Original article 201

Current Concepts in Pediatric Burn Care: Surgery of Severe Burns* H. Lochbühler l, M. Meuli 2 I Department of Surgery (Dir. Prof. Joppich), Dr. von Haunersches KinderspitaJ, University of Munieh, Germany, and 2pediatric Burn Center, Department of Surgery (Dir. Prof. Stauffer), L'ni\'ersity Children's Hospital Zurich, Switzerland

Optimal surgical therapy of se\'ere bums in children has been contro\'ersial for a long time. A re\'ie\\' of the current literature sho\\'s that prompt surgical excision of necrotic tissue and immediate autografting ha\'e become the standard in most burn centers. The author present a concept based on prompt excision of third degree bums and discuss the problems of intermediate cover arising in massiw bums. Key words Bums in children - Burn surgery - Prompt excision - Immediate autograft

Resume Le meilleur traitement chirurgical des brulures graves chez l'enfant a toujours fait l'objet d'opinions contradictoires. La litterature actuelle montre que I'excisiongreffe precoce avec peau autologue est devenue une attitude systematique dans les brillures du 3eme degre dans de nombreux centres de traitement. Les resultats s'en sont trouves ameliores. Les auteurs insistent sur le concept de l'excision precoce avec couverture simultanee et ils discutent le pro-

Introduction

Surgery of severely bumed children has been controversial for many years. The contrO\'ersy in thi field of urgery has one of its origins in the fact that terms are used that are not weil defined. Therefore misunderstandings arise. For example: 15 years aga necrosectomy 12 days postbum was called "early" excision, whereas today "early" excision is performed within the first cl8 hours posthum. There is a great difference indeed, whether excision is performed \\ithin the first 2 days postburn 01' after a \\'eek 01' two ha\'e elapsed. During the first week postbum the organism reacts to necrosis by the de\'el-

bleme de la COu\'erture temporaire dans les brGlures tres etendues. ~lots-c1es

BrGlures chez l'enfant - Excision-Greffe precoce

Zusammenfassung Die optimale chirurgische Therapie schwer\'erbrannter Kinder war über lange Zeit umstritten. Die aktuelle Literatur zeigt, daß die frühzeitige :\Tekrosektomie mit gleichzeitiger autologer Spalthauttransplantation bei drittgradigen Verbrennungen in \ielen Zentren zum Standard geworden ist, und daß die Ergebnisse damit haben verbessert werden können. Die Autoren erläutern da Konzept der Frühexzision mit gleichzeitiger Defektdeckung und diskutieren die Probleme der bei ausgedehnten Läsionen notwendigen Zwischendeckung.

Schlüsselwörter Verbrennungen im Kindesalter - Frühnekrosektomie mit gleichzeitiger Defektdeckung

opment of a capillary network between the necrotic tissue and the underlying healthy tissue. Surgical excision in this wellperfu ed layer results in major bleeding. This blood loss can be markedly reduced if excision i performed v.ithin 48 hours posthum. Another reason for controversy is the lack of reliable facts from carefully planned prospective studies with sufficient a number of patients, especially if bums in children are considered. This may be illustrated by two almost anecdotical papers of Leonpacher (17) from Germany (1900) and from Besson (3) from Belgium (1901). The intra\'enous administration of saline solution had been an issue of contro\'ersy

Recei\ed June 25. 199 I Eur J Pediatr Surg 2 (1992) 201-201 CO Hippokrates \'erlag Stuttgart .\ lasson Editeur Paris

* Paper read at the 21. Annual Congress of the S" iss As ociation of Pediatric Surgery, Zurich, September 5 to 6, 1991

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Summary

Eur J Pediatr Surg 2 (1992)

since the last decade of the 19th century. Leonpacher in Munich resuscitated 7 severely burned patients with intravenously administered saline solutions. The quantities of fluid he used, however, were too small to have any effecL On the other hand, Besson treated his patien1.5 with adequate volumes from today's standpoint, but the extent of the burns was so small that they would have urvived their injuries without any therapy at all. Both concluded: "The infusion of aline olution in burned patients has no therapeutical effect". Today we do have better knowledge concerning this lopic, but nobody is immune to similar errors when conquering new lerritories in medicine.

The goals of burn surger)_'_ The aim of burn care in general is survivaJ wilh the best possible functional and cosmelic resull. The contribution of burn surgery to altain this goal is most essential. The primary surgical lherapy should minimize lhe need for secondary corrections, in other words: Reconslruclion begins al lhe time of injury. Artlzurson (2) in Sweden was one of the first who pointed oullhe importance of the first hours subsequenllo postburn. His sludies demonstrated lhal change in vascular permeability is induced by histamine and prostaglandin. Most important was the finding that increased vascular permeability has been found in burned and non-burned tissues. The inflammatory response after thermal injuries is inilialed bya complex system of mosliy wound generated mediators, which have been only partly identified. Further knowledge concerning the locaJ as weil as the systemic effects of these factors will probably be crucial for substantial progress in burn care. Till et al (26) could show in an animal experiment that local and systemic inflammatory response could be prevented by early exci ion of the burned tissue. However, "early" in lheir experimental study was 5 to 10 minutes posthurn. Obviously this is far away from clinicaJ practice and only proves the causal context of burned tissue inducing inflammatory response. Beside a paper of witzer (24) and Gray (12) and several case reports unW 1986 there are only the papers of Burke (4, 5), Quinby (22), Herndon (13) and Pietsch (20) dealing with prompt excision of the burn wound in severely burned children based on adequate nurnbers of patien1.5. The resul1.5 of Burke's investigations are clear: Children with bums larger lhan 40 % of the total body surface area do much better when early excision is performed (4, 5). Pietsch had similar resul1.5 (20). Herndon's findings were not so clear-cut (13). Today there exis1.5 a wide agreement basing on several independent investigations that severely burned children and certain age groups in adults benefit substantially from prompt excision of the burn wound (9,10,14,23,27,28,29). The follO\ving considerations explain why the outcome, namely mortaJity, are strongly influenced. The role of lhe burn wound ~ ecrotic ti ue is an ideal ground for bacterial infection, and bacterial colonisalion starts at lhe border between healthy skin and burn wound as early as the third day po tburn. Although infeclion is one of the central problem in burn care, we should bear in mind that severely burned children do not die because of a simple wound infection. Death occurs

H. Lochbühler and M. Meuli

because of uncontrolled burn wound sep is and pneumonia leading to multiorgan failure. It is generally accepted that mulliorgan failure develops when most serious infections cannot be controlled. On lhe olher hand, arecent hypothesi sugges1.5 that multiorgan failure might be lhe result of a ma sive and uncontrolled inflammatory response which is initiated and perpetuated by mediators originating from burn wounds. Another pathway leading to multiorgan faiJure might be gutderived endotoxemia (30). Massive inflammatory reaction causes a breakdown of lhe inlestinal mucosal barrier leading to an influx of endoloxins normally contained in the gut into lhe systemic circulation, lhus prO\'oking a pattern similar to epsis. As a malter of fact, lhe iTI\'estigations of Aikawa (1) report on palients dying under lhe clinical picture of sepsis but with terile blood cullures and negati\'e wound swabs. These arguments underline lhal early and total necroseclomy as weil as early and possibly definitive wound closure are of paramount importance. As it is not possible lo clo e all wounds \\ilh autografts in very extended burns, one of the differenl techniques of intermediate cover or skin substitulion respectively musl be applied (19,21).

Praclice of burn surgery Ouring initial resuscitation escharotomy is performed in circumferencial deep burns on arms, legs, ehest wall and neck. This firsl surgical measure will immediately release constriction and imprO\'e perfusion or respiration respeclively. Furthermore it has to be decided whether or not cultured epithelial autografts (CEA) \\ill be used. If so, a skin biopsy is taken and immediately sent to the laboratory. Within 24-48 hours posthurn the first operation is performed. Third-degree burns, characterized by frank charring or leathery, greyish and dry appearance wilh obviously lhrombosed vessels, are excised and immediately grafted with split thickness skin grafts as far as donor sites are available. We usually excise with the electrosurgical knife, lhus minimizing blood loss. Bleeding from tangential excision lhrough subcutaneous tissue is comparable to bleeding from cutting in subcutaneous tissue in non-burned patients. Minimal bleeding is observed if excision to fascia is performed. Fixation of the healthy skin edges down to the fascia by sutures preven1.5 retraction. Oepth of second-degree burns is not always easy to deterrnine. Superficial second-degree bums heal spontaneously within 2 weeks and \vithout scarring. Oeep second-degree burns are hypesthetic and present with fixed erythema and./or whitish discoloration, the surface is slightly humid and the skin is virtually normal to touch and i1.5 contours are preserved. These lesions are excised tangentially and immediately grafted as soon as diagnosis of depth is established. This usually takes three lo five days because of progressive dermal ischemia. In certain cases indeterminate deplh may persist for some more days before distinct diagnosis is po ihle. Our preferred donor site is the scalp. The scalp accounts for about 8-10 % of the total body surface area in infants and for aboul 4-6 % of the total body surface area in school-aged children. The presence of a great number of epithelial cells deri\'ed from hair follicles allows rapid regeneration. Oependent on thickness of the pre\iously han'ested skin graft a second harvest can be performed after 7-10 days. Even after multiple han'esting of the kalp, no relevant bald or scar formations are obsen·ed. Before han'esting, the scalp is carefulIy shaved and the hair borders marked with a waterproof

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Current Concepts in Pediatric Bum Care: Surgery ofSevere Bums

sually plit thickness skin grafts are meshed, expanded if necessary and fixed with fibrin glue. In our experience, this kind of fixation results in optimal take. It has to be mentioned that the best take rates are u uall)' obtained from the initial operations. There are few contraindications for prompt exci ion of third degree bums. One of them is severe inhalation injury, when even mechanical \'entilation does not prO\'ide adequate oxygenation of the patient. Severel)' burned children regularI)' have a dy regulation of body temperature, and because of the large wound areas they are parlicularly prone to heat loss. Therefore, the setting for operative procedures is the same as for neonatai surgery: a) The operati\'e theatre is heated. b) Overhead heaters are used. c) The patient is \\Tapped in a foil which protects against heat loss. d) Exposure of the whole bod)' during operation is strictly avoided. Whenever possible two teams should be operating simultaneously, thus shorlening substanlially lhe duration of the procedure. In se\"ere bums, ranging from about 20-60 % of total body surface area, the routine approach consists of necrosectomy (usually tangential excision 01' tangential debridement respectively) and immediate grafting starling with the functionally most imporlant areas (1. face and neck, 2. hands, 3. arms, 4. feet, 5. legs, 6. trunk) is performed. In massive bums (larger than 60 % of TBSA), however, the strategy changes: The main goal is early removal of as much eschar as possible and to elose the wound with either autografts or skin substitutes. Therefore, we perform the first operation either on the anterior or posterior trunk, usually excising to fascia. Generally, necrosectomy of 10-20 % can be performed in almost every patient witllOut risk. With optimal conditions, namely perfeet team work between experienced burn surgeons, pediatric anesthetists and operating room nurses as weil as availability of all modern facilities of the operating theatre, escharectamies of 30-40 % or possibly even more may be safely carried out in one operation. However extended the operation will be, the patient must be continuously monitored and the procedure terminated befare potentially deleterious conditions such as severe hypothermia or excessive blood loss establish. Core temperatures around 35°C and a blood 10 s of 30-40 mVkglbody weight (adequate substitution provided) are generally welltolerated. There is liltle doubt lhat in criticall\' burned children this approach contributes significanUy to i~proved urvival (28). In these most serumsly injured patients the use of CEA should be carefully considered. Our own data from a few patients treated with CEA are relati\"el)' encouraging (16) and comparable to those reporled in the literature (6, 7,8, 11, 15, 18,25). The authors belie\-e thatthis promi ing technique \\ill Open up a ne\\' chapter in burn care in spite of still being associated v.ith serious problems in clinical practice.

Intermediate wound cover In large bums the question always arises how to best cover excised areas when no donor sites for autografts are available. The best intermediate cover would be fresh viable human skin applied as allograft. For reasons such as AIDS transmi sion, paucity of appropriate donors etc. viable human kin is rarely available. The same holds true in certain countries as far as banking of human skin 01' amniotic membranes is concerned. Therefore, many centers use porcine skin as a xenograft 01' one of the numerous biosynthetic or purely synthetic materials (19, 21). If the wound bed is elean and \iable, cO\'ering \\ith allografts 01' xenografts results in \'ascularisation and temporar)' take before active rejection of these non-autologous tisues occurs 1-2 week after grafting. Other s)l1thetic 01' biosynthetic materials become temporarily incorporated into the wound by a kind of vascularisation and connective tissue ingrowth, when a foam material, network 01' wea\-e is presented to the wound bed. RemO\-al of all these \mund cO\-erings is easy in the first few days after application. Later, when adherence is established, remO\'al has to be done surgically and is associated with considerable bleeding. If infection occurs, daily change of the intermediate wound cover is indispensable.

Wound dressing As probably most of the burn units do, we usually prefer elosed wound management to treatment by exposure. After excision and grafting the dressing consists of an innermost vaseline gauze impregnated with antimicrobial agents (e.g. fusidinic acid), followed by a voluminous cotton bandage, the inner portion being moistened (e.g. with polyvinylpyrrholidone-iodine solution) and finally elastic bandage or netting. These dressings are changed in two to four days depending on the individual situation of the patient. This practice allows early detection of infection, hematoma or displacement, and thus the graft can sometimes be saved. As soon as hea1ing has occurred, the grafted areas are exposed. The dressing of excised wounds treated with intermediate covering is simiIar.

The future The authors believe that today early excision and grafting is the treatment of choice. The benefit from this aggressi\'e surgical management of deep dermal and fullthickness bums in children is beginning to find \\idespread acceptance. This policy in fact contributes substantially to impro\'ed sUf\i\"al, decreased morbidity, decreased number of painful ward procedures, horlened hospital stay, and furlhermore functional and esthetic outcome seem to be superior, because less scarring is obsef\'ed. HO\\'e\'er, the main goal of early and definitive elosure of all \\'ounds in patients \\ith extensive bums is not achie\-ed today. Restricted donor sites, relatively long growing periods for CEA as weil as the non-a\"ailability of a permanent "arlificial skin" are serious limiting factors.

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higWighter. Previous subgalea1 injection of physiologie saline olution creates a kind of water pillow which renders handling of the dermatome easy. Injections inta fontanelles (infants!) or sutures are stricily avoided.

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Eur] Pediatr Surg 2 (1992)

Future research activities have therefore to be directed towards accelerated regeneration of harvested donor sites, acceleration and perfection of skin culturing as weIl as to· wards development of a readily available biological skin equiva· lent with permanent take.

References

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Aikawa S, Shinozawa }', lshibiki K, et al: Clinical analysis of multiple organ failure in burned patients. Burns Incl Therm Inj 13 (1987) 103109 2 Arlhurson G: .\Iicro\·ascular permeability to macromolecules in thermal injury. Acta Physiol Scand (Suppl) ..63 (1979) 11I 3 Besson .4.: Etude sur les causes de la mOlt dans les brulures gra\es et etendues et sur les injections massi\'es d'eau sale. J d sc med de Lilie (190112.. 1-253.265-2/8.313-321 I BurkeJF. BOl/doc Ce. Quinby ,rc: Primary burn excision and immediate grafting: a method shortening illness. J Trauma I.. (197.. ) 389-395 5 B/lrkeJF. Quinby IrCJr, Bondoc CC: Primary excision and prompt graft· ing as routine therapy for the treatment of thermal burns in children. Surg Clin "Jorth Amer 56 (19/6) t7l-"9 I 6 Complon CC. GillJ.\/. BradIord D.4.. Regal/er S. Gallico GG. O'COl/l/or SE' Skin regenerated from cultured epitbelial autografts on full· thickness burn \\ounds from 6 days to 5 years after grafting. Lab Im'est 60 (1989) 600-612 , Complol/ CC: Tbe biology of cultured epithelial autografts: an eight year study in pediatric burn patients. (In press) 8 De Iucu .11. Albal/ese E, Bondanza 5, ,'legJla ,\1, (:gozzoli I, ,\1olina F, Caneedda R. Sani PI, Bormioli ,\1. Stella .11, ,\lagliacani G: .\Iulticentre experience in the treatment of burns "ith autologous and allogenic cul· tured epithelium, fresh or presernd in a frozen state. Burns 15 (1989) 303-309 9 Engrar IH, Heimbaeh D,\1. ReusJI, et al: Early excision and grafting \'s. nonoperati\'e treatment of burn of indeterminant depth: a randomized prospecti\'e study. J Trauma 23 (1983) 100 I-I 00.. 10 Foy HJ1, Pavlin E, Heimbach DM: Excision and grafting of large burns: operation length not related to increased morbidity. J Trauma 26 (1986) 51-53 11 GaUico GG, O'Co/lllOr NE, Complon CC, Kehinde 0, Green H: Permanent cO\'erage of large burn \\'Ounds wilh autologous cultured human epilheli· um .• Engl J Med 311 (1984) 448-451 12 Gray DT, Pille RW, Harnar T], et al: Ear1y surgical excision versu con· \'entional lherapy in patients \\~lh 20 to 40 percent bums. Am J Surg 144 (1982) 76-80 13 Herndon DN, Thompson PB, Desai MH, van Osten Tj: Treatment of burns in children. Ped Clin N Am 32 (1985) 1311- J 331 14 Herndon DN, Barrow RE, Rutan RL, Rutan TC, Desai MH, Abston 5: A comparison of conservative versus early excision. Ann Surg 209 (1989) 547-553 1

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H. Lochbühler, M. D.

Oept. of Surgery Or. v. Haunersches KinderspilaJ Lindwurrnslr, 4 0-8000 München 2

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204

Current concepts in pediatric burn care: surgery of severe burns.

Optimal surgical therapy of severe burns in children has been controversial for a long time. A review of the current literature shows that prompt surg...
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