A Paradigm Shift in Practice-The Benefits of Early Active Wound Temporisation, page-36

The shift in our major burn protocol was immediate. From Patient 14 onwards (Supplemental Figure 1) (consent has been obtained from the patient to publish her clinical pictures), large or complex wounds following complete deep burn excision on arrival have been covered with BTM on Day 2 or 3. Considerably superior functional and aesthetic results have been generated (Supplemental Figures 2–7). In addition, there has been an enormous reduction in the need for subsequent reconstructive surgery.

There have been other benefits. Previously, we had harvested autograft as early as possible to commence definitive wound closure. This coincided with the patient being at their sickest and physiologically most vulnerable. Early grafting resulted in longer initial surgeries and prolonged anaesthesia. The patient’s wounds were iatrogenically expanded, adding further early physiological insult. The postoperative pain and patient status created the tendency for them to remain on the intensive care unit longer. In the early phase following burn injury, cutaneous perfusion is threatened by macrocirculatory insufficiency (arising from hypovolaemia, myocardial suppression and arterial vasomotor dysregulation) coupled with local thrombotic microangiopathy and dysregulated microvascular tone. Vasopressor therapy, a common recourse in the management of hypotension in critically ill patients, while potentially protecting vital organs with greater capacity for autoregulation, can severely compromise blood flow to the skin. As a result of the superficial ischaemia, the donor sites fail to heal and become deep wounds and the skin grafts fail to inosculate and wound infection follows. In the major burn scenario, the loss of graft and donor site is devastating for the patient and the clinical condition can become irretrievable.

At the present time, the first procedure to apply split skin autograft in major burn patients at the Royal Adelaide Hospital occurs around five weeks after their admission and burn excision, at a time when they are out of intensive care and physiologically well and strong (airway injury resolved, systemic inflammatory response syndrome settled, extubated, orientated, nutrition appropriate, mobilising out of bed and already undergoing rehabilitative therapy, all areas of more superficial burn healed, etc). At this point, the patient is better physiologically equipped to tolerate large donor site creation. The BTM at this stage is well integrated, but retention of the pseudo-epidermal seal allows staged grafting (the seal is merely left intact on BTM for which there is no autograft at the first grafting operation). The outcome of staged grafting over BTM is the same as one-stage grafting over BTM. Of 29 major burn patients treated with BTM, there have been no deaths in our practice.