Hemostasia

burns 37 (2011) 559–565

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

Review

Hemostasis in burn surgery—A review

Jose P. Sterling a, David M. Heimbach b,*
a
University of Texas, Southwestern Medical School, Dallas, TX, United States
b
University of Washington, Seattle Washington, USA

article info abstract

Article history: Over the past 30 years, techniques of early excision and grafting along with enhancement of
Accepted 29 June 2010 critical care have signiﬁcantly improved survival following burn injury. Despite these
advancements, large volume blood loss associated with surgical intervention continues
Keywords: to be a challenging aspect of burn surgery. This review article will examine the methods of
Thermal injury limiting blood loss during surgical procedures.
Burns Published by Elsevier Ltd and ISBI
Burn surgery
Burn excision
Blood transfusion
Tourniquets
Epinephrine
Thrombin
Fibrin sealant
Electrocautery
Terlipressin
Blood conservation

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
2.1. Literature search strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
2.2. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
2.3. Data extraction and synthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 560
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
3.1. Description of included studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
3.2. Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 561
3.3. Epinephrine tumescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
3.4. Thrombin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
3.5. Fibrin sealant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562
3.6. Electrocautery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563

* Corresponding author. Tel.: +1 206 779 9600.
E-mail address: heimbach@u.washington.edu (D.M. Heimbach).
0305-4179/$36.00 . Published by Elsevier Ltd and ISBI
doi:10.1016/j.burns.2010.06.010

560 burns 37 (2011) 559–565

3.7. Systemic therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
3.8. Blood conserving protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 563
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
4.1. Study limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564

1. Introduction Boolean search terms, from the establishment of the
database until Jan 2010. Searches were conducted without
Over the past 30 years, techniques of early excision and grafting language restriction. The bibliographies of all retrieved
along with enhancement of critical care have significantly articles were then manually searched for relevant missed
improved survival following severe burn. Despite these advance- articles. The search terms were: ‘‘‘‘haemostasis’’[All Fields]
ments, large volume blood loss associated with surgical OR ‘‘hemostasis’’[MeSH Terms] OR ‘‘hemostasis’’[All Fields])
intervention continues to be a challenging aspect of burn surgery. AND (‘‘burns’’[MeSH Terms] OR ‘‘burns’’[All Fields] OR
Traditionally, blood was transfused when the hemoglobin ‘‘burn’’[All Fields]) AND (‘‘surgery’’[Subheading] OR ‘‘surger-
levels fell bellow 10 mg/dl. This originated from the fear of the y’’[All Fields] OR ‘‘surgical procedures, operative’’[MeSH
deleterious effects of anemia on oxygen consumption, cardiac Terms] OR (‘‘surgical’’[All Fields] AND ‘‘procedures’’[All
function and tissue perfusion [1,2]. However, such liberal use Fields] AND ‘‘operative’’[All Fields]) OR ‘‘operative surgical
of blood has come under question. procedures’’[All Fields] OR ‘‘surgery’’[All Fields] OR ‘‘general
Multiple studies questioned the harmful effects of blood surgery’’[MeSH Terms] OR (‘‘general’’[All Fields] AND ‘‘sur-
component transfusion. Blood component transfusions can be gery’’[All Fields]) OR ‘‘general surgery’’[All Fields]) AND
associated with transfusion related acute lung injury, infec- (‘‘hemorrhage’’[MeSH Terms] OR ‘‘hemorrhage’’[All Fields]
tion, immunomodulation, age of the transfused component, OR (‘‘blood’’[All Fields] AND ‘‘loss’’[All Fields]) OR ‘‘blood
multi organ dysfunction, acute respiratory syndrome and loss’’[All Fields]’’.
increase in mortality [3–7]. Due to the risks associated with
blood component transfusion, restrictive transfusion prac- 2.2. Inclusion criteria
tices are recommended for both adult and pediatric patients
[7–10]. Furthermore, this has been extrapolated and demon- All articles reporting efficacy and/or outcome with the use of
strated in the burn patient [4,5,11]. hemostatic techniques and/or agents in humans during burn
Unfortunately, the surgical treatment of burn patients is surgery were included. Individual case reports were excluded.
associated with substantial blood loss [12–16]. Multiple hemo- The techniques were used for the management of excised
static techniques have been proposed for this problem. To wounds and/or donor sites in adults and children. A flowchart
address this issue, a review of the hemostatic techniques was of the search results is provided in Fig. 1. The two reviewers
undertaken and we present here the findings for assessment. independently applied the inclusion criteria and any differ-
ences were resolved through discussion.

2. Methods 2.3. Data extraction and synthesis

2.1. Literature search strategies Data was extracted by the researchers, to determine interven-
tion, management of burn and/or management of donor site,
A systematic search was conducted of Ovid MEDLINE, number of patients, age (pediatric or adult), and result of
EMBASE, Cochrane Library, CINAHL, and PubMed using intervention.
[()TD$FIG]

Fig. 1 – Flowchart of search results.

burns 37 (2011) 559–565 561

Table 1 – Included studies.
Study ref. Type of study Site Intervention N Type of Range of
(patients) patients % TBSA

[17] Comparative Burn Tourniquet versus No Tourniquet 10 All 3–31
[18] Descriptive Burn Tourniquet + Topical Epinephrine 52a NS <12
[19] Descriptive Burn Tourniquet + Thrombin 17 All 0.5–15
[20] Comparative Burn Epinephrine Tumescence or Tourniquet versus 44 Adult >5%
Historical Controls
[25] Descriptive Burn/donor Epinephrine/Bupivicaine Tumescence 29 Pediatric 1–12
[26] Descriptive Burn Epinephrine Tumescence 10 Adult 5–50%
[29] Comparative Burn/donor Epinephrine Tumescence + Thrombin 20 Adult 14–52%
versus 0.45% NS + Thrombin
[27] Comparative Burn/donor Topical/Tumescence Epinephrine + Thrombin 42 Pediatric 11–66%
versus 0.45% NS + Thrombin
[28] Comparative Donor Epinephrine/Lidocaine Tumescence + Topical 56 All 10–51%
Epinephrine versus 0.45% NS Tumescence + Topical
Epinephrine
[38] Descriptive Burn Thrombin 72 All 1–4%
[33] Comparative Donor Topical Epinephrine versus Thrombin 32 All NS
[37] Comparative Donor Topical Phenylephrine versus Thrombin 24 NS NS
[35] Comparative Donor Thrombin versus Bovine collagen sheet 20 NS NS
[36] Comparative Donor Thrombin Ointment versus Thrombin Solution 11 All NS
[46] Comparative Donor Thrombin versus Fibrin Sealant 46 Adult NS
[49] Comparative Donor Fibrin Sealant versus No Fibrin Sealant 61 All 2–8%b
[48] Comparative Donor Fibrin Sealant versus No Fibrin Sealant 47 All <15%
[47] Comparative Donor Thrombin + Fibrin versus Thrombin + Placebo 10 NS NS
[50] Comparative Burn Electrocautery knife with air spray versus No air spray 6 NS 10–30%
[53] Comparative Systemic Terlipressin versus Placebo 51 All 10–20%
[51] Descriptive Systemic rFVIIa 4 All 50–72%
[52] Comparative Systemic rFVIIa versus No rFVIIa 18 Adult 12–60%
[30] Descriptive Blood Conserving Protocol 23 Pediatric 1–55%
[21] Comparative Blood Conserving Protocol 2461 NS 1–>40%
[22] Comparative Blood Conserving Protocol 35 Adult 1–36%
[23] Comparative Blood Conserving Protocol 392 Pediatric 10–>50%
[24] Comparative Blood Conserving Protocol 30 Adult 8–46%

NS: not stated.
a
Upper extremities.
b
Donor percent total body area.

3. Results However, as part of their intraoperative protocol the wounds
in both groups were sprayed with thrombin solution and
3.1. Description of included studies wrapped with epinephrine soaked gauze.
Three other studies described the use and benefit of
A total of 27 studies were included (see Table 1.) From the tourniquets in the treatment of burns [18–20]. Smoot
included studies 8 are descriptive and 19 are comparative described the use of intermittent release and rapid reinflation
hemostatic interventions. Specifically, 5 studies compared the of the tourniquet to allow for assessment of tissue viability
implementation of blood conserving protocols at single [18]. This method was used in combination with epinephrine
institutions. Most studies discussed the use of subcutaneous soaks and compression wraps. Similarly, Sawada and
and topical agents to assist in hemostasis. However, 3 studies Yotsuyanagi described the use of a tourniquet and spraying
discussed the use of systemic pharmacoactive agents to assist the wound with thrombin prior to, and after, removal of the
with hemostasis. tourniquet along with pressure bandages [19]. Djurickovic
et al. described the use of a tourniquet during tangential
3.2. Tourniquets excision of the extremity [20]. After completion of the
excision the tourniquet was deflated to evaluate areas of
O’Mara et al. directly studied the value of tourniquet inadequate excision and then reinflated. After reinflation,
application without exsanguination of the limb prior to areas of major bleeding where coagulated and meshed
tourniquet inflation to improve visualization of viable tissue autograft was then placed along with cotton gauze dressing
during excision [17]. In this study they found that blood loss and elastic bandages. Furthermore, four out of the five studies
per area excised was less with tourniquet control that describe blood conserving protocols include tourniquets
(0.10 Æ 0.29 cc/cm2) versus no tourniquet (0.32 Æ 0.56 cc/cm2) as part of the hemostatic protocol [21–24]. It was felt by these
(P = 0.04). Additionally they demonstrated similar graft take authors that the use of tourniquet is an important adjunct to
between the two groups (98.2% versus 96.8%) (P > 0.1). limit bleeding.

562 burns 37 (2011) 559–565

3.3. Epinephrine tumescence Four studies compared the hemostatic efficacy of thrombin
(bThrombin) versus other products [33–36]. Brezel et al.
Three articles described the technique of epinephrine subcu- compared the visual amount of blood loss form donor sites
taneous infiltration as a hemostatic agent [20,25,26]. Djur- on 32 patients that were treated with thrombin (100 U/ml) or
ickovic et al. described the use of 1:1,000,000 epinephrine epinephrine solution (1:200,000) [33]. They demonstrated a
solution infiltrated to the burn in 23 patients [20]. They superior hemostatic effect from the epinephrine treated donor
estimated a 3.42 Æ 0.39% blood volume loss per 1% body site. Caucci et al. compared the hemostatic effect of
surface area excised. Fujita et al. preoperatively marked the phenylephrine (1:20,000) versus thrombin (100 U/ml) on the
burn wound of 10 consecutive patients with a 5 Â 5 cm square donor sites of 24 patients [37]. They demonstrated a superior
grid using crystal violet [26]. This grid was used a guide to hemostatic effect with phenylephrine compared to thrombin
inject 20 ml of a dilute epinephrine solution (1 mg/l) per when comparing blood absorbed in a paper filter disk covering
square. They felt that this provided an aide and safeguard to the donor site after treatment with the agents (P < 0.005).
the amount of epinephrine used with the tumescent tech- Prasad et al. compared thrombin versus a bovine collagen
nique. Beausang et al. reported on 29 pediatric patients in dressing on the donor sites of 21 patients [35]. Although, they
which the donor sites and burn wounds were infiltrated with a did not describe the concentration of the thrombin spray, they
1:500,000 epinephrine with bupivicane [25]. Bupivicane (0.25% did demonstrated superior hemostatic control with the spray
plain) was added to the solution at a 3 mg per kg body weight thrombin. Mean blood loss with thrombin (5.25 Æ 8.68 ml)
concentration. They reported no adverse effects and a versus collagen (8.24 Æ 13.54 ml) (P = 0.057). Sawada et al.
decrease of postoperative pain with this technique. compared the use of thrombin ointment versus thrombin
Three articles compared the use of epinephrine tumes- solution on the donor sites of 11 patients [36]. They created the
cence to determine effect on hemostasis [27–29]. Barret et al. ointment by mixing 10,000 units of powdered thrombin with
compared the use of topical and subcutaneous epinephrine on 10 g of petroleum jelly based gentamicin ointment. Again, this
a cohort of 42 pediatric patients [27]. Half of these patients study did not describe the concentration of the thrombin
received topical epinephrine (1:10,000 sprayed and 1:200,000 solution. However, the mean bleeding time with the thrombin
compresses) to the excised wound and donor sites and ointment (11.5 s) was less than that of the thrombin solution
subcutaneous infusion (1:300,000) to scalp donor sites only. (25.5 s, P < 0.01).
The other half of patients followed the same protocol using One study described the efficacy of the recombinant
0.45% normal saline solution. Additionally, both groups human Thrombin (rThrombin) as a hemostatic agent in burn
received topical thrombin (1000 units/ml) to the excised surgery. Greenhalgh et al. conducted a single-arm, open label
wounds and donor sites. They found no difference in the study of rThrombin (1000 U/ml) on the burn wounds of 72
amount of bleeding per square centimeter excised patients after excision [38]. Hemostasis at 20 min was
(0.48 Æ 0.12 ml/cm2 versus 0.51 Æ 0.15 ml/cm2, P = 0.681) be- achieved in 91.5% of the patients. Further application of
tween the two groups. Robertson et al. compared the results of rThrombin ensued hemostasis in all but 4 patients. Also, they
20 patients (26 operations) using epinephrine (1 mg/ml) demonstrated a low rate of anti-rThrombin antibody forma-
tumescence at the excision and donor sites to 10 patients tion (1.6%) without associated human thrombin neutraliza-
(11 operations) [29]. Also, topical thrombin spray was utilized tion, a concern that originated from the use of bThrombin [39–
in both groups. They demonstrated almost a 70% reduction in 42]. Furthermore, one out of the four studies that describe a
blood loss per unit area excised in the tumescent group blood conserving protocol utilize thrombin in their protocol
(0.37 Æ 0.2 ml/cm2 versus 1.15 Æ 0.28 ml/cm2, P 0.0001). [21].
Gacto et al. performed a prospective, randomized, controlled,
blinded trial of 56 patients [28]. Both groups received 3.5. Fibrin sealant
subcutaneous infiltration at donor sites with either epineph-
rine (1:500,000) solution with added lidocaine (5%, w/v) or with Fibrin sealants are human derived factors that are designed to
0.45% normal saline. They concluded that the infiltration of reproduce the final steps of the physiologic coagulation
this solution decreased intraoperative bleeding and decreased cascade of a stable fibrin clot [43,44]. Besides hemostatic
postoperative pain. Furthermore, four out of the five studies properties fibrin sealant have adhesive properties that can be
that describe blood conserving protocols utilize epinephrine utilized during skin grafts and flap procedures [45]. Drake and
tumescence as part of the protocol [22–24,30]. Wong compared the hemostatic effect of a patient derived
fibrin sealant against thrombin (100 U/ml) on the donor sites of
3.4. Thrombin 46 patients [46]. They determined the time to hemostasis to be
less with the fibrin sealant (31 s) versus thrombin (58 s,
Topical thrombin as a hemostatic agent is commonly used on a P = 0.0012). Achauer et al. conducted a study on 10 patients
variety of surgeries [31]. Thrombin is a clotting factor that with half of the donor site sprayed with thrombin and plasma
converts fibrinogen into fibrin that is the foundation of a blood placebo while the other half was sprayed with thrombin and
clot. Typically the thrombin is applied directly to the wound via fibrin glue [47]. They found no difference in blood loss between
a spray system or in combination with an absorbable gelatin or the two areas. Both Greenhalgh et al. and Nervi et al. compared
collagen sponge. Historically, thrombin (bThrombin) has been the effects of hemostasis of fibrin sealant versus no fibrin
derived from bovine plasma via different purification processes. sealant on donor wounds [48,49]. Greenhalgh et al. felt that
Currently, human plasma (hThrombin) derived and human bleeding at the donor sites were well controlled with the fibrin
recombinant thrombin (rThrombin) products are available [32]. sealant as demonstrated by surgeon estimates [48]. However,

burns 37 (2011) 559–565 563

the treatment failed to demonstrate benefit on semi quantita- pediatric patients [54]. The protocol consisted of debridement
tive measurements. On the contrary, Nervi et al. demonstrated of full thickness burns with electrocautery and partial
a reduction in the mean time to hemostasis of approximately thickness burns with dermabrasion. All donor sites were
200 s with the use of fibrin sealants (fibrin 193 Æ 131 s, control subcutaneously injected with a solution of epinephrine and
392 Æ 153 s, P < 0.001) [49]. The use of fibrin sealants is not saline. No more than 10 mg/kg of epinephrine was adminis-
described in the four studies that describe a blood conserving tered subcutaneously at one time. However, staggered injec-
protocol. tions were utilized that often resulted in total dose of
epinephrine being greater than 10 mg/kg. Additionally, all
3.6. Electrocautery debrided or harvested surgical sites were treated with
epinephrine solution soaked pads. Following this protocol
Most of the studies describe the use of electrocautery as an they report an average blood loss per percent TBSA treated to
adjunct to achieve hemostasis. However, Mitsukawa et al. be 17 ml.
describes a novel use for an electrocautery attachment to Cartotto et al. compared the results of a comprehensive
assist with hemostasis during large burn area excisions [50]. intraoperative blood conservation strategy and its effects on
They attached a smoke aspiration tip to the electrocautery. blood loss and wound outcome to a historical cohort [22]. The
Instead of utilizing the aspiration tip to aspirate they used it as blood conservation technique was as follows: Donor sites
a conduit to expel air. This stream of air cleared blood and fluid were infiltrated subcutaneously with a 1:500,000 adrenaline
from the tip allowing for improved visualization and electro- solution. After the grafts were harvested the sites were
cautery function. Compared to regular electrocautery this new dressed with epinephrine (1:33,333) soaked pads. Burn
device reduced the duration of surgery by 10% and the amount wounds on limbs where tangentially excised under tourni-
of blood loss by 14% for a 30% TBSA burn. quet control. After completion of excision, the wounds were
dressed with epinephrine (1:33,333) soaked pads and a firm
3.7. Systemic therapies circumferential wrapping was performed for full 10 min
prior to deflating the tourniquet. After deflation of the
Three studies discuss the use of systemic therapies to assist tourniquet major bleeding was cauterized and the extremity
with hemostasis in burn surgery [51–53]. Terlipressin is an rewrapped with epinephrine soaked pads for another 5 min.
analogue of vasopressin used as a vasoactive drug in the When the tourniquet could not be utilized the wound
management of hypotension. It has been found to be effective received subcutaneous infiltration with epinephrine solu-
when norepinephrine does not help. Mzezewa et al. describes tion (1:500,000) prior to excision. After the excision was
the results of a randomized trial comparing the use of completed the wound was dressed with epinephrine
terlipressin or placebo on 51 patients undergoing early (1:33,333) soaked pads. Final hemostasis was achieved using
excision and grafting of burns between 10 and 20% TBSA serial application of the epinephrine pads and electrocau-
[53]. Use of other hemostatic adjuncts where not described. In tery. Utilizing this blood conserving protocol, the estimated
this study the medication was given intravenously at a dose of blood loss was reduced from 211 Æ 166 ml per %TBSA excised
20 m/kg body weight and repeated every 4 h for 24 h. Following and grafted in the historical group to 123 Æ 106 ml in the
this protocol, terlipressin reduced blood loss on average 21% protocol driven group (P = 0.02). Furthermore, the intra-
compared to placebo. operative transfusion requirement was reduced from
Johansson et al. described a technique of utilizing recom- 3.3 Æ 3.1 units per case, in the historical group, to 0.1 Æ 0.3
binant factor VIIa (rFVIIa) at a dose of 100 mg/kg on 4 patients units per case in the protocol driven group (P < 0.001). Also
undergoing major wound excision that developed periopera- they reported no compromise on wound outcome and graft
tive uncontrollable bleeding [51]. They report hemostasis take with the new protocol.
within 15 min of administering the drug and no adverse Sheridan and Szyfelbein compared blood use between two
effects with the treatment. In a subsequent study, Johansson matched groups of 392 pediatric patients who where managed
et al. conducted a single centre, randomized, double blind, during the calendar years of 1982–1985 and 1992–1995 (blood
placebo controlled trial on 18 consecutive patients [52]. The conserving protocol) [23]. Three groups were analyzed:
patients were randomized to receive either placebo or 40 mg/kg children with 10–24%, 25–49% and 50–100% TBSA. The
dose of rFVIIa at the time of skin incision and a second dose of techniques for intraoperative blood conservation included:
placebo or rFVIIa (40 mg/kg) 90 min later. They demonstrated a clear preparation of excision plan, performing all extremity
decease in the total number of units of blood components excisions under tourniquet, and wrapping the extremity in a
transfused per patient compared to placebo (0.9 versus 2.2, hemostatic dressing prior to tourniquet deflation, conducting
P = 0.0013). Furthermore, they demonstrated a decrease in all fascial excision under electrocautery, performing all
fresh frozen plasma units and platelet units transfused tangential excisions as early as possible, executing all torso
utilizing this protocol. tangential excision after subcutaneous epinephrine injection,
and maintaining patient euthermic. They demonstrated a
3.8. Blood conserving protocols reduction in the use of PRBC’s in the 10–24% TBSA from
1.9 Æ 0.2 units per child to 0.2 Æ 0.1 units per child (P < 0.001),
Five studies directly address the implementation of multiple in the 25–49% TBSA from 6.9 Æ 1.1 to 2.5 Æ 0.6 units per child
hemostatic techniques as a blood conserving protocol to (P < 0.001), and in the 50–100% TBSA 49.5 Æ 10.3 to 10 Æ 1.7
decrease requirements for blood component transfusion units per child (P < 0.001) with the implementation of the
[21,23,24,54]. Losee et al. described a protocol followed on 23 blood conserving protocol.

564 burns 37 (2011) 559–565

Gomez et al. performed a retrospective review of the variability on the surgical techniques in the use and
requirement of blood products in 30 randomly selected adult concentration of tumescence, thrombin, fibrin, epinephrine
patients with more than 10% TBSA burns, who had an and systemic hemostatic agents. Unfortunately, a clear
operation [24]. The patients were stratified into 2 groups. conclusion as to the best hemostatic agent cannot be made.
Group 1 consisted of 15 patients that received treatment with However, as demonstrated by the studies comparing blood
implementation of a blood conserving protocol. Group 2 conserving protocols that the best option is not a single agent
consisted of 15 patients receiving the traditional surgical but a fusion of techniques. These studies demonstrate that
technique. The traditional surgical technique involved use of diligent implementation of blood conserving protocols can
epinephrine-thrombin (1 ml of 1:1000 epinephrine, 10,000 U of decrease blood component requirements in burn surgery.
thrombin in 1 l saline) soaked gauze compresses for 10 min,
and electrocautery on the remaining bleeding points until
hemostasis was achieved. The blood conserving protocol Conflict of interest
involved the use of tourniquets for extremity harvesting and
excisions, subcutaneous infiltration of epinephrine The author(s) declare that there are no conflicts of interest in
(1:1,000,000) solution of donor and burn sites, use of epineph- the writing of this manuscript.
rine (1:1000) soaked wraps, and the use of electrocautery for
remaining bleeding areas. They demonstrated a decrease in
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