|Year : 2021 | Volume
| Issue : 1 | Page : 26-30
Timing of excision of full-thickness burns and the effect of delay on outcome
Faraj Elmishat, Adelin R Muganza, Ifongo Bombil, Aylwyn Mannell, Marietha Johanna Nel
Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
|Date of Submission||06-Aug-2020|
|Date of Acceptance||13-Mar-2021|
|Date of Web Publication||03-Feb-2022|
Dr. Marietha Johanna Nel
Department of Surgery, Faculty of Health Sciences, Wits Medical School, 7 York Road, Parktown, Johannesburg 2193, Gauteng Province
Source of Support: None, Conflict of Interest: None
Context: The time of debridement of burn wounds is controversial. This study assessed the outcomes of various times of excision of full-thickness thermal burns involving a total body surface area (TBSA) of 15%–40% when immediate grafting is not possible.
Aims: This study aimed to compare mortality rate and hospital days between very early excision, delayed early excision, and delayed excision.
Setting and Design: This was a retrospective observational research study of 103 patients older than 18 years with full-thickness thermal burns involving a TBSA of 15%–40%, admitted to our Adult Burns Unit from January 2014 to December 2016.
Subjects and Methods: Only “traditional” burn wound dressings such as Jelonet, Melladerm, Anticoat, or bandages were used without immediate skin grafting. Using the STATA Version 14.2 (College Hill, TX) statistical program, the Mann–Whitney U-test was used to compare any two groups, the Kruskal–Wallis test to determine differences between any three groups and the Chi-square test to measure associations between gender and patient outcome. Linear regression was used to determine the predictors of the number of hospital days postsurgery.
Results: With a median patient age of 34 years, 66% were male. The majority had delayed excision (41.7%), 34% had delayed early excision and 24.3% had very early excision.
Conclusions: Where immediate cover after excision is not possible due to cost or availability, and the wound is only covered with “traditional” burn dressings, early excisions had no advantage over delayed excisions with regard to mortality rate or duration of hospital stay.
Keywords: Excision, full-thickness burn, timing
|How to cite this article:|
Elmishat F, Muganza AR, Bombil I, Mannell A, Nel MJ. Timing of excision of full-thickness burns and the effect of delay on outcome. Indian J Burns 2021;29:26-30
|How to cite this URL:|
Elmishat F, Muganza AR, Bombil I, Mannell A, Nel MJ. Timing of excision of full-thickness burns and the effect of delay on outcome. Indian J Burns [serial online] 2021 [cited 2022 Nov 28];29:26-30. Available from: https://www.ijburns.com/text.asp?2021/29/1/26/337206
| Introduction|| |
With an estimated 21 million homes in South Africa using kerosene as the only or the primary energy source, burns are a substantial cause of mortality and morbidity. There is a general agreement that standard of care in burn management is early excision and immediate grafting. No consensus on optimal time of “early” excision has been reached. Immediate grafting is also not always possible in developing countries such as South Africa. This is the first much-needed South African study assessing the patient outcomes by comparing early-, delayed early-, and delayed excision where no immediate grafting is performed.
| Subjects and Methods|| |
All adult patients older than 18 years who met the study inclusion criteria of full-thickness thermal burns with a total body surface area (TBSA) of 15%–40% have been included in the study. However, patients admitted with a 24 h or more delayed presentation, and patients who received conservative wound care were excluded from this study.
Patients were classified into three groups according to the number of days from admission until surgery (presurgery days), such as very early excision, delayed early excision, and delayed excision as outlined in [Table 1]. No patient selection criteria was used since the policy at our Adult Burns Unit at the time of this study favored early excision as soon as the patient was stable and with the proviso that an operating theater, water, and electricity were available.
|Table 1: Very early excision, delayed early excision, and delayed excision classification|
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The tangential excision method described as the Eschar plane technique was used for all excisions. With no immediate grafts available, traditional cover such as Jelonet, Melladerm, Anticoat, or bandages were used until the wound was clean and ready for a split skin graft.
Statistical analysis used
The STATA Version 14.2 (College Station, TX, USA) statistical software package was used for data analysis. The Shapiro–Wilk test for normality of the continuous variables showed that the variables were not normally distributed. Therefore, the Mann–Whitney U test was used to test for significance between any two groups, and the KruskalWallis test was used to determine differences between any three groups. To measure the association between gender and patient outcome status, the Chi-square test was used. Linear regression was used to determine the predictors of the number of days spent in hospital postsurgery.
This study was approved by the Human Research Ethics Committee (medical) of the University of the Witwatersrand on the January 26, 2018, with the ethics clearance number: M180109.
| Results|| |
Gender and age
Out of a total of 103 patients, male patients showed a higher survival rate than females, with a P = 0.045 [Table 2]. There was no significant difference in the age of the patients who survived or died (P = 0.08), regardless of gender.
The majority of patients, according to the number of days from admission until surgery (presurgery days), were in the delayed excision group as outlined in [Table 3].
|Table 3: Percentage of patients who had early excision, delayed early excision, and delayed excision (n=103)|
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Hospital stay, excision time, and patient outcome
For every additional day in hospital presurgery, the patient's chance to survive increased by 19% (P = 0.01), (confidence interval [CI] 1.04–1.36), and reduced the number of postsurgery hospital days by 24%. However, this relationship is not statistically significant (P = 0.07). In patients who survived (n = 61), the overall median number of days in hospital postsurgery was 27. Patients with delayed early excision spent the highest total number of days in the hospital [Table 4].
The Chi-square test showed a significant association between patient outcome and excision time (P = 0.03) [Table 5]. Of the 61 patients who survived, the majority had delayed excisions while the majority of patients who died had delayed early excisions [Table 5].
Both univariate and multivariate regression models were used to determine the predictive relationship between excision times and patient survival. Very early excision and delayed early excision significantly decrease patient survival to <68% (P = 0.03, CI 0.11–0.9) and <67% (P = 0.02, 95%, CI 0.13–0.84), respectively, compared to delayed excision. When the model reference was very early excision, the chance of a patient's survival was increased by 2% for delayed early excision. The odds ratio for patients who survived and had delayed excisions was 3.15 times that of patients who had very early excisions. Indeed, the odds increase in patient survival was statistically significant with P = 0.03, for the delayed excision group compared to the very early excision group.
Total body surface area
Patients who died had, as to be expected, a significantly higher TBSA burnt than patients who survived [Table 6]. Determining the predictors of the number of hospital days postsurgery by univariate linear regression shows that a 1% increase in TBSA burnt, significantly increases the number of hospital days postsurgery by 28.2% (P = 0.03).
In our setting, a 1% increase in the burnt TBSA increases the chance of a patient to have very early excision compared to delayed excision by 14%, with a P = 0.001 (CI 1.06–1.23). Furthermore, a 1% increase in the burnt TBSA increases the chance of a patient to have a delayed early excision compared to a delayed excision by 10%, with a P = 0.005 (CI of 1.03–1.18).
Irrespective of patient outcome, patients who had very early excisions had a significantly larger TBSA (30%) burnt than patients who had delayed early excision or delayed excision. However, in patients who survived, there was no significant difference in the TBSA burnt between the three excision categories, with a P = 0.28. In contrast, the deceased patients in the early and delayed early-excision times had a significantly lower percentage of TBSA injury compared to patients who had delayed excisions, with a P = 0.002.
After adjusting for TBSA burnt, age, and gender in the multivariate regression model for patients who had very early excisions shows an equal chance of survival compared to patients who had delayed excision. However, the result is not significant with a P = 0.99 (CI 0.33–3.09). Patients who had delayed early excision had a 3.32 odds ratio of survival compared to patients who had delayed excision, but the result is still not significant since the P = 0.06.
The spearman correlation analysis was used to determine the relationship between days in hospital pre- and post-surgery, age, and TBSA burnt. This correlation analysis shows that there was a significant inverse relationship between the number of hospital days postsurgery and the number of hospital days presurgery rs = −0.35, P = 0.01. As to be expected, there was a positive relationship between the TBSA burnt and the number of hospital days postsurgery rs = 0.41, P = 0.00. A multivariate stepwise linear regression using gender, TBSA burnt, age, and hospital days presurgery to predict the number of hospital days postsurgery also shows that TBSA is a significant predictor of the number of days postsurgery. [Figure 1] illustrates the linear relationship between hospital days postsurgery and TBSA.
|Figure 1: Linear regression relationships between total body surface area burnt and the number of hospital days postsurgery|
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Interestingly, the spearman analysis showed a significant inverse relationship between age and TBSA burnt rs = −0.28, P = 0.03, while gender (male) together with TBSA is a predictor of hospital days postsurgery. Gender and age each on their own are not significant predictors of the number of hospital days postsurgery.
| Discussion|| |
This study shows that gender is a significant predictor of burn patient survival with male patients having a better chance to survive a major burn injury involving 15%–40% of the TBSA than women. Although according to other studies, mortality was increased significantly with increasing age,, the survival of male patients in this current study was not dependent on age since there was no statistical significant difference in the age of the male patients who survived and those who died.
The median burnt TBSA for the patients was 25.1%, and as expected patients who died had a higher burnt TBSA than patients who survived. There is a significant positive relationship between the TBSA burnt and the number of hospital days postsurgery. Indeed, the length of hospital stay depends mainly on % TBSA burnt. Delayed excisions had better patient outcomes in terms of length of hospital stay compared to very early excisions and delayed early excisions. Irrespective of patient outcome, patients who had very early excisions had a significantly larger burnt TBSA than patients who had delayed early excision and delayed excision. This is in line with the routine practice and policy in the Adult Burns Unit at the study hospital with the main reason for early excision being that it decreases inflammatory mediator release and decreases the risk of bacterial colonization, which attenuates the systemic inflammatory response syndrome, thereby reducing the development of metabolic derangement, multi-organ failure, and sepsis. However, a retrospective study of 39 patients, of which twenty patients had excisions within 3 days and 19 patients had excisions after 3 days, the mortality and incidence of sepsis were not significantly different and both groups had the same length of hospital stay.
Patients who survived spent on average 27 days in hospital postsurgery. Patients with delayed early excision spent the highest total (preplus postsurgery) number of days in hospital compared to patients who had very early excision and delayed excision, respectively. This difference in the number of days between very early and delayed excision may be explained by the fact that patients who had early excisions had a larger TBSA burnt than patients who had delayed excisions as per the Adult Burns Unit policy.
Similar earlier studies compared early excision to delayed excision with immediate grafting, which is vastly different from the current study in which patients also had either early-or delayed excisions, but with “traditional” burn dressings and late grafting. Importantly, the optimum time for early excision is still debated. Despite reported findings, there is no consensus in the literature as to the timeframe of “early” and which treatment protocol is optimal. Ayaz et al. compared the outcome of patients with burns involving < 15% of TBSA. Half of the patients underwent early excision and skin grafting (within 14 days of injury) and the other half underwent delayed excision and skin grafting (after 14 days of burn injury). These authors found that “early” excision, which is equivalent to delayed excision in this current study, was associated with a higher graft success rate compared to delayed excision and grafting. However, the length of hospital stay and the resultant scar were similar in both the early and the delayed excision patients.
In a study by Saaiq et al., half of the patients had early burn wound excisions and skin autografting (within 4–7 days of the initial burn injury), and the other half had delayed excision and autografting (within 1–4 weeks after the initial injury. The delayed excision in the Saaiq et al., study (1–4 weeks) is similar to the delayed excision in the Ayaz report (more than 14 days) and the current study's delayed excision number of days (more than 7). However, the Saaiq et al.'s study supports early excision and auto skin grafting. In the present study, only “traditional” burn wound dressing was used without immediate skin grafting being available in the setting in the years for which the study data were collected. Fortunately, later on after this study, the availability of xenografts increased and excision with immediate grafting became more available.
| Conclusions|| |
In previous studies originating from mostly developed countries comparing early excision and delayed excision, the skin was immediately covered using either auto or xenografts, and therefore the outcomes were better with early excision. The value of this current study is however in showing that in circumstances where immediate grafting after excision is not always possible, due to graft nonavailability, no theater availability, no water or electricity supply, as often is the case in developing countries, and the wound is covered with “traditional” burn dressings, practicing early excision is not more advantageous than delayed excision.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]