces minimal acute cardiovascular effects.     

Antithrombin in the treatment of burn trauma

Antithrombin (AT) is a natural anticoagulant with anti-inflammatory properties that has demonstrated value in sepsis, disseminated intravascular coagulation and in burn and inhalation injury. With high doses, AT may decrease blood loss during eschar excision, reducing blood transfusion requirements. There are no human randomized, placebo-controlled studies, which have tested the true benefit of this agent in these conditions. Two main forms of AT are either plasma-derived AT (phAT) and recombinant AT (rhAT). Major ovine studies in burn and smoke inhalation injury have utilized rhAT. There have been no studies which have either translated the basic rhAT research in burn trauma, or determined the tolerance and pharmacokinetics of rhAT concentrate infusions in burn patients. Advantages of rhAT infusions are no risk of blood borne diseases and lower cost. However, the majority of human burn patient studies have been conducted utilizing phAT. Recent Japanese clinical trials have started using phAT in abdominal sepsis successfully. This review examines the properties of both phAT and rhAT, and analyzes studies in which they have been utilized. We believe that it is time to embark on a randomized placebo-controlled multi-center trial to establish the role of AT in both civilian and military patients with burn trauma.     

Oxygen consumption is increased in the postanesthesia period after burn excision

We studied the intraoperative and postoperative effects of anesthesia and wound excision on oxygen delivery and oxygen consumption after burn injury. Twenty adult sheep were studied: six had halothane anesthesia alone and 14 had anesthesia and third-degree burns over 15% of the total body surface. Body temperatures were maintained within 1 degree C of baseline value during the operations. The burns on six sheep were totally excised and hide from donor sheep was grafted 3 hours after injury; in eight sheep, excision and grafting were done 5 days after injury. We found that 3 hours of anesthesia in controls decreased oxygen delivery (DO2) by 22% +/- 6% and oxygen consumption (VO2) by 30% +/- 7% from waking baseline values primarily because of a decrease in cardiac output as oxygen (O2) extraction from hemoglobin also decreased. However, no base deficit developed. DO2 and (VO2) transiently increased to 9% +/- 3% above baseline value on the sheeps' return to the waking state. Anesthesia and wound excision, which began 3 hours after the burns were formed, decreased DO2 and VO2 by 25% +/- 4% and 32% +/- 4%, respectively, despite baseline filling pressures. However, a base deficit of -3 +/- 1 mEq/L developed during the two-hour operations, which began with the administration of anesthesia alone. Oxygen consumption increased to 25% +/- 6% above the waking baseline value upon each subject's return to the waking state. In the sheep treated 5 days after burn injury, DO2 decreased by 35% +/- 6% and VO2 decreased by 42% +/- 6% below the value during the waking hypermetabolic state when the sheep were under anesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Metabolic and hormonal effects of early nutritional supplementation after surgery in burn patients

We evaluated, in burn patients, the metabolic and hormonal effects of early nutritional supplementation after a severe stress event represented by the deep surgical excision of the burn wounds and autograft coverage. The surgical procedure induced a 50% increase from baseline value of the resting metabolic rate. Immediate nutritional supplementation avoids the adaptive stress-related increments of urinary catecholamine excretion and glucagon secretion while insulin secretion is maintained. The urinary cortisol excretion, significantly increased after surgery in study and control groups, was unaffected by the nutritional intervention. The favorable insulin/glucagon ratio and the control of catecholamine response in early nutritionally supplemented patients are associated with the maintenance of a positive N balance in the days after surgery.     

Virtual reality as an adjunctive pain control during burn wound care in adolescent patients

For daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care. The first was a 16-year-old male with a deep flash burn on his right leg requiring surgery and staple placement. On two occasions, the patient spent some of his wound care in VR, and some playing a video game. On a 100 mm scale, he provided sensory and affective pain ratings, anxiety and subjective estimates of time spent thinking about his pain during the procedure. For the first session of wound care, these scores decreased 80 mm, 80 mm, 58 mm, and 93 mm, respectively, during VR treatment compared with the video game control condition. For the second session involving staple removal, scores also decreased. The second patient was a 17-year-old male with 33.5% total body surface area deep flash burns on his face, neck, back, arms, hands and legs. He had difficulty tolerating wound care pain with traditional opioids alone and showed dramatic drops in pain ratings during VR compared to the video game (e.g. a 47 mm drop in pain intensity during wound care). We contend that VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain.     

Burn excision with intraoperative vasopressin

Reducing blood flow to the skin during burn wound excision should decrease blood loss, which remains a major problem during primary excision of large burns. This clinical investigation demonstrates that arginine-vasopressin appears to reduce intraoperative blood loss and is relatively free of complications. This treatment has potential benefits for the patient with small burns as well. The amount of banked blood required could be greatly reduced, thus decreasing the risks of transfusion and the cost of burn care.     

The present status of research in burn toxins

Modern intensive care combined with current improvements in the specific, systemic and local therapy of burns has delayed the mortal effects of severe burns. Nor has there been any significant improvement in this mortality during the last decade.The occurrence of uncontrollable infection and sepsis due to gram-negative bacteria or fungi as the basic cause of death was not a satisfactory explanation. So, progress should only be expected from a new concept in burn treatment. This new concept should be to view the burn disease as being caused by toxic factors induced by thermal injury to the skin. Electron-microscope studies in mice and rats have revealed similar mitochondrial alterations in hepatocytes after either a sublethal controlled burn injury or an intraperiotoneal application of an equivalent dose, of a cutaneous burn toxin. The intraperitoneal injection of different amounts of the burn toxin indicated, that the extent of the mitochondrial changes correlated directly with the dose of toxin. Investigations of liver metabolism suggested an inhibition of the oxygenation chain. The incubation of isolated liver cells together with the burn toxin demonstrated by scanning electron microscopy a direct cytotoxic effect of the burn toxin. In animal tests the pathogenic effect of the burn toxin could be prevented by treatment with an antitoxic IgG generated in sheep.The fatal sepsis of severely burned patients is the consequence of a decreased host defence against infections, which is caused by a primary and general toxic alteration of the whole organism. One important aspect of treatment should therefore be the elimination of burn toxins. To achieve this management should include primary excision of the burns, local application of nonabsorbable protein-complex-binding substances and specific passive immuno-therapy with an antitoxic IgG.     

A half-century of burn epidemiology and burn care in a rural state

The aim of this study is to quantify the changes in incidence, severity, and mortality in burn injuries in the state of Maine over the past 50 years from both prevention and treatment perspectives. The authors analyzed the data from multiple sources, including the U.S. Census, death certificates, hospital discharge abstracts, and institutional burn registries in Maine and Boston. The average annual number of burn-related deaths decreased from 53 in 1960-1964 to 14 in 2004-2008. The Maine age-adjusted rate of burn deaths was 8.6% above the national rate in 1960 and 1.4% below it in 2006. The annual number of burn patients admitted to Maine hospitals declined by 65% from 1978 to 2009. Since 1999, 12% of hospitalized patients in Maine were treated in an American Burn Association-certified burn center in Boston. Mortality for Maine burn patients, including those treated at Boston hospitals, is directly related to age and burn severity and similar to stratified mortality in the National Burn Repository. Incidence, severity, and mortality of burn injuries in Maine have decreased dramatically over the past 5 decades. Prevention programs, legislation, and a regionalized system of burn care have all likely contributed to bringing Maine's morbidity and mortality rate below the national average.     

Mini-abdominoplasty in burn reconstruction

The excision of excessive fat and subcutaneous tissue in the infraumbilical region, also known as "mini-abdominoplasty, " can be used to harvest skin for burn reconstruction. The resultant full-thickness grafts are less prone to contracture than split-thickness grafts. They are particularly useful in areas where mobility is important, such as the neck and areas overlying major joints. It allows a single-stage reconstruction with little donor site morbidity and favorable long-term functional outcomes. Multiple other donor sites have been reported, most commonly the groin and small pinch grafts on the trunk, but they provide only small amounts of skin when compared with the abdomen. The authors report 12 cases of patients who were treated for sequelae of burns with full-thickness abdominal skin grafts that were procured by mini-abdominoplasties for the sole purpose of obtaining the skin. The mini-abdominoplasty in this series was found to be an effective, safe technique that provides large amounts of full-thickness skin for reconstruction. While the size of the grafts varied with age and size of the abdomen, up to 40 × 15 cm can be obtained in adults. The donor site complications are rare but most commonly include seromas and dehiscence of the wound.