Cost-benefit analysis of outcomes from the use of fibrin sealant for fixation of skin grafts in small-size burns compared to staples as historical controls: a retrospective review.

INTRODUCTION: Historically, split-thickness skin grafts have been fixed onto the recipient site by suture and/or staples. Fibrin sealants have become available for the fixation in the past 10 years. Fibrin sealants have been shown to be at least as effective as staples, and recent reports show them to cause less pain. However, the product is much more expensive than traditional suture and/or staple fixation. The cost-benefit ratio of sealant has not yet been proven. METHODS: A review of charts for 202 consecutive patients was undertaken for patients with burns that were less than 10% total body surface area (TBSA) that underwent excision and grafting using fibrin sealant at the regional burn center. A historical control comprising 48 consecutive patients with burns that were less than 10% TBSA that underwent excision and grafting using staples as the only means of fixation was used for comparison. Demographics (such as age, weight, and sex), personal history of tobacco use, previous diagnosis of diabetes, type and depth of burn, TBSA, area of grafting, graft and donor locations, mesh type, rate of hematomas, rate of graft loss, rate of complete closure at 1 month, and time to discharge after surgery were recorded for each patient in both cohorts. The data were compared and statistical analysis performed for graft loss complications and number of days until the patient could be discharged home with outpatient wound care. RESULTS: Use of fibrin sealants has resulted in statistically significant lower rates of loss of graft at our institution. Additionally, a decrease in the number of days until discharge to outpatient wound care of nearly 2 days produced a lower cost of care in patients with less than 10% TBSA undergoing excision and grafting. CONCLUSIONS: The use of fibrin sealants allows for fewer graft loss complications and earlier discharge in patients who have burns that are less than 10% TBSA. This decrease in hospital days results in savings, although this difference is not statistically significant.

The safety of low molecular-weight heparin after blunt liver and spleen injuries.

BACKGROUND: Anticoagulation is routinely administered to all trauma patients owing to the high incidence of venous thromboembolism (VTE). However, the timing of administration of anticoagulation is not clearly defined when patients have blunt spleen or liver injuries because of the perceived risk of hemorrhage with early administration. METHODS: A retrospective chart review was performed of all blunt trauma patients who sustained blunt liver and/or spleen injuries during the 5-year period from 2007 to 2011. Data were collected for all patients managed with nonoperative therapy for these injuries while also receiving routine prophylactic anticoagulation with low molecular-weight heparin. Patients were categorized based on the initiation of enoxaparin therapy after injury: early (<48 hours), intermediate (48 to 72 hours), and late (>72 hours). Primary and secondary outcomes were designated as need for operative or radiologic intervention secondary to spleen or liver hemorrhage, number of transfusions, and incidence of VTE. RESULTS: Three hundred and twenty-eight patients were included. There were no enoxaparin-related hemorrhagic complications or hemorrhage necessitating operative intervention. Patients in the early, intermediate, and late groups received an average of .9, .93, and 1.55 units of blood, respectively. There was 1 pulmonary embolism in the early group, and there were 6 VTE complications in the late group (3 deep venous thromboses and 3 pulmonary embolisms). CONCLUSIONS: There are currently no standards for the initiation of prophylactic anticoagulation in trauma patients with blunt liver and spleen injuries. Early administration may be safe and reduce the incidence of thrombotic complications in patients with blunt spleen and liver injuries. Prospective studies in this area are warranted.