/clinical/,/clinical/references/,/clinical/references/burn/,/clinical/references/burn/surgery/,

/clinical/references/burn/surgery/

201606159

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UWHC,UWMF,

Patient Care,

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Clinical Hub,References,Burn Basics

Surgery

Surgery - Clinical Hub, References, Burn Basics

Focus

Scheduling Cases

Every Tuesday the burn service has room 25 all day. Because of the busy OR, we often schedule inpatient cases before the decision is made to actually do the surgery in order to hold the room. It is easier to cancel a scheduled case than schedule a late case. At 11am on Monday, all cards have to be submitted or the cases will not make the schedule. As soon as we make a decision as to when the patient needs surgery, book it through the burn attendings administrative assistant.

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Pre-op Preparation

Patients that are admitted > 1week prior to surgery (or whom never had admit labs) will have a basic metabolic panel, calcium, magnesium and phosphate, cbc and type & screen/crossmatch (if blood for sure needed- check with attending, i.e. >20% excision not under tourniquet or if anemic or symptomatic prior to OR) on the Monday prior to the case so the results are available and can be acted upon prior to surgery to avoid unnecessary cancelations or delays in surgery. The surgical navigator preoperative order set in Healthlink should be used to place preoperative antibiotic orders to ensure they will be available for the patient OCTOR. The benefits of pre-op antibiotics are questionable, but we use one dose of 1-2g (wt based dosing) Cefazolin.  If allograft will be needed, make sure that it has been ordered and will be available through the blood bank.

If the patient is coming in through FDS they do not need preoperative labs, except for a pregnancy test for women of childbearing age. Pediatric patients do not need any labs preoperatively – unless it is a large >10-20% TBSA.

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Surgery

Be present at 7:30am. Maximally warm the room and begin positioning. Wear eye protection. Make sure patient arrives with any splints that were made for the case. At the end of the case, put in the post op orders. The burn attending will dictate the operative note, unless they otherwise ask you to do it. For learning purposes, most burn operations are actually two operations in one; the excision of the burn (tangential or fascial) and how the wound was covered. The percentage of the burn injury that was operated on is used with the calculated body surface area to determine the square centimeters of burn excised and covered. Additionally, we will specify whether the autograft was full or split thickness. If other material was used to cover the wound such as Integra or allograft, we will specify the square centimeters in the same manner as with autograft.

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Skin Grafts

More intact dermis means less scarring and contraction, therefore we use visual assessment with our tangential excision to determine when we have reached viable tissue with the intent of leaving as much viable dermis behind as possible. Full-thickness skin grafts are infrequently used and are limited to small areas by donor availability. The donor site is then primarily closed. Therefore it is often in a groin crease or other area of very mobile skin to facilitate ease of closure. Split-thickness skin allows the donor site to heal-in as a second-degree injury (about two weeks). Skin that is not meshed is called “sheet” and is used to cover open wounds where a smooth surface and good pliability/function/cosmesis is important such as in the hands and face. Meshing the skin allows a greater surface area to be covered with a smaller amount of donor skin. Additionally, any seroma or hematoma that is produced after the graft is placed will be evacuated through the mesh interstices. In a sheet graft, any fluid collection under the graft with cause graft loss in those areas unless evacuated. Meshed skin is used at the expense of scarring and decreased pliability. Meticulous hemostasis is of utmost importance for graft take in both meshed and sheet autograft.

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Skin Substitutes

Allograft (cadaver) skin is used as a biologic dressing that is always temporary (it will reject in approximately 7-10 days). It comes frozen, irradiated, or fresh from tissue banks. Our institution uses frozen allograft and it should be ordered the day prior to going to the OR.

Integra is dermal substitute consisting of an acellular matrix of collagen and GAG with a silicone covering that becomes incorporated and forms a neo-dermis after approximately 2-3 weeks. It is useful in full thickness injury and requires fascial excision prior to placement. The theoretical benefit of using Integra is less scarring and it provides temporary closure of the open wound to decrease the fluid loss in the early stages of the burn. It additionally allows early excision of the burn wound with the option of serially harvesting and reharvesting donor sites when they are limited in number in large burns without the need for repeated allograft placement. Once Integra is well vascularized, the protective silicone layer is removed and a thin, epithelial autograft is placed.

Cultured skin, or Cultured Epithelial Autograft (CEA)/Epicel® is an option for epithelial coverage of very large burns. A small biopsy of intact skin is sent to a laboratory and the keratinocytes are isolated, cultured into large cell stocks that are used to grows sheets of keratinocytes approximately eight cell layers thick. These sheets are placed on debrided wounds as autografts. CEA is often used over dermal substitutes such as Integra. CEA is extremely expensive, time intensive to care for and is very fragile; therefore, it is not regularly used except in cases where there are no other options for autologous skin coverage.

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Donor Site Dressings

Philosophy: The goals are the same for donor site dressings as they are for a grafted site, to provide a warm, moist, clean environment for the wound and to be as pain free as possible until the wound heals.

Please see the Donor Site Care area for guidelines of the donor care.

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Tube Feeding Prior to Operative Intervention

Tube feeding

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Post Grafting Activity Guidelines

Surgery Type

Dressing Change

Activity OT/PT ROM

STSG mesh

POD 3, 6

hold ROM of affected joint until POD 6

STSG sheet

POD 3, 6

hold ROM of affected joint until POD 6

Integra

Per guidelines

hold ROM of affected joint until POD 5

Cadaver

POD 3, 6

Hold ROM of affected joint until POD 1

Delay ambulation until day 6 for grafts below the knee, day 3-6 for grafts above the knee – at the discretion of the attending.

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Pain Management

PHILOSOPHY

We divide burn pain into two types conceptually, background pain and procedural/evoked pain. Background pain is always present with minimal fluctuation, although the background pain from donor sites may be particularly intolerable during the first 8-12 hours post-op. For background pain it is appropriate to provide sustained analgesia in the form of oral agents with a long half-life or as PCA if intolerant of oral agents.

The second type of pain, procedural/evoked pain, is when something is done to the patient such as wound cleansing, dressing changes, OT, PT, etc. This is often the worst pain the patient has ever encountered in their lives and few patients can even make a comparison. Assume that your burn patients will have severe evoked pain and pretreat with short acting narcotic agents prior to painful interventions.

FENTANYL

A short-acting IV opioid agonist. Also comes in convenient buccal tablet and transdermal patch forms. This is our standard IV pain medications given that it is short acting, well-tolerated and good safety profile.

OXYCODONE

Oxycodone is a good oral agent. There are multiple doses. It is the effective agent in Percocet, although it does not contain the Tylenol that Percocet does, therefore dosing is not limited by Tylenol toxicity.

MS CONTIN AND OXYCONTIN

MS Contin and Oxycontin are two long-term drugs that are sustained release. Oxycontin is a good medication, but is has a high abuse potential, is expensive, and many insurance companies are not covering it as a first choice medication. For these reasons we prefer to use MS Contin as our long acting narcotic pain medication.

GABAPENTIN

Gabapentin is a GABA analog that provides nerve pain relief for pain unique to burn patients and uncontrolled by narcotics alone. It should be considered on all burn injured patients, but is required to be added unless contraindicated on all patients who have required initiation of MS Contin. The usual starting dose is 300 mg po TID. The major side effect is sedation at high doses.

MORPHINE

Morphine is a strong alternative IV narcotic if there is a fentanyl intolerance. We rarely use morphine IV anymore.

DILAUDID

Dilaudid is a strong IV narcotic that gives a significant euphoria feeling along with the analgesic effect. This medication can be very effective with initial management of pain in the ED or post-op. Transitioning off of IV dilaudid to a PO narcotic medication (that does not give that euphoric feeling) can be challenging. For this reason we tend to use Fentanyl for our daily IV narcotic use.

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Pain vs Anxiety

ANXIOLYTICS

Anxiolytics should be used for anxiety, while narcotics are used for pain. Sometimes when the patient is agitated it is difficult to tell which is which, and trial and error needs to be used to figure out which type agent is best. Most patients with large burns require a therapeutic dose of anxiolytic as well. Midazolam is the standard anxiolytic to use.  For intubated patients who have normal blood pressure, start with propofol for sedation. Propofol is easier to titrate and has quick on/off. Midazolam metabolites from a continue infusion in patients with renal failure, are not adequately eliminated and can contribute to prolonged sedation after discontinuation.

MODERATE SEDATIONS

Occasionally in adults, and almost exclusively with children, we will need to perform a moderate sedation during wound cares. These sedations are performed by the attending burn surgeons or nurse practitioner only, and are performed per the sedation policies at UW Hospital. Occasionally, this may need to be accomplished by non-burn team members (pediatric anesthesiologists). Ketamine is a dissociative anesthetic that is used in conjunction with midazolam during dressing changes, IV line placements, etc. Patients must be npo although post-pyloric tube feeding need not be stopped. Hallucinations can be tempered with the use of midazolam given 5-10 minutes before – therefore use of midazolam and ketamine together is a standard combination. Use of Ketamine is considered moderate sedation and requires following the complete moderate sedation policy/documentation. We additionally may utilize nitrous oxide inhalation by mask in conjunction with oral midazolam. This is also considered a moderate sedation and follows the same monitoring as the ketamine and midazolam.

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Reviewed by Burn Director, May 2016