The early excision of burns

Burns, 1, 65-69

65

The early excision of burns Dan Mahler*

and John Watson

Mclndoe Burns Centre, Queen Victoria Hospital, East Grinstead Summary

This paper discusses the indications for the treatment of deep burns by early excision, describes the methods used at East Grinstead, and analyses the results obtained in 18 cases so treated. The importance of immediate and complete skin cover is stressed.

in an electric burn, and Young (1942) did the same in an extensive burn on the back. Many subsequent publications support this approach, but differ as to the indications, to the extent to be dealt with and the timing. The method of early excision practised in the McIndoe Burns Centre is herewith presented, and the results have been sufficiently promising to warrant more extensive trial. SYSTEM

INTRODUCTION

THE survival of severely burned patients has always been a challenge to medicine. Yet, in pite of the improvement of nursing management, the recent advances in the management of fluid balance and the shock phase and progress in antibiotic treatment, the third-degree burn over 50 per cent body surface area is still regarded as having a very poor prognosis. Infection is the main cause nowadays of mortality in burns, and any means of preventing this will lead to higher survival rates in burns. One of the possible means by which this might be achieved is by early surgery, with removal of sloughs before suppuration occurs, and sealing the wounds with skin (Cope et al., 1947; Cramer et al., 1962; Sachs and Watson, 1969; MacMillan, 1970). The early excision of burns has already been practised at the beginning of this century on burns of limited area, later publications mentioning wider excisions as well (Wallace, 1966). Wells (I 929) performed successfully an early excision

*From the Department of Plastic Surgery, Rambam Government Hospital, Haifa, Israel. A Rayne Fellow in Burns Research, Queen Victoria Hospital, East Grinstead, 1970-71.

OF

TREATMENT

Early excision is performed after the patient has recovered from his initial shock-period, mainly between the fifth and tenth post-burn days. There is no absolute limitation regarding the extent of the burn itself or the age of the patient. However, the following must be taken into consideration before operation is started : Duration

of surgery

This should be limited to one hour, because of the growing hazards of general anaesthesia prolonged for a greater period, as well as the physiological changes in the patient, especially haemodilution (Bond, 1969); blood loss monitoring systems are unable to register accurately in such conditions. Manpower

In order to guarantee a quick operation, sufficient personnel should be available and ready, using, when needed, more than one team. Performance of surgery by a single surgeon or single nurse should be avoided in severe cases, and preparations such as the spreading of homograft completed before the operation starts. Haemoglobin level This must be assessed prior to surgery, and low levels should be treated.

Burns Vol. 1 /No. 1

66

immediately with skin, either viable (autografts and allografts), or lyophilized skin (freeze dried). Absence of skin-grafting material is a contraindication to early excision, as the aim is to provide skin cover, and to prevent bacterial invasion of the newly opened planes. Failure to seal these extensive operation wounds nullifies the main objective of burn excision. The use of lyophilized skin is favoured in severely burned patients, where there is shortage of autograft, and where it is essential for the viable skin subsequently grafted to take uneventfully. The following properties of the lyophilized skin make it suitable in these cases (Mahler and Hackett, 1972): 1. Reduction of infection.

Antibiotic cover This should start two days before the operation, according to the bacterial flora present. Estimation of operative blood loss This is accomplished by means of a monitoring device of local design using a Perometer head. Accurate evaluation of blood loss is required for its rapid and immediate replacement, and to give confidence in the correction of large blood losses, which may reach up to half of the circulating blood volume in infants (Mahler and Davies, 1972). Reserves of skin-The Skin Bank It is very important to seal the excised wound

Table /-Results

Case no.

Age

of early excision

Percenttage total burn

of burned

areas

Percent$$?,‘t;

L yophi1;;;

bsy

“,“r;;

;;t

Ioss

‘;iig

Comments

(days)

1

6

9

5

10

-

+

2

4;

10

7

5

-

+

-

30 10

3

78

10

10

10

-

+

4

70

15

10

7

-

+

5

70

20

10

5

+

+

6

65

20

20

9

+

+

7

5

25

25

7

-

+

8

7

30

20

7

+

+

9

39

30

15

10

-

+

10

18

35

30

11

+

+

11

16

43

30

9

+

+

+ -

12

61

45

35

5

+

+

+

60

Recurrent operations on foot

28

50

40

10

+

+

+

60

Amputation both lower limbs

47

50

35

9

+

+

+

15

25

53

45

11

i-

+

-

30

Septicaemia, thirty-eighth

16

55

55

30

10

-i-

+

-t

60

Prolonged treatment ankle ulceration

17

61

55

45

5

+

f

+

18

-

28 24 25 35 33 25 32 45 42

Septicaemia, brain abscess, death seventy-fifth day died day

Cardiac disease, limb amputation, jaundice, died forty-sixth day 20

Jaundice, died twenty-first day

Mahler

and Watson

: Early Excision of Burns

67

2. Acceleration of the formation of a satisfactory granulating bed. 3. Stimulation of the formation of blood vessels in the new granulation tissue. 4. Lessening the risk of losing vital autografts. 5. No risk of systemic rejection reactions because of poor or lacking immunogenic potency. 6. Ease of storage and transportation. In the case of a very extensive burn, the excision has to be undertaken in stages. When limbs are involved, the burned tissues are desloughed under tourniquet in order to diminish bleeding. Usually, in extensive deep burns the chosen plane of excision is that of the deep fascia, unless this would expose essential underlying structures, in which case the desloughing is being carried out by Table //.-Mean early excision Percentage of burn 29 per cent 30-49 per cent 50 per cent

healing

time

of

burned

Mean healing

patients

the extent of full-thickness loss from 5 to 45 per cent. We find a relationship between the extent of the burn and the healing time. Burns of up to 29 per cent body surface area healed in an average of 27 days, those of 30-49 per cent in 41 days, and severe burns of 50 per cent or over had a mean healing time of 42 days (Table ZZ). In 12 of the 18 cases lyophilized skin was used primarily, being replaced 40-72 hours later either by autografts, or in 6 cases by a combination ofautograft and viable typed allograft. Where the burned area is limited in extent, we apply autografts in the tirst instance if the wound is suitable and the patient in good condition (Constable, 1971). In the 6 patients treated by primary autografting, 4 had limited burns, but following

time (days)

27 41 42

Watson or Cobbett knife in serial tangential sections. The exposed area is immediately closed by skin, using autografts, tissue-typed allografts (Hackett and Batchelor, 1971), orlyophilized skin.*

the remaining 2 were of 25 per cent and 15 per cent deep skin loss, but had sufficient donor skin to allow uneventful operation and healing in 32 and 33 days respectively.

RESULTS The data derive from I8 patients, all with deep burns and admitted primarily to this Burns Centre (Table I). Other patients transferred late from other hospitals or suffering from superficial burns only are not included in this series. Four of the 18 patients died, 2 after the wounds had healed, I death occurred on the seventy-fifth post-burn day from brain abscess and septicaemia, another on the thirtieth post-burn day from septicaemia, and the remaining 2 cases from jaundice and liver failure on the twenty-first and forty-sixth post-burn days respectively. The age of the patients in this series ranged between 4: and 78 years (mean 37+ years). Their hospitalization time extended from 12 to 120 days, but this showed no relationship to healing time, prolonged hospitalization being due to associated medical or surgical conditions. The healing-time itself ranged from 10 to 60 days, with a mean of 35 days. The total extent of the burns lay between 9 and 70 per cent, and

DISCUSSION Extent of burns Various investigators differ in their opinion, whether or not the extent of the burn is an indication for performing early excision. While some (Cramer et al., 1962; Artz and Moncrief, 1969; MacMillan 1970) limit the technique to 15-20 per cent body surface burn or others (Muir and Grummitt, 1957; Jackson, 1960; Constable, 1971) who apply the technique to more extensive burns, there are those who find that early excision is contra-indicated altogether (Sorensen and Thomsen, 1968), or except for essential areas, e.g. eyelids, fingers and hands (Maisels and Saad, 1969). It is the view at this centre that the extent of the burned area is no contra-indication to aggressive surgery, nor is the age of the patient.

* Allografts used in this centre are tissue typed and staled by the staff of the Blond Laboratories. Lyophilzied skin is prepared by this team as well.

Timing There are still various opinions regarding the best timing of early excision. Some advocate it during the first 24 post-burn hours (Jackson et al., 1960; MacLean and Rayner, 1962)--’ immediate excision ’; others prefer to undertake it during the first 3 post-burn days-‘ primary excision ‘;

Burns Vol. 1 /No.

66

while more frequently it is accepted that the preferable time is between the third to the tenth post-burn days-‘ early excision ’ (Meeker and Snyder, 1956; Muir and Grummitt, 1957; Cramer et al., 1962 and MacMillan, 1970). Extensive wound excisions undertaken within the first postburn day, unfortunately, still carry a heavy mortality (Sachs and Watson, 1969), although the earlier the procedure is performed, the better the chance of prevention of infection. In this series early excision was performed between the fifth to the tenth post-burn days, except for 2 cases where excision was undertaken on the eleventh day due to difficulties in patient communication and in a very severe burn associated with intracerebral injury. This refers to the first surgical procedure, as several patients underwent more than one operation. The timescale adopted was thought to be preferable because the condition of the patient would seem to be optimalwiththe least liability to complications. CONCLUSIONS The treatment of burns by the method of early excision is described and discussed. Early excision aims to prevent infection, which is the main cause nowadays of mortality in burns. It is performed between the fifth and tenth post-burn days in burns of all dimensions and irrespective of age of the patient. Proper accomplishment of this technique requires : 1. Limitation of duration of surgery to one hour. 2. Sufficient manpower in the operating team. 3. Control of blood loss by using a tourniquet on limbs and by monitoring the operative blood loss with immediate replacement. 4. Immediate and complete sealing of the exposed area by skin. The existence of a Skin Bank is essential and enables one to use, besides autografts, viable tissue-typed allografts and lyophilized skin. The results, presented in 18 patients who underwent this operation show a short healing period. Burned patients with up to 30 per cent thirddegree burns had a mean healing time of 27 days, those with burns of 30-50 per cent41 days, and patients with over 50 per cent burns42 days. The results indicate that by using aggressive surgery with early excision of the sloughs and early skin cover, the phase of suppuration and sepsis which causes such a poor prognosis in burns can be mitigated. Acknowledgements The authors wish to express their thanks to the Surgical and Nursing Staff, McIndoe Burns Unit,

1

for their assistance and contributions, and to the Max Rayne Foundation for a grant which has permitted this work to be carried out.

REFERENCES

ARTZ C. P. and MONCRIEFJ. A. (1969) The Treat, ment of Burns, 2nd ed. Philadelphia, Saundersp. 148. BONDA. G. (1969) Determination of operative bloodloss. Anaesthesia 24,219. CONSTABLEJ. D. (1971) Extended use of primary excision in the treatment of extensive thermal burns. In: Transactions of the Fifth Congress o.f the InternationaI Society ofPlastic Surgeons, Australia, Butterworths (Ed. J. HUESTON)p. 896. COPEO., LANGOHRJ. L., MOOREF. D. and WEBSTER R. C. (1947) Expeditious care of full thickness burn wounds. Ann. Surg. 1251-22. CRAMERL. M., MCCORMACKR. M. and CARROLL D. B. (1962) Progressive partial excision and early grafting in lethal burns. Plastr. Reconstr. Surg. 30, 59.5-599.

HACKETT M. E. and BATCHELORJ. R. (1971) The HL-A system and its importance for skin grafting in burned patients. In: Research in Burns. Berne Hans Huber, p. 337. HAYNESB. W. (1969) Early excision and grafting in third degree burns. Ann. Surg. 169,736. JACKSOND. (1960) Primary excision and grafting of burns. Transactions of the Second Congress of the International Society of Plastic Surgeons, London, Livingstone, (Ed. A. B. WALLACE),p. 483. JACKSOND., TOPLEYE., CAXIN J. S. and L~WBURY E. J. L. (1960) Primary excision and grafting of burns. Ann. Surg. 152,167. MACLEAN L. D. and RAYNER R. R. (1962) Treatment of burns by early debridement. Arch. Surg. 85, 297-304.

MACMILLAN B. G. (1970) Indications for early excision. Surg. Clin. North Am. 50,337. MAHLER D. and DAVIES R. M. (1972) Calorimetric estimation of blood-loss during surgery of burns. Br. J. Plast. Surg. 25,127.

MAHLER D. and HACKETTM. (1972) Resurfacing of burns with preserved skin. Isr. J. Med. Sci. 8, 141-147.

MAISELSD. 0. and SAADM. N. (1969) Early surgery in the treatment of burns. Br. J. Sura. 56.466471. MEEKERI. A., jun., and SNYDERW. H., jun. (1956) Dermatome dtbridement and earlygraftingofextensive third degree burns in children. Surgery gynecol. Ohstet. 103, 527-534. MUIR I. F. K. and GRUMMITT M. (1957) Early excision of burns with particular reference to blood replacement. In: Transactions of the First Congress of the International Society of Plastic Surgeons, New York, Williams and Wilkins (Ed. S~ooc and IVY), pp. 98-99.

A. and WATSONJ. (1969) Four years’ experience at a specialized burns centre. Lancer 1,718.

SACHS

Mahler

and Watson

: Early

Excision

69

of Burns

B. and THOMSENM. (1968) The burn unit Copenhagen. 3. Treatment and Mortality.

SORENSEN

in

Stand. J. Plast. Reconstr.

Surg. 2, 16.

90, 1069.

WALLACEA. F. (1966) The problem of skin cover in extensive burns. Br. J. Plast. Surg. 19, lhl-172.

Keyucsts

or rrprinrs

D. B. (1929) The treatment of electric burns by immediate resection and skin graft. Ann. Surg.

WELLS

YOUNG F. (1942) lmmediate skin grafting in the treatment of burns: a preliminary report. Ann. Surg. 116,445-451.

shouldhc

addressed to: J.

Watson,Esq.,

M&doe

Burns Centre,

Queen Victoria

Hospital,

East Grinstead.