Annals of Burns and Fire Disasters - vol. XII - n. 1 - March 1999

Barret J.P., Wolf S.E.,Desai M.H., Herndon D.N.

Shriners Burns Hospital and The University of Texas Medical Branch, Galveston, Texas

SUMMARY. Massive burns still present important morbidity and mortality. Early excision and coverage with skin substitutes have improved survival. The aims of our study were to study the safety and efficacy of total burn wound excision in the first 24 h postinjury and assess its impact on survival. Between July 1996 and December 1997 we studied a cohort of 30 consecutive paediatric burned patients affected with massive burns (TBSA burned > 60%) admitted within 24 h of their injury. All full-thickness burns were excised and auto- and/or homografted on admission. Data are depicted as mean ± SEM. Mean TBSA burned was 80% (± 2.2) and TBSA full-thickness burns were 72% (± 4.8). Five patients presented burns of over 95% and three of them were covered with cultured epidermal autografts. Incidence of smoke inhalation injury was 54%, and 47% of patients presented septic episodes. There were no intra-operative or post-operative complications. Mean circulating blood volume of the patients was 1694 ull (± 308), and 4133 rril (± 1692) of whole blood was transfused in the operation. Length of stay was 67 days (± 8.8) and mortality in this cohort of severely burned children was 10% (3 patients). Immediate total burn wound excision and grafting is a safe and effective technique in severe burn injuries.

Introduction

Despite all recent advances in burn care, massive burns still present high morbidity and mortality. Early excision is currently the standard of care for deep partial-thickness and full-thickness burns. In massive burns, however, modem treatment of burn wounds present a challenge to the burn team, since it is not always possible to excise and cover with autografts the entire wound before sepsis and multiple organ failure challenge the survival of the patients.
Total burn wound excision in the first 24 h post-injury has been performed in our institution for the last decade. Nevertheless, its use is still in debate. The aim of the present study was to study the safety and efficacy of this technique and its impact on survival.

Patients and methods

In the period of time between July 1996 and December 1997, we studied a cohort of paediatric burned patients affected with massive burns (burns of over 60% total body surface area). Only patients admitted within 24 h of the injury were included. All full-thickness burns were excised on admission and the wound bed was covered with autografts and homografts (inclusion criteria are summarized in Table 1). We compiled demographic data, total body surface area (TBSA) burned and excised, laboratory data, complications, septic episodes, and surface area covered with skin substitutes. Data are depicted as mean ± SEM. Statistical analysis was performed with paired mest and multiple linear regression.

Total wound excision was performed in the following way: resuscitation was started according to the Galveston formula (Table II), and enteral nutrition started according to calculated enteral needs (Table Ill) via a tube feed positioned beyond the second portion of the duodenum.

Resuscitation was continued intra-operatively subtracting the fluid losses of the operation and with careful monitoring of urine output. Patients were anaesthetized with neuroleptanalgesia with spontaneous breathing. All full-thickness burns were excised down to viable tissue, and a superficial debridement was performed in all partialthickness burns. Autografts were then harvested and the trunk was always autografted in the first operation. The remaining excised burns, including the superficial debridement of partial-thickness burns, were homografted. At this time, full-thickness skin biopsies were taken in burns over 95% TBSA for culture epidermal autograft techniques. During the operation, minimal crystalloids were infused, and blood loss was replaced with reconstituted whole blood (I unit of packed red cell with I unit of fresh frozen plasma). Haemostasis was achieved with topical epinephrine (1/10,000) and topical thrombin (1000 units/ml). Donor sites were infiltrated with 0.45% normal saline with epinephrine at a concentration of 1/300,000.

Results

Thirty patients were included in the study. Mean age was 6.4 ± 1.2 yr, TBSA burned was 80 ± 2.2%, and TBSA full-thickness burns 72 ± 4.8%. Length of stay in the hospital was 67 ± 8.8 days, i.e,, 0.83 ± 0.2 days per 1% burned. Fifty-four per cent of all patients presented smoke inhalation injury on admission, which was diagnosed by positive findings on bronchoscopy examination.
Five patients presented burns in over 95% TBSA, and three of them were covered with cultured epidermal autografts (CEA). Half of the patients had septic episodes during their hospital course, and three patients (10%) died. Characteristics of patients and cause of death are summarized in Tables IV and V. Mean blood volume of the patients was 1694 ± 308 mI, and 4133 ± 1692 mI of blood were transfused during the operation (0.47 ± 0.19 mI per square em excised). There were no intra-operative deaths or complications. A post-operative depressior post-operative laboratory values was observed, but th recovered 24 h after excision. The differences between all pre- and post-operative laboratory values presented no statistical difference, and resuscitation was completed without problems in all patients. There were no septic episodes in the post-operative period.

Discussion

The leading causes of death in severely burned patients are still sepsis and respiratory distress syndrome following smoke inhalation injury. The skin is the largest human body organ, and when it is burned it produces an important depression in the immune response and exerts a strong metabolic response that leads to a prolonged inflammatory response, which in turn frequently leads to a multiple organ dysfunction syndrome, with or without the presence of sepsis. As in any other kind of trauma patient, early excision of all dead tissues and closure of the remaining open wounds has been advocated. Nevertheless, this poses a big challenge when dealing with massive burns. If left in place, the burn eschar maintains the patient's inflammatory response and eventually develops invasive infection which in many cases is lethal. In our recent experience we have managed to excise the entire burn wound in the first operation, even though the mean full-thickness burn wound was 72%.
We have followed this line because we strongly believe that the patient morbidity and mortality were improved, since mortality in this cohort of patients was only 10%. One of the possible reasons for their good survival may have been the prompt evacuation and despatch to a burn centre. Good resuscitation parameters were encountered in these patients, and pre- and post-operative resuscitation values were correct. In a rec6nt review, Wolf et all. found that delay in resuscitation had a great impact on mortality.'Other studies have shown that early excision (before day 14) increases survival in severely burned patients and decreases hospital stay and complications; early excision has also been proved superior to traditional conservative treatments. Even though the pattern of mortality has not changed dramatically in the past years with treatment by early excision,' it has been shown that early excision is beneficial in restoring cellular and humoral immunity in burn patients and in modulating the stress response to burn injury. This supports the belief that the improvement in survival and the decrease in hospital stay may be related to early excision.
No intra-operative deaths or complications were encountered with the use of this technique. The current experience is consistent with that previously reported by the senior authors, who noted an improval in survival and a decrease in blood loss and hospital stay, without any complications or operative deaths.
Many ethical issues arise when dealing with massive paediatric burns. Treating severely burn children is sometimes stressing and challenging. Decision-making is more than ever a team approach. The answer as to whether all burn victims are candidates for survival has still to be found, especially in the paediatric population, whose functional and psychological skills are still to be developed. Nevertheless, Blakeney et al.` showed in a recent study that children who survive massive burn injuries can achieve positive psychosocial adaptation. On all objective measurement scales, the groups of survivors and their parents were within normal limits. Adjustment neither improved nor deteriorated over time. Currently, nearly all patients should be considered to be candidates for survival, regardless of age, burn size, presence of inhalation injury, delay in resuscitation, or laboratory values on initial presentation.
In conclusion, total burn wound excision in the first 24 h post-injury is a safe technique. A high survival rate in massive paediatric burns can be achieved. Nowadays, the technique of immediate burn excision, which has been proved widely useful, can be extended to any kind of patient and burn size.

RESUME. Les brûlures étendues présentent une morbidité et une mortalité importante. L'excision précoce et la couverture avec des substituts de la peau ont amélioré les possibilités de la survie. Dans cette étude les Auteurs se sont proposés de considérer la fiabilité et l'efficacité de l'excision totale des brûlures dans les premières 24 h après la lésion et d'évaluer son effet sur la survie Dans la période juillet 1996-décembre 1997 ils ont étudié un groupe de 30 patients consécutifs pédiatriques atteints de brûlures étendues (surface brûlée totale > 60%) hospitalisés dans les premières 24 h après la brûlure. Toutes les brûlures à toute épaisseu ont été traitées avec l'excision et l'auto- et l'homogreffe immédiatement après l'hospitalisation. La surface moyenne brûlée étai 80 ± 2,2% et les brûlures à toute épaisseur 72 ± 4,8%. Cinq patients présentaient des brûlures dans plus de 95% de la surface corporelle et trois patients ont été couverts avec des autogreffes épidermiques culturées. La fréquence des lésions dues à l'inhalation de la fumée était 54%, et 47% présentaient des épisodes septiques. On n'a pas observé aucune complication intra- ou post-opératoire Le volume moyen de sang circulant des patients était 1694 ± 308 ml, et pendant l'opération une quantité de 4133 ± 1692 ml de sang entier a été transfusée. La durée moyenne de l'hospitalisation était 67 ± 8,8 jours et la mortalité dans ce groupe d'enfant gravement brûlés était 10% (3 patients). Il a été démontré que l'excision immédiate et totale de la lésion et la greffe est un( technique sûre et efficace dans le traitement des brûlures sévères.

BIBLIOGRAPHY

1. Saffle J.R., Davis B., Williams P.: 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., 16: 21932, 1995.
2. Heimbach D.M.: Early burn excision and grafting. Surg. Clin. North 10. Am., 67: 93-107, 1987.
3. Wolf S.E., Rose J.K., Desai M.H., Mileski J.P., Barrow R.E., Hemdon D.N.: Mortality determinants in massive pediatric burns. An analysis of 103 children with > or = 80% TBSA burns (> or 70% full-thickness). Ann. Surg., 225: 554-65, 1997.
4. Herndon D.N., Barrow R.E., Rutan R.L., Rutan T.C., Desai M.H., Abston S.: A comparison of conservative versus early excision therapies in severely burned patients. Ann. Surg., 209: 547-52, 1989.
5. Hidder F., Traber D.L.: Pathophysiology of the systemic inflammatory response syndrome. In: "Total Burn Care", D.N. Hemdon (ed.), Saunders, London, 1996.
6. Thompson P., Hemdon D.N., Abston S., Rutan T.: Effect of early excision on patients with major thermal injury. J. Trauma, 27: 2057, 1997.
7. Caldwell F.T., Jr, Wallace B.H., Cone J.B.: 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., 17: 137-46, 1996.
8. Peck M.D., Heimbach D.M.: Does early excision of burn wound change the pattern of mortality? J. Burn Care Rehabil., 10: 7-10 1989.
9. Yamamoto H., Siltharm S., de Serres S., Hultman C.S., Meyer A.A. Immediate burn wound excision restores antibody synthesis to bacteria] antigen. J. Surg. Res., 63: 157-62, 1996. Cetinkale 0., Ulualp K.M., Ayan F., Duren M., Cizmeci 0., Pusane A.: Early wound excision and skin grafting restores cellular immunity after severe burn trauma. Br. J. Surg., 80: 1296-8, 1993. 1. Desai M.H., Herndon D.N., Broemeling L., Barrow R.E., Nichols R.J., Jr, Rutan R.L.: Early burn wound excision significantly reduces blood loss. Ann. Surg., 211: 753-9, 1990.
10. Blakeney P., Meyer W. 3rd, Robert R., Desai M., Wolf S., Hemdo D.: Long-term psychosocial adaptation of children who surviv burns involving 80% or greater total body surface area. J. Trauma 44: 625-32, 1998.