Effect of subcutaneous epinephrine/saline/local anesthetic versus saline-only injection on split-thickness skin graft donor site perfusion, healing, and pain.

The technique for split-thickness skin graft harvest varies among surgeons. Even though there is scientific evidence that the subcutaneous injection of modified tumescent solution reduces blood loss during burn surgery, the technique has not been unanimously adapted because of, in part, fear of healing retardation. This study prospectively examines the effect of tumescent injection on donor site perfusion, healing, and pain. Ten burn patients in need of grafting with a need for two distinctly different donor sites were included. During the grafting procedure, the two donor areas were randomly assigned to receive either modified tumescent solution or warm sterile saline solution subcutaneously before skin graft harvest with a dermatome. Perfusion, pain, pruritus, and donor site healing were measured, and a follow-up evaluation on scar quality was performed. Baseline perfusion on day 1 was significantly less in the donor site injected with modified tumescent solution (62.26 vs 95.71 perfusion units; P = .031), whereas the response to heat was similar in both sites. The physiologic response to injury (hyperemia) on days 2 and 3 was not suppressed in the modified tumescent group. Pain reported on day 1 was 2.38/10 in the tumescent site and 3.38/10 in the saline site (P = .21). On all other days, measurements showed no difference between the two sites. Donor sites healed in an average of 16.1 days with modified tumescent solution and in 16.4 days with saline. Late follow-up showed no difference in scar quality. The subcutaneous injection of modified tumescent solution before split-thickness donor site harvest has no adverse effect on donor site perfusion past day 1 or donor site healing. The addition of a local anesthetic may decrease pain for 24 hours postoperatively, but the difference in this study group was not significant. This technique should be universally recommended.

Brother, have you got a light? Assessing the need for intubation in patients sustaining burn injury secondary to home oxygen therapy.

Home oxygen therapy use has steadily increased for the past 30 years. A majority of these patients suffer from chronic obstructive pulmonary disease secondary to smoking. Although warned of the danger of smoking while on oxygen, patients continue to do so, potentially resulting in cutaneous burns and suspected inhalation injury. Those suspected of inhalation injury are intubated for airway control. In the English literature, there is a paucity of data discussing the need for intubation. To date, this is the largest study to determine whether intubated patients had inhalation injury as observed by bronchoscopy and whether intubation was necessary. All patient's charts who sustained burns while on home oxygen therapy from May 2000 to May 2010 were retrospectively reviewed (n = 86). Data collected were age, sex, TBSA, ventilator days, length of stay (LOS), and presence or absence of inhalation. Of those patients intubated, a subset analysis was performed to determine whether intubation in the "Field" or "Outside Hospital" correlated with inhalation injury compared with intubation in our Emergency Department. Eighty-six patients (mean age 64 years, mean %TBSA 2.6) were included. Before transfer to the burn unit, 32 patients (37%) were intubated and 52 patients (61%) were not intubated. Of the 32 intubated patients, bronchoscopy confirmed inhalation injury in 12 patients (39%). No significant difference was seen in %TBSA between intubated vs nonintubated patients (3.5 vs 2.0, respectively). However, there was a difference in LOS between the two groups (12.7 vs 2.8, respectively). No difference was found in incidence of inhalation injury between patients intubated in the "Field/Outside Hospital" compared with patients intubated in our Emergency Department (39% and 37.5%, respectively). Between the subgroups, no difference was found in %TBSA, ventilator days, or LOS. One patient admitted for airway observation required intubation and one patient failed extubation, postoperatively. Patients on home oxygen therapy suspected of inhalation injury should ideally be observed for signs of airway compromise before intubation is performed.