Reduction of blood loss in burn surgery

Dr sumer yadavMch plastic and

reconstructive surgery

Early excision and grafting

• increased survival• lower rates of burn sepsis• shorter hospitalization• reduced costs• Less time away from work or school• Less post burn contractures• increased transfusion requirements

techniques to reduce intraoperative blood loss

• application of topical epinephrine with or without thrombin to excised wounds and/or donor sites

• the subcutaneous infiltration of vasoconstrictors such as epinephrine, phenylephrine,or vasopressin at donor and/or excision sites

• the administration of systemic vasopressin• Controlled intraoperative hypotension• performing excision with a laser• use of limb tourniquets.

methods of intraoperativeblood conservation

• Donor sites were infiltrated subcutaneously with a 1:500,000 adrenaline solution (2 mL of 1:1,000 adrenaline in 1 liter of warm injectable normal saline)

• using 60-mL syringes attached to 18-gauge spinal needles. Infusion was by hand pressure.

• The tissues were infiltrated until they were firm (i.e., tumescent).

• After grafts were harvested by dermatome, the sites were dressed with jelonet/ mops soaked in warm 1:33,333 adrenaline solution (30 mL of 1:1,000 adrenaline in 1 liter of injectable normal saline).

• all fascial excision under electrocautery

methods of intraoperativeblood conservation

• Burn wounds in areas where tourniquets could not be applied received subeschar infiltration with the 1:500,000 adrenaline solution to the point of tumescence. After tangential excision with the Humby knife, the wounds were dressed with serial applications of mops soaked in the topical 1:33,333 solution.

• Burn wounds on limbs were tangentially excised under tourniquet control. The limb was first elevated and suspended, and then the tourniquet was inflated to 100 mm Hg above systolic blood pressure. When the excision was complete, the limb was wrapped with mop soaked in the topical 1:33,333 adrenaline solution, secured with a circumferential firm wrapping of bandage, also soaked in the topical adrenaline solution, for a full 10 minutes after deflation of the tourniquet. the dressing was removed, major bleeders were cauterized, and the limb was rewrapped for another 5 minutes with the adrenaline-soaked mops. Final hemostasis was then achieved with serial applications of adrenaline-soaked mops and with cautery.

• Grafts were applied only when hemostasis was complete. Grafts were never applied before tourniquet deflation out of concern for subgraft hematoma formation.

methods of intraoperativeblood conservation

• Estimates of blood loss in adults during burn surgery range from 196 to 269 mL for each percent of the body surface area excised and grafted. To put this into perspective, on the basis of these estimates, as much as 36% to 49% of the blood volume of a 70-kg man could be lost during the excision and grafting of one upper extremity.(traditional method)

• New method cuts loss to 50 – 100 ml/% burns

• Use warm saline for infiltration and soakings• Maintain patient euthermic• Tachcardia and hypertension are rarely create

problems . Pulse > 140• Cuts too much of the intraoperative blood

transfusion• Extra time requires to do surgery (x2 times)• > 20 % tbsa can be approached in single sitting

assessment of tissue viability• the dermis must be pearly white, with no hemorrhagic staining• minor vessels on the wound surface must be patent• the fat must be pale yellow, firm, and moist (dry, or golden brown

fat is unhealthy)• and the excised wound rapidly becomes hyperemic, even under

tourniquet Control• In particular, shortly after what appears to be adequate excision,

the white dermis and pale yellow fat appear to develop hemorrhagic staining.

• evidence of inadequate excision (e.g., tissue fails to reperfuse, remains dry, or contains thrombosed vessels on the wound surface)

• Better graft take rate (> 95%)• No bad effect of this technique in graft take

but hemostasis leads to better take rate• the intraoperative transfusion requirement

was reduced from 3.3 +/- 3.1 units per case, in the historical group, to 0.1 +/- 0.3 units per case

• Journal of Burn Care & Rehabilitation:• March/April 2001 - Volume 22 - Issue 2 - pp 11

1-117• Original Articles• Reduced Blood Loss During Burn Surgery• Gomez, M. MD; Logsetty, S. MD, FRCS(C); Fish,

J. S. MD, MSc, FRCS(C)

The purpose of this study was to investigate the use of subcutaneous injection of burn wounds and skin graft donor sites with an adrenaline-saline solution to reduce blood loss

during burn surgery. This retrospective study reviewed the requirements of blood products in 30 randomly selected adult patients with more than 10% body area burned, who had at least one burn operation at a university regional burn center, between January 1991 and June 1997. Patients were matched by age and percent body area burned and stratified

according to the surgical technique in two groups. In Group 1, 15 patients received the modified tumescent surgical technique: subcutaneous injection of adrenaline (1 part/million in warm saline solution) into the subcutaneous tissue

of the donor sites for autologous skin graft and areas of burn eschar to be excised, combined with pneumatic tourniquets in extremities and saline-adrenaline soaked

nonadherent pads. In Group 2, 15 patients received the traditional surgical technique: soaked gauze

compresses with an adrenaline-thrombin solution (1 ml of 1:1,000 adrenaline, thrombin 10,000 units, and 1 L of normal saline). Outcome measures, transfusion of blood products, operating time and complications between the two patient groups were analyzed using the

Wilcoxon 2-sample test. The two patient groups were not different by age (40.4 ± 19.4 vs 38.9 ± 17.9), percent total body area burned (27.6 ± 15.4 vs 32.8 ± 13.4), or percent full

thickness burn (7.0 ± 8.5 vs 11.5 ± 8.5). The modified tumescent surgical technique significantly reduced mean total blood units transfused per patient (7.9 ± 11.5 vs 15.7 ±

12.9 units;P = .031), and the mean blood units transfused intraoperatively per patient (4.7 ± 7.8 vs 8.9 ± 8.0 units;P = .026). The modified tumescent surgical technique significantly reduced the intraoperative and total blood transfusion requirements in our thermally

injured patients.

Staged high-dose epinephrine clysis is safe and effective in extensive tangential burn excisions in children R.L Sheridan, S.K Szyfelbein Accepted: May 10, 1999;

• Prodigious blood loss commonly accompanies extensive tangential burn excisions. Staged high-dose epinephrine clysis may facilitate blood conserving excisional burn surgery. Prospective data was collected in 25 consecutive children who underwent tangential excision over the torso of at least 10% of the body surface with staged high dose epinephrine clysis. The children had an average age of 6.3±1.1 years and burn size of 45.7±3.9%. Total operative wound size (excision plus donor site) averaged 21±0.8% of the body surface. Total dose of epinephrine averaged 24.6±2.8 mcg/kg. Based on pre- and postoperative hematocrit and known volume of transfusion, the percent of the total blood volume lost per percent total wound generated averaged 0.98±0.19% of the blood volume per % of the body surface; 18 of the children (72%) required no blood in the perioperative period. There were no complications related to epinephrine use, graft take averaged 98±0.6% and all children survived and have been discharged home in good condition. Due to its rapid metabolism, subcutaneous epinephrine at high doses can be repetitively administered as long as time is allowed for its metabolism to occur. Use of this technique facilitates a marked reduction in blood requirements for these traditionally bloody operations.

The tumescent technique to significantly reduce blood loss during burn surgeryRon D Robertson, Patricia Bond, Bonny Wallace, Kristopher Shewmake, John Cone

Department of General Surgery, University of Arkansas for Medical Sciences, Slot 520, 4301 West Markham, Little Rock, AR 72205, USAAccepted: May 21, 2001;

• Introduction: burn surgery is complicated by blood loss. The tumescent technique of subdermal injection of epinephrine has been utilized to decrease intraoperative blood loss. We hypothesized that this would safely decrease blood loss during burn surgery.

• Methods: twenty patients utilized the tumescent technique. The tumescent group had subdermal injections of epinephrine beneath the excision and donor site plus thrombin spray and warm saline soaked laparotomy pads. Ten patients grafted prior to adopting the tumescent technique utilized thrombin spray and warm saline soaked laparotomy pads for hemostasis. Blood loss was determined by operative estimation and calculation. Data were analyzed by Student's t-test and paired t-test.

• Results: the two groups were demographically similar. The tumescent group had significantly less total blood loss and blood loss per unit area excised. There were no clinically detectable arrythmias, changes in heart rate or blood pressure noted.

• Conclusions: the tumescent technique significantly reduced intraoperative blood loss. It is safe, inexpensive and easy to use. The subdermal epinephrine/saline injection creates a smooth, tense surface which assists with debridement and donor harvest.

Minimizing Blood Loss in Burn SurgeryRobert Cartotto, MD, FRCS(C), Melinda A. Musgrave, MD, PhD, Massey Beveridge, MD, FRCS(C),

DTM&H, Joel Fish, MSc, MD, FRCS(C), and Manuel Gomez, MD

• Background: Significant blood loss continues to plague early tangential excision of the burn wound. Although various techniques to reduce intraoperative blood loss have been described, there is an absence of uniformity and consistency in their application. Furthermore, it is unclear whether these techniques compromise intraoperative tissue assessment and wound outcome. The purpose of this study was to evaluate the effects of a comprehensive intraoperative blood conservation strategy on blood loss, transfusion requirements, and wound out-come in burn surgery. Methods: An intraoperative blood conservation strategy (CONSV) that included donor site and burn wound adrenaline tumescence, donor site and excised wound topical adrenaline, and limb tourniquets was prospectively evaluated and compared with a historical control group (HIST) where only topical adrenaline and thrombin were applied to donor sites and excised wounds.

• Results: Estimated blood loss was reduced from 211 +/- 166 mL per percentage body surface area excised and grafted in the HIST group to 123 +/- 106 mL in the CONSV group (p 5 0.02). Similarly, the intraoperative transfusion requirement in the HIST group was reduced from 3.3 +/- 3.1 units per case to 0.1 +/- 0.3 units per case in the CONSV group (p < 0.001). There was no compromise in wound outome in the CONSV group, which had a mean skin graft take rate of 96 +/- 4.2%.

• Conclusion: The application of a strict and comprehensive intraoperative blood conservation strategy during burn excision and grafting resulted in a profound reduction in blood loss and transfusion requirements, without compromising wound outcome.

J Trauma. 2000;49:1034–1039.

Journal of Burn Care & Rehabilitation:January/February 2001 - Volume 22 - Issue 1 - pp 1-5

Tourniquet and Subcutaneous Epinephrine Reduce Blood Loss During Burn Excision and Immediate AutograftingDjurickovic, S. MD, FRCSC*; Snelling, C. F. T. MD, FRCSC†; Boyle, J. C. MD, FRCSC†

• Blood loss has been reduced using both tourniquets and epinephrine-injected subeschar during burn wound excision. This study quantified and compared blood loss in extremities distal to an inflated tourniquet with that after subeschar infusion of 1:1,000,000 epinephrine in saline into the trunk or proximal extremities. Tangential excision of eschar to viable dermis or fat was followed by immediate application of meshed autograft. Blood loss was calculated by determining the difference of preoperative and postoperative hemoglobin values and the volume of whole blood administered between these. With tourniquets for limbs, 2.07 ± 0.34% of circulating blood volume per 1% body surface excised was lost; whereas after epinephrine injection 3.42 ± 0.39% of blood volume per 1% body surface excised was lost (P < 0.05). Both methods effectively reduced blood loss when compared with excision followed by delayed autograft application. Where there was a choice the tourniquet was more effective.

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