Early excision of burns: Has the approach fulfilled its promise?

Research output: Contribution to journalArticle

Abstract

The rate of survival of burn patients has increased significantly over the past 20 years because of advances in both supportive care and wound management. Recent data suggest that the burn size considered to be lethal to 50% of patients (LA50) has steadily increased from 40% of total body surface area (TBSA) in the 1940's to 81% of TBSA today.1 One reason purported to decrease mortality and improve outcome for the burn patient is early excision and grafting of burn wounds.1-7 But what exactly is "early excision"? As seen in the above papers, this definition can vary. Generally, early excision ranges from early massive excision of the entire burn wound within 48 to 72 hours5,7 to sequential excision of the entire burn wound over approximately 7 days.8 Numerous studies in the 1970's and 1980's suggested that early excision increased survival as well as functional and aesthetic outcome in children, adults, and the elderly.1-9 Proponents of early excision cite decreased hospital length of stay and costs, less operative blood loss, a lower incidence of hypertrophie scar formation, improved immune response, and decreased intensity and duration of the hypermetabolic response to burn injury with early excision and wound coverage. Early excision and grafting is applicable to both small and large burns. Disadvantages of this approach include inadvertent removal of potentially viable tissue, limited donor sites, wound closure, and the need for multiple blood transfusions.5 Not all studies have fully supported the concept. The data for the elderly have shown both improvement9,10 and equivocal11 results, and 1 study suggested that selection bias may play a role.12 Nonetheless, early excision and grafting of burns is the method of treatment utilized by most burn centers.13 There are relatively few contraindications to early excision and grafting. A notable exception is in the case of scald burns, in which the depth of the injury can be difficult to determine in the first several days after injury.14,15 To avoid excessive removal of viable tissue, the scald burn is usually initially observed. Once it is clear that the wound will not heal within 2 to 3 weeks, the area in question is generally promptly excised and grafted. The other exception is the patient who cannot tolerate an anesthetic or operative procedure. Although early excision and grafting has decreased burn mortality, it has not changed the pattern of burn mortality: pneumonia, sepsis, and multisystem organ failure are still leading causes of death in these patients.16,17 A recently tested probability model implicated age more than 60 years, TBSA burn more than 40%, and inhalation injury as independent risk factors for burn mortality.18 Future improvements in early excision may well reside in several distinct arenas. The first involves, as the article by Sheridan et al17 suggested, finding a more efficient method of eschar excision that does not adversely effect wound healing. The role of the laser and other devices in the removal of burn eschar is still being defined. Advances in support of the critically ill patient will continue to have an impact on patient survival. Although early excision and grafting are integral to the care of the burn patient, it is important to remember that they are only links in the chain of care. It is vital to integrate excision with other aspects of care, such as nutritional support, cardiopulmonary care, physical therapy and rehabilitation, and nursing care. Even the most precise excision and grafting procedure will be unsuccessful if nutritional support is inadequate, organ perfusion is not maintained, or wounds are improperly cared for. Has early excision of burns fulfilled its promise? Yes and no. With judicious planning and implementation of burn care principles, the overall mortality rate associated with burn injury has decreased. Yet despite these advances, the promise for the future remains.

Original languageEnglish (US)
Pages (from-to)305-308
Number of pages4
JournalCurrent Surgery
Volume56
Issue number6
StatePublished - Jul 1999

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Burns
Wounds and Injuries
mortality
Body Surface Area
Nutritional Support
Mortality
cause of death
pharmaceutical
Length of Stay
rehabilitation
Rehabilitation Nursing
aesthetics
nursing
incidence
Device Removal
coverage
Survival
Selection Bias
Hospital Costs
Operative Surgical Procedures

ASJC Scopus subject areas

  • Surgery

Cite this

Early excision of burns : Has the approach fulfilled its promise? / Palmieri, Tina L.

In: Current Surgery, Vol. 56, No. 6, 07.1999, p. 305-308.

Research output: Contribution to journalArticle

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title = "Early excision of burns: Has the approach fulfilled its promise?",
abstract = "The rate of survival of burn patients has increased significantly over the past 20 years because of advances in both supportive care and wound management. Recent data suggest that the burn size considered to be lethal to 50{\%} of patients (LA50) has steadily increased from 40{\%} of total body surface area (TBSA) in the 1940's to 81{\%} of TBSA today.1 One reason purported to decrease mortality and improve outcome for the burn patient is early excision and grafting of burn wounds.1-7 But what exactly is {"}early excision{"}? As seen in the above papers, this definition can vary. Generally, early excision ranges from early massive excision of the entire burn wound within 48 to 72 hours5,7 to sequential excision of the entire burn wound over approximately 7 days.8 Numerous studies in the 1970's and 1980's suggested that early excision increased survival as well as functional and aesthetic outcome in children, adults, and the elderly.1-9 Proponents of early excision cite decreased hospital length of stay and costs, less operative blood loss, a lower incidence of hypertrophie scar formation, improved immune response, and decreased intensity and duration of the hypermetabolic response to burn injury with early excision and wound coverage. Early excision and grafting is applicable to both small and large burns. Disadvantages of this approach include inadvertent removal of potentially viable tissue, limited donor sites, wound closure, and the need for multiple blood transfusions.5 Not all studies have fully supported the concept. The data for the elderly have shown both improvement9,10 and equivocal11 results, and 1 study suggested that selection bias may play a role.12 Nonetheless, early excision and grafting of burns is the method of treatment utilized by most burn centers.13 There are relatively few contraindications to early excision and grafting. A notable exception is in the case of scald burns, in which the depth of the injury can be difficult to determine in the first several days after injury.14,15 To avoid excessive removal of viable tissue, the scald burn is usually initially observed. Once it is clear that the wound will not heal within 2 to 3 weeks, the area in question is generally promptly excised and grafted. The other exception is the patient who cannot tolerate an anesthetic or operative procedure. Although early excision and grafting has decreased burn mortality, it has not changed the pattern of burn mortality: pneumonia, sepsis, and multisystem organ failure are still leading causes of death in these patients.16,17 A recently tested probability model implicated age more than 60 years, TBSA burn more than 40{\%}, and inhalation injury as independent risk factors for burn mortality.18 Future improvements in early excision may well reside in several distinct arenas. The first involves, as the article by Sheridan et al17 suggested, finding a more efficient method of eschar excision that does not adversely effect wound healing. The role of the laser and other devices in the removal of burn eschar is still being defined. Advances in support of the critically ill patient will continue to have an impact on patient survival. Although early excision and grafting are integral to the care of the burn patient, it is important to remember that they are only links in the chain of care. It is vital to integrate excision with other aspects of care, such as nutritional support, cardiopulmonary care, physical therapy and rehabilitation, and nursing care. Even the most precise excision and grafting procedure will be unsuccessful if nutritional support is inadequate, organ perfusion is not maintained, or wounds are improperly cared for. Has early excision of burns fulfilled its promise? Yes and no. With judicious planning and implementation of burn care principles, the overall mortality rate associated with burn injury has decreased. Yet despite these advances, the promise for the future remains.",
author = "Palmieri, {Tina L}",
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N2 - The rate of survival of burn patients has increased significantly over the past 20 years because of advances in both supportive care and wound management. Recent data suggest that the burn size considered to be lethal to 50% of patients (LA50) has steadily increased from 40% of total body surface area (TBSA) in the 1940's to 81% of TBSA today.1 One reason purported to decrease mortality and improve outcome for the burn patient is early excision and grafting of burn wounds.1-7 But what exactly is "early excision"? As seen in the above papers, this definition can vary. Generally, early excision ranges from early massive excision of the entire burn wound within 48 to 72 hours5,7 to sequential excision of the entire burn wound over approximately 7 days.8 Numerous studies in the 1970's and 1980's suggested that early excision increased survival as well as functional and aesthetic outcome in children, adults, and the elderly.1-9 Proponents of early excision cite decreased hospital length of stay and costs, less operative blood loss, a lower incidence of hypertrophie scar formation, improved immune response, and decreased intensity and duration of the hypermetabolic response to burn injury with early excision and wound coverage. Early excision and grafting is applicable to both small and large burns. Disadvantages of this approach include inadvertent removal of potentially viable tissue, limited donor sites, wound closure, and the need for multiple blood transfusions.5 Not all studies have fully supported the concept. The data for the elderly have shown both improvement9,10 and equivocal11 results, and 1 study suggested that selection bias may play a role.12 Nonetheless, early excision and grafting of burns is the method of treatment utilized by most burn centers.13 There are relatively few contraindications to early excision and grafting. A notable exception is in the case of scald burns, in which the depth of the injury can be difficult to determine in the first several days after injury.14,15 To avoid excessive removal of viable tissue, the scald burn is usually initially observed. Once it is clear that the wound will not heal within 2 to 3 weeks, the area in question is generally promptly excised and grafted. The other exception is the patient who cannot tolerate an anesthetic or operative procedure. Although early excision and grafting has decreased burn mortality, it has not changed the pattern of burn mortality: pneumonia, sepsis, and multisystem organ failure are still leading causes of death in these patients.16,17 A recently tested probability model implicated age more than 60 years, TBSA burn more than 40%, and inhalation injury as independent risk factors for burn mortality.18 Future improvements in early excision may well reside in several distinct arenas. The first involves, as the article by Sheridan et al17 suggested, finding a more efficient method of eschar excision that does not adversely effect wound healing. The role of the laser and other devices in the removal of burn eschar is still being defined. Advances in support of the critically ill patient will continue to have an impact on patient survival. Although early excision and grafting are integral to the care of the burn patient, it is important to remember that they are only links in the chain of care. It is vital to integrate excision with other aspects of care, such as nutritional support, cardiopulmonary care, physical therapy and rehabilitation, and nursing care. Even the most precise excision and grafting procedure will be unsuccessful if nutritional support is inadequate, organ perfusion is not maintained, or wounds are improperly cared for. Has early excision of burns fulfilled its promise? Yes and no. With judicious planning and implementation of burn care principles, the overall mortality rate associated with burn injury has decreased. Yet despite these advances, the promise for the future remains.

AB - The rate of survival of burn patients has increased significantly over the past 20 years because of advances in both supportive care and wound management. Recent data suggest that the burn size considered to be lethal to 50% of patients (LA50) has steadily increased from 40% of total body surface area (TBSA) in the 1940's to 81% of TBSA today.1 One reason purported to decrease mortality and improve outcome for the burn patient is early excision and grafting of burn wounds.1-7 But what exactly is "early excision"? As seen in the above papers, this definition can vary. Generally, early excision ranges from early massive excision of the entire burn wound within 48 to 72 hours5,7 to sequential excision of the entire burn wound over approximately 7 days.8 Numerous studies in the 1970's and 1980's suggested that early excision increased survival as well as functional and aesthetic outcome in children, adults, and the elderly.1-9 Proponents of early excision cite decreased hospital length of stay and costs, less operative blood loss, a lower incidence of hypertrophie scar formation, improved immune response, and decreased intensity and duration of the hypermetabolic response to burn injury with early excision and wound coverage. Early excision and grafting is applicable to both small and large burns. Disadvantages of this approach include inadvertent removal of potentially viable tissue, limited donor sites, wound closure, and the need for multiple blood transfusions.5 Not all studies have fully supported the concept. The data for the elderly have shown both improvement9,10 and equivocal11 results, and 1 study suggested that selection bias may play a role.12 Nonetheless, early excision and grafting of burns is the method of treatment utilized by most burn centers.13 There are relatively few contraindications to early excision and grafting. A notable exception is in the case of scald burns, in which the depth of the injury can be difficult to determine in the first several days after injury.14,15 To avoid excessive removal of viable tissue, the scald burn is usually initially observed. Once it is clear that the wound will not heal within 2 to 3 weeks, the area in question is generally promptly excised and grafted. The other exception is the patient who cannot tolerate an anesthetic or operative procedure. Although early excision and grafting has decreased burn mortality, it has not changed the pattern of burn mortality: pneumonia, sepsis, and multisystem organ failure are still leading causes of death in these patients.16,17 A recently tested probability model implicated age more than 60 years, TBSA burn more than 40%, and inhalation injury as independent risk factors for burn mortality.18 Future improvements in early excision may well reside in several distinct arenas. The first involves, as the article by Sheridan et al17 suggested, finding a more efficient method of eschar excision that does not adversely effect wound healing. The role of the laser and other devices in the removal of burn eschar is still being defined. Advances in support of the critically ill patient will continue to have an impact on patient survival. Although early excision and grafting are integral to the care of the burn patient, it is important to remember that they are only links in the chain of care. It is vital to integrate excision with other aspects of care, such as nutritional support, cardiopulmonary care, physical therapy and rehabilitation, and nursing care. Even the most precise excision and grafting procedure will be unsuccessful if nutritional support is inadequate, organ perfusion is not maintained, or wounds are improperly cared for. Has early excision of burns fulfilled its promise? Yes and no. With judicious planning and implementation of burn care principles, the overall mortality rate associated with burn injury has decreased. Yet despite these advances, the promise for the future remains.

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