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Pitfalls in Burn Management
1. PITFALLS IN BURN
MANAGEMENT
Dr Sunil Keswani
Cosmetic Surgeon and Burns Surgeon
NATIONAL BURNS CENTRE
Navi Mumbai
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
2. Aim of burn care
•
•
•
•
Rescue
Resuscitate
Refer
Resurface
• Rehabilitate
• Reconstruct
• Review
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
3. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
4. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
5. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
6. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
7. Principles of BURN MANAGEMENT
• Airway management-quick and appropriate
• Prompt and accurate fluid resuscitation
• Removal of dead burnt skin and replacement
with homograft(cadaveric skin from SKIN BANK)
or biologic skin substitutes
• Appropriate adequate nutrition
• Good chest PT
• Replacement of homograft with autograft or
cultured skin(cultured keratinocytes)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
8. Which burn patients need
HOSPITALISATION?
• We go by the AMERICAN BURN ASSOCIATION
GUIDELINES
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
9. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
10. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
11. Does a child with only head face
burns require hospitalisation?
• YES.
• The head face in a child constitues about 18%
BSA while in an adult it is 9 %!!
• Anything above 10% BSA in a child needs
hospitalisation
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
12. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
13. How do we reduce INFECTION IN
BURNS?
• Hand washing
• Infection control measures like Isolation,Use
of disposables,Separate bedpan,stethoscope
and BP apparatus for each burn patient and a
1:1 nurse patient ratio.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
14. Philipp Ignaz Semmelweis
• Hungarian Physician
reduced the incidence
of Puerperal Fever in a
Vienna Hospital by
introducing the practice
of HAND WASHING with
chlorinated water
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
15. Louis Pasteur
• French microbiologist
and chemist
• Germ theory of disease
• Founder of
Microbiology along with
Robert Koch
• Pasteurisation of milk
• Popularised the concept
of HAND WASHING
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
16. LEVELS OF ICU CARE
• Level - I – provides
monitoring, observation
and short term
ventilation.
• Level - II – Provides
Observation,
Monitoring & Long
Term Ventilation With
Resident Doctors.
• Level - III – provides
all aspects of intensive
care including invasive
haemo dynamic
monitoring & dialysis.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
17. BED STRENGTH
• IDEALLY 8 TO 12 BEDS.
• LARGER AREAS –
DIFFICULT TO
ADMINISTER AND
SMALLER AREAS NOT
BEING COST EFFECTIVE.
• 5 TO 8 BEDS PER 50
HOSPITAL BEDS FOR A
LEVEL III ICU / 10-16%
OF THE TOTAL NUMBER
OF HOSPITAL BEDS.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
18. BED SPACE & BEDS
• ALL SEPARATE CUBICLES
• 225 – 250 SQUARE FEET
PER BEDS
• BEDS - ADJUSTABLE, NO
HEAD BOARD, SIDE RAILS
AND WITH
WHEELS,REMOTE
CONTROLLED WITH
FACILITY FOR ALL
POSITIONING FOR
NURSING CARE AND
PHYSIOTHERAPY AND
EMERGENCY SITUATIONS
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
19. Fluid Management
•
•
•
•
Fluids per hour=Wt(kg) x % of Burns divided by 4
Start with RL in adults and Isolyte P in children
After 24 hrs start DNS
If not adequate urine output in 12 hrs start
colloids FFP
• CVP above 10 cms water and inadequate uo Inj
Lasix
• More fluids required in Electric Burns and
Inhalation Injury
• Always central line (sometimes even thro burnt
tissue) for initial resuscitation
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
20. Fluid resuscitation
•
•
•
•
Need to replace losses to maintain homeostasis.
Formulas are ONLY GUIDELINES.
Monitor physiologic parameters.
Maintain adequate tissue perfusion to prevent
increase in depth of burn.
• Too little fluid ► Hypotension ► renal failure, etc.
• Too much fluid ► Edema ► Tissue hypoxia
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
21. Electrical injury resuscitation
• Fluid needs greater
• 9 mL x TBSA burn (%) x body weight (kg) in
first 24 hrs
• If myoglobinuria, may require bicarbonate
infusion to alkalinize urine to pH > 8
• End point: urine output of 1.5-2 mL/kg/hr
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
22. Electrolyte Abnormalities
• HYPOKALEMIA- seen more often than
Hyperkalemia
• Commonest cause of non infective paralytic
ileus
• Serum K <3mEq/l KCl at 10mEq/hr
• Serum K <2mEq/l KCl at 40mEq/hr
• Daily Ser Electrolytes in first 3 days
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
23. Electrolyte Abnormalities
• HYPOCALCEMIA-most commonly due to
Hypoalbuminemia
• Lowering of Ser Albumin by 1g/ml lowers Ser
Calcium by 1g/ml
• Alkalosis also lowers Ser Ca by increasing
protein binding
• Correction required only if symptomatic
• Associated Hypomagnesemia needs
simultaneous correction to prevent tetany
and arrhythmias
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
24. Reducing the HYPERMETABOLIC
RESPONSE
• Temperature regulation
• Nutrition
• Pharamacological manipulation-Propranolol
40 mg BD and Oxandrolone 5mg BD
• Early excision and homografting
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
25. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
26. Role of LMWH
• Incidence of Deep Vein Thrombosis is
significant enough to warrant routine use of
LMWH
• Incidence of Pulmonary embolism is reduced
significantly
• Daltaparin or Enoxiparin
• Fragmin or Clexane
• This is stopped once patient is mobile
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
27. Role of Intermittent Compression
Device
• Intermittent
compression pump
along with LMWH
decreases the incidence
of DVT by as much as
50%
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
28. Nutrition
• Aggressive nutritional support to
counterbalance the effect of
Hypermetabolism and Protein catabolism
following Burns
• ENTERAL feeding is preferred over
PARENTERAL feeding
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
29. Nutritional support
• Burns patient is hypercatabolic – up to 150200% above baseline.
• Nutrition needed for burns >20% TBSA.
• Curreri formula
– Adult: 25kcal/kg/day + 40kcal/ % TBSA burn
– Child: 60kcal/kg/day + 35kcal/ % TBSA burn
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
30. BUTTERMILK DIET(BMD)
• Eggs- 4 /Protein
powders(Whey protein
or Soya protein)
• Bananas- 4
• Sugar- 4 Tbsf
• Curds (Yoghurt) -1000cc
• Mixed with water to
1600cc
Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
31. Tracheostomy
• Head face neck
burns IMMEDIATE
TRACHEOSTOMY to
facilitate airway and
nursing
Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
34. Fasciotomy
• Pain
• Pallor-look at capillary refill
• Compartmental
time-if less than 2 secspressures above
VENOUS OBSTRUCTION and
25mm Hg warrant
if more than 5 secs –
a FASCIOTOMY
ARTERIAL OBSTRUCTION
• Pressure
• There are devices
• Pulselessnes
to measure this
• Paresthesia
pressure
• Paralysis
• Poikilothermia
• We use DOPPLER
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
to decide
• Progression
nbcairoli@gmail.com
39. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
40. Esharotomy
• Thick circumferential non-yielding
eschar warrants an ESHCAROTOMY
Dr. Sunil Keswani, National Burns Centre, www.burnsindia.com, nbcairoli@gmail.com
48. Early excision Vs Delayed excision
• Always early excision if patient comes early
enough and facilities exist
• Early enough is upto 72 hrs postburn
• Early excision decreases the chances of Sepsis
and facilitates early moblisation and better
and more predictable functional recovery.
• Delayed excision is generally at 3 weeks or
later
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
49. Early Excision
• Within the first 3-5days
• After 5 days chances of Sepsis higher and
bleeding more
• 15% of BSA is excised at a time
• Coverage of excised area by Meshed
Homograft is mandatory
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
50. Order of excision
• Areas easy and quick to excise: trunk and
legs
• Joints and throats
• Hands and face
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
51. Early Excision
• Blood Loss
– Clear pre-operative plan
– Excision prior to wound hyperemia
– Elevation of extremities
– Tourniquet control
– Dilute Epinephrine tumescent fluid
– Epinephrine soaked sponges
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
52. Early Excision
• Procedure (En Bloc)
– For deeper burns
– Skin and fat excised in one session
– Less time consuming
– Excision down to the natural cleavage plane
– Down to fat or Fascia
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
53. Allograft
Classic benefits of allograft as a physiologic and
mechanical barrier:
• Reduction in water, electrolyte and protein
loss
• Reduction in energy requirements
secondary to the attainment of a closed
wound
• Reduction in wound infection rates
• Reduction in pain
• Conservation of autografts
• Improved general welfare and psychological
outlook of the patient
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
54. Allograft
• Reduction in the number of bacteria under a
biological dressing
• Phagocytes within a wound use the fibrin
network established between the allograft and
the wound to trap and phagocytose bacteria
without the production of opsonins or antibody
• The effects of allografts in reducing bacteria
and promoting healing have proven beneficial
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
55. Porcine Skin
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
56. Porcine skin being meshed
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
57. Differences Between Skin Substitutes
• Materials that are applied for short periods
then removed, to stimulate autologous healing
• Cell free material that encourage colonization
by autologous cells, to stimulate new skin
formation
• Cell containing skin substitutes: to provide
immediate functional replacement
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
58. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
59. Integra
•
•
•
•
Most widely accepted synthetic skin substitute
Bilaminar structure
The median ‘take’ is 85%
Two-stage procedure, with a minimum interval
of 3 weeks between the application of the
Integra and the split-skin grafting
• Relatively expensive
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
64. Covered with Acticoat
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
65. Cultured autologous keratinocytes
• Grown in vitro and then applied to wounds
• Take of cultured epithelial autografts depends
on the wound bed
• Expensive
• Skilled labour and quality control,
• 3–5 weeks to produce 1.8m2 confluent sheets
of cells from a 2 cm2 biopsy
• Fragile sheets
• Blistering, infection, and contractures.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
66. Wound Closure
• Suggested Clinical Indications for CAE
– burn injuries >90% broad
– 70-90% more limited
– <70% no clear indication
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
67. Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
68. Meshed graft Vs Meek Micrografting
Vs Sheet Graft
• Acute burns always meshed or meek
micrografting for better takes
• Reconstructive procedures like overgrafting
and release of contractures always sheet
grafting for better cosmesis
• Meek micrografting gives wider coverage and
more predictable takes than mesh grafting but
more expensive
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
69. MATERIALS & METHODS
Surplus cutting
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
70. MATERIALS & METHODS
Positioning on plate.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
71. MATERIALS & METHODS
Dermatome cut through
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
72. MATERIALS & METHODS
Adhesive Spraying
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
73. MATERIALS & METHODS
Adhesive Spraying
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
74. MATERIALS & METHODS
Cork removing.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
75. MATERIALS & METHODS
Gauze expansion
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
76. MATERIALS & METHODS
Gauze expanded.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
77. MATERIALS & METHODS
Micrograft positioning
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
78. MATERIALS & METHODS
After gauze removal. 7th day.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
79. MATERIALS & METHODS
10th day wound care.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
80. MATERIALS & METHODS
Long term control.
POST-PHYSICAL REHABILITATION OUTCOME
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
81. DISCUSSION
•
•
•
•
•
•
•
•
Reliable alternative.
Easy technique.
Larger expansions.
High integration.
Fast epithelization.
Better infection response versus mesh graft.
Easy to handle because of its pliability.
Comparative with mesh tecniques and functional
results studies are required in the future.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
82. NEED FOR PAIN RELIEF
•
•
•
•
•
•
•
PAIN IS A FORM OF STRESS AND PRODUCES ELEVATION IN STRESS
HORMONES AND CATECHOLAMINES.
PAIN RELIEF ADVANTAGES:SHORTER HOSPITAL STAY.
IMPROVED MORTALITY RATES
LESS CATABOLISM AND ENDOCRINE DERANGEMENTS.
FEWER THROMBOEMBOLIC COMPLICATIONS
PAIN FREE DRESSINGS MAKE PATIENTS MORE COMFORTABLE AND
DECREASES THE MORBIDITY AND MORTALITY.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
83. NEED FOR PAIN RELIEF
• Circumferential chest burns-pain restricts full
respiratory excursions ,atelectasis and pneumonias
• Pain prevents patients from eating well-nutrition
affected.
• Pain depresses the patient-psychosomatic problems
• Pain contributory to Post burn psychosis
• Pain-poor compliance during physiotherapy-poor
rehabilitation-poor functional outcome
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
99. CLINICAL USE OF
HOMOGRAFT
AT NBC
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
100. Skin Bank and Skin Donation
DONATE SKIN AND SAVE A LIFE
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
101. PATIENT
DETAILS
Patient Name- Neeta Parekh
Age- 48
Gender- Female
TBSA Of Burns- 35%
Degree Of Burns-2nd Degree
Areas Of Burns-chest, Both
Upper Extremities
Cause Of Burns-During Lighting
Diya
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
102. ADMISSION FORM
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
103. PHOTOS ON DAY OF ADMISSION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
104. PHOTOS ON DAY OF ADMISSION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
105. EARLY BURN EXCISION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
113. 1ST DRESSING CHANGE OF HOMOGRAFT
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
114. 2ND DRESSING CHANGE OF HOMOGRAFT (4TH DAY)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
115. 3RD DRESSING CHANGE OF HOMOGRAFT (6TH DAY)
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
116. FOLLOW UP
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
117. FOLLOW UP
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
118. END RESULT
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
119. PATIENT DETAILS
Patient Name- Ramsingh
Age- 52
Gender- Male
TBSA Of Burns- 55%
Degree Of Burns-2nd Degree
Areas Of Burns- Face ,Chest,
Both Upper Extremities,,
Lower Extremities.
Cause Of Burns- Explosion
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
120. ADMISSION FORM
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
121. PHOTOS ON DAY OF ADMISSION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
122. PHOTOS ON DAY OF ADMISSION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
123. EARLY BURN EXCISION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
138. PATIENT DETAILS
Patient Name- Yojana D.
Ghase
Age- 24
Gender- Female
TBSA Of Burns- 20%
Degree Of Burns-2nd Degree
Deep
Areas Of Burns- Chest,
Abdomen, Right Upper
Extremity, Lower Face .
Cause Of Burns-flame Burn.
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
139. ADMISSION FORM
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
140. PHOTOS ON DAY OF ADMISSION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
141. EARLY BURN EXCISION
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
147. END RESULT
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
148. PITFALLS IN BURN MANAGEMENT
•
•
•
•
•
•
•
•
Early tracheostomy
Prompt adequate resuscitation
Colloids after 12 hrs
Infection control practices
Pain relief
Early enteral nutrition
Early mobilisation and Intensive chest PT
DVT prophylaxis
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
149. PITFALLS IN BURN MANAGEMENT
•
•
•
•
Escharotomy
Fasciotomy
Early excision and use of banked skin
Fascial excison and use of banked skin or
autografts
• Early rehabilitationphysical,social,psychological
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
150. TEAM APPROACH TO BURNS
•
•
•
•
•
•
•
•
•
Plastic Surgeon
General Surgeon
Ophthalomologist
ENT surgeon
Intensivist
Nephrologist
Anesthesiologist
Cardiologist
Psychiatrist
Nurses
Microbiologist
Physiotherapist
Occupational therapist
Psychological Counsellor
Social Worker
Dietitian
Prevention team
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
151. Screening of patients
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
152. Surgeries being performed in the previous camps
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
153. Post- Operative care of the patients
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
154. Skin Donation Helpline:
022 2779 3333
www.skindonation.in
www.burns-india.com
skinbanknbc@gmail.com
Dr. Sunil Keswani, National Burns Centre,
www.burns-india.com,
nbcairoli@gmail.com
Editor's Notes
Blood loss
averages 134ml/% excised (1st day 100mL/%, 4th day 200mL/%
Alternatively 8.8% of circulating blood volume is lost for each 1% excised.
Tourniquet
Esmarch bandage followed by pneumatic tourniquet 100mmHG above SBP
Excise through grey/brown tissue to white glistening dermis or bright yellow fat.
Apply grafts prior to letting down the tourniquet.
Apply a pressure bandage
Reports decreasing blood loss to 29mL/% excised BSA.
Fat or Fascia
No difference in graft take if fat is viable. Better contouring if fat is preserved.
Inner layer is 2mm thick and is a combination of GAG and collagen fibers from bovine tissue
Inner layer has 70-200 nm pore size that allows fibrovascular ingrowth, after which it is designed to slowly biodegrade
Outer layer is 0.009 inches thick polysiloxane polymer with vapor transmission characteristics similar to normal epithelium
such asburns, chronic leg ulcers, giant pigmented naevi,epidermolysis bullosa and neonatal scalp necrosis
separation from the tissue culture substrate using a proteolytic enzyme
spontaneous blistering many months after grafting, increased susceptibility to infection, and contractures
Bovine serum proteins
act as growth promoters
Delayed loss of graft
initial take 64% declined to 47% at discharge for one study of 16 patients
Cost $2000-34 000 pr percent of definitive wound closure at discharge.
Blistering
associated with high PGE2 and thromboxane levels suggesting an ongoing inflammatory response
Effects of fibrin glues being evaluated with limited success
Fibrin-glue suspensionSome success has been achieved by applying cells together with fibrin glue, in a suspensionof growth medium or using a membrane for delivery.
Fibrin-glue sheets. Subconfluent cultured keratinocyteshave been grown on fibrin glue, and then transferred as asheet onto the wounds in three patients with excised fullthicknessburns. The fibrin was found to provide a satisfactorybarrier for 10 days,
>90% burns
limited donor sites
can contribute to limited wound closure in a potentially y important manner
70-90-%
clinical judgement depending on the donor sites
e.g. face feet hands and genitalia are difficult to harvest
<70% TBSA
not usually necessary