The use of a bioactive skin substitute decreases length of stay for pediatric burn patients

BACKGROUND: To optimize burn care for children, the authors introduced a protocol incorporating the use of a bioactive skin substitute, TransCyte (Advanced Tissue Sciences, La Jolla, CA). This study was designed to determine whether this management plan was safe, efficacious, and decreased hospital inpatient length of stay (LOS) compared with conventional burn management in children. METHODS: All pediatric burns greater than 7% total body surface area (TBSA) that occurred after October 1999 underwent wound closure with TransCyte (n = 20). These cases were compared with the previous 20 consecutive burn cases greater than 7% TBSA that received standard therapy. Standard therapy consisted of application of antimicrobial ointments and hydrodebridement. The following information was obtained: burn mechanism, age, size of burn, requirement of autograft, and LOS. Data were analyzed using the student's t test. RESULTS: Data for age, percent TBSA burn and LOS are reported as means +/- SEM. The children who received standard therapy were 2.99 +/- 0.7 years compared with those receiving TransCyte were 3.1 +/- 0.8 years. There was no difference between the treatment groups with regard to percent TBSA burn: standard therapy, 14.3 +/- 1.4% TBSA versus TransCyte, 12.7 +/- 1.3% TBSA. There was no difference in the type of burns in each group, the majority were liquid scald type, 70% in the standard therapy group versus 90% in the TransCyte group. Only 1 child in the TransCyte group required autografting (5%) compared with 7 children in the standard therapy group (35%). Children treated with TransCyte had a statistically 6 significant decreaed LOS compared with those receiving standard therapy, 5.9 +/- 0.9 days versus 13.8 +/- 2.2 days, respectively (P =.002). CONCLUSIONS: This is the first study using TransCyte in children. The authors found that this protocol of burn care was safe, effective, and significantly reduced the LOS. This new approach to pediatric burn care is effective and improves the quality of care for children with burns.     

A retrospective analysis of securing autologous split-thickness skin grafts with negative pressure wound therapy in paediatric burn patients

Background and Aim

Deep dermal and full-thickness burn wounds are excised and grafted with split-thickness skin grafts. Especially in less compliant patients such as young children, conventional fixing methods can often be ineffective due to high mobility rates in this age group.The aim of this retrospective single-centre study was to give an overview of our experience in the fixation of autologous split-thickness skin grafts (ASTSGs) on burn wounds by negative pressure wound therapy (NPWT) in paediatric patients.

Methods

A retrospective analysis describing 53 paediatric patients with burns or burn-related injuries who were treated as 60 individual cases were conducted. All patients received ASTSGs secured by NPWT.

Results

Of the individual cases, 60 cases with a mean age of 8 ± 6 years (the youngest was 3 months, the eldest was 24 years old) were treated in a single procedure with ASTSG and NPWT. Total burn surface area (TBSA) was, median (med) 4.5% (3.0–12.0%). The TBSA of deep dermal thickness to full-thickness (IIb–III°) burns was med 4.0% (2.0–6.0%). The TBSA treated with ASTSG and NPWT was med 3.5% (2.0–6.0%). Take rate was, med 96% (90–99%) with a total range of 70–100%. The only significant correlation that could be found was between the grafted TBSA and the take rate. The smaller the grafted TBSA the better the take rate resulted, as expected. In three cases, major complications were noted.

Conclusion

To sum up our experience, the NPWT system has developed itself to be a constant, well-implemented and useful tool in securing ASTSGs to the wound bed. The main advantage of the technique is a much higher mobility of the patient compared to conventional fixation methods. The high compliance rate of an often challenging group of patients such as children recompenses possible higher costs compared to conventional fixation methods.     

The dermis graft: another autologous option for acute burn wound coverage

BackgroundSplit-thickness skin autografts are the gold-standard in providing permanent acute wound closure in major burns. Split-thickness dermal grafts harvested from the same donor site may provide an additional autologous option for permanent acute coverage and increase the number of potential autologous donor sites.Materials and methodsWe performed 16 dermis grafts (DG) harvested from the skin of the back in 9 consecutive burn patients. A control donor site consisted of an area of adjacent back skin from which a standard split-thickness skin graft was harvested. The mean age was 63 years (range 23–79 years). The mean initial burn size was 24% TBSA (range 2–40% TBSA). The size of the 16 DG recipient wound beds ranged from 20 to 180 cm², with mean and median sizes of 62 and 45 cm², respectively.ResultsDermis graft take was complete in 15/16 cases. All grafts recorded >90% epithelialisation by 4 weeks. There was no significant difference in dermis graft and control donor site healing times (p value 0.05).ConclusionDermis grafts can provide an additional autologous option for permanent coverage in acute major burn wounds without increasing donor site size or morbidity.     

Efficacy of hydrosurgical excision combined with skin grafting in the treatment of deep partial-thickness and full-thickness burns: A two-year retrospective study

IntroductionDeep partial-thickness and full-thickness burn wounds often undergo tangential excision or escharectomy to expose healthy tissue, combined with skin grafting to promote wound healing. However, conventional tangential excision with the humby knife leads to inevitable damage to the dermis while excising burn tissue due to the lack of precision. Indeed, the preservation of dermal tissue is a key factor in determining wound healing and scar quality. The precision and tissue selectivity of the Versajet Hydrosurgical System has been established for excising burn tissue while preserving dermal tissue. In this study, we retrospectively compared the efficacy of "Hydrosurgical excision combined with skin grafting" and "Conventional tangential excision combined with skin grafting" in treating deep partial-thickness and full-thickness burn wounds to demonstrate that hydrosurgery improved the treatment of deep partial-thickness and full-thickness burns.MethodsA total of 86 patients with deep partial-thickness and/or full-thickness burns with a total burn surface area (TBSA) ≤ 25% from July 2018 to July 2020 were included in this study and were divided into experimental (hydrosurgical excision combined with skin grafting, n = 43) and control (conventional tangential excision combined with skin grafting, n = 43) groups. Parameters were analyzed, including the intraoperative blood loss volume per unit area of grafted skin, surgery duration, wound healing time, skin graft survival, and the treatment costs per unit of burned area. Scar assessment was performed at 1 year with the modified Vancouver Scar Scale linked with TBSA (mVSS-TBSA).ResultNo significant difference was found in male to female ratio, age, weight, TBSA, burn depth, skin grafting area (SKA), skin grafting methods, cases treated with carbon dioxide fractional laser or incidence of inhalation injury, and the incidence of hypovolemic shock between two groups(p > 0.05). Compared with the control group, patients treated with hydrosurgical excision combined with skin grafting experienced less intraoperative blood loss volume per unit area of grafted skin (p < 0.05). The mVSS-TBSA of patients that underwent hydrosurgical excision combined with skin grafting was significantly improved in comparison to the control group (p < 0.01). No significant difference was found in surgery duration, wound healing time, skin graft survival and treatment costs per unit of burned area between the two groups (p > 0.05).ConclusionHydrosurgical excision combined with skin grafting reduced intraoperative blood loss volume per unit area of grafted skin, improved scarring 1-year after injury, and did not increase the treatment costs per unit of burned area. This technique provides a novel alternative for managing deep partial-thickness and full-thickness burn wounds.     

Analysis of skin-graft loss due to infection: infection-related graft loss

This prospective study was performed to analyze the causes of infection-related skin-graft loss in a general population of plastic and reconstructive surgery patients. One hundred thirty-two patients who received either full- or split-thickness skin grafts to reconstruct soft-tissue defects were included. The tissue defects were grouped according to the cause as follows: vascular ulcers (9.2%), burns (14.5%), traumatic tissue defects (36.6%), and flap donor-site defects (39.7%). In all cases, the preoperative evaluation indicated an adequate wound-bed preparation. However, graft loss secondary to infection was recorded in 31 patients (23.5%). The microbiological cultures revealed Pseudomonas aeruginosa in 58.1% of the cases (P<0.05), followed by Staphylococcus aureus, Enterobacter, enterococci, and Acinetobacter; 58.3% of grafts in vascular ulcers, 47.4% of grafts in burns, 16.7% of grafts in traumatic-tissue defects; and 13.5% of grafts in donor-site defects were lost due to infection. Vascular ulcers and burns were more commonly associated with graft losses due to infection than other tissue defects (P<0.001). No correlation was found between the etiological cause of the defects and the microorganisms cultured. However, Pseudomonas infections were more fulminant and caused an increased reoperation rate 4.2 times (P<0.05). Full-thickness grafts were more resistant to infection than split-thickness grafts (P<0.05). Graft loss due to infection was also more common in grafts applied to the lower extremities or when performed at multiple sites. In conclusion, 23.7% of skin grafts were lost due to infection in a group of general plastic surgery patients. Infection-related graft loss was more commonly encountered in vascular ulcers and burn wounds, and the most common cause was Pseudomonas aeruginosa.     

Verbrennungsbehandlung von Kindern

BACKGROUND: A retrospective epidemiological multifactorial study of pediatric burn patients admitted to the Burn Center Bochum in the period of 1992-2002 was performed. METHODS: Data from 628 patients were analyzed and included age, sex, mortality, hospital stay, percent of total body surface area (TBSA) burned, localization of burns, number of surgical procedures, source of the burn as well as social standing of the families. RESULTS: The majority of patients (414) were between 0 and 3 years. The median age was 2.99. The median TBSA was 11.9%. There were 387 males (62%) and 241 females (38%, ratio of 1.6:1). The overall mortality rate was 1.4% (6/629). The main causes of injury were scald burns (435; 70%), followed by flame burns (153; 24%), electric injuries (17; 3%), and hot oil (21; 3%). Surgery was performed on 365 (58%) children. The others (263; 42%) were treated without surgery. DISCUSSION: The number of children with a background other than German was higher; moreover, a high number of injuries was not covered by health insurance. Having identified the high-risk group among the pediatric burn patients, we suggest that prevention programs should be directed towards these families in order to reduce further risk of pediatric burns.     

Tandir burns: a severe cause of burns in rural Turkey

Tandir is the name given to an oven used for baking bread in the eastern and south-eastern part of Anatolia. Tandir burn is a special kind of burns in which primarily women and small children fall in it and have deep extensive burns (TBSA %). The records of 60 patients with tandir burn who were treated in our Burn Center from September 1999 to January 2006 were reviewed. The patients consisted of 9.2% of all burned patients. The mean age was 17.10 years (1-60 years) and 61.50% of the patients were female. The mean total body surface area (TBSA) burned was 21.09% (6-58) and 88% of the patients had third-degree burns. Eight of the patients underwent amputation of an extremity, 10 had fasciotomies, and 25 partial thickness skin grafts. The mean hospitalization period was 31.64 days (3-73 days). Fifteen patients (25%) died. Tandir burn is a severe kind of burn with a higher morbidity and mortality.     

Artificial skin, split-thickness autograft and cultured autologous keratinocytes combined to treat a severe burn injury of 93% of TBSA

Despite refinements in burn shock resuscitation, improvements in surgical techniques, advances in intensive care medicine and the presence of very expert surgeons, the treatement of patients with severe burns exceeding 60% TBSA remains a big challenge. A major problem in the treatment of severe burn injuries is the lack of autologous skin. In selected cases cultured epidermal autograft (CEA) may be used. However, they are available only 2-3 weeks after biopsy, thus requiring a temporary wound closure after necrosectomy. A new option is Integra(TM), an artificial skin consisting of a bilayer membrane system. The three-dimensional porous matrix from bovine tendon collagen and a glycosaminoglycan layer is covered by a silicon sheet. The latter prevents fluid loss from the wounds and serves as a barrier against germ invasion. After adequate vascularisation of the dermal template, the silicon layer is removed and replaced by a thin autograft. We present a 26-year old male who sustained a 93% TBSA burn injury (60% full-thickness burn, 33% partial-thickness burn). He was treated with artificial skin, split-thickness autograft and CEA in combination. The clinical history and the follow-up of approx. 1 year are presented and the results discussed. We consider the survival of this patient being a result of the therapeutic progress of the recent decades.     

The treatment of deep dermal hand burns: How do we achieve better results?: Should we use allogeneic keratinocytes or skin grafts?

The treatment of deep dermal burns has a broad spectrum and has been subject to discussion over the past years. The treatment of hand burns is challenging due to the high requirements to aesthetic and functional outcome. 27 patients, 7 women and 20 men with deep dermal hand burns with a mean age of 41.3 ± 16.5 and a mean TBSA of 15% ± 19.6% were treated either with allogeneic cryopreserved keratinocytes or with split skin grafts. Long-term follow-up revealed no statistical significant differences between the two groups concerning Vancouver Scar Scale as well as hand function judged by the DASH score; however there was a tendency to higher VSS scores and impaired aesthetic results in the keratinocyte group. Allogeneic keratinocytes are a suitable armentarium for the treatment of deep dermal hand burns; and, if used correctly, they can produce a timely healing comparable to split-thickness skin grafts. Limited availability, high costs as well as the need for special skills are key factors, which render application of this technique outside specialist burn centres virtually impossible. In our opinion, the cultivation and use of keratinocytes should be reserved to these centres in order to facilitate a sensible application for a full range of indications. We recommend usage of allogeneic keratinocytes for deep dermal hand burns only in severely burned patients with a lack of donor sites. Patients with unrestricted availability of donor sites seem to profit from the application of split-thickness skin grafts according to our results.     

Total full-thickness skin grafting for treating patients with extensive facial burn injury: A 10-year experience

IntroductionFacial burns are not only a severe burn injury, but result in psychological disturbance. The improvement of the methods of treating facial burns remains topical. The aim of the study was to evaluate the effectiveness of approach based on full-thickness skin autografting for facial burn injuries.MethodsDuring 2000–2019, ninety seven patients with the facial burn were treated in Burn Center. All patient were divided into two groups. The comparative analysis between groups was done.ResultsGroup A was treated with full-thickness skin grafts (42 patients – 43.3%). Since 2010, total full-thickness skin graft was used in 11 patients from Group A. In group B, 55 patients (56.7%) were treated with split-thickness skin grafts, including 9 patients (16.4%) with total split-thickness skin graft transplantation. Total full-thickness skin graft was performed in case of a deep and extensive facial burn and cicatricial deformities. During the long-term period, a positive cosmetic result and the absence of indications for reconstructive operations were noted.ConclusionThe approach of facial burn treatment based on total full-thickness skin graft allows conditions for engraftment and adaptation of autograft, reduces the risk of scar developing and achieves maximum cosmetic results of treatment.     

Should dermal scald burns in children be covered with autologous skin grafts or with allogeneic cultivated keratinocytes?—“The Viennese concept”

The treatment of scald burns in children is still under discussion. The aim of the present study was to evaluate an optimised treatment regime for scald burns in children. Between 1997 and 2002, 124 children underwent surgical intervention due to burn injuries. Thirty-six out of these 124 children were enrolled into the evaluation of our recent treatment protocol. Twenty-two children with scald burns covering an average body surface area (TBSA) of 18.5% were treated by early excision and coverage with allogeneic keratinocytes in case of partial thickness lesions (keratinocyte group). Fourteen children with a TBSA of 17.2% were treated with autologous skin grafts alone (skin graft group). Both groups were comparable according to age, burn depth and affected TBSA. The complete clinical follow-up examination of at least 17 months was performed in 12 out of 22 children of the keratinocyte group and in 9 out of 14 patients of the comparative group. Visible scar formations were classified according to the Vancouver Scar Scale (VSS) in each patient. The use of allogeneic keratinocytes led to complete epithelialisation within 12 days in 20 of the 22 cases. No secondary skin grafting procedures had to be done. Skin take rate at the sixth postoperative day was 100% in the skin graft group. Blood transfusions were administered intraoperatively according to the clinical need of the patients by the responsible anaesthesiologist. The mean volume of blood, which had to be transfused was 63.9 ml in the keratinocyte group and significantly lower than the volume of 151.4 ml, which was administered in the skin graft group (p=0.04). At follow up the VSS observed in areas covered by keratinocytes was 2.33 on the average and therefore, significantly lower than the VSS of 5.22 in skin grafted areas of the comparative group (p=0.04). In children the use of cultivated keratinocytes in partial thickness scald burns is a procedure, which renders constantly reliable results. It minimizes the areas of autologous skin harvesting and reduces the amount of blood transfusions. The fact that less scarring is observed after keratinocyte grafting leads to the conclusion that skin grafting in children should be restricted to scalded areas, which have to be excised to the subcutaneous fat tissue.     

Air-fluidized therapy in the treatment of severe burns: A retrospective study from a burn intensive care unit in Austria

IntroductionAir-fluidized therapy (AFT) has long been used in the treatment of severe burns. In patients with extensive burns involving the posterior trunk, we aim to keep affected posterior areas dry and to postpone their treatment, initially applying available split-thickness skin grafts in functionally more important regions. We retrospectively assessed the impact of AFT on the survival of patients treated in the burn intensive care unit (ICU) of the Medical University of Vienna, Austria, between 2003 and 2016.MethodsThis retrospective single-center study included patients aged ≥18 years with burned total body surface area (TBSA) ≥20% and IIb–III° thermal injuries on the posterior trunk who received AFT. Survival rates were compared with those predicted by the abbreviated burn severity index (ABSI). Demographic, clinical, and surgical data were analyzed.ResultsSeventy-five of 110 patients with posterior trunk burns received AFT. Their survival rate exceeded that predicted by the ABSI score (mean ABSI, 10.0 ± 2.0; 73.3% (95% CI: 62-83%) survival rate vs. 20-40% predicted; p < 0.0001); no such difference was observed in the non-AFT group (mean, 8.8 ± 1.9; 65.7% (95% CI: 48-81%) survival rate vs. 50-70% predicted). Patients receiving AFT had significantly greater TBSA (median, 50% (35–60) vs. 30% (25–45) and longer ICU stays (median, 63 (36–92) vs. 18 (9–52) days; both p < 0.0001). Fifty-one (68.0%) patients in the AFT group and 26 (74.3%) patients in the non-AFT group underwent posterior trunk surgery (p = 0.66) a median of 16 (10–26) and 5 (2.5–9.5) days, respectively, after admission (p < 0.0001).ConclusionsPatients receiving AFT had significantly better survival than predicted by ABSI score in contrast to patients not receiving AFT although burn injuries in this group were more severe (greater TBSA, higher ABSI). As intensive care was similar in these groups aside from AFT, the better survival could be attributed to this additional therapy.     

Full-thickness burns across joints: results of coverage with acellular dermal matrix and thin autograft

The use of acellular dermal matrix and thin autograft to graft full-thickness burns over elbow and knee joints is evaluated. The percent of graft adherence, joint range of motion, and scar quality, as evaluated by the Vancouver scale, was noted for ten joints in eight patients following grafting. Graft adherence ranged from 75–100% at 7 days postoperatively. All patients maintained full elbow range of motion at long-term follow-up (average 4 months). Vancouver scales ranged from 3–4.5 as opposed to 4.5–8 for adjacent areas of conventional split-thickness skin grafts, the lower scores more closely approximating normal skin. Complete healing was demonstrated with maintenance of full range of motion and acceptable scar quality. The use of thinner split-thickness skin grafts would be expected to reduce donor-site morbidity, and the ability to re-harvest donor sites may be enhanced in patients with large surface area burns. Further follow-up of these patients is needed to evaluate the need for future reconstructive procedures.     

Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds — A double blind randomised controlled trial

IntroductionThis study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns.MethodsThis was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15?55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH).ResultsThirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm²; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups.ConclusionTXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.     

Increased risk of blood transfusion in patients with diabetes mellitus sustaining non-major burn injury

BackgroundDue to the increased mortality and morbidity associated with blood transfusion, identifying modifiable predictors of transfusion are vital to prevent or minimise blood use. We hypothesised that burn patients with diabetes mellitus were more likely to be prescribed a transfusion. These patients tend to have increased age, number of comorbidities, infection risk and need for surgery which are all factors reported previously to be associated with blood use.ObjectiveTo determine whether patients with diabetes mellitus who have sustained a burn ≤20% total body surface area (TBSA) are at higher risk of receiving red blood cell transfusion compared to those without diabetes mellitus.MethodThis was a retrospective cohort study including patients admitted to the major Burns Unit in Western Australia for management of a burn injury. Only the first hospital admission between May 2008 to February 2017 were included.ResultsAmong 2101 patients with burn injuries ≤20% TBSA, 48 (2.3%) received packed red blood cells and 169 (8.0%) had diabetes. There were 13 (7.7%) diabetic patients that were transfused versus 35 (1.8%) non-diabetic patients. Patients with diabetes were 5.2 (p = 0.034) times more likely to receive packed red blood cells after adjusting for percentage TBSA, haemoglobin at admission or prior to transfusion, number of surgeries, total comorbid burden and incidence of infection. As percentage TBSA increases, the probability of packed red blood cell transfusion increases at a higher rate in DM patients.ConclusionsThis study showed that diabetic patients with burn injuries ≤20% TBSA have a higher probability of receiving packed red blood cell transfusion compared to patients without diabetes. This effect was compounded in burns with higher percentage TBSA.     

Early burn wound excision significantly reduces blood loss.

The hypothesis that near-total early excision of large burns in children can be performed safely with a reduction in blood loss was tested. Of 1662 acutely burned patients admitted to this institution between 1982 and 1989, 594 underwent near-total excision of cutaneous flame or scald burn injuries in a single procedure. Operations took less than 3 hours and there were no operative deaths. Blood losses in burns of more than 30% total body surface area (TBSA) were significantly less at 0.40 +/- 0.06 mL/cm2 and 0.49 +/- 0.49 mL/cm2 excised when surgery was performed within the first 24 hours or after the 16th day after burn, respectively, when compared to 0.75 +/- 0.02 mL/cm2 for those excised between 2 and 16 days after burn (p less than 0.05). Blood loss for burns of less than 30% TBSA was of 1.19 +/- 0.13 mL/cm2. Early excision did not increase mortality rate when compared to later excision times. We suggest that near-total excision of large burns within the first 24 hours reduces blood requirements and morbidity without adversely altering hemodynamic stability or increasing mortality risks.     

Surgical treatment of burns in elderly patients

This study evaluates our experience with surgical treatment of burns in the elderly. Forty-two patients more than 59 years old were treated from 1982 to 1986. The mean age was 73, and the mean TBSA burned was 29%. The patients were divided into three groups. Group I had 22 patients with less than 20% TBSA burn (mean of 11%, with a mean of 6% full-thickness burns). Their survival rate was 91%. Group II had 11 patients with 21-40% TBSA burns (mean of 32%, with a mean of 17% full-thickness burns). Their survival rate was 82%. Group III had nine patients with burns greater than 40% TBSA (mean, 71%). None of these patients survived. Twenty of 29 (68%) survivors required a total of 36 operations. The mean area grafted per procedure was 8%. Each procedure required a mean of 2U packed red blood cells, and a mean of 2 1/4 hours. The complication rate was 33%, with partial graft loss (14%) being the most frequent. The average hospital stay was 27 days in Group I and 45 days in Group II. Only 25% of the patients required nursing home assistance at discharge.     

Minimizing blood loss in burn surgery

BACKGROUND: 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. METHODS: 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. RESULTS: 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%. CONCLUSION: 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 scalp as a donor site: revisited

The scalp cannot be used as skin graft donor site with impunity. A review of 2,620 charts identified 194 pediatric patients whose scalps served as donor sites for split-thickness skin grafts for the treatment of acute burns. The overall incidence of alopecia was 32%. However, the incidence of alopecia in unburned scalps was 13%. The occurrence of alopecia in this group was associated with larger burn area requiring more frequent use of the scalp and shorter intervals between graft harvests (p less than 0.05). Among this group of patients (n = 15), nine had mild spotty alopecia, four had surgically correctable alopecia, and two had global patchy alopecia not amenable to surgical correction. In the patients with concomitant burns to their scalps, the incidence of alopecia was 61%. Whether the burn or the graft harvest caused alopecia could not be established. Meticulous donor site care is mandatory in this latter group when the scalp donor site is indicated.     

特重度烧伤后伴多处严重畸形的功能重建

To explore new measures for functional reconstruction of multiple severe deformities as a result of extensive deep burn( total burn surface area ≥90% TBSA, including deep burn ≥ 70% TBSA)in late stage. Twelve severe bum patients with above-mentioned deformities were hospitalized in our ward during 1960 ～ 2005,the sears resulted from bums were distributed from head to foot with 173 deformities, including 27 scar ulcers. All patients lacked of self-care ability, among them some could not stand. Due to inadequate skin source, deformities were corrected by skin from matured scars expanded with subcutaneous balloon at late postburn stage. Following our former clinical experience, anatomic investigation and experimental re search, we chose the following methods to correct deformities and restore functions: application of split-thickness scar skin after expansion(88 wounds) ; use of sear skin flap/scar-Achilles tendon flaps (59 wounds) ; combination of thin split-thickness skin grafts from scar and allogeneic acellular dermal matrix (composite skin,40 wounds).All grafts survived, the appear ance and function were improved obviously without complica tions. Follow-up 1～ 40 years, all patients could take care them selves with satisfactory function and appearance, and among them 8 patients returned to work ( one had worked for 40 years),2 pa tients married and had children. The above-mentioned measures are safe, reliable and effective for functional reconstruction of deformities.