Abstract
The aim of the study was to reassess surgical protocols developed and introduced in 2005; to examine the changes that have been made and to understand why they have been necessary or felt to be an improvement on the original; and to introduce a new protocol to assist with burn depth assessment. A discussion of how the protocols were developed and the environment in which they are used is undertaken. Four years of experience using the protocols has been accrued. An examination of alterations is performed. The protocols have allowed a single-handed practitioner to deal successfully with a large caseload and enabled a greater understanding of time and resource management. The original development of the protocols was worthwhile but their continued evolution by frequent audit and evaluation of innovations in burn care is mandatory.
Introduction
In 2006, a paper was published by the Australian and New Zealand Journal of Surgery (the official organ of the Royal Australasian College of Surgeons), 1 which documented a process of protocol development and introduction that had been undertaken by the Adult Burn Service at the Royal Adelaide Hospital and underlined why such development had been felt necessary. There had been a marked increase in burn admissions over the preceding years which precipitated the paper's publication. This increase in workload was not met with any resource increase including, unfortunately, no increased elective operating time. The obvious consequence of this increase was thus a reliance on the ability to manage burns injuries ‘out of hours’. Although consultant presence was common at such sessions, the simpler cases tended to be performed by the on-call team without senior specialist supervision. The increasing workload was and continues to be complicated by sudden major surges of activity (2002 Bali bombings, 2004 Port Lincoln Explosion, 2005 Eyre Peninsula fires, 2005 Gladstone Explosion, 2009 Mount Barker Explosion). To ensure that a high standard of care continued to be delivered even throughout such busy periods, surgical protocols for the management of the burn patient were developed and instituted.
The protocols were introduced into practice by the Adult Burn Service at the Royal Adelaide Hospital in January 2005. Their impact was immediate and broad based, with a succession of very large and complicated burn injuries being managed with no mortality. The protocols rapidly became invaluable as instructional aids for the junior surgeons who cover the service on call and standardized burn patient management. In the years since publication, it has become obvious that few burn units boast any such pathways, let alone such a comprehensive collection (which has now expanded to include a range of community, Emergency Department, nursing and dressing protocols). Some of the units we have been in contact with have adapted these protocols for their own practice.
A series of pre- and postoperative nursing wound management pathways has also been designed to complement the surgical protocols, facilitating the education of new Burn Unit nursing staff.
This paper aims to outline how the protocols have developed since their introduction and shows how they have become an invaluable resource within our unit.
Methods
Factors in protocol development
The Royal Adelaide Burns Unit caters for burns of any size, but burns complicated by airway compromise, inhalation injury, systemic poisoning or significant complicating co-morbidities are cared for initially on the intensive care unit (ICU). These ICU-based patients receive input from the same multidisciplinary burn team as they do on the Burns Unit; however, the ICU physicians are afforded free rein to ensure appropriate airway, respiratory and cardiovascular support. Certain elements of the protocols have thus been designed to allow, for example, the need for a period of inotrope administration.
Four elective half-day operating sessions per week are routinely available for burn patient management in the specialized burns theatre. Efficient use of this time requires meticulous planning and foresight to ensure that each stage of a major burn injury patient's treatment happens at the appropriate time, while maintaining the day-to-day treatment of smaller burn injuries.
Organization of the protocols and basic caveats
A number of surgical protocols are in current use: burn depth assessment, management of <20% total body surface area (TBSA) injuries, 20–50% TBSA injuries, >50% TBSA injuries, non-survivable injuries and technical protocols outlining early excision, proper application of dressings (e.g. Biobrane™) and subcutaneous adrenaline tumescence. The rather arbitrary distinction of burn area has been chosen to assist with the rationalization of dressing materials, skin substitutes and cellular therapy and will be discussed later.
The protocols
Burn depth assessment
This pathway uses simple observation. If the epidermis is present and cannot be gently sheared (Nikolsky sign), the burn is superficial (epidermal) (Figure 1). If missing (or ‘shearable’), the next question is whether the burn bed is ‘slippery’ (i.e. is the burn exuding?). A dry burn will generally require excision and grafting (except on the face where spontaneous healing of some quite deep-looking injuries will occur – Figures 2, a–c). The bed is either red (deep dermal – often displaying mottling and no refill) or white (full thickness). An exuding burn, however, generally has an intact dermal circulation and thus if treated appropriately should heal spontaneously. Blister remnants (or intact blisters) indicate the depth. Blister fluid accumulates between the dead roof and viable underlying tissue. If the roof is thin (a thin-walled blister), the burn is superficial partial thickness. Blisters of this type have often ruptured. A thick-walled blister indicates a mid-dermal injury (the dead roof is thicker; therefore, the tissue is destroyed to a greater depth).
Protocol for burn depth assessment
Spontaneous healing in an apparently deep facial burn. (a) Original injury; (b) dressed with Transcyte™; and (c) spontaneous healing
Early burn excision
The basic caveat on which these protocols pivot is the need for expeditious burn excision. 2–8 In patients with lower airway inhalation injury, there appears (at least anecdotally) to be a ‘surgical window’ which opens at the time of the burn injury and closes 48–72 hours later. During this window, although resuscitation is ongoing, the respiratory tract appears robust to early surgery. Following resuscitation, in patients with a significant inhalation injury, as chemical pneumonitis and acute respiratory distress syndrome (ARDS) develop around the 48–72 hour point, the patient becomes more difficult to manage from an anaesthetic point of view. If the burn has not been excised by this stage, the patient is often too unwell for an aggressive surgical approach and thus this is invariably delayed. By the time the patient has stabilized sufficiently from a respiratory perspective, any retained burn eschar is degrading and bacterially contaminated. Systemic problems, especially renal, typically ensue. With the burn excised by protocol on admission (or within 12 hours), the recovery of the respiratory tract can be the prime focus of the ICU staff without the worry of persisting burn eschar.
Surgical protocol for <20% TBSA burn injuries
Initial burn surgery occurs either on arrival or within 12 hours depending on the quality of first-aid and primary treatment at the referring centre and the degree of resuscitation and stabilization needed in our Emergency Department (Figure 3). As with all burns, trauma clearance is an absolute necessity to rule out concomitant injury.
Surgical protocol for burns <20% total body surface area
Most patients have received first aid in a manner guaranteed to contaminate the burn wound. Additionally, in our experience, burns with organic materials (such as hot cooking oil, petrol, etc.) have a high likelihood of infection and subsequent deepening. Combined with the discomfort of the burn injury, such contamination mandates that all but the very small superficial burn injury patients attend the operating theatre where, under general anaesthesia, they undergo an aggressive scrub and cleaning of their burn with an antiseptic brush, cleaning and trimming of fingernails/toenails if appropriate and the removal of all non-viable material. If the burn is superficial partial thickness down to mid-dermal, the burn wound and the surrounding non-burned skin is shaved and Biobrane™ applied, according to the protocol as described later.
If the burn is obviously deep dermal or full thickness (as gauged by the depth assessment protocol above), the burn is excised, autograft harvested and applied as sheet skin to the dorsal aspect of the hands and as meshed autograft at 1:1.5 to the remaining burn wounds. Palmar and plantar burns are treated conservatively, regardless of TBSA, even if clinically deep dermal, and dressed with Acticoat™. Similarly, if the face is injured, even if the burn appears deep dermal, conservative treatment with soft paraffin (nursed on the Burns Unit) or Aquacel Ag™ (nursed on the ICU) is commenced. The loss of Transcyte™ is deeply felt (Figure 3).
Surgical protocol for burns 20–50% TBSA
Again trauma clearance is mandatory. Patients attend theatre for an aggressive scrub and shave of their entire burn area (Figure 4). Burn depth assessment is much easier once non-viable material, soot, blood, dirt and other contaminants have been completely removed. If the burn is superficial to mid-dermal, Biobrane™ is applied. In this protocol however, Acticoat™ (nanocrystalline silver dressing) is preferred as the secondary dressing as it requires less frequent dressing changes. In this bigger burn group, its expense is justified by reduction in the frequency of painful and manpower-intensive dressing changes.
Surgical protocol for burns 20–50% total body surface area
The next consideration in this group is the presence of concomitant inhalation injury. If the patient has sustained an inhalation injury, they frequently deteriorate over the first few days and typically require the administration of inotrope medication. High doses of inotropes, while necessary for survival, anecdotally result in such severe superficial vasoconstriction as to result in the loss of skin grafts, Integra™ and other skin substitutes. Conversion of skin graft donor sites to full-thickness skin injuries has also been seen in such cases. Literature support for this observation remains scant. 9 For this reason, patients at risk of such deterioration have their excised burn wounds dressed with Biobrane™ and Acticoat™. They are monitored on the ICU for the next 48 hours and, if not requiring inotropes, then proceed to autografting.
In those patients who are not at risk of developing the systemic effects of severe inhalation injury, autografting is performed at the time of burn excision. In the larger (40–50% TBSA) injuries where donor sites may be insufficient for complete coverage of the burn at the initial procedure, further surgery may be required when donor re-harvesting is possible.
Surgical protocol for burns >50% TBSA
In this group of patients, the area of the non-viable burn injury typically exceeds available autograft (Figure 5). Mandatory trauma clearance is again required on arrival followed by theatre for an aggressive scrub and excision of the entire burn if deep dermal/full thickness. At this initial surgery, a split-skin biopsy is taken for ACKT (autologous cultured keratinocytes for transplantation). This is undertaken on the hospital campus. The process takes approximately five days to provide preconfluent cultured keratinocyte suspension.
Surgical protocol for burns >50% total body surface area
If the patient is to return to the Burns Unit postoperatively, split-skin graft is harvested and posterior trunk burns grafted with 1:2 or 1:4 meshed autograft (depending again on the availability of donor skin). The remaining debrided wounds are dressed with Biobrane™ and Acticoat™. Face care is identical to the 20–50% group. For those patients at risk of deterioration secondary to inhalation injury, autografting is delayed.
The next phase of surgery occurs typically 48 hours postgrafting of the posterior trunk and involves sheet grafting to hands (if donor site is available). Simultaneously, Integra™ is applied to all debrided and ungrafted wounds after appropriate refreshing of the wound bed. The Integra™ is held with Fastinet™ and overdressed with Acticoat™ on the trunk and with Acticoat™ and crepe on the limbs. Integra™ is thereafter inspected on a daily basis.
A general anaesthetic dressing change and staple removal, combined with inspection and planning the next phase of treatment, occurs next, usually at seven days for uncomplicated cases and nine days in others. When further donor sites are available, serial de-lamination of the Integra™ occurs with autografting at 1:2 mesh combined with application of ACKT. Grafting begins with the upper limbs, then anterior trunk and then lower limbs. ACKT is also used to accelerate the healing of donor sites.
Protocol for the management of patients with non-survival burn injuries
Despite aggressive surgery and intensive treatment on the ICU, there remain a few patients with burn injury so severe that survival is not possible (Figure 6). In our experience, it has not been possible to achieve survival in patients who present with greater than 80% full-thickness burn injuries with bronchoscopic evidence of significant lower airway inhalation injury.
Protocol for the management of non-survivable burn injury
In these situations, the decision not to treat is made by three members of the consultant staff. This always includes a burns surgeon and a senior anaesthetist (who performs the bronchoscopy) and either a consultant intensive care physician or a consultant emergency department physician. The severity of injury, probable death and the recommendation for comfort care is discussed with any available relatives. In the event that the relatives wish for treatment to be pursued, the patient is managed aggressively as outlined previously in the >50% burn injury protocol.
This protocol is designed to allow relatives to say their goodbyes as ‘atraumatically’ as possible and to remove the visible (and the sometimes more important olfactory) signs of often horrendous burn injury.
Patients who fulfil the criteria for comfort care only have intravenous analgesia titrated to their requirements and are intubated and ventilated. The burn eschar is scrubbed in the resuscitation cubicle to remove all surface non-viable material (blisters/charcoal/soot/partially detached tissue) before being dressed with gauze and crepe.
The hands are cleaned meticulously including the nails which may be trimmed, or even removed if loose. If the burn injury permits, at least one hand is left cleaned and undressed for relative contact.
Facial hair is shaved (including eyebrows if necessary) and scalp hair is trimmed back from the face. The hair is washed with warm water and soap and (if the burn injury permits) the face is left undressed.
All smoky, charred or soiled clothing is bagged, labelled and removed from the cubicle. The patient is then transferred to a quiet, low-lit cubicle on either the Burns Unit or the ICU as appropriate. The injuries are discussed with the relatives present and arrangements made for them to stay with the patient if they so wish.
Since all burn deaths in South Australia are the subject of Coroner's postmortem and investigation, no further relative contact is permissible once death occurs.
Protocol for the application of Biobrane™
The first author recently published an extensive treatise on his experience with Biobrane™ and reference to that article should be made for in-depth understanding (Figure 7). 10 This temporary, biosynthetic epidermal substitute has a number of applications; however, in inexperienced hands it may be unpredictable. Problems have been related to seemingly unimportant details, such as failing to shave the surface of the burn and the surrounding unburned skin. Once the hairs spring upright, the material can lift and infective problems ensue. A formal protocol for the use of this material was created to facilitate learning and good clinical practice.
Biobrane™ application
While staples were originally used to hold this material, sterile adhesive tape is now used. In contaminated burn wounds that have been scrubbed, overdressing the Biobrane™ with betadine-soaked gauze, even changed on a daily basis, resulted in rapid drying and stiffening of the gauze layer. A keenness to maintain a degree of antibacterial effect, coupled with a dressing which maintains pliability, led to the use of a weak betadine solution (100 mL betadine in 1000 mL sterile normal saline). Gauze soaked in this solution, and well wrung out prior to application, does not stiffen noticeably on drying. Outer dressings are afforded by crepe bandage on the limbs. The use of Acticoat™, overdressed by Exudry™ on the posterior trunk and by Cutilin™ on the anterior trunk, is easier to manage.
The outer dressings are changed on a daily basis until the Biobrane™ is firmly adhered at which stage the patient is discharged home. Review every two or three days allows the repeated trimming of Biobrane™ (which has lifted off healed areas) until the wound is completely healed.
Tumescence
Every burn to be excised and all proposed donor sites are tumesced subcutaneously with a solution of 1:500,000 adrenaline and weak bupivacaine (2 vials of adrenaline 1:1000 plus 40 mL of 0.5% bupivacaine in 1 L of normal saline) (Figure 8). The resultant blood loss, even with a very large burn is small and easily managed. The requirement for blood transfusion is uncommon, and the usage of this precious resource has diminished since the introduction of this technique (unpublished data). Even massive excisions (80% TBSA+) can thus be performed in a single procedure on admission. 11,12 A protocol for the tumescence technique has been included with this article (Figure 1). Tumescence removes the need for a haemostatic donor site dressing.
Protocol for burn and donor site tumescence
Discussion
The impact of protocol-driven patient management
Following the introduction of the surgical protocols, copies were distributed both to the Burns Theatre and General Operating Theatre Suite where they were incorporated into in-service education programmes. This had the immediate potential to facilitate theatre staff planning for major burn cases, especially the preparation of essential items such as the tumescence solution and the availability of specific consumables. Administrators can clearly see that if the case will require large volumes of complicated dressing materials, skin substitutes and cellular products (all necessitating specialist nurse input), then utilizing the dedicated burns theatre is preferential, and thus this decision-making process has been streamlined.
Audit
The protocol-led patient care (both nursing and medical) has facilitated clinical audit. Without formal protocols, the process of audit can be difficult with single changes in practice occasionally necessitating several smaller (and usually ignored) changes. In such cases, it can be difficult establishing with certainty which change is responsible for the overall perceived changes in outcome. Later in this article, some illustrations are given showing how auditing practice is when the impact of changing individual components can be isolated by standardizing all the other parameters.
Similarly, as new technologies and dressings have become available, the protocols have allowed for their considered evaluation against an established ‘gold standard’. This, together with assimilation of data from well-designed studies from the published literature, will continue to allow evidence-based updating of the protocols on a frequent basis.
Burn care is increasing in complexity as skin substitute usage and the employment of cellular therapies becomes more common. When the original paper was written, Australian burn surgeons had access to cadaver skin, Biobrane™, Transcyte™ and Integra™. Purpose-designed dressings and new skin substitutes are becoming more available and finding wider use. The haphazard introduction of such novelties risks a skyrocketing cost of burn injury. However, these innovations must be assessed and rationalized. The development of protocols has allowed for the thoughtful use of existing expensive therapy, and the introduction of those proven to be superior, while confining many of the most expensive materials to the management of major (>50% TBSA) burn injury. This has simultaneously safeguarded the purchase and use of such therapies in the appropriate patient from administrative and budgetary constraints.
Evolution of the protocols
Since the introduction of the original surgical protocols in 2005, there have been several developments that have led to change. Of course, this was always the intention. For example, in the original paper our primary face care in burns >20% was with Transcyte™, a material sadly unavailable for this use for the past few years. While face care on the Burn Unit can be very adequately managed by soft paraffin and meticulous care alone, the ICU situation demands something more rigorous. The sitting of the endotracheal tube and nasogastric tube/feeding tube, together with intraoral and airway burns, can lead to fluid leaking from nares and oral commissures. Frequently malodorous due to difficulties with mouth care, this can lead to infection of facial burns. Aquacel Ag™ is currently used in these patients. This silver-impregnated alginate material adheres well to facial exudate and needs no fixation. It can be easily removed and refreshed and is simple to fashion into a face mask. However, frequent monitoring is necessary as in certain cases a collection can develop beneath the material without an outward sign.
The evaluation of innovative and emerging materials such as AWBAT-S™ and Neuskin-F™ can be easily accommodated by the current protocols and the effects accurately interpreted. A randomized controlled trial of AWBAT-S™ in superficial partial thickness burns (compared with Biobrane™) is already underway; Neuskin-F™ will undergo similar evaluation when it becomes available in Australia.
The Skin Engineering Laboratory at the Royal Adelaid Hospital previously supplied an enzymatically created non-cultured suspension of keratinocytes and melanocytes (CellStat), analogous to C3's Re-Cell™ product. We used this in an attempt to hasten the re-epithelialization of donor sites and the interstices of meshed split-skin grafts. However, a randomized, placebo-controlled trial of the technique and product failed to show any ability to expedite re-epithelialization. 13 As a result, it was deemed that the CellStat process had no clinical role and it was removed from the protocols.
The use of gauze soaked in weak (1 in 10) betadine solution over Biobrane™ was reviewed for the trunk, where it was found to be difficult to maintain. It was changed at this site to Acticoat™, which could easily be taped into place before being covered by Cutilin™ anteriorly and Exudry™ posteriorly. These alterations are relatively small, but have resulted from an audit process which was designed to be facilitated by protocol-directed practice.
The repeated failure of both the Victorian and New Zealand Cadaver Skin banks to reliably provide this resource for major burn patients has led to the complete removal of cadaver skin from the protocols. Biobrane™ works just as well in temporizing the debrided burn wound when used as outlined previously.
Conclusion
These protocols were developed based upon ongoing clinical activities and did not represent a change in practice, but rather an element of standardization. As such, they continue to work in practice at the Royal Adelaide Hospital. The bonuses to their development, outlined in the introduction, have more than rewarded the work involved in their development. While no protocols have required deletion or withdrawal, several changes have been made to the original protocols. These have chiefly been forced by material withdrawal (e.g. Transcyte™), resource availability (e.g. cadaveric skin) or research and audit findings. Their introduction into our surgical practice has not restricted or impeded in anyway, but rather facilitated and standardized the care provided to patients, allowing all members of the multidisciplinary team to be able to predict accurately the surgical course.