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Ash A, Brune M, Willson TD, Colbert SH, Klifto KM. Tumescent technique for split-thickness skin graft donor sites: A systematic review of randomized controlled trials. J Plast Reconstr Aesthet Surg 2024; 90:292-304. [PMID: 38394837 DOI: 10.1016/j.bjps.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 12/06/2023] [Accepted: 01/29/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Split-thickness skin grafting (STSG) is widely used for reconstructive wound management. This review aimed to use level I evidence to determine if tumescent techniques were safe and effective compared to other interventions for STSG donor sites. It was hypothesized that tumescent techniques were safe and effective for STSG donor sites. METHODS Five databases (MEDLINE via PubMed, Embase, Cochrane Library, Web of Science, and Scopus) were searched to identify studies concerning the use of tumescent solutions for STSG. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Cochrane's guidelines were strictly followed. RESULTS Nine randomized controlled trials met the criteria. Included studies were published from 2001 to 2021, with results from 40 of 121 possible queried outcomes and complications. Outcomes included patient demographics, formulations of tumescent solutions, tumescent technique, hemodynamics, pain, perfusion, graft take, healing time, and postoperative complications. The tumescent technique reduced estimated blood loss (standard mean differences [SMD]: -2.68, 95%CI: -3.41 to -1.94; participants = 72; studies = 2; I2 = 96%; p < 0.001), and postoperative analgesic use within 24 hours (SMD: -1.75, 95%CI: -2.09 to -1.41; participants = 202; studies = 2; I2 = 96%; p < 0.001), without increasing graft loss/take (SMD: 0.29, 95%CI: -0.02 to 0.61; participants = 158; studies = 3; I2 = 41%; p = 0.07) and infection (risk ratios [RR]: 0.52, 95%CI: 0.08 to 3.54; participants = 87; studies = 3; I2 = 0%; p = 0.58) complications compared to other interventions. CONCLUSIONS Level I evidence demonstrated tumescent techniques were safe and effective for STSG donor sites. Tumescent techniques reduced blood loss and postoperative analgesic use within 24 hours without increasing graft loss/take and infection complications compared to other interventions. Inconsistencies between studies limit conclusions and emphasize the need for standardized protocols regarding tumescent solution formulations, techniques, and reported outcomes.
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Affiliation(s)
- Angela Ash
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Madison Brune
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Thomas D Willson
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Stephen H Colbert
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.
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Souto J, Rodrigues AG. Reducing Blood Loss in a Burn Care Unit: A Review of Its Key Determinants. J Burn Care Res 2023; 44:459-466. [PMID: 36106386 DOI: 10.1093/jbcr/irac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with a major burn injury differ considerably from the typical critical ill and trauma population. Very often, burn patients suffer from anemia throughout their hospital stay. This is caused both by combination of persistent blood loss with decreased erythropoiesis. Therefore, burn patients do have major transfusion requirements. However, transfusion is not devoid of risks or costs. We hereby review the best surgical techniques and medical approaches, aiming to reduce blood loss in a burn patient and optimize red cell production, so that we can reduce the need of RBC transfusion. The implementation of a combination of surgical techniques aiming to reduce blood loss and medical care approaches to prevent anemia, rather than single attitudes, should be adopted in burn care. There is an urgent need for clear guidelines that can easily be accepted, applied, and spread across different burn units to methodically implement measures to reduce blood loss and transfusion needs, and ultimately improve burn patients' outcome and the health care financial status.
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Affiliation(s)
- João Souto
- Faculty of Medicine, University of Porto, Portugal
| | - Acacio Goncalves Rodrigues
- Burn Unit and Department of Plastic and Reconstructive Surgery, Faculty of Medicine, S. João University Hospital Center, Porto, Portugal.,CINTESIS@RISE, Faculty of Medicine, University of Porto, Portugal
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3
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Battistini A, Gottlieb LJ, Vrouwe SQ. Topical Hemostatic Agents in Burn Surgery: A Systematic Review. J Burn Care Res 2023; 44:262-273. [PMID: 36516423 DOI: 10.1093/jbcr/irac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Indexed: 12/15/2022]
Abstract
Acute burn surgery has long been associated with significant intra-operative bleeding. Several techniques were introduced to limit hemorrhage, including tourniquets, tumescent infiltration, and topical agents. To date, no study has comprehensively investigated the available data regarding topical hemostatic agents in burn surgery. A systematic review was performed by two independent reviewers using electronic databases (PubMed, Scopus, Web of Science) from first available to September 10, 2021. Articles were included if they were published in English and described or evaluated topical hemostatic agents used in burn excision and/or grafting. Data were extracted on the agent(s) used, their dosage, mode of delivery, hemostasis outcomes, and complications. The search identified 1982 nonduplicate citations, of which 134 underwent full-text review, and 49 met inclusion criteria. In total, 32 studies incorporated a vasoconstrictor agent, and 28 studies incorporated a procoagulant agent. Four studies incorporated other agents (hydrogen peroxide, tranexamic acid, collagen sheets, and TT-173). The most common vasoconstrictor used was epinephrine, with doses ranging from 1:1000 to 1:1,000,000. The most common procoagulant used was thrombin, with doses ranging from 10 to 1000 IU/ml. Among the comparative studies, outcomes of blood loss were not reported in a consistent manner, therefore meta-analysis could not be performed. The majority of studies (94%) were level of evidence III-V. Determining the optimal topical hemostatic agent is limited by low-quality data and challenges with consistent reporting of intra-operative blood loss. Given the routine use of topical hemostatic agents in burn surgery, high-quality research is essential to determine the optimal agent, dosage, and mode of delivery.
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Affiliation(s)
- Andrea Battistini
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL, USA
| | - Lawrence J Gottlieb
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL, USA
| | - Sebastian Q Vrouwe
- Section of Plastic & Reconstructive Surgery, University of Chicago, Chicago, IL, USA
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Frew GH, Dick L, Young J. Common haemostatic techniques used in surgical practice. Br J Hosp Med (Lond) 2021; 82:1-8. [PMID: 34431343 DOI: 10.12968/hmed.2021.0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Intraoperative bleeding can be difficult to manage and is associated with worse patient outcomes. Good intraoperative haemostasis by the surgeon is a key factor in ensuring a bloodless field and reducing intraoperative blood loss. There is a myriad of mechanical, thermal and energy-based techniques available to use, each of which has their own benefits and drawbacks. The decision of which to use will depend on patient and procedural factors as well as the surgeon's preference. This article reviews techniques commonly used in surgical practice to maintain intraoperative haemostasis.
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Affiliation(s)
- Georgina H Frew
- Department of General Surgery, Borders General Hospital, Melrose, UK
| | - Lachlan Dick
- Department of General Surgery, Borders General Hospital, Melrose, UK
| | - Jamie Young
- Department of General Surgery, Borders General Hospital, Melrose, UK
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5
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Asuku M, Yu TC, Yan Q, Böing E, Hahn H, Hovland S, Donelan MB. Split-thickness skin graft donor-site morbidity: A systematic literature review. Burns 2021; 47:1525-1546. [PMID: 33781633 DOI: 10.1016/j.burns.2021.02.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 12/08/2020] [Accepted: 02/02/2021] [Indexed: 12/21/2022]
Abstract
The purpose of this systematic literature review is to critically evaluate split-thickness skin graft (STSG) donor-site morbidities. The search of peer-reviewed articles in three databases from January 2009 to July 2019 identified 4271 English-language publications reporting STSG donor-site clinical outcomes, complications, or quality of life. Of these studies, 77 met inclusion criteria for analysis. Mean time to donor-site epithelialization ranged from 4.7 to 35.0 days. Mean pain scores (0-10 scale) ranged from 1.24 to 6.38 on postoperative Day 3. Mean scar scores (0-13 scale) ranged from 0 to 10.9 at Year 1. One study reported 28% of patients had donor-site scar hypertrophy at 8 years. Infection rates were generally low but ranged from 0 to 56%. Less frequently reported outcomes included pruritus, wound exudation, and esthetic dissatisfaction. Donor-site wounds underwent days of wound care and were frequently associated with pain and scarring. Widespread variations were noted in STSG donor-site outcomes likely due to inconsistencies in the definition of outcomes and utilization of various assessment tools. Understanding the true burden of donor sites may drive innovative treatments that would reduce the use of STSGs and address the associated morbidities.
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Affiliation(s)
- Malachy Asuku
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Tzy-Chyi Yu
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA.
| | - Qi Yan
- Oxford PharmaGenesis Inc., 4 Caufield Place, Suite 201, Newtown, PA, 18940, USA
| | - Elaine Böing
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Helen Hahn
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Sara Hovland
- Mallinckrodt Pharmaceuticals, Shelbourne Building, 53 Frontage Rd Suite 300, Hampton, NJ, 08827, USA
| | - Matthias B Donelan
- Shriners Hospital for Children-Boston, 51 Blossom Street, Suite 930, Boston, MA, 02114, USA; Harvard Medical School, 25 Shattuck St, Boston, MA, 02114, USA; Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Shahzad F. Management of skin graft donor site in pediatric patients with tumescent technique and AQUACEL ® Ag foam dressing. J Plast Surg Hand Surg 2021; 55:309-314. [PMID: 33591240 DOI: 10.1080/2000656x.2021.1883632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Split thickness skin graft donor sites are challenging to manage in children because of patient fear and anxiety. Therefore, strategies that minimize the frequency of dressing change are beneficial. This paper describes a technique to simplify wound care for split thickness skin graft donor sites. A tumescent solution of saline containing 0.25% bupivacaine with epinephrine is infiltrated into the graft donor site. Skin grafts are harvested with an electric dermatome. The donor sites are dressed with AQUACEL® Ag Foam, which is a sodium carboxymethylcellulose hydrofiber dressing that contains silver ions. A total of 17 split thickness skin grafts were performed with this technique. Patient age ranged from 2.4 year to 16.9 years (average 12 years). The AQUACEL® Ag Foam dressings were removed at an average of 23 days (range 11 to 31 days) at which time complete donor site epithelialization was seen in 13/17 (76.5%) patients. The remaining 4 patients had < 5% of the donor site that had not epithelialized; these went on to heal uneventfully with a brief period of petrolatum gauze dressing changes. Two patients had foul smelling discharge under the dressing that resolved promptly with dressing removal. The above technique allows the primary dressing to stay in place long enough for epithelialization to take place. The obviation of dressing changes in the early post-operative period results in patient comfort and care giver convenience.
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Affiliation(s)
- Farooq Shahzad
- Division of Plastic & Reconstructive Surgery, Ann & Robert H Lurie Children's Hospital, Northwestern University, Chicago, IL, USA
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Fukuoka K, Yagi S, Suyama Y, Kaida W, Morita M, Hisatome I. Effect of Subcutaneous Adrenaline/Saline/Lidocaine Injection on Split-Thickness Skin Graft Donor Site Wound Healing. Yonago Acta Med 2021; 64:107-112. [PMID: 33642909 DOI: 10.33160/yam.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/06/2021] [Indexed: 11/05/2022]
Abstract
Background Subcutaneous injection of tumescent solution, which contains local anesthetic, adrenaline, and saline, before split-thickness skin graft harvesting, shows a significant hemostatic effect. This method can reduce the initial bleeding from the donor site. The aim of this study is to assess the benefits of controlling the bleeding from donor sites by tumescent injection. A randomized, controlled trial was performed to compare the wound healing of split-thickness skin graft donor sites treated with or without tumescent injection. Methods This randomized, controlled trial examined donor site healing days as the main measure of outcome. postoperative pain, donor site ulceration, and scar quality were evaluated as secondary outcome measures. Patients planned for split-thickness skin graft harvest were randomly assigned to receive either pre-harvest subcutaneous injection of local anesthetic, adrenaline, and saline solution (tumescent solution) (Group 1) or post-harvest application of adrenaline solution-soaked gauze to the skin graft donor sites (Group 2). Donor sites were treated with calcium alginate dressings after graft harvesting. On the 10th postoperative day, the dressings were removed and donor site healing were measured. Follow-up evaluation of scar quality was performed 6 months after surgery. Postoperative pain was evaluated on the 1st day after operating. Results Forty-five patients (26 males; average age 61.8 years) completed the late follow-up evaluation (6 months postoperatively), with 26 patients in group 1 and 19 in group 2. There were no significant differences between the two groups in any of the outcome measures. Conclusion Tumescent technique provides sufficient hemostasis in split skin graft donor sites, especially the initial bleeding just after graft harvesting, without any negative effects. Larger series should be studied to evaluate the effect in donor site wound healing.
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Affiliation(s)
- Kohei Fukuoka
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Shunjiro Yagi
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Yoshiko Suyama
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Wataru Kaida
- Department of Plastic and Reconstructive Surgery, Shimane Prefectural Central Hospital, Izumo 693-0068, Japan
| | - Maki Morita
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Ichiro Hisatome
- Department of Genetic Medicine and Regenerative Therapeutics, Institute of Regenerative Medicine and Biofunction, Graduate School of Medical Sciences, Tottori University, Yonago 683-8503, Japan
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Oryan A, Alemzadeh E, Moshiri A. Role of sugar-based compounds on cutaneous wound healing: what is the evidence? J Wound Care 2019; 28:s13-s24. [PMID: 30900931 DOI: 10.12968/jowc.2019.28.sup3b.s13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Cutaneous wound healing is a complex orchestrated process influenced by many endogenous and exogenous imbalances. The main goal of tissue regeneration in wound healing is to increase wound contraction and reduce scar formation, effectively to regenerate a new healthy epidermis and prevent scar contracture. Additionally, prevention, control and treatment of wound infections, particularly in burn wounds, is a vital strategy in the healing process. It was previously supposed that local application of sugar-based materials increases the chance of wound infection and delays wound healing. This review shows that topical application of sugar-based compounds has no negative effects on different wound types. Whereas, hyperglycaemia created by diabetes, stress or certain medications can act to impair wound healing. Therefore, this work was designed to review the recent studies that evaluated the role of sugar-based compounds on wound healing and to demonstrate in various cutaneous wound models how these compounds may be involved in healing. It also deals with different physio-pharmacologic conditions resulting in hyperglycaemia in different models of cutaneous wound healing in order to illustrate the role of endogenous glucose in wound healing and remodelling.
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Affiliation(s)
- Ahmad Oryan
- Professor of Comparative Pathology, Department of Pathology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Esmat Alemzadeh
- Assistant Professor of Biotechnology, Department of Biotechnology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Ali Moshiri
- Department of Surgery and Radiology, Dr. Moshiri Veterinary Clinic, Tehran, Iran
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9
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Ho CWG, Kok YO, Chong SJ. Photographic evaluation of different adrenaline-containing tumescent solutions on skin graft donor site bleeding: A prospective randomised trial. Burns 2018; 44:2018-2025. [DOI: 10.1016/j.burns.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 02/18/2018] [Accepted: 03/09/2018] [Indexed: 12/30/2022]
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10
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Treating pain on skin graft donor sites: Review and clinical recommendations. J Trauma Acute Care Surg 2017; 83:954-964. [DOI: 10.1097/ta.0000000000001615] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Determinants and time to blood transfusion among thermal burn patients admitted to Mulago Hospital. BMC Res Notes 2017; 10:258. [PMID: 28683773 PMCID: PMC5501556 DOI: 10.1186/s13104-017-2580-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 06/28/2017] [Indexed: 11/28/2022] Open
Abstract
Background Blood transfusion, a practice under re-evaluation in general, remains common among thermal burn patients due to the hematological alterations associated with burns that manifest as anemia. Today advocacy is for restrictive blood transfusion taking into account individual patient characteristics. We went out to identify the parameters that may determine transfusion requirement and the time to blood transfusion for thermal burn patients in Mulago Hospital in order to build statistics and a basis to standardize future practice and Hospital protocol. Methods 112 patients with thermal burns were enrolled into a prospective cohort study conducted in the Surgical Unit of the Accidents and Emergency Department and Burns Unit of Mulago Hospital. Relevant data on pre-injury, injury and post-injury factors was collected including relevant laboratory investigations and treatment modalities like surgical intervention. Patients were clinically followed up for a maximum period of 28 days and we identified those that were transfused. Results 22.3% of patients were transfused. The median time to transfusion was 17 days from time of injury and varied with different patient characteristics. The median pre-transfusion hemoglobin (Hb) level was 8.2 g/dL. Transfusion was significantly related to; admission to the intensive care unit (p = 0.001), a body mass index (BMI) <2 kg/m2 (p = 0.021), % total burn surface area (TBSA) >20 (p = 0.049), pre-existing illness (p = 0.046), and white blood cell (WBC) count <4000 or >12,000/μL (p = 0.05). Conclusion Pre-existing illnesses, a low BMI, TBSA of >20%, admission to the intensive care unit and abnormalities in the WBC count are useful predictors of blood transfusion among thermal burns patients admitted to Mulago Hospital. The precise time to transfusion from time of burns injury cannot be generalized. With close monitoring of each individual patient lies the appropriateness and timeliness of their management.
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Zubairi AJ, Rashid H, Rashid RH, Ali M, Hashmi PM. Outcome of Judet's quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss. Chin J Traumatol 2017; 20:147-150. [PMID: 28554591 PMCID: PMC5473712 DOI: 10.1016/j.cjtee.2017.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/11/2017] [Accepted: 04/05/2017] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To evaluate the effectiveness of Judet's quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure. METHODS A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet's quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet's outcome, blood loss, drop in hemoglobin and required blood transfusion were noted for all patients and compared between both groups. RESULTS Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture (p = 0.02). All functional outcome measures including Judet's outcome were similar in both groups. In contrast, duration of surgery (p = 0.01), blood loss (p = 0.02), drop in hemoglobin (p = 0.01) and number of transfusions (p = 0.03) were significantly reduced in epinephrine group. CONCLUSION Judet's quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.
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Affiliation(s)
- Akbar Jaleel Zubairi
- Section of Orthopedics, Department of Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan,Corresponding author.
| | - Haroon Rashid
- Section of Orthopedics, Department of Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Rizwan Haroon Rashid
- Section of Orthopedics, Department of Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan
| | - Moiz Ali
- Aga Khan University Medical College, Karachi 74800, Pakistan
| | - Pervaiz Mehmood Hashmi
- Section of Orthopedics, Department of Surgery, Aga Khan University Hospital, Karachi 74800, Pakistan
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Rojas S, Pérez del Caz MD, Esteban Vico JR, Villaverde E, Llinas A, Martínez JR, Brage C, Valero J, González Rodríguez A, Garcia Barreiro J, López-Suso E, Fernandez-Cañamaque JL, López R, Murat J. EHTIC study: Evaluation of a new hemostatic agent based on tissue factor in skin grafting procedures. Burns 2017; 43:780-788. [DOI: 10.1016/j.burns.2017.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 11/21/2016] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
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14
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Gacto-Sanchez P. Surgical treatment and management of the severely burn patient: Review and update. Med Intensiva 2017; 41:356-364. [PMID: 28456441 DOI: 10.1016/j.medin.2017.02.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 02/08/2017] [Accepted: 02/18/2017] [Indexed: 01/20/2023]
Abstract
Since one of the main challenges in treating acute burn injuries is preventing infection, early excising of the eschar and covering of the wound becomes critical. Non-viable tissue is removed by initial aggressive surgical debridement. Many surgical options for covering the wound bed have been described, although split-thickness skin grafts remain the standard for the rapid and permanent closure of full-thickness burns. Significant advances made in the past decades have greatly improved burns patient care, as such that major future improvements in survival rates seem to be more difficult. Research into stem cells, grafting, biomarkers, inflammation control, and rehabilitation will continue to improve individualized care and create new treatment options for these patients.
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Affiliation(s)
- P Gacto-Sanchez
- Plastic Surgeon, Plastic and Reconstructive Department, Burns Unit, Virgen del Rocio University Hospital, Sevilla, Spain.
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15
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Butts CC, Bose K, Frotan MA, Hodge J, Gulati S. Controlling intraoperative hemorrhage during burn surgery: A prospective, randomized trial comparing NuStat® hemostatic dressing to the historic standard of care. Burns 2017; 43:374-378. [DOI: 10.1016/j.burns.2016.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 08/24/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
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16
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Nonclinical Evaluation of the New Topical Hemostatic Agent TT-173 for Skin Grafting Procedures. J Burn Care Res 2017; 38:e824-e833. [PMID: 28157787 DOI: 10.1097/bcr.0000000000000497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Blood loss during grafting surgery represents a major concern of this procedure and the development of hemostatic agents for this indication is highly desirable. TT-173 is the first biologically active treatment based on tissue factor instead of thrombin. This study sought to investigate the efficacy, systemic absorption, and toxicology of TT-173 in animal models to support clinical evaluation of the product in donor sites of patients subjected to skin grafting. Procoagulant efficacy of 148 μg of TT-173 was evaluated in pigs in presence and absence of anticoagulant treatment with unfractioned heparin. Systemic absorption was quantified and characterized in rats subjected to severe skin lesions with affectation of muscular plane using TT-173 radiolabeled with I. The same animal model was used to test the toxicology of a dose of 80 μg of the product. Application of TT-173 significantly reduced the bleeding time of donor sites, even under anticoagulant treatment. Systemic absorption was low; it was excreted through urine and did not concentrate in organs such as liver, lung, or spleen suggesting that the absorbed dose could correspond to degradation fragments without procoagulant activity. Finally, a dose of 80 μg of TT-173 did not cause analytical disturbances suggestive of intravascular coagulation or any other adverse reaction. Nonclinical data obtained suggest that TT-173 could be useful to reduce the blood loss associated to burns treatment and support the clinical evaluation of the product in donor sites of patients subjected to skin grafting.
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17
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Vasoconstrictor clysis in burn surgery and its impact on outcomes: Systematic review and meta-analysis. Burns 2015; 41:1140-6. [DOI: 10.1016/j.burns.2015.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 01/30/2015] [Accepted: 03/13/2015] [Indexed: 11/18/2022]
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18
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Ræder J. Warming and alkalinisation of lidocaine with epinephrine mixture: Some useful aspects at first glance, but not so simple? Scand J Pain 2014; 5:41-42. [DOI: 10.1016/j.sjpain.2013.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Johan Ræder
- Department of Anaesthesiology, Ullevaal , Oslo University Hospital and Faculty of Medicine, University of Oslo , Pb 4950 Nydalen, 0224 Oslo , Norway
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19
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Howe N, Cherpelis B. Obtaining rapid and effective hemostasis. J Am Acad Dermatol 2013; 69:659.e1-659.e17. [DOI: 10.1016/j.jaad.2013.07.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 07/01/2013] [Accepted: 07/09/2013] [Indexed: 11/25/2022]
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D'Cruz R, Martin HCO, Holland AJA. Medical management of paediatric burn injuries: best practice part 2. J Paediatr Child Health 2013; 49:E397-404. [PMID: 23551985 DOI: 10.1111/jpc.12179] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 12/16/2022]
Abstract
Burns remain a leading cause of injury in the paediatric population in Australia despite efforts in prevention. Advances in surgical management include novel debridement methods and blood conserving techniques. Patients with severe burns (>20%) remain significantly more complex to manage as a result of extensive alterations in metabolic processes. There appears increasing evidence to support the use of pharmacological modulators of the hyper-metabolic state in these patients. The management of a child with burns involves acute, subacute and long-term planning. This holistic approach seems optimally co-ordinated by a Burns Unit in which each discipline required to provide care to these children in order to achieve optimal outcomes is represented.
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Affiliation(s)
- Rachel D'Cruz
- Burns Unit, The Children's Hospital at Westmead Burns Research Institute, Sydney, New South Wales, Australia; Douglas Cohen Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Groenewold MD, Gribnau AJ, Ubbink DT. Topical haemostatic agents for skin wounds: a systematic review. BMC Surg 2011; 11:15. [PMID: 21745412 PMCID: PMC3143913 DOI: 10.1186/1471-2482-11-15] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 07/12/2011] [Indexed: 11/15/2022] Open
Abstract
Background Various agents and techniques have been introduced to limit intra-operative blood loss from skin lesions. No uniformity regarding the type of haemostasis exists and this is generally based on the surgeon's preference. To study the effectiveness of haemostatic agents, standardized wounds like donor site wounds after split skin grafting (SSG) appear particularly suitable. Thus, we performed a systematic review to assess the effectiveness of haemostatic agents in donor site wounds. Methods We searched all randomized clinical trials (RCTs) on haemostasis after SSG in Medline, Embase and the Cochrane Library until January 2011. Two reviewers independently assessed trial relevance and quality and performed data analysis. Primary endpoint was effectiveness regarding haemostasis. Secondary endpoints were wound healing, adverse effects, and costs. Results Nine relevant RCTs with a fair methodological quality were found, comparing epinephrine, thrombin, fibrin sealant, alginate dressings, saline, and mineral oil. Epinephrine achieved haemostasis significantly faster than thrombin (difference up to 2.5 minutes), saline or mineral oil (up to 6.5 minutes). Fibrin sealant also resulted in an up to 1 minute quicker haemostasis than thrombin and up to 3 minutes quicker than placebo, but was not directly challenged against epinephrine. Adverse effects appeared negligible. Due to lack of clinical homogeneity, meta-analysis was impossible. Conclusion According to best available evidence, epinephrine and fibrin sealant appear superior to achieve haemostasis when substantial topical blood loss is anticipated, particularly in case of (larger) SSGs and burn debridement.
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Affiliation(s)
- Marieke D Groenewold
- Department of Quality Assurance & Process Innovation, Academic Medical Center, Amsterdam, The Netherlands
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Phenylephrine tumescence in split-thickness skin graft donor sites in surgery for burn injury- a concentration finding study. J Burn Care Res 2011; 32:129-34. [PMID: 21131843 DOI: 10.1097/bcr.0b013e318204b39b] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study is to determine the lowest concentration of subcutaneous phenylephrine (neosynephrine) required for effective vasoconstriction in skin graft donor sites. Surgery for burn injury is associated with blood loss. Tourniquet use and tumescence with epinephrine have decreased blood loss. However, absorption of epinephrine has been reported with systemic effects. Phenylephrine, an α1-adrenergic receptor agonist, has vasoconstrictive properties similar to epinephrine's without other α-adrenergic or β-adrenergic activity. The aim of this study is to determine the lowest effective concentration of phenylephrine that will provide vasoconstriction in split-thickness graft donor sites. By using intensive care unit equivalency tables, the authors estimated a concentration of phenylephrine on the basis of current epinephrine tumescence. This concentration was titrated up or down according to an algorithm established a priori, determining the minimum concentration that achieved vasoconstriction in three consecutive patients. The primary outcome was local vasoconstriction. Secondary outcomes measured were pre-, intra-, and postoperative mean arterial pressure, systolic pressure and heart rate, graft take, and donor site healing. The subjects were six otherwise healthy adult patients (five men and one woman) with a mean age of 36 years. The average TBSA was 737.5 cm². Vasoconstriction was achieved at 5 μg/ml. No significant alterations in hemodynamic measures were observed. The optimal concentration of phenylephrine for prevention of bleeding in donor sites appears to be 5 μg/ml. Participants will be able to identify the effects of phenylephrine and epinephrine tumescence. They will also identify the concentration at which phenylephrine will be effective in donor sites.
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Sterling JP, Heimbach DM. Hemostasis in burn surgery--a review. Burns 2010; 37:559-65. [PMID: 21194843 DOI: 10.1016/j.burns.2010.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Accepted: 06/29/2010] [Indexed: 10/18/2022]
Abstract
Over the past 30 years, techniques of early excision and grafting along with enhancement of critical care have significantly improved survival following burn injury. Despite these advancements, large volume blood loss associated with surgical intervention continues to be a challenging aspect of burn surgery. This review article will examine the methods of limiting blood loss during surgical procedures.
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Affiliation(s)
- Jose P Sterling
- University of Texas, Southwestern Medical School, Dallas, TX, USA
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