Massive transfusion of reconstituted whole blood is well tolerated in pediatric burn surgery

Examining 1:1 vs. 4:1 Packed Red Blood Cell to Fresh Frozen Plasma Ratio Transfusion During Pediatric Burn Excision

Blood transfusions following major burn injury are common due to operative losses, blood sampling, and burn physiology. While massive transfusion improves outcomes in adult trauma patients, literature examining its effect in critically ill children is limited. The study purpose was to prospectively compare outcomes of major pediatric burns receiving a 1:1 vs. 4:1 packed red blood cell to fresh frozen plasma transfusion strategy during massive burn excision. Children with >20% total body surface area burns were randomized to a 1:1 or 4:1 packed red blood cell/fresh frozen plasma transfusion ratio during burn excision. Parameters examined include patient demographics, burn size, pediatric risk of mortality (PRISM) scores, pediatric logistic organ dysfunction scores, laboratory values, total blood products transfused, and the presence of blood stream infections or pneumonia. A total of 68 children who met inclusion criteria were randomized into two groups (n = 34). Mean age, PRISM scores, estimated blood loss (600 ml (400-1175 ml) vs. 600 ml (300-1150 ml), P = 0.68), ventilator days (5 vs. 9, P = 0.47), and length of stay (57 vs. 60 days, P = 0.24) had no difference. No differences in frequency of blood stream infection (20 vs. 18, P = 0.46) or pneumonia events (68 vs. 116, P = 0.08) were noted. On multivariate analysis, only total body surface area burn size, inhalation injury, and PRISM scores (P < 0.05) were significantly associated with infections.

Effect of single dose intravenous tranexamic acid on blood loss in tangential excision of burn wounds - A double blind randomised controlled trial

INTRODUCTION

This study was carried out to evaluate role of intravenous tranexamic acid (TXA) in reducing blood loss during tangential excision of burns.

METHODS

This was a single center, prospective double-blinded parallel arm superiority randomized placebo-controlled trial. Patients (15-55 years) with deep dermal thermal burns <30% undergoing tangential excision were randomly assigned (1:1) to TXA and placebo groups. Patients in TXA and placebo groups received injection TXA 15 mg/kg and 10 ml saline respectively, 10 min preoperatively. Primary outcome was volume of blood loss per square centimeter area of burn excised. Secondary outcomes were total volume of blood loss, postoperative hemoglobin, intraoperative fluid requirement, blood transfusion, graft take and length of hospitalization (LOH).

RESULTS

Thirty patients were included. Both groups were comparable in terms of Body Mass Index (BMI) preoperative hemoglobin, area of burn excised, duration of surgery and the intraoperative temperature. The average blood loss per square centimeter burn area excised was found to be significantly lower in TXA when compared to placebo group (mean difference: 0.28 ± 0.025 ml/cm²; p = 0.000). The total volume of blood loss was lower in TXA group (258.7 ± 124.10 ml vs 388.1 ± 173.9 ml; p = 0.07). None of the patients required transfusion. The requirement of intra-operative fluids was similar between the two groups (crystalloids: p = 0.236; colloids: p = 0.238). Postoperative hemoglobin, length of hospitalization and graft-take were comparable between the two groups.

CONCLUSION

TXA reduced blood loss per unit burn area of tangential excision in <30%TBSA burn, however, we found no significant effect on postoperative Hb and transfusion.

An analysis of outcomes for pediatric trauma warm fresh whole blood recipients in Iraq and Afghanistan

BACKGROUND

Whole blood therapy-which contains the ideal balance of components, and particularly fresh whole blood-has been shown to be beneficial in adult trauma. It remains unclear whether there is potential benefit in the pediatric population.

STUDY DESIGN AND METHODS

This is a secondary analysis of previously published data analyzing pediatric casualties undergoing massive transfusion in the Department of Defense Trauma Registry. Pediatric patients with traumatic injury who were transfused at least one blood product were included in the analysis. We compared children who received component therapy exclusively to those who received any amount of warm fresh whole blood.

RESULTS

Of the 3439 pediatric casualties within our dataset, 1244 were transfused at least one blood product within the first 24 h. There were 848 patients without severe head injury. Within this cohort, 23 children received warm fresh whole blood overall, 20 of whom did not have severe head injury. In an adjusted analysis, the odds ratio (95% confidence interval [CI]) for survival for warm fresh whole blood recipients was 2.86 (0.40-20.45). After removing children with severe brain injury, there was an independent association with improved survival for warm fresh whole blood recipients with an odds ratio (95% CI) of 58.63 (2.70-1272.67).

DISCUSSION

Our data suggest that warm fresh whole blood may be associated with improved survival in children without severe head injury. Larger prospective studies are needed to assess the efficacy and safety of whole blood in children with severe traumatic bleeding.

Transfusion and Infections in the Burn Patient

Background: Blood product transfusion has historically been utilized after major burn injury in the resuscitative as well as the acute phase. Transfusion has been implicated in infection and immunosuppression in many disease states. Recommendations for blood product transfusion has varied, but several landmark studies have helped define optimal burn transfusion strategies with respect to infection. The purpose of this article is to review the evidence describing the relation between transfusion and infection in burn injury during different phases of burn treatment to identify optimal transfusion strategies and suggest future targets for transfusion research in burns. Methods: This article presents the history, current status, and future research directions related to blood and blood product transfusion in burn injury. Results: Patients with burns are subject to infectious complications resulting from the loss of skin and burn-related immunosuppression. The use of blood in burn treatment has varied during both the resuscitative phase and the acute treatment phase. Whole-blood use in resuscitation was replaced with crystalloid infusion. Future trials are examining the role of plasma and albumin in burn resuscitation. A randomized prospective multicenter transfusion trial was able to decrease transfusion by 50% with no change in infection. Further examination of the role of hemostatic resuscitation in burn excision may help to better define transfusion goals. Conclusions: Blood product transfusion in burn injury has varied throughout the last century. Although advances in the understanding of blood transfusion in burn injury have occurred, initiatives to define optimal care better are required.

The evolution of pediatric transfusion practice during combat operations 2001-2013

BACKGROUND

Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system.

METHODS

The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric patients (<18 years). Patients with burns, drowning, and missing injury severity score were excluded. Volumes of crystalloid, packed red blood cells (PRBC), whole blood, plasma, and platelets (PLT) given in the first 24 hours were calculated per kilogram body weight. Tranexamic acid use was also determined. Patients were divided into Early (2001-2005) and Late (2006-2013) cohorts, and subgroups of transfused (TX+) and massively transfused (MT+) patients were created. Intensive care unit and hospital length of stay and 24-hour and in-hospital mortality rates were compared.

RESULTS

A total of 4,358 patients met inclusion criteria. Comparing Early versus Late, injuries from explosions, isolated or predominant head injuries, and injury severity score all increased. The proportion of TX+ patients also increased significantly (13.6% vs 37.4%, p < 0.001) as did the number of MT+ patients (2.1% vs 15.5%, p < 0.001). Transfusion of high plasma:RBC and PLT:RBC ratios increased in both the TX+ and MT+ subgroups, although overall, PLT and whole blood use was low. After adjusting for differences between groups, the odds of death was no different Early versus Late but decreased significantly in the MT+ patients with time as a continuous variable.

CONCLUSION

Transfusion practice in pediatric combat casualty care shifted toward a more hemostatic approach over time. All-cause mortality was low and remained stable overall and even decreased in MT+ patients despite more injuries due to explosions, more head injuries, and greater injury severity. However, further study is required to determine the optimal resuscitation practices in critically injured children.

LEVEL OF EVIDENCE

Epidemiologic study, level IV.

Treatment of combined traumatic brain injury and hemorrhagic shock with fractionated blood products versus fresh whole blood in a rat model

INTRODUCTION

Treatment of combined traumatic brain injury and hemorrhagic shock, poses a particular challenge due to the possible conflicting consequences. While restoring diminished volume is the treatment goal for hypovolemia, maintaining adequate cerebral perfusion pressure and avoidance of secondary damage remains a treatment goal for the injured brain. Various treatment modalities have been proposed, but the optimal resuscitation fluid and goals have not yet been clearly defined. A growing body of evidence suggests that in hypovolemic shock, resuscitation with fresh whole blood (FWB) may be superior to component therapy without platelets (which are likely to be unavailable in the pre-hospital setting). Nevertheless, the effects of this approach have not been studied in the combined injury. Previously, in a rat model of combined injury we have found that mild resuscitation to MABP of 80 mmHg with FWB is superior to fluid resuscitation or aggressive resuscitation with FWB. In this study, we investigate the physiological and neurological outcomes in a rat model of combined traumatic brain injury (TBI) and hypovolemic shock, submitted to treatment with varying amounts of FWB, compared to similar resuscitation goals with fractionated blood products-red blood cells (RBCs) and plasma in a 1:1 ratio regimen.

MATERIALS AND METHODS

40 male Lewis rats were divided into control and treatment groups. TBI was inflicted by a free-falling rod on the exposed cranium. Hypovolemia was induced by controlled hemorrhage of 30% blood volume. Treatment groups were treated either with fresh whole blood or with RBC + plasma in a 1:1 ratio, achieving a resuscitation goal of a mean arterial blood pressure (MAP) of 80 mmHg at 15 min. MAP was assessed at 60 min, and neurological outcomes and mortality in the subsequent 24 h.

RESULTS

At 60 min, hemodynamic parameters were improved compared to controls, but not significantly different between treatment groups. Survival rates at 48 h were 100% for both of the mildly resuscitated groups (MABP 80 mmHg) with FWB and RBC + plasma. The best neurological outcomes were found in the group mildly resuscitated with FWB and were better when compared to resuscitation with RBC + plasma to the same MABP goal (FWB: Neurological Severity Score (NSS) 6 ± 2, RBC + plasma: NSS 10 ± 2, p = 0.02).

CONCLUSIONS

In this study, we find that mild resuscitation with goals of restoring MAP to 80 mmHg (which is lower than baseline) with FWB, provided better hemodynamic stability and survival. However, the best neurological outcomes were found in the group resuscitated with FWB. Thus, we suggest that resuscitation with FWB is a feasible modality in the combined TBI + hypovolemic shock scenario, and may result in improved outcomes compared to platelet-free component blood products.

High ratio plasma resuscitation does not improve survival in pediatric trauma patients

BACKGROUND

Damage control resuscitation including balanced resuscitation with high ratios of plasma (PLAS) and platelets (PLT) to packed red blood cells (PRBC) improves survival in adult patients. We sought to evaluate the effect of a high ratio PLAS to PRBC resuscitation strategy in massively transfused pediatric patients with combat injuries.

METHODS

The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head trauma, and older teens were excluded. Those who received massive transfusion (≥40 mL/kg total blood products in 24 hours) and early deaths who received any blood products were then evaluated. Primary outcomes were mortality at 24 hours and in-hospital. Secondary outcomes included blood product utilization over 24 hours, ventilator-free days, intensive care unit-free days, and hospital length of stay.

RESULTS

The Department of Defense Trauma Registry yielded 4,980 combat-injured pediatric trauma patients, of whom 364 met inclusion criteria. Analysis of PLAS/PRBC ratios across the entire spectrum of possible ratios in these patients demonstrated no clear inflection point for mortality. Using a division between low (LO) and high (HI) ratios of PLAS/PRBC 1:2, there was no difference in all-cause mortality at 24 hours (LO, 9.2% vs. HI, 8.0%; p = 0.75) and hospital discharge (LO, 21.5% vs. HI, 17.1%; p = 0.39). HI ratio patients received less PRBC but more PLAS and PLT and more total blood products. Those in the HI ratio group also had longer hospital length of stay. Regression analysis demonstrated no associated mortality benefit with a HI ratio (hazards ratio, 2.04; 95% confidence interval, 0.48-8.73; p = 0.34).

CONCLUSION

In combat-injured children undergoing a massive transfusion, a high ratio of PLAS/PRBC was not associated with improved survival. Further prospective studies should be performed to determine the optimal resuscitation strategy in critically injured pediatric patients.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Massive transfusion in children and neonates

Resuscitation of children and neonates with severe or refractory bleeding due to surgery or trauma often requires massive transfusion (MT). Findings from recent studies have led to a better understanding of the complex pathophysiology in massive haemorrhage and the effects of MT on haemostasis. Current management of the massively bleeding adult patient has evolved over the past few decades, shifting to early transfusion of products in a balanced ratio as part of MT protocols (MTPs). Paediatric data on successful management of MT are limited and the optimal transfusion approach is currently unknown, leading to practice variability among institutions, depending on resource availability and patients' needs. Here, we review new important concepts in the biology of massive bleeding and MT, outline important management principles and current practices, and highlight available relevant adult and paediatric data.

A pediatric massive transfusion protocol

BACKGROUND

Pediatric massive blood transfusions occur widely at hospitals across the nation; however, there are limited data on pediatric massive transfusion protocols (MTPs) and their impact. We present a pediatric MTP and examine its impact on morbidity and mortality as well as identify factors that may prompt protocol initiation.

METHODS

Using a prospective cohort, we collected data on all pediatric patients who required un-cross-matched blood from January 1, 2009, through January 1, 2011. This captured patients who received blood products according to the protocol as well as patients who were massively transfused at physician discretion. Outcomes between groups were compared.

RESULTS

A total of 55 patients received un-cross-matched blood, with 22 patients in the MTP group and 33 patients receiving blood at physician discretion (non-MTP group). Mortality was not significantly different between groups. Injury Severity Score for the MTP group was 42 versus 25 for the non-MTP group (p ≤ 0.01). Thromboembolic complications occurred more exclusively in the non-MTP group (p ≤ 0.04). Coagulopathy, evidenced by partial thromboplastin time (PTT) greater than 36, was associated with initiation of the MTP.

CONCLUSION

MTPs have been widely adopted by hospitals to minimize the coagulopathy associated with hemorrhage. Blood transfusion via MTP was associated with fewer thromboembolic events. Coagulopathy was associated with initiation of the MTP. These results support the institution of pediatric MTPs and suggest a need for further research on the protective relationship between MTP and thromboembolic events and on identifying objective factors associated with MTP initiation.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Blood product transfusion: does location make a difference?

Early blood product administration during acute blood loss may improve outcomes, yet blood product transfusion for anemia of critical illness has been associated with increased mortality. After major burn injury, patients have two sources of anemia: massive acute blood loss during excision and insidious losses in the intensive care unit (ICU). The purpose of this study was to assess the relationship between the administration of fresh frozen plasma (FFP), platelets, and cryoprecipitate and outcomes in children with major burn injury. This was a retrospective review of children admitted with >20% TBSA burn from 2006 to 2009. Parameters measured included demographics, injury characteristics, operations, blood product transfusions, and outcomes. A total of 143 children received a mean of 3342 ± 283 ml blood. Nonsurvivors had larger burns (62.1 ± 4.6% vs 41.0 ± 1.5% TBSA, P < .001) and received similar amounts of packed red blood cells (PRBCs) during hospitalization (12.8 ± 2.4 units vs 10.9 ± 1.0 units, P = .5) than survivors. Nonsurvivors received more total units of FFP during hospitalization than survivors (8.0 ± 1.7 units vs 3.1 ± 0.4 units, P < .0001) because of the FFP units transfused in the ICU (5.5 ± 1.2 units vs 1.1 ± 0.2 units, P < .0001). The overall FFP:PRBC transfusion ratio in survivors was 1:4, whereas mean FFP:PRBC volume ratio in nonsurvivors was 3:4 (P < .0001). Nonsurvivors received more platelets (3.4 ± 1.0 units vs 0.50 ± 0.1 units, P < .001) and cryoprecipitate (1.9 ± 0.9 units vs 0.3 ± 0.1 units, P < .001) than survivors, both in the operating room and in the ICU. Blood product use in children with severe burns is associated with increased mortality. Appropriate use of blood products may need to be different in the operating room (massive acute hemorrhage) vs the ICU (ongoing red cell senescence).

Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years?

BACKGROUND

Recent military experience reported casualties who receive > 10 units of packed red blood cells (PRBC) in 24 hours have 20% versus 65% mortality when the fresh-frozen plasma (FFP) to PRBC ratio was 1:1 versus 1:4, respectively. We hypothesize a similar improvement in mortality in civilian trauma patients that require massive transfusion and are treated with a FFP to PRBC ratio closer to 1:1.

METHODS

Four-year retrospective study of all trauma patients who underwent emergency surgery in an urban Level I Trauma Center. Patients were divided into two groups; those that received < or = 10 units or > 10 units of PRBC during and after initial surgical intervention. Only patients who received transfusion of both FFP and PRBC were included in the analysis. The primary research question was the impact of initial FFP:PRBC ratio on mortality. Other variables for analysis included patient age, gender, mechanism, and Injury Severity Scale score. Both univariate and multivariate analysis were used to assess the relationship between outcome and predictors.

RESULTS

A total of 2,746 patients underwent surgical intervention of which 1,985 (72.2%) received no transfusion. Of those that received transfusion, 626 (22.8%) received < or = 10 units of PRBC and 135 (4.9%) > 10 units of PRBC. Out of the 626 patients that received < or = 10 units of PRBC, 250 (39.9%) received FFP and 376 (60.1%) received no FFP. All the patients that received > 10 units PRBC received FFP. In univariate analysis, a significant difference in mortality was found in patients who received > 10 units of PRBC (26% vs. 87.5%) when FFP:PRBC ratio was 1:1 versus 1:4 (p = 0.0001). Multivariate analysis in the group of patients that received > 10 units of PRBC showed a FFP:PRBC ratio of 1:4 was consistent with increased risk of mortality (relative risk, 18.88; 95% CI, 6.32-56.36; p = 0.001), when compared with a ratio of 1:1. Patients who received < or = 10 units of PRBC had a trend toward increased mortality (21.2% vs.11.8%) when the FFP:PRBC ratio was 1:4 versus 1:1 (p: 0.06).

CONCLUSION

An FFP to PRBC ratio close to 1:1 confers a survival advantage in patients requiring massive transfusion.

The Use of Fresh Whole Blood in Massive Transfusion

BACKGROUND

Most indications for whole blood transfusion are now well managed exclusively with blood component therapy, yet the use of fresh whole blood for resuscitating combat casualties has persisted in the U.S. military.

METHODS

Published descriptions of whole blood use in military and civilian settings were compared with use of whole blood at the 31st Combat Support Hospital (31st CSH) stationed in Baghdad in 2004-2005.

FINDINGS

Concerns about logistics, safety, and relative efficacy of whole blood versus component therapy have argued against the use of whole blood in most settings. However, military physicians have observed some distinct advantages in fresh warm whole blood over component therapy during the massive resuscitation of acidotic, hypothermic, and coagulopathic trauma patients. In this critical role, fresh whole blood was eventually incorporated as an adjunct into a novel whole-blood-based massive transfusion protocol.

CONCLUSIONS

Under extreme and austere circumstances, the risk:benefit ratio of whole blood transfusion favors its use. Fresh whole blood may, at times, be advantageous even when conventional component therapy is available.

Transfusion-free pediatric burn surgery: techniques and strategies

More than 1.3 million children sustain burns each year, resulting in 40,000 admissions and more than 3000 pediatric deaths. Pediatric burn surgery has been described as excessively bloody. Strategies to reduce intraoperative blood loss include the use of topical thrombin and epinephrine, extremity tourniquets, acute normovolemic hemodilution, and hypotensive anesthesia. This study reviews the single surgeon pediatric burn experience at a children's hospital and describes a comprehensive blood conservation protocol to achieve transfusion-free pediatric burn surgery. A retrospective chart review of consecutive pediatric burn surgeries from July 2000 to April 2002 was performed. Patient demographics, burn characteristics, treatment, blood loss, laboratory values, transfusion history, and complications were reviewed. Blood loss per percent total body surface area (TBSA) treated as well as percent total blood volume (TBV) loss divided by percent TBSA treated were calculated. A total 31 burn surgeries in 23 patients were reviewed. The average age was 7 years (range, 9 months-17 years). There were 17 extremity, 6 trunk, and 2 head/neck burns. The average TBSA burned was 15% (range, 1-55%). The protocol to reduce intraoperative blood loss consisted of the debridement of full-thickness burns with electrocautery and partial-thickness burns with dermabrasion. All debrided or harvested surgical sites were treated immediately with epinephrine solution-soaked pads. All graft harvest sites were injected with an epinephrine solution before harvesting split-thickness skin grafts. The average TBSA treated per surgery was 7% (range, 1-29%). The average blood loss per percent TBSA treated was 15 mL (range, 0.7-37 mL). The average percent TBV/percent TBSA was 0.76% (range, 0.04-3.6%). All 20 patients underwent surgical debridement, 7 patients were treated with AlloDerm and ultrathin split-thickness skin grafts, 2 with full-thickness skin grafts, and 17 with split-thickness skin grafts alone. Five children required blood transfusions. These burns averaged 32% TBSA (range, 20-55%). All 5 children receiving transfusions had anemia of thermal injury and demonstrated an average preoperative drop in hematocrit of 12% (range, 10-14%). There was a 29% complication rate, with 7 patients experiencing partial graft loss, and 1 patient who developed a postgraft contracture that required revisional surgery. There was a single mortality secondary to systemic inflammatory response syndrome and acute respiratory distress syndrome. After the proposed pediatric burn treatment protocol, intraoperative blood loss requiring transfusion can be minimized or eliminated. Large TBSA burns must be surveilled for burn wound anemia that may ultimately require blood transfusion.

Disseminated intravascular coagulation: a rare entity in burn injury

Severe burns are traditionally quoted as causes for acute disseminated intravascular coagulopathy (DIC). However, literature is scarce, and the real incidence of DIC is still unknown. In order to determine the incidence and the clinical implications of DIC in the burned population, 3331 consecutive burned patients were review. There were three episodes of DIC (0.09%) and six patients had abnormal levels of fibrin degradation products. All DIC episodes resolved with aggressive supportive therapy and replacement therapy, although two of the patients died from the underlying pathology. There were no deaths attributed to DIC and there were no signs of DIC on autopsy. In conclusion, disseminated intravascular coagulopathy is a rare complication following severe burn trauma. It complicates the course of the critically ill burn patient, although appropriate therapy prevents its fulminant course. However, a prospective multicenter study with close monitoring of all coagulation parameters may be necessary to elucidate the real incidence of DIC in burn patients.

Blood transfusion in burns: what do we do?

Over 11 million units of blood are transfused yearly in the United States. Although blood transfusion is common in burns, data are lacking on appropriate transfusion thresholds. The purpose of the study was to identify current burn center physician blood transfusion practices. A 30-question survey of blood transfusion practices was developed and sent to burn center directors. The survey assessed demographics, burn experience, and blood transfusion thresholds. Physicians were asked to list factors affecting their blood transfusion thresholds and then to give their blood transfusion threshold for patients based on age and percent burn. The final section presents three case scenarios with alterations in one physiological parameter to assess the effect on transfusion thresholds. A total of 55 of the 180 surveys (31%) were returned. Mean number of burn beds was 15.7 +/- 1.4, with 264 +/- 25 burn admissions per year. The respondents had been in burn care for 15.9 +/- 1.4 years. Their mean hemoglobin transfusion threshold was 8.12 +/- 1.7 g/dl. The most frequent reasons for transfusion were ongoing blood loss (22%), anemia (20%), hypoxia (13%), and cardiac disease (12%). Inhalation injury influenced the decision to transfuse blood in 34%. The hemoglobin level below which respondents would transfuse blood increased with increasing TBSA burn, history of cardiac disease, acute respiratory distress syndrome, and age. Blood transfusion thresholds in burns vary based on burn percentage, age, and presence of cardiac disease. To date, no standard of care exists for blood transfusions in burns. Future prospective studies are needed to determine the appropriate use of blood in burns.

Effects of burn wound excision on bacterial colonization and invasion

Rates of survival after thermal injury have improved in the past two decades, and rates of wound infections and sepsis have decreased during the same period. Early excision has been advocated as one of the major factors, but its safety and efficacy and the exact timing of burn excision are still under debate. It was hypothesized that acute burn wound excision (in the first 24 hours after burning) would be superior to conservative treatment and delayed excision in preventing bacterial colonization and invasion. Twenty consecutive patients with thermal injuries were studied. Twelve patients underwent acute burn wound excision, and eight patients underwent conservative treatment and delayed excision. The second group of patients received topical treatments in another facility and underwent delayed excision after transfer to our service, on postburn day 6. Quantitative bacteriological assessments of the excised wound and biopsy samples of the wound bed, obtained before autografting and/or homografting, were performed. The effects of time on bacterial counts, differences between superficial and deep biopsy samples, and the effects of early versus late debridement were studied. Patients admitted early exhibited bacterial counts of less than 10 bacteria per gram of tissue. Patients in this group did not experience infection or graft loss. Patients admitted late exhibited counts of more than 10 bacteria (p = 0.001, compared with early admission). Three patients in the late excision group experienced infection and graft loss (p < 0.05, compared with the early excision group). Burn wound excision significantly decreased bacterial colonization for all patients (p < 0.001). Greater bacterial colonization and higher rates of infection were correlated with topical treatment and late excision (p < 0.001). It is concluded that burn wound excision significantly reduces bacterial colonization. Patients who undergo topical treatment and delayed burn wound excision exhibit greater bacterial colonization and increased rates of infection. Acute burn wound excision should be considered for all full-thickness burns.