Early excision of burns: has the approach fulfilled its promise?

Early excision of burns: has the approach fulfilled its promise?

General Early Excision of Burns: Has the Approach Fulfilled Its Promise? Guest Reviewer: Tina L. Palmieri, MD EARLY EXCISION AND GRAFTING VERSUS CONS...

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General

Early Excision of Burns: Has the Approach Fulfilled Its Promise? Guest Reviewer: Tina L. Palmieri, MD EARLY EXCISION AND GRAFTING VERSUS CONSERVATIVE MANAGEMENT OF BURNS IN THE ELDERLY.

Kirn DS, Luce EA. Plast Reconstr Surg 1998;102:1013–1017. To compare survival and outcome for early versus late burn excision in elderly patients.

Objective

Review of all patients over the age of 70 treated between January 1975 and December 1994 by the same surgeon and at the same institution. Patients in the first period of the study were treated “conservatively” (ie, delayed operative intervention), whereas those in the second half of the study period had operative excision within 7 days of admission.

Design

University of Kentucky burn intensive care unit.

Setting

All patients over the age of 70 who were admitted to the University of Kentucky burn intensive care unit from January 1975 through December 1994. Seventy-three patients met age criteria. Six patients were excluded from the study either because they were not resuscitated or did not respond to resuscitation.

Participants

A total of 67 patients were included in the study. The 28 patients in the early excision group had an average age of 78.3 years and body surface area burn of 23.6% compared with 79.3 years and 20.9% for the 39 patients in the conservative management group. Excision took place at an average of 4.8 days in the early excision group and 18.3 days in the conservative group. Inhalation injury was present in 18% of the early excision group and 23% of the conservative management group, with overall mortality for inhalation injury of 93%. There was no significant difference between groups in survival, do not resuscitate (DNR) status, or length of stay. All patients with burns on greater than 30% of their total body surface area died.

Results

In this retrospective series analyzing patients treated by the same burn unit director, elderly burn patients did not demonstrate a survival benefit from early excision and grafting of their burn wounds. Hospital length of stay was not decreased by early excision. The mortality rate for elderly patients with associated inhalation injury remains high.

Conclusions

REVIEWER COMMENTS. This study examined the effectiveness of burn excision within 7 days of admission in the “old” elderly burn patient treated by the same surgeon and burn team over 2 sequential time periods. There was no survival advantage in early excision in this group of elderly burn patients. This study is limited by its retrospective format and sequential rather than concurrent treatment of the patient groups. However, these authors raise several valid points. Elderly burn patients have higher morbidity and mortality than their younger counterparts for virtually any size burn. One disadvantage of early excision is that potentially viable tissue may be excised in the initial procedure. Although younger patients may be able to tolerate larger excisions, the elderly have less physiologic reserve. Operative intervention needs to be carefully timed, planned, and executed in this group. IMPROVED SURVIVAL OF ADULTS WITH EXTENSIVE BURNS.

Fratianne RB, Brandt CP. J Burn Care Rehabil 1997;18:347–351. CURRENT SURGERY



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Objective

To evaluate the effectiveness of a revised surgical protocol and treatment plan for adults with extensive burns.

Design

Review of charts of all patients 18 years or older admitted between January 1, 1988, and December 31, 1994, with 75% or greater total body surface area (TBSA) burn after institution of a revised burn protocol. The protocol included specific guidelines for fluid resuscitation, early enteral nutrition, topical silver sulfadiazine, avoidance of the use of prophylactic antibiotics, excision of all nonviable tissue by postburn day 7, immediate coverage of newly excised wounds, and early definitive wound closure. Charts were analyzed for age, TBSA involved, hospital length of stay, survival, presence of inhalation injury, and functional outcome.

Setting

Review was conducted for patients admitted to Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio.

Participants

The charts of 23 patients, 20 men and 3 women, aged 18 or older and admitted with greater than 75% TBSA injury were reviewed. One patient was lost to long-term follow-up. All patients were included in the study.

Results

Overall survival was 34.8%. Of note, 10 of the 15 patients who died were believed to have sustained nonsurvivable injuries and were not resuscitated. The average age of this group was 59.2 years (range, 30 to 79), TBSA was 89%, and 9 of the 10 had sustained inhalation injury. The average age of the remaining 5 nonsurvivors was 46 years, TBSA 85%, and 2 of the 5 had inhalation injury. Average length of survival was 30.2 days. The average age of the 8 survivors was 32.7 years (range, 24 to 56) with 81.4% TBSA burn and an average length of stay of 93.3 days. The survivors returned to functional activities with the exception of the 56-year-old patient, who was transferred to a nursing home and died within a year.

Conclusions

The protocol for the treatment of burns of at least 75% TBSA in adults resulted in an improved rate of survival compared with the previous 5 years. This improvement in survival was attributed to multiple interventions, including early enteral nutrition, early excision and grafting of burn wounds, and attention to physical therapy. The most important factor responsible for the improvement in survival was found to be early excision and closure of the burn wound. This protocol utilizes widely available and inexpensive techniques. REVIEWER COMMENTS. Unlike the authors of the previous abstracted article, Fratianne and Brandt maintained that they markedly improved patient survival utilizing a protocol for early excision and grafting combined with aggressive supportive care. On first inspection, the results of this study seem to contradict those of Kim and Luce. However, the patient population in this study was much younger, and they also had significantly larger burns than patients in the previous study. Their improved survival is consistent with earlier studies that showed increased survival with early excision in younger patients.1–7 This article emphasized the importance of perioperative care of the burn patient. Aggressive early enteral nutrition and attention to details of wound care and rehabilitation are essential adjuncts to the success of early excision and grafting. Of note, patient outcome in terms of activity resumption was good despite the extent of burn injury. MORTALITY DETERMINANTS IN MASSIVE PEDIATRIC BURNS.

Wolf SE, Rose JK, Desai MH, et al. Ann Surg 1997;225:554 –569.

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Objective

To define the predictors of mortality in massively burned children and document the extent of improvement in their care.

Design

Review of all patients between July 1982 and September 1996 up to 17 years of age with burns covering at least 80% of the total body surface area (TBSA). All patients were treated with early total burn excision within 48 hours of admission. Survivors were compared with nonsurvivors.

Setting

Shriners Burns Institute, Shriners Hospital for Children Galveston, Galveston, Texas.

Participants

Two thousand eight hundred ninety patients were admitted during the study period. Of those, 103 patients aged 5 months to 17 years met the entry criteria.

Results

Seventy-six males and 27 females were included in the study. Mean age for the patients in the study was 6.40 ⫾ 0.45 years (range, 0.5 to 17 years); mean total burn size was 88%, with a mean full-thickness component of 85%. Inhalation injury was present in 60 patients. Overall mortality for burns of 80% or higher was 33%. Mortality increased to 57% for patients aged 2 years or less and CURRENT SURGERY



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progressively declined to a level of 16% for 11 to 17 year olds. Mortality ranged from 19% for 80% to 85% TBSA burn to 69% for 96% to 100% TBSA burn. Injury characteristics predictive of increased mortality included lower age, increased TBSA burn, inhalation injury, delay in obtaining intravenous access for resuscitation, lower base deficit, increased serum osmolarity on admission, sepsis, increased time on ventilator, need for inotropic support, and severe thrombocytopenia (⬍20,000/ mm2). No survival difference was noted in the period from 1982 to 1996. Hospital length of stay increased with increasing burn size. Virtually all pediatric patients who have sustained burn injury should be considered as having survival potential despite the presence of variables that increase mortality. Patients most likely to have an adverse outcome include those with inhalation injury, limited donor sites, delays in resuscitation, sepsis, or multiorgan failure.

Conclusions

REVIEWER COMMENTS. The authors, who are proponents of total burn excision within 48 hours, have achieved impressive survival in this group of massively burned children. They attribute their success to multiple factors, including early excision, infection control, enteral nutrition, and aggressive respiratory support. In this study, they reviewed their experience and delineated multiple factors associated with increased mortality. Note that the very young, like the very old, have a higher overall burn mortality and that delays in resuscitation adversely affected outcome. There was no demonstrable improvement in survival throughout the study period. This is not surprising given that the same early excision protocol was used throughout the study. LASER ABLATION OF BURNS: INITIAL CLINICAL TRIAL.

Sheridan RL, Lydon MM, Petras LM, et al. Surgery 1999;125:92–95. To report the first use of the laser to ablate burn eschar in humans.

Objective

A prospective analysis of children requiring serial excision of burn eschar. Each patient acted as his or her own control. A full-thickness wound was randomly divided into 2 segments. One half was ablated with a rapidly scanned cw CO2 laser system, while the other half was sharply excised. Both wounds were immediately autografted and evaluated for time to engraftment, at 7 days, and at postoperative intervals by a blinded examiner using the Vancouver Scar Score. The Vancouver Scar Score assesses scar for pliability, pigmentation, vascularity, and height on a 1 (normal) to 4 scale.

Design

Shriners Burns Hospital and the Division of Burns and Trauma, Massachusetts General Hospital, Boston, Massachusetts.

Setting

A total of 21 children, 16 boys and 5 girls, with full-thickness burns requiring serial excision were enrolled in the study. An 8 ⫻ 4 cm2 segment was divided into 2 segments, with half sharply excised and the other half ablated with a rapidly scanned cw CO2 laser. Laser ablation was aborted in 3 children due to excessive bleeding or difficulty with eschar laser ablation.

Participants

Average age was 8.3 ⫾ 1.2 years, weight 36.3 ⫾ 4.9 kg, burn size 40% ⫾ 5.1%. Excision and autografting were undertaken at an average of 11.3 ⫾ 2.3 days postburn with an average energy of 99.2 ⫾ 5.7 W. Initial engraftment at 7 days was 95.8% in both groups. There was no difference in Vancouver Scar Score at 32 weeks or at 1 year postburn.

Results

This pilot study demonstrated that high-power, rapidly scanning, cw CO2 laser ablation of burn scar with immediate autografting can yield short- and long-term results comparable to those of sharp excision. There was no difference in hypertrophic scarring. This new technology has the potential to reduce blood loss without sacrificing engraftment rates. However, further refinement in technique is necessary before it can be recommended.

Conclusions

REVIEWER COMMENTS. Full- and partial-thickness burns have traditionally been excised sharply, often with prodigious blood loss. Sheridan et al17 explored a recently developed technology (the laser) first in the animal model and now in this controlled human study, in search of a more effective method to remove the eschar without increasing subsequent scar formation or blood loss. These preliminary results are indeed promising. However, as the author stated, several issues need to be addressed before this laser system can be recommended for routine use in burns, including the impact of laser ablation on scar formation or prolonged operative times or equipment malfunction for larger burn wounds. Determination of adequate eschar removal is also different with the laser: the diffuse capillary bleeding that accompanies sharp excision is not present. Cost of this new technology may also be a limiting factor.

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SUMMARY The rate of survival of burn patients has increased significantly over the past 20 years because of advances in both supportive care and wound management. Recent data suggest that the burn size considered to be lethal to 50% of patients (LA50) has steadily increased from 40% of total body surface area (TBSA) in the 1940’s to 81% of TBSA today.1 One reason purported to decrease mortality and improve outcome for the burn patient is early excision and grafting of burn wounds.1–7 But what exactly is “early excision”? As seen in the above papers, this definition can vary. Generally, early excision ranges from early massive excision of the entire burn wound within 48 to 72 hours5,7 to sequential excision of the entire burn wound over approximately 7 days.8 Numerous studies in the 1970’s and 1980’s suggested that early excision increased survival as well as functional and aesthetic outcome in children, adults, and the elderly.1–9 Proponents of early excision cite decreased hospital length of stay and costs, less operative blood loss, a lower incidence of hypertrophic scar formation, improved immune response, and decreased intensity and duration of the hypermetabolic response to burn injury with early excision and wound coverage. Early excision and grafting is applicable to both small and large burns. Disadvantages of this approach include inadvertent removal of potentially viable tissue, limited donor sites, wound closure, and the need for multiple blood transfusions.5 Not all studies have fully supported the concept. The data for the elderly have shown both improvement9,10 and equivocal11 results, and 1 study suggested that selection bias may play a role.12 Nonetheless, early excision and grafting of burns is the method of treatment utilized by most burn centers.13 There are relatively few contraindications to early excision and grafting. A notable exception is in the case of scald burns, in which the depth of the injury can be difficult to determine in the first several days after injury.14,15 To avoid excessive removal of viable tissue, the scald burn is usually initially observed. Once it is clear that the wound will not heal within 2 to 3 weeks, the area in question is generally promptly excised and grafted. The other exception is the patient who cannot tolerate an anesthetic or operative procedure. Although early excision and grafting has decreased burn mortality, it has not changed the pattern of burn mortality: pneumonia, sepsis, and multisystem organ failure are still leading causes of death in these patients.16,17 A recently tested probability model implicated age more than 60 years, TBSA burn more than 40%, and inhalation injury as independent risk factors for burn mortality.18 Future improvements in early excision may well reside in several distinct arenas. The first involves, as the article by Sheridan et al17 suggested, finding a more efficient method of eschar excision that does not adversely effect wound healing. The role of the laser and other devices in the removal of burn eschar is still being defined. Advances in support of the critically ill patient will continue to have an impact on patient survival. Although early excision and grafting are integral to the care of the burn patient, it is important to remember that they are only links in the chain of care. It is vital to integrate excision with other aspects of care, such as nutritional support, cardiopulmonary care, physical therapy and rehabilitation,

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and nursing care. Even the most precise excision and grafting procedure will be unsuccessful if nutritional support is inadequate, organ perfusion is not maintained, or wounds are improperly cared for. Has early excision of burns fulfilled its promise? Yes and no. With judicious planning and implementation of burn care principles, the overall mortality rate associated with burn injury has decreased. Yet despite these advances, the promise for the future remains. TINA L. PALMIERI, MD Division of Burn Surgery Shriners Hospitals for Children Northern California University of California, Davis Sacramento, California

References 1. Saffle JR, Davis B, Williams P, and The American Burn Association Registry Participant Group. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association Patient Registry. J Burn Care Rehabil 1995;16:219 –232. 2. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and immediate grafting: a method of shortening illness. J Trauma 1974;14:389 –395. 3. Curreri PW, Luterman A, Braun DW, et al. Burn injury analysis of survival and hospitalization time for 937 patients. Ann Surg 1980; 192:427– 436. 4. Engrav LH, Heimbach DM, Reus JL, et al. Early excision and grafting versus nonoperative treatment of burns of indeterminate depth: a randomized prospective study. J Trauma 1983;23:1001– 1007. 5. Herndon DN, Barrow RE, Rutan RL, et al. A comparison of conservative versus early excision: therapies in severely burned patients. Ann Surg 1989;209:547–552. 6. Tompkins RG, Remensnyder JP, Burke JF, et al. Significant reductions in mortality for children with burn injuries through the use of prompt eschar excision. Ann Surg 1988;208:577–585. 7. Herndon DN, Gore D, Cole M, et al. Determinants of mortality in pediatric patients with greater than 70% full-thickness total body surface area thermal injury treated by early total excision and grafting. J Trauma 1987;27:208 –212. 8. Caldwell FT Jr, Wallace BH, Cone JB. Sequential excision and grafting of the burn injuries of 1507 patients treated between 1967 and 1986: end results and the determinants of death. J Burn Care Rehabil 1996;17:137–146. 9. Deitch EA. A policy of early excision and grafting in elderly burn patients shortens the hospital stay and improves survival. Burns 1985;12:109 –114. 10. Burdge JJ, Katz B, Edwards R, Ruberg R. Surgical treatment of burns in elderly patients. J Trauma 1988;28:214 –217. 11. Kare M, Peters WJ, Douglas LG, Morris SF. An early surgical approach to burns in the elderly. J Trauma 1990;30:430 – 432. 12. McManus WF, Mason AD, Pruitt BA. Excision of the burn wound in patients with large burns. Arch Surg 1989;124:718 –720. 13. Heimbach D, Herndon DN, Luterman A, et al. Early excision of thermal burns—an international round-table discussion, Geneva, Switzerland, June 22, 1987. J Burn Care Rehabil 1988;9:549 –561. 14. Desai MH, Rutan RL, Herndon DN. Conservative treatment of scald burns is superior to early excision. J Burn Care Rehabil 1991;12: 482– 484. 15. Ou LF, Lee SY, Chen YC, Yang RS, Tang YW. Use of Biobrane in pediatric scald burns— experience in 106 children. Burns 1998;24: 49 –53. 16. Peck MD, Heimbach DM. Does early excision of burn wounds change the pattern of mortality? J Burn Care Rehabil 1989;10:7–10. 17. Sheridan RL, Ryan CM, Yin LM, Hurley J, Tompkins RG. Death in the burn unit: sterile multiple organ failure. Burns 1998;24:307–311. 18. Ryan CM, Schoenfeld DA, Thorpe WP, et al. Objective estimates of the probability of death from burn injuries. N Engl J Med 1998;338: 362–366.

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