reduction of blood loss in burn surgery

1. Reduction of blood loss in burn surgery
Dr sumer yadav
Mch plastic and
reconstructive surgery

2. 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

3. 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.

4. methods of intraoperative
blood 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

5. methods of intraoperative
blood 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.

6. methods of intraoperative
blood 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

7. • 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

8. 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)

9. • 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

10. • Journal of Burn Care & Rehabilitation:
• March/April 2001 - Volume 22 - Issue 2 - pp
111-117
• Original Articles
• Reduced Blood Loss During Burn Surgery
• Gomez, M. MD; Logsetty, S. MD, FRCS(C); Fish,
J. S. MD, MSc, FRCS(C)

11. 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.

12. 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.

13. The tumescent technique to significantly reduce blood loss during burn surgery
Ron 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, USA
Accepted: 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.

14. Minimizing Blood Loss in Burn Surgery
Robert 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.

15. 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
Autografting
Djurickovic, 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.

16. Thanks