skin graft management for burn patients...post-graft the burn wound is not sufficientlycovered...

NSW Statewide Burn Injury Service

Skin graft management for burn patients

A clinical guideOCTOBER 2020

aci.health.nsw.gov.au

The information is not a substitute for healthcare providers’ professional judgement.

Agency for Clinical Innovation

1 Reserve Road St Leonards NSW 2065 Locked Bag 2030, St Leonards NSW 1590 T +61 2 9464 4666 | F +61 2 9464 4728 E aci‑[email protected] | www.aci.health.nsw.gov.au

Produced by: NSW Statewide Burn Injury Service

Further copies of this publication can be obtained from the Agency for Clinical Innovation website at www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the Agency for Clinical Innovation.

Preferred citation: NSW Agency for Clinical Innovation. Skin graft management for burns patients – A clincial guide.

SHPN (ACI) 200184 ISBN 978‑1‑76081‑390‑1

Version: V2; ACI_0451 [10/20] Date amended: October 2020

Cover image credit: Shutterstock.com

Trim: ACI/D20/137

© State of New South Wales (NSW Agency for Clinical Innovation) 2020. Creative Commons Attribution No derivatives 4.0 licence.

https://www.aci.health.nsw.gov.au

Summary 1

Definitions 2

Skingraftinginoperatingtheatres 3

Debridinggraftsite 5

Skinapplication 6

Dressingprocedure 8

Dressingremoval 9

References 10

Acknowledgements 11

Contents

Skin graft management for burn patients – A clinical guide October 2020

Agency for Clinical Innovation www.aci.health.nsw.gov.au

Introduction

ThisdocumentwasdesignedtoaccompanytheBurn Patient ManagementandtheDonor Site Management for Burn Patientsdocuments.Itprovidesspecificskingraftingmanagementadviceanddirection.Allofthesedocumentsweredesignedtocomplementrelevantclinicalknowledgeandthecareandmanagementtechniquesrequiredforeffectivepatientmanagement.Cliniciansworkingoutsideaspecialistburnunitareencouragedtoliaisecloselywiththeircolleagueswithinthespecialistunitsforadviceandsupportinburnpatientmanagement,includingfollow-upcarepost-discharge.

Thisdocumentwillbereviewedeveryfiveyears,ormorefrequentlyifindicated,andupdatedasrequiredwithcurrentinformationatthattime.


Agency for Clinical Innovation 1 www.aci.health.nsw.gov.au

Skin graft

Askingraftisacommonsurgicalprocedureinwhichthegraft,athinshavingofskinharvestedfromtheepidermalanddermaltissue,isusedtoprovidecovertoreplaceadefectelsewhereonthebody.Thesecanbeusedforcoveringareasofburnorotherlosssuchastrauma,skintearorlesionremoval.1Skingraftscanbesplitthicknessorfullthickness.Thisisusuallydoneinoperatingtheatreswiththepatientanaesthetised.

Woundswithskinlossaffectingthedeepdermal,subcutaneousfatlayerandmuscletissue,requireaskingrafttoassistwithhealing.Forexample,burnwoundsconsidereddeepdermaltofullthickness(Figure1),wouldrequireaskingrafttofacilitatehealingandreducescarandcontractureformation.2

Therearecircumstanceswhenthepatientisunabletohaveskingraftingproceduresduetocomorbiditiesthatpreventsafeanaesthesia.

Earlyexcisionandgraftingisconsideredtobethemostappropriatemanagementfordeeperburninjuries.2-5Thisisforamultitudeofreasons,includingfasterwoundhealingandbetteraestheticoutcomes,inadditiontoreducedcomplicationsanddecreasedlengthofhospitalstay.3,6,7

Autograft, allograft and xenograft

Formostpatients,theuseofautograftortheirownskin,isthemostappropriateduetoskinbeinganorganandthuspronetorejectionifanalternativeisused.However,forthosepatientswithverylargepercentagetotalbodysurfaceareaburnsandlittleavailabledonorskin,theuseofanalternativemayberequiredasatemporaryskinsubstitute.

Alternativestoautograftsincludeallograftsandxenografts.Allograftsaregraftsfromthesamespeciesandcanincludecadavericor‘livingdonor’fromarelativeorotherperson.Axenograftisatissuegraftfromanotherspecies,suchasporcine,bovineorshark.Thisisusuallymaterialfromthesespeciesimpregnatedintoadressingmaterial.

Definitions

Epidermal

Burn depth Skin layer

Epidermis Split thickness

Dermis

Subcutaneous tissue

Muscle

Mid dermal

Deep dermal

Full thickness

Superficial dermalFullthickness

Burn skin depth

Figure 1: Burn skin depth diagram



Skin grafting in operating theatre

Harvesting donor skin

Therequiredskinisremovedeitherwithabladeormorecommonlywithanelectronicsurgicalcuttingtoolcalledadermatome.3,6Thedermatomehasmultipledepthsettingsandcantakeaverythin

shavingofskin.Forfurtherinformationregardingdonorsites,seetheDonor Site Management for Burn Patientsdocument.

Figure 2: Taking donor skin with dermatome

Oncetheskinhasbeenharvesteditislaidflatwiththemoistsidefacingupwardsreadyforapplicationontothegraftsite.

Figure 3: Donor skin ready for application



Mesh vs sheet

Iftheareatocoverislarge,orthesurgeonwantstoreducethesizeofthedonorsite,thedonorskinismeshedusingameshingtoolorblade.1Thisinvolvestinyslitsbeingmadethroughouttheskinsothatit

canstretchandcoveralargersurfacearea(Figure4andFigure5).

Figure 4: Skin meshing

Figure 5: Meshed skin



Priortografting,thewoundbediscleanedandnecrotictissueorescharisremoved.Theareaisdebridedtoableedingwoundbedtoencourageoptimumgraftsurvival.1,2Debridementmaybecarriedoutinnumerousways,includingexcising,orcuttingawaydeadtissueusingasurgicalbladeorahydrodebridementtoolsuchastheVersajet®.Thisexcisioncanincludeatangentialexcision,wheretheescharistakenoffinthinslices,or

Debriding graft site

Figure 6: Debrided wound bed ready for graft application

Excisionandprimaryclosure

fascialexcision,wheretheescharandsubcutaneousfatisremovedtothedeepfascialevel.1Thedebridementmethodcanberelatedtotheavailableequipmentorthedepthoftheburnwound.Somesmallorlinearburnscanbeexcisedandprimarilyclosedwithoutneedingaskingraft(Figure6).

Achieveintraoperativehaemostasispriortograftapplication.Thismayincludetumescence,topicaladrenalin,tourniquets,diathermy,pressurebandagesandelevation.



In the operating theatre

Thedonorskinisappliedtothedebridedwoundbed,dermisside(wetside)facingdownontowoundbed,makingsurethatallareasaresuitablycovered.

Outside the operating theatre

Skingraftinggenerallyoccursintheoperatingtheatreafterthedonorskinhasbeentaken.However,sometimesmoredonorskinistakenthanisappliedduringtheoperation.Ifatthefirstdressingchangepost-grafttheburnwoundisnotsufficientlycoveredfollowingsurgerytheexcessdonorskincanbelaidonthepreparedwoundbed(cleanedandvascularwoundbed)inthewardareaforupto7dayspostharvest.Whenapplyingtheskinthe‘shiny’ormoistsideshouldbeplacedfacedownontothewoundsurfaceusingasteriletechnique.Skinshouldbestabilisedusingglueoradhesivedressingsuchasretentiontapeorwoundclosurestrips.Theskingraftmustbeappropriatelymanagedandcaredforfollowingtheprocedure.

Skin application

Figure 8: Graft in place

Thegraftskinisattachedusingeitherskinglue,staples,suturesoranadhesivedressing. Theselectionisdependentongraftsiterequirementsandthesurgeon’spreference.

Figure 7: Applying donor skin



Aim

• Toallowtheskingrafttohealthroughthebody’sownprocessofre-epithelialisation

• Toapplymostappropriatedressingusingthecorrecttechnique

• Toapplydressingintimelymannertoavoidhypothermia,excesspainortrauma

• Tomaintainanaseptictechniqueatalltimes

Procedure

• Onceskinhasbeenappliedtograftsite,appropriatefixationisapplied,e.g.glue,staples,suturesoradhesivedressing.Atopicalnegativepressure(TNP)dressingcanalsobeusedtoassistfixationandgrafttake.

• Whenthegrafthasbeenfixedinplace,thegraftsiteisdressedwithanappropriatedressingsuchasanimpregnatedgauzeorsiliconedressing.

• Ensuretheareaiscleanedusingasteriletechnique.

• Ensureanybuild-upofbloodorfluidunderthegrafthasbeenevacuatedtoreducetheriskofgraftfailure.

• Applytheprimarydressingdirectlytothegraftsite.Theprimarydressingshouldhavea2-5cmoverlapandborder.Itisimportanttocoverthewholearea,onandslightlyaroundthewoundsite,toallowformovementandshrinkage.

• Applyasuitabledryabsorbentsecondarydressingsuchasapadorfoamdressing.

• Secondarydressingsmustnotcomeintocontactwiththegraftsiteastheymayadhereandcausetraumaonremoval.

• Useafixationdressingsuchasanadhesivetapetosecurethedressing.

• Forgraftstoextremities,considerimmobilisationtoreducegraftmovementandfriction.Immobilisationcanbeachievedwithsplintingmaterialssuchasthermoplastic,plasterofparis,fibreglassortopicalnegativepressure.

Dressing procedure in the operating theatre

Important

Care must be taken not to tightly wrap primary dressings circumferentially around the burns.



Graft site dressing

Selectingthemostappropriatedressingforawoundcanbechallengingandgraftsitesarenoexception.Therearemanydifferentopinionsofwhichisthemostappropriatedressingforthesewounds.

Theaimofagraftsitedressingistoprotectthewoundfromshearingforces,supportepithelialisationandenhanceskingraftingvascularisation.Althoughthegraftissecuredatapplication,agoodsupportivedressingisrequiredtoensuregraft‘take’whenvascularisationoccurs.

Anyinfectiontothesitemustbecleansedanddressedappropriately.

Topical Negative Pressure (TNP)

Topicalnegativepressure(TNP)isaspecialvacuumdressingthatmayhelpregeneratewoundtissue,totemporarilycloseanopenwoundortohelpholdanewskingraftinplace.

Thedressingandvacuummachinegenerallystaysinplace3to7days.Thedressingmusthaveagoodsealcompletelyaroundthedressingusingadhesivedrapesprovidedwithdressing,orappropriatealternative.

TroubleshootingtipsforusingTNP:

• Makesurethemachinestaysonastable, flatsurface.

• Ifanalarmsounds,lookatthescreenofthemachinetoseewhatitisalarmingforandfollowanyinstructions.

• Donotremoveanydressingsunlessinstructedtodosobyaspecialistclinician.

• Ifyouhaveanycontinuedproblems,pleasecallyourhospitalorthecompanyhelpline.



Dressing removal

Aim• Observeskingraftprogress.• Provideappropriatemanagementforlevelofhealing.

Taking graft site dressing down at day 3 to 7 post-operation• Ensureappropriateanalgesiaisadministeredwith

adequatetimetotakeeffectpriortoprocedure.• Skingraftdressingsshouldbefullytakendown

andtheskingraftsiteassessedwithinthistimeframeunlessotherwiseadvisedbyanappropriatespecialistclinician.

• Ensureappropriatemultidisciplinaryteammembersarepresentfortheprocedure.

• Removedressing,takingcarenottopulloffthegraftintheprocess.

• Thegraftshouldbereviewedbyappropriateclinicalstaffandawoundmanagementplanshouldbeformulated.

• Takedigitalimagesforclinicianswhoareunabletoattendprocedure.

• Monitorwoundprogress.

Dressing application• Thegraftsiteshouldbere-dressedusingprinciples

discussedinBurn Patient Managementdocument.

• Applymoisturisertohealedareas.

• Applyappropriatedressingformoistwoundhealingtoanyopenareas.Applyantimicrobialifaninfectionispresent.

Graft healedIftheskinisintact,wellvascularisedandtherearenomoistareas:

• discussscarmanagementwithatherapist(e.g.physiotherapistoroccupationaltherapist)

• applymoisturiserifanadhesiveisnotbeingapplied

• applyappropriatepressuredressingorgarment.

Graft is unhealed but present Iftheskingraftispresentandvascularisedbutremainsmoistandnothealed:

• dresswithimpregnatedgauzeorsiliconedressing

• applyappropriatesecondarydressingandfixation.

Graft is lost Iftheskingraftisnotvisibleonwoundsurfaceoritisvisiblebutnotvascularised(thewoundisrawandunhealed),assessforcausativefactorssuchasinfectionorfrictionandtreataccordingly.

Ifinfectionissuspected,swabthewoundandsendforculture.Cleanthewoundbedthoroughlyandapplysilverorotherantimicrobialdressing,asecondarydressingandfixation.

Forgraftlossduetofriction,applyappropriateprimary,secondaryandfixationdressingsandensurefrictiondoesnotcontinuetooccur.Iffrictioniscausedbyscratchingduetoitch,arrangeforappropriatemedicationsuchasantihistamines.Ifitiscausedbyproximitytootherbodysurfaces,dressthewoundwellwithprotectiveandpaddeddressing.

Figure 9: Dressing removal



Moisturising

Onceepithelialisationhasoccurredandthewoundishealed,thewoundbedwilloftenbecomedry.Thisisduetodisturbanceinthesebaceousglandswhichlubricatetheskin.Ifleftdry,thewoundwillbecomeitchyandthepatientislikelytoscratchofftherecentlyepithelialisedskin.Thiswillleadtoopenorrawareas.

Topreventthisfromoccurring,itisrecommendedthatallburnshavemoisturiserappliedtoanyhealedwoundifadhesivedressingisnotbeingusedforscarmanagement.Massageasmallamountofnon-perfumedmoisturiser,suchassorboleneintotheskinuntilitisfullyabsorbed.Thisshouldbedonethreetofivetimesperdaytoavoidtheskinbecomingdryanditchy.

Sun care

Avoidthesunasthenewskinisfragileandwillburnmoreeasily.Wearprotectiveclothingandahat,suncreamifoutside.



1. GomesRC,etal.High-voltageelectricstimulationofthedonorsiteofskingraftsacceleratesthehealingprocess.Arandomizedblindedclinicaltrial.Burns.2018;44(3):636-645.

2. ISBIPracticeGuidelinesCommittee,SteeringSubcommittee,andAdvisorySubcommittee,ISBIPracticeGuidelinesforBurnCare.Burns,2016;42(5):953-1021.

3. Herndon,D.TotalBurnCare(5thEdition).5thed.Saunders:London;2018.

4. BurnettLN,etal.Patientexperienceslivingwithsplitthicknessskingrafts.Burns,2014.40(6):1097-105.

5. Boekema,B.K.,B.Boekestijn,andR.S.Breederveld,Evaluationofsaline,RPMIandDMEM/F12forstorageofsplit-thicknessskingrafts.Burns,2015.41(4):848-52.

6. IsmailAlyME,etal.OperativeWoundManagement,inTotalBurnCare.5thEd.Saunders:London;2018.114-130e2p.

7. SinghM,etal.Evolutionofskingraftingfortreatmentofburns:ReverdinpinchgraftingtoTannermeshgraftingandbeyond.Burns.2017;43(6):1149-1154.

8. PripotnevS,PappA.Splitthicknessskingraftmeshingratioindicationsandcommonpractices.Burns.2017;43(8):1775-1781.

References Acknowledgements

Methodology

ThesedocumentsweredevelopedbythemembersofthemultidisciplinaryteamoftheACIStatewideBurnInjuryService(fromRoyalNorthShoreHospital,ConcordRepatriationGeneralHospitalandTheChildren’sHospitalatWestmead).

Thisdocumentwasoriginallydevelopedin2006bymembersoftheACIStatewideBurnInjuryService(thenGMCT),inconsultationwithcliniciansfromthethreeNSWburnunits.Itwascreatedusingevidenceandclinicalopinionfromspecialistburnclinicians.Thedocumenthasbeenupdatedseveraltimessincecreationinconsultationwithburnclinicians,andateachreviewtheauthorsidentifiedandreviewedrelevantpublishedresearch.SearchesusingMedline,BurnsjournalandClinicalKeywereconductedusingsearchtermsincluding(burn[title/abstract]AND/ORskingraft[title/abstract]ORdonorsite[title/abstract]ORdressing[title/abstract]).ThemostrecentsearchwasconductedinMay2020.



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SummaryDefinitionsHarvesting the donor skin in operating theatres (OT)Initial inspectionDressing removalReferences

skin graft management for burn patients...post-graft the burn wound is not sufficientlycovered...

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