Preoperative and Postoperative Considerations in the Extensively Burned Patient

Preoperative and Postoperative Considerations in the Extensively Burned Patient NICHOLAS S. GIMBEL, M.D., F.A.C.S.*

THE goals of treatment in the extensively burned patient are often easier to formulate than to accomplish: (1) to cover full-thickness burns with grafts, once surgical debridement or spontaneous separation of slough has taken place; (2) to protect partial-thickness burns and skin donor sites from mechanical and bacterial injury while they heal; (3) to support nutrition, blood volume, resistance to bacterial invasion, joint function, and morale. In all surgical diseases, problems of the operation merge with those of preoperative and postoperative care; in none, however, is the distinction more arbitrary or more difficult to draw than in burns. The subject will be approached as it presents itself to the surgeon in five situations: (a) the days before operation, (b) the morning of operation, (c) in the operating room, (d) immediately following operation, and (e) the days after operation, which merge again into the first situation. The commonest operative procedures are removal of burned tissue and replacement with split-thickness grafts. There is considerable variation in the frequency with which burned patients go to the operating room; the intervals range from two days to two weeks. Occasionally a patient exhausted after a three months' struggle for survival must be allowed to rest and consolidate his gains, heal his donor sites, and fuse his grafts, rather than be obliged immediately to attempt fresh gains by surgical maneuvers. The Days Before Operation

The propriety of operation is considered first from the systemic standpoint. 1. Hemoglobin concentration should be no less than 14 grams; however if the deficit is of only 1 or 2 grams, it is wiser to conserve veins and give extra blood at operation. * Associate Professor of Surgery, Wayne State University, College of Medicine; Assistant Surgeon, Harper Hospital; Associate Surgeon, Receiving Hospital; Attending Surgeon, Sinai Hospital, Detroit, Michigan. 1583

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2. The program for the patient's nutrition is reassessed. He should be receiving a gavage of homogenized hospital diet as intensive as his intestinal tract will accept without rebellion. The feedings continue until six hours prior to operation so as not to waste feeding time. The regimen must provide supplementary water to forestall prerenal azotemia, always a hazard during intensive force-feeding of protein, since the staff may depreciate the patient's thirst and water requirements. 3. The patient's general condition has to be evaluated against the background of the preceding days. Clouding of the sensorium and irrational behavior are serious signs, often associated with septicemia, and may call for a postponement of operation for a few days while blood cultures are obtained and antibiotic therapy is intensified. If there is any place for treating the burned patient with corticoids, it is probably here. Gastrointestinal hemorrhage is another indication for temporarily abandoning surgery. Since it appears in the midst of an intensive feeding program, it is clearly not amenable to the acid-neutralizing approach employed for peptic ulcer. If desperate, we would be inclined to experiment with intravenous pitressin or gastric lavage with ice water. The gastric erosions are often multiple, and resection offers little except a prohibitive risk. Operation is then considered from the standpoint of the burn wound. If the slough is gone and a granulating wound is to be grafted, the granulations should be hard and red. The space between the shoulder blades and the buttocks is the easiest to prepare because, as he lies on his back, the patient applies continuous firm pressure. Granulation tissue should not be left exposed to the air for long periods, since tenacious septic crusts develop. When stubborn infection of granulations persists, however, it has at times seemed effective before applying a fresh dressing to leave them exposed to the air for a few hours after dressing removal or after emerging from the shower or tub soak. Infected granulation tissue should not be dressed with perforated plastic (Telfa) or finely woven rayon (Owens cloth) in immediate contact with them, since there is insufficient drainage; at the subsequent dressing the granulations will be slick with a puddle of exudate over them. Fine mesh gauze (44 by 48 mesh) is appropriate. The frequency of dressings and wound cleansings prior to operation cannot be generally prescribed. With full-thickness burns the limiting factors are only the associated blood loss and distress; intervals of 24 or 48 hours are usually appropriate. With partial-thickness burns (and skin donor sites), however, frequent dressing changes are grave errors. The regenerating epithelium is ripped off, however gentle the surgeon; healing is always delayed and a partial-thickness wound is commonly converted into one of full thickness. Therefore, when a burn consists of mixed partial and full-thickness areas, the surgeon faces a difficult problem in protecting the partial burn while preparing the deep burn for grafting.

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The Morning of the Operation

All patients should be visited the morning of operation, and the burned patient is no exception. The following items are noteworthy: 1. A temperature of 103° F. in most patients scheduled for elective surgery calls for cancellation of the operation. In burned patients the fever generally accentuates the need to make progress with the treatment. There are exceptions. The patient may appear too ill to withstand the operation contemplated (and then perhaps a lesser procedure under analgesia or local anesthesia may be considered). The fever may be accompanied by respiratory distress, so that the surgeon is concerned about penumonia and may decide that inhalation anesthesia is ill-advised that day. 2. The emptiness of the stomach is verified by irrigating the feeding tube. 3. A decision is made as to whether the patient proceeds to the operating room on his bed (or turning frame) or is moved to a litter. The former is generally preferred, since each transfer is painful and tiring. Furthermore, the bed is needed in the operating room if skin grafts are to be laid on without dressings, so that the operative team can transfer him to his bed and supervise the cradle or drape that shields the grafts. 4. If it is necessary to cut down on a vein, this procedure should not be done on the ward in order to save this time later. Veins are precious, and the possibility of mutilating the vessel without good light, good instruments and good supervision is greater in the patient's room. Furthermore, the burned patient's susceptibility to infection is always a hazard; it is virtually impossible to perform a sterile phlebotomy away from the operating room. We have seen a patient contract septic phlebitis of the inferior vena cava subsequent to contamination of a saphenous vein cannulation. 5. If a urethral catheter is not already in place, one is inserted in patients whose mobility will be limited after operation because of special positions required by skin grafting. In the Operating

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The following nonoperative considerations are important: 1. Personnel should conduct themselves quietly and without loud conversation. The calming effects of the preoperative medication are discounted by any stimulation of the patient. It is usually best not to disturb the dressings while the patient is awake. 2. Anesthesia should be as brief as possible. The anesthesiologist should not begin until he sees the sterile nurse, the surgical team, and the sterile instruments in the operating room. Time is often wasted because all the surgeons scrub and gown, and leave an inexperienced intern to tediously remove the dressings, one limb at a time. The larger the surgi-

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cal team the shorter will be the operation, provided the numbers are not increased to the point that no one has space to work. 3. If the patient is to be prone on the operating table for any length of time or if grafts are to be placed upon the face, the endotracheal tube is a necessity. Otherwise, it should be avoided if at all possible. Especially in children, intubations at weekly intervals risk laryngeal edema and postoperative airway obstruction. bnlllediately Following Operation

Burn patients should be seen by their surgeon an hour after returning from the operating or recovery room. 1. The most pressing reason for an early visit is the possibility of bleeding. Considering the hyperemia of the wound and the scores of arterioles and venules that are transected during the excision of a burn or even in the course of less radical debridement, it is not surprising that on occasion serious hemorrhage takes place. One may be greeted by a pint of blood leaking through the dressing or around the grafts. After wiping away the clots, the vessel can often be controlled by prolonged pressure with a silver nitrate stick. 2. An early visit is particularly important if grafts have been applied without a stent or dressing. Open grafting depends upon the fact that grafts are adequately bonded to their beds by fibrin alone, provided they are protected from shearing or scraping forces such as bedclothes, cradles, fingers, or the patient's weight. Immobilization is directed at the patient rather than at the grafts, and the surgeon devises various ingenious restraints to keep his grafts topside and undisturbed. It is essential to re-examine the patient at frequent intervals on the day such grafting is carried out. 3. If dressings have been applied about the thorax, it is usually wise to divide the outer ones in the midline and apply tape loosely, otherwise the cumulative increased work of breathing may lead to respiratory complications, particularly in young children and in the aged. 4. Postanesthetic vomiting is uncommon in burned patients, perhaps because they become accustomed to general anesthetics. It is usually feasible therefore to reinstitute tube feedings four hours after operation, although the rate is sharply reduced until the next morning. 5. Antibiotics are always appropriate for the extensively burned patient, not so much for what they may accomplish in the burned area but rather for the support of the patient against the repeated bacteremias to which he is subjected. Debridement and manipulation of granulation tissue produce a heavy bacteremia, and antibiotic coverage is particularly important immediately after operation. In children, who dread needles so intensely, and in adults with burns over the usual sites of intramuscular injection, we add Chloromycetin palmitate to the gavage feedings. In seriously burned patients intramuscular gamma globulin is

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administered twice weekly when it is available. Any femoral vein catheter or phlebotomy catheter is removed as soon as possible after operation to minimize the opportunity for septic phlebitis to develop. The Days After Operation

1. The hemoglobin and leukocyte concentrations are determined three times a week. We commonly overtransfuse the patient at operation to a hemoglobin concentration of 17 grams so as to avoid having to search for veins during the subsequent few days. Every fortnight the serum albumin is determined, as the most readily available index of protein nutrition. Electrolyte studies are not made unless there is reason to doubt the patient's renal function; blood is saved and the determinations are rarely of clinical importance. 2. The patient is up and about unless his lower extremities are burned or have recently been used as donor sites or unless recent open grafting requires that he be immobilized. Ambulation aids morale and retards bone and muscle catabolism; it also aids in the exposure treatment of circumferential burns of the trunk and upper limbs, if such treatment has been elected. When activity cannot be relied upon to exercise joints, particular attention is given to the prevention of foot drop and hand clawing, knee and elbow flexion, and hip flexion-adduction-internal rotation. Foot boards, splints, casts and physiotherapy are the armamentarium. It is important to keep in mind the distinction between deformities that tend to appear across joints that are unburned or healed after superficial burns or adequate grafting, and those deformities that arise across burned joints that are granulating or heavily scarred from prolonged healing by secondary intention. No splinting or exercise can overcome the latter, unless scar excision and grafting are carried out first. 3. If grafts are being treated without covering, they are inspected twice daily, and collections of serum, blood or pus are released whenever noted. Instruments should be cleansed so that iatrogenic cross-contamination among the grafts is minimal. If the grafts have been covered, a decision must be made as to when the first dressing change should be carried out. In general, small, thin postage-stamp grafts are dressed later (fifth to tenth day) than large thick grafts (second to fifth day). Not only are the former more hardy, but the more vulnerable thicker grafts can often be saved by strategic stab wounds to evacuate collections. Great delicacy attends the initial dressing so as not to dislodge the grafts; when a graft edge is sighted, an instrument holds it against the base to oppose the traction placed upon the gauze. The gauze is pulled parallel to the body surface rather than outward at right angles to it. 4. Skin donor sites are treated as partial thickness burns. On surfaces which do not bear weight and are not dependent, any dressings superficial to the fine-mesh gauze in contact with the skin may be removed in 12 to 24 hours. The remaining layer should never be avulsed, but simply

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trimmed at the edges as it detaches with re-epithelization. Infection of donor sites may lead to complete loss of epithelium and a wound that is equivalent to a full-thickness burn; it is more likely to occur in debilitated patients or when grafts have been cut repeatedly from the same site. The diagnosis is made by the appearance or odor of pus; the treatment is to cut away the overlying gauze and to institute wet soaks. If these steps are carried out promptly, healing usually follows. Staff Organization

The more facets of patient care the surgeon is competent to assume and the fewer "specialists" he is obliged to lean on, the more coherent will be the therapeutic program. There are hazards in the care of the burned patient by a team-the surgeon for the skin and the internist for its contents; the physiatrist for the movements of the limbs and the psychiatrist for the care of the soul. If a number of consultant services are unavoidable, it is essential that the consultants remain as such rather than become absolute dictators over isolated provinces of the patient. Only one service is privileged to write orders; the others recommend them. When the urologist treats the burned penis, the proctologist the buttocks, the plastic surgeon the ears, the hand specialist the fingers, and the ophthalmologist the lids, the "general" surgeon "in charge" has problems in defending his title and responsibility. 1401 Rivard Street Detroit 7, Michigan