Nursing management of the burn-injured person

improvements the burn patient wishes to see first. For many, the wish is for functional improvements first before the esthetic procedures.

Surgical care

Full-thickness burn wounds do not have sufficient numbers of skin-reproducing cells in the dermal appendages to satisfactorily heal on their own. The area may slowly fill in with granulation and fibrous scar tissues, migrating in from the wound margins and underlying connective tissue. However, the process is very slow and the results unacceptable from a functional wound closure and esthetic outcome perspective. Common practice in surgical burn management is to begin surgically removing (excising) full-thickness burn wounds within a week of admission. This technique of early excision has had a significant positive impact on survival, especially for those patients with moderate to large-sized burn wounds. In the past, patients with extensive burns frequently died of overwhelming sepsis and/or malnutrition while awaiting surgery to remove the devitalized burn tissue (eschar). Most patients undergo excision and grafting in the same operative procedure. In some instances, if there is concern the wound bed may not be ready for a graft, the wounds are excised and covered with topical antimicrobials, followed by a temporary biologic or synthetic dressing. The donor skin (skin graft), which is harvested in this first O. R., is then wrapped up in sterile fashion and placed in a skin fridge for later application. Two days later, if the the recipient bed is clean, the patient returns to the OR to have the donor skin laid as a skin graft on the clean recipient bed. With large burn areas, it is necessary to serially excise and graft over a period of days to several weeks. Concern over blood loss and lack of sufficient donor sites are the two limiting factors when attempting to excise and graft patients with extensive wounds.

Burn surgery involves excision of the non-viable eschar down to the point of punctate bleeding at the level of subcutaneous tissue or fascia (Fig. 16). Harvesting of donor sites for skin grafts is performed using a dermatome (Fig. 17). Hemostasis of both surgical sites must then be achieved and the donor skin placed onto the freshly excised recipient bed. Attempts are made to match skin thickness and colour

Fig. 16. Surgical excision of full-thickness burn wound

as closely as possible between donor sites and recipient sites. Grafts can be split-thickness or full-thick- ness in depth, meshed or unmeshed in appearance, temporary or permanent in nature (Table 11). The skin grafts are very thin (about.017 of an inch thick), but may be thicker, depending on the location of the recipient bed. For example, skin for an upper eyelid site would be much thinner than that intended for the back or a leg. Grafts should be left as unmeshed sheets for application to highly visible areas, such as the face, neck or back of the hand (Fig. 18). Sheet grafts are generally left open and frequently observed for evidence of serosanguinous exudate under the skin. In order to encourage a good blood supply from the recipient site to the donor site, the exudate needs to be removed. Two strategies fre-

Fig. 17. Harvesting a split-thickness skin graft

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Table 11. Sources of skin grafts

Type	Source	Coverage
Autograft	Patient’s own skin	Permanent
Isograft	Identical twin’s skin	Permanent
Allograft/Homograft	Cadaver skin	Temporary
Xenograft/Heterograft	Pigskin, amnion	Temporary

quently recommended include aspirating the exudate using a small gauge needle and syringe, or creating a small slit in the blister and gently using normal-saline soaked, cotton-tipped applicators to roll the fluid from the centre of the “bleb” to the opening. On other parts of the body, grafts can be meshed using a dermatome mesher (Fig. 19). The mesher is set to an expansion ratio chosen by the surgeon. If there are sufficient donor sites to cover the excised areas, a 1½: 1 ratio is selected. This expansion ratio allows for exudate to come through and be wicked into a protective dressing, while at the same time be cosmetically acceptable (Fig. 20). Wider expansion ratios (3:1, 6:1) allow for increased coverage when there are limited donor sites. However, the long-term appearance is less acceptable as the mesh pattern is more visible after healing and scar maturation are complete. Meshed skin grafts are generally covered with one of a number of possible options, including silver-impregnated, vacuum-as- sisted closure, greasy gauze, or cotton gauze dressings. Most are left intact for 5 days to allow for good vascularization between the recipient bed and the skin graft. Following the initial “takedown” at postop day 5, the dressings are changed every day until the graft has become adherent and stable, usually

Fig. 19. Putting a skin graft through a dermatome mesher

around day 8. It is possible to gradually determine the percentage of “graft take” during these dressing changes. If necessary, “touch-up” surgeries can be arranged over the next few weeks. For the next year or so post-burn, the skin grafts mature and their appearance improves (Fig. 21). In the Operating Room, once hemostasis has been assured through the application of pressure and thrombin/adrenalin soaks, the donor site can be dressed with either a transparent occlusive, hydrophilic foam or greasy gauze dressing (Fig. 22). To encourage moist wound healing, the dressing should be left intact for several days, inspected and reapplied if indicated. Donor sites generally heal in 10–14 days and can be reharvested, if necessary, at subsequent operative procedures (Fig. 23).

Blood loss during burn excisions poses significant concerns from an operative point of view. The burn surgeon must carefully gauge how much excision and grafting can be performed in a single opera-

Fig. 18. Unmeshed split-thickness sheet graft

Fig. 20. Meshed split-thickness skin graft

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Fig. 21. Mature split-thickness skin graft

Fig. 23. Healed donor site

tion and be prepared to conclude earlier if the blood loss is too great. From the anaesthetist’s perspective, it is a challenge to estimate blood loss during a burn excision and then to know what blood replacement to give intraoperatively. From the patient’s point of view, he/she may not wish to receive donated blood unless it is absolutely necessary. Today, with modern operative techniques, blood loss is less of a problem. The application of pressure, thrombin/adrenalin soaks, use of surgical tourniquets and the newer tumescent technique have decreased blood loss significantly for burn excision procedures.

Over the past 10 years, there have been major advancements in the development, manufacture and clinical application of a number of temporary and permanent, biologic skin substitutes. Most of these products were initially developed in response to the

Fig. 22. Harvested donor site

problemsfacedwhengraftingthemassive(i. e. > 70%) burn wound where donor sites are limited (Table 12). As experience increases with these products, alternate applications are also being explored in both the burn patient and wound care populations. The search for a permanent skin substitute continues.

Table 12. Biologic skin replacements

Source	Product	Description
Cultured	Epicel	–	cultured, autologous keratino-
epithelial	(Genzyme		cytes grown from patient’s
autograft	Corpor-		donated skin cells
(CEA)	ation,	–	6–8 cells thick, 2–3 weeks
	Massach-		culture time
	usetts)	– lacks dermal component;
			susceptible to infection
		–	lacks epidermal cell-to-connect-
			ive tissue attachment and is,
			therefore, very fragile
Dermal	Integra	–	synthetic, dermal substitute
replace-	(Johnson &	– neodermis formed by fibrovas-
ment	Johnson,		cular ingrowth of wound bed
	Texas)		into 2 mm thick glycosamino-
			glycan matrix dermal analog

–epidermal component, Silastic, removed in 2–3 weeks and replaced with ultrathin

–autograft

–functional burn wound cover

–requires 2 O.R.’s: 1 for dermal placement, 1 for epidermal graft

Dermal	AlloDerm	–	cadaver allograft dermis
replace-	(LifeCell		rendered acellular and nonim-
ment	Corpor-		munogenic
	ation, Texas)	–	covered with autograft in same
			O.R. procedure

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