- Email: [email protected]
Burn Treatment
AORN JOURNAL
FEBRUARY 1989, VOL. 49, NO 2
Burn Treatment COVERING BURN WOUNDS WITH
AUTOLOGOUS MICROSKIN GRAFTS
Cheng-Hui Fang, MD; Guang-Shu Yu, MD; Ming-Liang Zhang, MD; J. Wesley Alexander, MD
T
he skin is the body’s major barrier against the invasion of microbes. In extensively burned patients, this skin barrier has been destroyed and wound sepsis (or septicemia) is the main cause of death. If the wounds are grafted in a timely manner, the prognosis for extremely burned patients is improved markedly. Badly burned patients rarely have enough undamaged skin to provide adequate graft donor sites. The method of intermingling autografts (tissue from one’s own body) and allografts (tissue from a donor) and meshing skin autografts with meshed skin allograft overlays has been developed and used to cover extensive burn wounds with a high degree of success.’ In addition, several temporary artificial coverings have been developed, but they are less successful in the treatment of large burm2
Additional clinical trials are needed for epidermal cell culture technique, but it appears to have limited value.3
Cheng-Hui Fang, MD, is associate professor of surgery and director of the burn unit, First Teaching Hospital, Beijing Medical University. A t the time the article was written, he was a research fellow, Shriners Hospitals for Crippled Children, Bum Institute, Cincinnati. He received his medical degree from Beijing Medical University,
department,Beijing Jishuitan Hospital,He received his medical degree from Beijing Medical University.
Guang-Shu Yu, MD, is an associate professor of surgery, First Teaching Hospital, Beijing
Medical [email protected] received his medical degree from Hubei (China) College.
Ming-Liang Zhang, MD, is an associate professor and the associate director of the burn 526
Microskin Grafting
A
new technique, microskin grafting, has been developed that shows encouraging results for the treatment of severe burns! Eight patients in a study at First Teaching Hospital, Beijing Medical University, Beijing, China, reported being completely healed six to seven weeks postoperatively; one patient died of overwhelming pulmonary infection 22 days postoperatively .5 The procedure involves mincing skin autografts into tiny skin particles, evenly dispersing the skin
J. WesleyAlexander, MD, isprofessor of surgery and director of transplantation division, Department of Surgery, University of Cincinnati College of Medicine. He also is director of research, Shriners Burns Institute, Cincinnati Unit. He received his doctorate in medicine from the University of Texas, Galveston. The authors would like to acknowledge Maribn Jenkins, RN, MBA, Vicki Greene, and Lois Marchionnefor their assistance with the article.
AORN JOURNAL
FEBRUARY 1989, VOL. 49, NO 2
Fig 1. A step-by-step illustration of the microskin grafting procedure with allograft overlay. The purpose is to float and evenly disperse the skin particles (SPs) on the saline, transfer the skin particles to the dermal surface of the allograft, and transplant the allograft to the wound. (Adapted from M L Zhang et al, “Microskingrafting in the treatment of extensive burns: A preliminary report, Journal of Trauma 28(6) (June 1988) 804-807, with permission from The Williams C? Wilkins Co) ”
particles using a piece of silk cloth and saline, transferring the skin particles to the dermal surface of an allograft, and transplanting the allograft to the excised wound (Fig 1). The skin particles grow larger until they coalesce with each other and resurface the whole area. Then the allograft is rejected. Patient selection criteria. The microskin grafting technique is applied to those patients whose burn injuries, particularly third-degree burns, are very extensive. The intact skin area on badly burned patients is so small and scattered that harvested autografts either cannot be meshed properly or they do not provide a sufticient covering using the usual grafting techniques. With the microskin grafting application, the patient’s own skin can be used to cover the wound. The final selection should be based on accurate 528
evaluation of the patient’s age, area of burns, the concomitant injuries, and the preexisting diseases of the patient.
Preoperative Preparation
T
he surgeon explains the patient’s status and risks of the planned surgery to the family. Although there has not been a documented case, a potential risk of using allograft includes a remote possibility of contracting acquired immune deficiency syndrome. The OR nurses observe the patient before the procedure to understand the distribution of burn wounds, the areas that are planned for excision and grafting, where the donor areas will be, and how the patient will be positioned during surgery. They also provide emotional support for the
FEBRUARY 1989, VOL. 49, NO 2
AORN J O U R N A L
The microskin graft procedure requires two surgical teams that work together in placing the grafts and applying the dressings. patients who usually have to undergo several surgical procedures. The night before surgery, the OR nurses explain the planned procedure and expected postoperative regimen to the patient. Any questions or concerns are addressed at this time. Preoperative teaching is adjusted to meet the patient’s level of understanding and age-appropriate modalities. Before administration of preoperative medications the day of surgery, the OR nurses reinforce the information they provided the patient the night before. They also explain the procedures that occur before anesthesia is initiated, and they continue to provide emotional support throughout the administration of anesthesia. Preoperative teaching should also include family members in an effort to assist their understanding and secure their support of the postoperative regimen. To prepare for the procedure, the nurse prepares a regular autoclaved or gas-sterilized tray and a penetrated tray (both 40 by 55 cm). The penetrated tray has several 2 mm holes aligned 5 mm apart to allow saline to pass through. If the patient does not have an intravenous (IV) line and a urinary catheter, they are inserted before the patient is taken to the OR. Some patients are not acutely ill at the time of scheduled grafting and may not require a Foley catheter. After checking the patient’s identification tag, the circulating nurse assists in placing the patient in the dorsal supine position on the OR bed. Although the location of the grafts determine the patient’s position, the dorsal supine position is used most of the time. The patency of the IV line and the urinary catheter are checked, and the patient is anesthetized. The nurse places an electrosurgical dispersive pad on a site where intact skin remains. He or she also pads bony prominences to prevent normal skin breakdown or deepening of the burn wound. The circulating nurse preps the donor site with a 75% alcohol solution. Then for the areas to be 530
excised, he or she washes off any local antimicrobial agent from the wound, dries the area, and preps it with povidone-iodine. The scrub nurse assists the surgeon in draping the surgical area.
Intraoperative Procedure
T
he procedure requires two surgical teams: one surgeon/scrub nurse team is in charge of harvesting the skin autografts and preparing skin particles and allografts; the second surgeon/scrub nurse team performs the escharectomy. The two teams work together in placing the grafts and applying the dressings. The No. 1 team surgeon chooses a donor site for autografts one tenth the size of the wound to be covered. The scalp is a good site because it heals faster due to its profuse blood supply and dense distribution of sweat glands, hair follicles, and sebaceous glands, all of which have the ability to regenerate epithelium. Its blood supply also provides resistance to infection. The thicker skin provides greater potential for multiple harvesting. There also is no scarring after the skin graft harvesting and no harm to hair growth. To obtain the donor skin, the surgeon uses either an air-powered, electric, or handheld dermatome set at 0.008 inch. After the skin is taken, the surgeon covers the donor site with a single layer of fine mesh gauze or other suitable material. Bulky, coarse mesh gauze is added to the site, and if the donor site is on one of the extremities, a pressure dressing also is used. The No. 1 team scrub nurse takes the autografts to another sterile table, puts them in a shallow container, washes off the blood clots with saline, and minces the grafts into tiny skin particles as small as possible with fine scissors (Fig 2). At the same time, the No. 1 team surgeon is combining a number of allografts into a large sheet using staples or sutures. The allograft should be large enough to cover the whole excised wound
FEBRUARY -
AORN JOURNAL
1989, VOL. 49, NO 2
Fig 2. Thin split-thicknessskin autografts are minced into tiny skin particles. on the patient and protect it from infection. Allografts are procured from donors and preserved in liquid nitrogen in a tissue bank. They are ready for use at any time. No human lymphocyte antigen matching is needed. An allograft sheet has two surfaces-the dermal and the epidermal-with the dermal surface making contact with the wound. After the allografts are combined, the surgeon makes a few stab wounds to allow for drainage. Concurrently, the No. 2 team surgeon and scrub nurse excise the wound either tangentially or down to the fascia1 level depending on the depth of the burns. An air-powered, electric, or handheld dermatome may be used for tangential excision. During excision, the surgeon and scrub nurse maintain hemostasis by cauterizing small vessels and by clamping and ligating the larger vessels. The No. 1 team surgeon places the recombined allograft over the patient's excised areas. He or she trims the allograft to fit the contour of the wound; it is very important to mark the position of the allograft along the wound's edges. Then the allograft is brought back to the worktable and stretched with the dermal surface up. Any blood clots are removed using wet sponges. After the skin particles are ready, the No. 1 team scrub nurse prepares the trays and silk cloth and positions the penetrated tray in the regular
tray. The nurse places the silk cloth in the penetrated tray with its four sides hanging over the edges. The nurse wets the silk with saline, expresses the air bubbles from underneath the silk, and ensures that all wrinkles are removed. Both the No. 1 team surgeon and the nurse place the skin particles on the silk. As the surgeon holds the trays, the nurse pours saline in the top tray and the surgeon lightly agitates the trays until all skin particles float up and are evenly dispersed. The saline drains through the silk and the penetrated tray, and it is collected in the bottom tray. This leaves the skin particles evenly distributed on the silk. The skin particles are now ready for transferring to the allograft. The two surgeons lift the piece of silk out of the tray by the corners. It is inverted so that the side of the silk bearing the skin particles is placed against the dermal side of the allograft. The scrub nurse gently presses against the silk with a wet sponge to ensure that the skin particles make contact with the allograft. As the surgeon peels the silk off, the skin particles remain. This process is repeated until all skin particles are transferred to the allograft. The teams return to the patient. The surgeons control bleeding and oozing completely and irrigate the wound copiously with saline. The circulating nurse and the scrub nurses make a final 531
FE
49, NO 2
AORN JOURNAL
Fig 3. The patient sustained a flame burn involving 85%of his total body surface area. The third-degree burns were 75% of the total body surface area, and the other 10%were deep second-degree burns. Microskin grafting and allografting was done on the lower left leg immediately after an escharectomy (top). Thirty-nine days later, the wounds were completely healed (right). Wounds usually heal in an average of six to seven weeks. -
sponge count. The surgeons then transplant the allograft to the wound according to the premarked position marks; special care is taken not to move the allograft over the wound after it has been applied. After the edges of the allograft are stapled, the surgeons place fine mesh gauze soaked with multiple antibiotic solutions over the graft and apply bulky dressings. If the procedure is performed on the extremities, plaster may be used to immobilize the grafted areas. After the dressing is applied, the circulating nurse reports the patient's status to the burn unit nurse. Before being transported to the intensive care section of the burn unit, the nurse checks the patency of the IV line and urinary catheter.
Postoperative Care
I
n the burn unit, the patient is put onto a Stryker"" bed. The nurse places him or her in the supine position with both upper and lower extremities abducted. The patient should not be turned face down until he or she is awake and vital signs are stable. The nurse monitors vital signs and output, and observes the dressings for
bleeding from both the excised area and the donor area. If the patient's temperature drops dramatically, the nurse turns the room temperature up and covers the patient with blankets. The nurse also monitors an IV infusion and transfusion. Enteral feeding is administered after the patient has recovered from anesthesia. Physical therapy and occupational therapy that involves the grafted area is not encouraged in the first week postoperatively to ensure that the graft takes. The first dressing change that the surgeon must attend is scheduled between the fifth and seventh postoperative day. The nurse soaks the inner layers of the dressing with saline before they are removed. If no infection is noted, the nurse rewraps the wound in the same fashion as before, and the dressing is changed once every three days. If the wound is infected, the physician takes a swab culture and the dressing is changed daily or twice a day. Systemic antibiotics are administered if indicated. The wounds heal in an average of six to seven weeks (Fig 3). The dressing change for the donor site differs. The outer dressings are removed layer by layer, starting at 48 hours postoperatively. The inner 533
AORN JOURNAL
layer of fine mesh gauze is left in place until the seventh to the 10th postoperative day. It is soaked with mineral oil to make it easy to peel off. Burn wounds, other than the ones in the grafted area, are treated with Silvadenes. The type depends on the microoganisms recovered and the sensitivity to the agents. To prevent occurrence of sepsis, the nurse needs to protect the grafted area against contamination by stool and urine. Because of prolonged bed rest, stool softeners are sometimes prescribed for the patient. Keeping the IV line clean also helps decrease the Occurrence of sepsis. The gauze that is used to wrap the connection sites of an IV line should be changed every nursing shift. In addition to bedside care, the nurse can provide the patient with emotional care. Major burns are physically disfiguring and many times disabling, and the burn patient is psychologically fragile. If little hope of recovery is communicated either verbally or nonverbally, the patient can get depressed. The nurse may be able restore a patient’s self-esteem and will to live with a positive, encouraging attitude. The preliminary experience with this procedure has been encouraging in the treatment of extensively burned patients. 0 Notes 1. C C Yang et al, “Intermingled transplantation of auto- and homografts in severe burns,” Burns, Including Thermal Injury 6 (1980) 141-145; J W Alexander et al, “Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay,” Journal of Trauma 21 (June 1981) 433-438. 2. JFBurke et al, “Successfuluse of aphysiological& acceptable artifical skin in the treatment of extensive burn injury,” Annals of Surgery 194 (October 1981) 413-428; B A Pruitt Jr, N S Levine, “Characteristics and uses of biologic dressings and skin substitutes,” Archives ofsurgery 119 (March 1984) 312-322. 3. G G Gallic0 111 et al, “Permanent coverage of large burn wounds with autologous cultured human epithelium,” New England Journal of Medicine 3 11 (Aug 16, 1984) 448-451; E L Heck, P R Bergstresser, C R Baxter, “Composite skin graft: Frozen dermal allografts support the engraftment and expansion of autologous epidermis,” Journal of Trauma 25 (February 1985) 106-112. 4. M L Zhang et al, “Microskin grafting: 11. Clinical report,” Burns, Including Thermal Injuty 12 (December 1986) 544-548. 534
FEBRUARY 1989, VOL. 49, NO 2
5. C H Fang et al, “A preliminary report on transplantation of microskin autografts overlaid with sheet allograft in the treatment of large burns,” Journal of Burn Care and Rehabilitation 9 (November/ December 1988).
Untested Blood Released, Workers Disciplined After discovering last March that 24 blood products that should have been destroyed were distributed for transfusion, the Red Cross Blood Services took disciplinary action and doubled its record inspections. A subsequent internal review involved examinations of all blood and blood products that should have been quarantined or destroyed after testing. This review revealed that 2,400 products were mistakenly released, including 5 18 blood products that were not tested for the human immunodeficiency virus (HIV), according to the November 1988 issue of Hospital Infection Control. Most of the mistakes, however, involved products that tested negative for HIV but should have been held or destroyed because of other Red Cross standards. For example, the Red Cross does not release blood products from a donor who previously had a false-positive HIV test. Fortunately, none of the products were found to be contaminated. Since the review, the Red Cross has suspended or replaced personnel and closed or transferred virology testing facilities in Washington, DC, and St Louis. The organization also plans to begin a national system that will recheck each unit of plasma that is submitted, improve computer systems, and require regional medical directors to personally ensure appropriate disposition of all quarantined products. It also will update operating procedure requirements in coordination with the US Food and Drug Administration (FDA) and retrain staff at all centers in FDA Good Manufacturing Practices and Red Cross standards.
FEBRUARY 1989, VOL. 49, NO 2
Burn Treatment COVERING BURN WOUNDS WITH
AUTOLOGOUS MICROSKIN GRAFTS
Cheng-Hui Fang, MD; Guang-Shu Yu, MD; Ming-Liang Zhang, MD; J. Wesley Alexander, MD
T
he skin is the body’s major barrier against the invasion of microbes. In extensively burned patients, this skin barrier has been destroyed and wound sepsis (or septicemia) is the main cause of death. If the wounds are grafted in a timely manner, the prognosis for extremely burned patients is improved markedly. Badly burned patients rarely have enough undamaged skin to provide adequate graft donor sites. The method of intermingling autografts (tissue from one’s own body) and allografts (tissue from a donor) and meshing skin autografts with meshed skin allograft overlays has been developed and used to cover extensive burn wounds with a high degree of success.’ In addition, several temporary artificial coverings have been developed, but they are less successful in the treatment of large burm2
Additional clinical trials are needed for epidermal cell culture technique, but it appears to have limited value.3
Cheng-Hui Fang, MD, is associate professor of surgery and director of the burn unit, First Teaching Hospital, Beijing Medical University. A t the time the article was written, he was a research fellow, Shriners Hospitals for Crippled Children, Bum Institute, Cincinnati. He received his medical degree from Beijing Medical University,
department,Beijing Jishuitan Hospital,He received his medical degree from Beijing Medical University.
Guang-Shu Yu, MD, is an associate professor of surgery, First Teaching Hospital, Beijing
Medical [email protected] received his medical degree from Hubei (China) College.
Ming-Liang Zhang, MD, is an associate professor and the associate director of the burn 526
Microskin Grafting
A
new technique, microskin grafting, has been developed that shows encouraging results for the treatment of severe burns! Eight patients in a study at First Teaching Hospital, Beijing Medical University, Beijing, China, reported being completely healed six to seven weeks postoperatively; one patient died of overwhelming pulmonary infection 22 days postoperatively .5 The procedure involves mincing skin autografts into tiny skin particles, evenly dispersing the skin
J. WesleyAlexander, MD, isprofessor of surgery and director of transplantation division, Department of Surgery, University of Cincinnati College of Medicine. He also is director of research, Shriners Burns Institute, Cincinnati Unit. He received his doctorate in medicine from the University of Texas, Galveston. The authors would like to acknowledge Maribn Jenkins, RN, MBA, Vicki Greene, and Lois Marchionnefor their assistance with the article.
AORN JOURNAL
FEBRUARY 1989, VOL. 49, NO 2
Fig 1. A step-by-step illustration of the microskin grafting procedure with allograft overlay. The purpose is to float and evenly disperse the skin particles (SPs) on the saline, transfer the skin particles to the dermal surface of the allograft, and transplant the allograft to the wound. (Adapted from M L Zhang et al, “Microskingrafting in the treatment of extensive burns: A preliminary report, Journal of Trauma 28(6) (June 1988) 804-807, with permission from The Williams C? Wilkins Co) ”
particles using a piece of silk cloth and saline, transferring the skin particles to the dermal surface of an allograft, and transplanting the allograft to the excised wound (Fig 1). The skin particles grow larger until they coalesce with each other and resurface the whole area. Then the allograft is rejected. Patient selection criteria. The microskin grafting technique is applied to those patients whose burn injuries, particularly third-degree burns, are very extensive. The intact skin area on badly burned patients is so small and scattered that harvested autografts either cannot be meshed properly or they do not provide a sufticient covering using the usual grafting techniques. With the microskin grafting application, the patient’s own skin can be used to cover the wound. The final selection should be based on accurate 528
evaluation of the patient’s age, area of burns, the concomitant injuries, and the preexisting diseases of the patient.
Preoperative Preparation
T
he surgeon explains the patient’s status and risks of the planned surgery to the family. Although there has not been a documented case, a potential risk of using allograft includes a remote possibility of contracting acquired immune deficiency syndrome. The OR nurses observe the patient before the procedure to understand the distribution of burn wounds, the areas that are planned for excision and grafting, where the donor areas will be, and how the patient will be positioned during surgery. They also provide emotional support for the
FEBRUARY 1989, VOL. 49, NO 2
AORN J O U R N A L
The microskin graft procedure requires two surgical teams that work together in placing the grafts and applying the dressings. patients who usually have to undergo several surgical procedures. The night before surgery, the OR nurses explain the planned procedure and expected postoperative regimen to the patient. Any questions or concerns are addressed at this time. Preoperative teaching is adjusted to meet the patient’s level of understanding and age-appropriate modalities. Before administration of preoperative medications the day of surgery, the OR nurses reinforce the information they provided the patient the night before. They also explain the procedures that occur before anesthesia is initiated, and they continue to provide emotional support throughout the administration of anesthesia. Preoperative teaching should also include family members in an effort to assist their understanding and secure their support of the postoperative regimen. To prepare for the procedure, the nurse prepares a regular autoclaved or gas-sterilized tray and a penetrated tray (both 40 by 55 cm). The penetrated tray has several 2 mm holes aligned 5 mm apart to allow saline to pass through. If the patient does not have an intravenous (IV) line and a urinary catheter, they are inserted before the patient is taken to the OR. Some patients are not acutely ill at the time of scheduled grafting and may not require a Foley catheter. After checking the patient’s identification tag, the circulating nurse assists in placing the patient in the dorsal supine position on the OR bed. Although the location of the grafts determine the patient’s position, the dorsal supine position is used most of the time. The patency of the IV line and the urinary catheter are checked, and the patient is anesthetized. The nurse places an electrosurgical dispersive pad on a site where intact skin remains. He or she also pads bony prominences to prevent normal skin breakdown or deepening of the burn wound. The circulating nurse preps the donor site with a 75% alcohol solution. Then for the areas to be 530
excised, he or she washes off any local antimicrobial agent from the wound, dries the area, and preps it with povidone-iodine. The scrub nurse assists the surgeon in draping the surgical area.
Intraoperative Procedure
T
he procedure requires two surgical teams: one surgeon/scrub nurse team is in charge of harvesting the skin autografts and preparing skin particles and allografts; the second surgeon/scrub nurse team performs the escharectomy. The two teams work together in placing the grafts and applying the dressings. The No. 1 team surgeon chooses a donor site for autografts one tenth the size of the wound to be covered. The scalp is a good site because it heals faster due to its profuse blood supply and dense distribution of sweat glands, hair follicles, and sebaceous glands, all of which have the ability to regenerate epithelium. Its blood supply also provides resistance to infection. The thicker skin provides greater potential for multiple harvesting. There also is no scarring after the skin graft harvesting and no harm to hair growth. To obtain the donor skin, the surgeon uses either an air-powered, electric, or handheld dermatome set at 0.008 inch. After the skin is taken, the surgeon covers the donor site with a single layer of fine mesh gauze or other suitable material. Bulky, coarse mesh gauze is added to the site, and if the donor site is on one of the extremities, a pressure dressing also is used. The No. 1 team scrub nurse takes the autografts to another sterile table, puts them in a shallow container, washes off the blood clots with saline, and minces the grafts into tiny skin particles as small as possible with fine scissors (Fig 2). At the same time, the No. 1 team surgeon is combining a number of allografts into a large sheet using staples or sutures. The allograft should be large enough to cover the whole excised wound
FEBRUARY -
AORN JOURNAL
1989, VOL. 49, NO 2
Fig 2. Thin split-thicknessskin autografts are minced into tiny skin particles. on the patient and protect it from infection. Allografts are procured from donors and preserved in liquid nitrogen in a tissue bank. They are ready for use at any time. No human lymphocyte antigen matching is needed. An allograft sheet has two surfaces-the dermal and the epidermal-with the dermal surface making contact with the wound. After the allografts are combined, the surgeon makes a few stab wounds to allow for drainage. Concurrently, the No. 2 team surgeon and scrub nurse excise the wound either tangentially or down to the fascia1 level depending on the depth of the burns. An air-powered, electric, or handheld dermatome may be used for tangential excision. During excision, the surgeon and scrub nurse maintain hemostasis by cauterizing small vessels and by clamping and ligating the larger vessels. The No. 1 team surgeon places the recombined allograft over the patient's excised areas. He or she trims the allograft to fit the contour of the wound; it is very important to mark the position of the allograft along the wound's edges. Then the allograft is brought back to the worktable and stretched with the dermal surface up. Any blood clots are removed using wet sponges. After the skin particles are ready, the No. 1 team scrub nurse prepares the trays and silk cloth and positions the penetrated tray in the regular
tray. The nurse places the silk cloth in the penetrated tray with its four sides hanging over the edges. The nurse wets the silk with saline, expresses the air bubbles from underneath the silk, and ensures that all wrinkles are removed. Both the No. 1 team surgeon and the nurse place the skin particles on the silk. As the surgeon holds the trays, the nurse pours saline in the top tray and the surgeon lightly agitates the trays until all skin particles float up and are evenly dispersed. The saline drains through the silk and the penetrated tray, and it is collected in the bottom tray. This leaves the skin particles evenly distributed on the silk. The skin particles are now ready for transferring to the allograft. The two surgeons lift the piece of silk out of the tray by the corners. It is inverted so that the side of the silk bearing the skin particles is placed against the dermal side of the allograft. The scrub nurse gently presses against the silk with a wet sponge to ensure that the skin particles make contact with the allograft. As the surgeon peels the silk off, the skin particles remain. This process is repeated until all skin particles are transferred to the allograft. The teams return to the patient. The surgeons control bleeding and oozing completely and irrigate the wound copiously with saline. The circulating nurse and the scrub nurses make a final 531
FE
49, NO 2
AORN JOURNAL
Fig 3. The patient sustained a flame burn involving 85%of his total body surface area. The third-degree burns were 75% of the total body surface area, and the other 10%were deep second-degree burns. Microskin grafting and allografting was done on the lower left leg immediately after an escharectomy (top). Thirty-nine days later, the wounds were completely healed (right). Wounds usually heal in an average of six to seven weeks. -
sponge count. The surgeons then transplant the allograft to the wound according to the premarked position marks; special care is taken not to move the allograft over the wound after it has been applied. After the edges of the allograft are stapled, the surgeons place fine mesh gauze soaked with multiple antibiotic solutions over the graft and apply bulky dressings. If the procedure is performed on the extremities, plaster may be used to immobilize the grafted areas. After the dressing is applied, the circulating nurse reports the patient's status to the burn unit nurse. Before being transported to the intensive care section of the burn unit, the nurse checks the patency of the IV line and urinary catheter.
Postoperative Care
I
n the burn unit, the patient is put onto a Stryker"" bed. The nurse places him or her in the supine position with both upper and lower extremities abducted. The patient should not be turned face down until he or she is awake and vital signs are stable. The nurse monitors vital signs and output, and observes the dressings for
bleeding from both the excised area and the donor area. If the patient's temperature drops dramatically, the nurse turns the room temperature up and covers the patient with blankets. The nurse also monitors an IV infusion and transfusion. Enteral feeding is administered after the patient has recovered from anesthesia. Physical therapy and occupational therapy that involves the grafted area is not encouraged in the first week postoperatively to ensure that the graft takes. The first dressing change that the surgeon must attend is scheduled between the fifth and seventh postoperative day. The nurse soaks the inner layers of the dressing with saline before they are removed. If no infection is noted, the nurse rewraps the wound in the same fashion as before, and the dressing is changed once every three days. If the wound is infected, the physician takes a swab culture and the dressing is changed daily or twice a day. Systemic antibiotics are administered if indicated. The wounds heal in an average of six to seven weeks (Fig 3). The dressing change for the donor site differs. The outer dressings are removed layer by layer, starting at 48 hours postoperatively. The inner 533
AORN JOURNAL
layer of fine mesh gauze is left in place until the seventh to the 10th postoperative day. It is soaked with mineral oil to make it easy to peel off. Burn wounds, other than the ones in the grafted area, are treated with Silvadenes. The type depends on the microoganisms recovered and the sensitivity to the agents. To prevent occurrence of sepsis, the nurse needs to protect the grafted area against contamination by stool and urine. Because of prolonged bed rest, stool softeners are sometimes prescribed for the patient. Keeping the IV line clean also helps decrease the Occurrence of sepsis. The gauze that is used to wrap the connection sites of an IV line should be changed every nursing shift. In addition to bedside care, the nurse can provide the patient with emotional care. Major burns are physically disfiguring and many times disabling, and the burn patient is psychologically fragile. If little hope of recovery is communicated either verbally or nonverbally, the patient can get depressed. The nurse may be able restore a patient’s self-esteem and will to live with a positive, encouraging attitude. The preliminary experience with this procedure has been encouraging in the treatment of extensively burned patients. 0 Notes 1. C C Yang et al, “Intermingled transplantation of auto- and homografts in severe burns,” Burns, Including Thermal Injury 6 (1980) 141-145; J W Alexander et al, “Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay,” Journal of Trauma 21 (June 1981) 433-438. 2. JFBurke et al, “Successfuluse of aphysiological& acceptable artifical skin in the treatment of extensive burn injury,” Annals of Surgery 194 (October 1981) 413-428; B A Pruitt Jr, N S Levine, “Characteristics and uses of biologic dressings and skin substitutes,” Archives ofsurgery 119 (March 1984) 312-322. 3. G G Gallic0 111 et al, “Permanent coverage of large burn wounds with autologous cultured human epithelium,” New England Journal of Medicine 3 11 (Aug 16, 1984) 448-451; E L Heck, P R Bergstresser, C R Baxter, “Composite skin graft: Frozen dermal allografts support the engraftment and expansion of autologous epidermis,” Journal of Trauma 25 (February 1985) 106-112. 4. M L Zhang et al, “Microskin grafting: 11. Clinical report,” Burns, Including Thermal Injuty 12 (December 1986) 544-548. 534
FEBRUARY 1989, VOL. 49, NO 2
5. C H Fang et al, “A preliminary report on transplantation of microskin autografts overlaid with sheet allograft in the treatment of large burns,” Journal of Burn Care and Rehabilitation 9 (November/ December 1988).
Untested Blood Released, Workers Disciplined After discovering last March that 24 blood products that should have been destroyed were distributed for transfusion, the Red Cross Blood Services took disciplinary action and doubled its record inspections. A subsequent internal review involved examinations of all blood and blood products that should have been quarantined or destroyed after testing. This review revealed that 2,400 products were mistakenly released, including 5 18 blood products that were not tested for the human immunodeficiency virus (HIV), according to the November 1988 issue of Hospital Infection Control. Most of the mistakes, however, involved products that tested negative for HIV but should have been held or destroyed because of other Red Cross standards. For example, the Red Cross does not release blood products from a donor who previously had a false-positive HIV test. Fortunately, none of the products were found to be contaminated. Since the review, the Red Cross has suspended or replaced personnel and closed or transferred virology testing facilities in Washington, DC, and St Louis. The organization also plans to begin a national system that will recheck each unit of plasma that is submitted, improve computer systems, and require regional medical directors to personally ensure appropriate disposition of all quarantined products. It also will update operating procedure requirements in coordination with the US Food and Drug Administration (FDA) and retrain staff at all centers in FDA Good Manufacturing Practices and Red Cross standards.