Meta-analysis of early excision of burns
Introduction
Severe burn is a devastating form of injury, and is also a significant public health risk in developing countries. Traditionally, patients with burns have been treated with dressings and topical antimicrobial agents until the eschar separates. The granulating wound would then be covered with split thickness skin graft, a process which could take 3–5 weeks. Patients with severe burns treated in this manner are more likely to die from sepsis due to the massive release of inflammatory mediators from the burn wounds. This is further exacerbated by subsequent infection of these wounds. With the traditional approach, patients often have a prolonged hospital stay and are more prone to develop problems like joint contractures and hypertrophic scars due to the delayed wound healing process.
A paradigm shift occurred with the introduction of tangential excision of burns by Janzekovic in 1970 [1]. This technique involved removal of necrotic burnt tissue while preserving as much of the underlying viable tissue as possible. The wounds are then covered immediately with split thickness skin graft. When performed early, excision and immediate wound closure has been shown to improve survival, decrease length of hospital stay in burn patients, especially children [2], [3], [4]. The rationale for early excision of burns is that it decreases release of inflammatory mediators and bacterial colonization of wounds. This, in turn, attenuates the systemic inflammatory response syndrome (SIRS) hence reducing the occurrence of metabolic derangements, sepsis and multi-organ failure.
The opponents of early excision from the early days of early excision were mainly concerned with the massive blood loss seen after early excision. However, with improvement in intensive care management, we are now able to better manage these patients. Other reasons cited against early excision include difficulty of assessing depth of burn in the early period and the need to use cadaveric skin for coverage after early excision. Some authors have also shown no difference in mortality when early excision was compared with more conservative approaches [5], [6].
Early excision and grafting of burns is the standard of practice in most major burn centres around the world now. Our objective was to perform a systematic review of the current evidence on efficacy and safety of early excision of burns and determine if it should be applied across the board to all burn patients.
Section snippets
Material and methods
We included only prospective randomized, controlled trials in our review. The participants could be from all age groups with major or minor burns. The intervention was early excision and immediate grafting of burns with the control arm consisting of patients treated with dressings only followed by delayed grafting after eschar separation. The specific outcomes we sought were mortality, blood loss and blood transfusion requirements, wound healing time, length of hospital stay, duration of
Mortality (Figs. 1 and 2)
This first Forest plot (Fig. 1) compares mortality in early excision group with traditional treatment group. The squares represent the relative risk with the horizontal lines representing the 95% confidence interval. You can see that all trials have 95% CI includes the value 1. When we pooled all the data together, the combined relative risk was 0.72 with 95% CI from 0.52 to 1.01 which shows that there was a reduction in mortality with early excision of burns but the difference is not
Discussion
Early excision of burns is now the standard of care in most major burn centres around the world. The rationale is that it reduces bacteraemia, endotoxin production and release of inflammatory mediators. This would limit the extent of sepsis and multi-organ failure which are the leading causes of death in major burn injuries. There are a number of randomized control trials comparing early excision of burns with the more traditional method of treatment, that is, dressing with topical
Conclusion
From this meta-analysis, we can conclude that early excision of burns reduces mortality in patients without inhalational injury, increases blood transfusion requirements and reduces the length of hospital stay in patients. We were unable to draw any conclusions on duration of sepsis, operating hours, wound healing time, skin graft take and long term morbidities like hypertrophic scarring.
References (15)
- et al.
Early excision of major burns in children: effect on morbidity and mortality
J Paediatr Surg
(1985) Early tangential excision and skin grafting of moderate burns is superior to honey dressing: a prospective randomized trial
Burns
(1999)A new concept in early excision and immediate grafting of burns
J Trauma
(1970)- et al.
Primary burn excision and immediate grafting: a method of shortening illness
J Trauma
(1974) - et al.
Treatment of severe burns with widely meshed skin autograft and meshed skin allograft overlay
J Trauma
(1981) - et al.
Significant reductions in mortality for children with burn injuries through the use of prompt eschar excision
Ann Surg
(1988) - et al.
Comparisons of serial debridement and autografting and massive early excision with cadaver skin overlay in the treatment of large burns in children
J Trauma
(1986)