Early excision and skin grafting in burns by Dr. Sunil Keswani, National Burns Centre, Airoli

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  • {"5":"Blood loss\naverages 134ml/% excised (1st day 100mL/%, 4th day 200mL/%\nAlternatively 8.8% of circulating blood volume is lost for each 1% excised.\nTourniquet\nEsmarch bandage followed by pneumatic tourniquet 100mmHG above SBP\nExcise through grey/brown tissue to white glistening dermis or bright yellow fat.\nApply grafts prior to letting down the tourniquet.\nApply a pressure bandage\nReports decreasing blood loss to 29mL/% excised BSA.\n","6":"Fat or Fascia\nNo difference in graft take if fat is viable. Better contouring if fat is preserved.\n","13":"Inner layer is 2mm thick and is a combination of GAG and collagen fibers from bovine tissue\nInner layer has 70-200 nm pore size that allows fibrovascular ingrowth, after which it is designed to slowly biodegrade\nOuter layer is 0.009 inches thick polysiloxane polymer with vapor transmission characteristics similar to normal epithelium\n","19":"such asburns, chronic leg ulcers, giant pigmented naevi,epidermolysis bullosa and neonatal scalp necrosis\nseparation from the tissue culture substrate using a proteolytic enzyme\nspontaneous blistering many months after grafting, increased susceptibility to infection, and contractures\nBovine serum proteins\nact as growth promoters\nDelayed loss of graft\ninitial take 64% declined to 47% at discharge for one study of 16 patients\nCost $2000-34 000 pr percent of definitive wound closure at discharge.\nBlistering\nassociated with high PGE2 and thromboxane levels suggesting an ongoing inflammatory response\nEffects of fibrin glues being evaluated with limited success\nFibrin-glue suspensionSome success has been achieved by applying cells together with fibrin glue, in a suspensionof growth medium or using a membrane for delivery.\nFibrin-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, \n","20":">90% burns\nlimited donor sites\ncan contribute to limited wound closure in a potentially y important manner\n70-90-%\nclinical judgement depending on the donor sites\ne.g. face feet hands and genitalia are difficult to harvest \n<70% TBSA\n not usually necessary\n"}
  • Early excision and skin grafting in burns by Dr. Sunil Keswani, National Burns Centre, Airoli

    1. 1. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com DR SUNIL KESWANI Plastic Surgeon NATIONAL BURNS CENTRE,Mumbai
    2. 2. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com     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
    3. 3. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com     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
    4. 4. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com    Areas easy and quick to excise: trunk and legs Joints and throats Hands and face
    5. 5. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com  Blood Loss       Clear pre-operative plan Excision prior to wound hyperemia Elevation of extremities Tourniquet control Dilute Epinephrine tumescent fluid Epinephrine soaked sponges
    6. 6. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com  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
    7. 7. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com 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
    8. 8. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com    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
    9. 9. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    10. 10. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    11. 11. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com    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
    12. 12. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    13. 13. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com      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
    14. 14. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    15. 15. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    16. 16. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    17. 17. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    18. 18. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    19. 19. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com        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.
    20. 20. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com  Suggested Clinical Indications for CAE  burn injuries >90% broad  70-90% more limited  <70% no clear indication
    21. 21. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    22. 22. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com    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
    23. 23. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    24. 24. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    25. 25. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    26. 26. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    27. 27. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    28. 28. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    29. 29. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    30. 30. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    31. 31. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    32. 32. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    33. 33. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    34. 34. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com POST-PHYSICAL REHABILITATION OUTCOME
    35. 35. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    36. 36. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    37. 37. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    38. 38. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    39. 39. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    40. 40. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    41. 41. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    42. 42. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    43. 43. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    44. 44. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    45. 45. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    46. 46. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    47. 47. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    48. 48. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com Pre-Op wound Application of Homograft Day 3 Complete healing Day 21
    49. 49. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    50. 50. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    51. 51. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    52. 52. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    53. 53. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    54. 54. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    55. 55. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    56. 56. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    57. 57. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    58. 58. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    59. 59. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    60. 60. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    61. 61. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    62. 62. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    63. 63. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    64. 64. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com
    65. 65. Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, nbcairoli@gmail.com THANK YOU BURNS Helpline: 022 2779 3333 www.burns-india.com

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