Full thickness burn if not managed properly can result in lifelong disabilities and impairment as these injuries frequently lead to burn scar contractures. Burn scar contractures may cause extreme disfigurement, pain, limitation of motion and itch which hinder with daily routine of the person. This assignment is prepared to provide an outline of the preoperative and postoperative management of a patient who will be treated with split skin graft following a full thickness burn to the anterior chest wall. The postoperative management will include preoperative aspects like assessment, evaluation, investigation and education. Further postoperative management will involve immediate post-operative period (first 24 hours) care and long-term management and complications that may be related to the surgery.
The standard preoperative evaluation will include age of the patient, airway patency, lung dysfunction, current resuscitation regimen, and patient’s response, potential vascular access sites, coexisting morbidities, altered mental states and tolerance to enteral feeding (Bittner, Shank, Woodson, & Martyn, 2015). It should be ensured that the perioperative care is managed and communicated to surgeons and critical care team in a way that surgical treatment goals are compatible with intensive care unit. Further, the details of the surgical plan must be evaluated to assess blood loss to arrange suitable vascular access, invasive monitors, and to order relevant blood products.
The pre-operative management is based on a range of goals which are airway maintenance, edema reduction, prevention of structural damage, contracture and deformity, maintenance of ROM, keeping the patient as active and independent as possible and to prevent infection. Various methods can be adopted to accomplish these goals such as breathing Exercises, positioning, splinting, passive and strengthening exercises, etc.
Patient or his/her appointed guardians must be educated regarding the sustained injuries and they must be made aware of the surgical procedure in a manner that they understand it fully. It is only after full understanding of the split-skin grafting procedure and the possible positive negative outcomes, a consent must be obtained from them. it must be made sure that all the questions of the patient is answered and he/she is made to be in relaxed mental state before the surgery.
Significant immediate postoperative concerns for burn patients are location of extubation, safe transportation to the ICU, handover of care to the ICU staff, and postoperative pain management.. The decision of intubation in OR can be based on airway patency, metabolic status, chances for continued bleeding, and return of patient for surgery. The ongoing bleeding can be covered by dressings. For safe transport of patient from OR to ICU, monitors as per the patient’s physiological status, transport oxygen availability with suitable respiratory assistance, a plan to keep the patient warm, sufficient transport staff, resuscitation drugs, and availability of intravenous drug administration site are essential (Fanara, Manzon, Barbot, Desmettre, & Capellier, 2010).
If the pain is not controlled, it will lead to anxiety which can negatively influence the wound healing and mental state of the patient. Due to the freshly excised tissue and harvested donor sites, the patient will experience extreme pain. Patients must be given long-acting opiates, as analgesia are opiates to control postoperative pain (Woodson, Sherwood, Kinsky, Morvant, & Talon, 2012).
It is observed that in spite of careful precautions in the OR, several patients experience hypothermia, therefore, it is essential that an ambient temperature should be maintained and if required portable heating units can be positioned over patient’s bed. When the patient is warmed and his/her body temperature goes towards normal, vasoconstriction declines and the patient may become tachycardic, hypovolemic and oliguric. The hypovolemia of warming must be expected and therefore managed appropriately with the infusion of additional crystalloid fluids run through a fluid warmer. Further fluid and electrolyte replacements must be corrected and sufficient nutritional consumption must also be ensured (Ellis, 2017).
After the split-skin grafting, the dressings are classically taken off on the fourth or fifth day after the surgery. Post-operative physical and occupational therapy also initiates at this time, and the patient must be motivated to be as much independent as possible. The grafts and donor sites must be kept clean, moist and concealed. The first post-operative dressing can be performed between four and ten days after the surgery at which time fluid may be expressed. Donor sites usually take eight to 14 days to epithelialise. Donor sites are very painful post-operatively which should be managed by treating it with topical anaesthetic (Hernandez, et al., 2013). While removing the dressing, pain can be reduced by drenching the donor site with saline water. Alginates, hydrocolloids and gels are used as main dressings on donor sites. These dressings should remain intact until healing occurs or at least 10-14 days. There are also chance of bacterial infection at donor sites therefore, local antimicrobial wound products can be used (Simman, 2009). At the donor site in split thickness, skin graft application of pressure garments can assist in prevention of hyper trophic scan.
In addition, since the skin graft lacks nerves and the glands are not fully functional, it requires lubrication. topical lubricant must be used to give massage after 5 to 10 days of epithelialization. The donor and recipients sites also give sensations of itching, which can be managed by administration of antihistamines, and keeping the sites cool. Further, the skin graft must be safeguarded from the sun for at least 6 months by using a total sun block and pressure garments (El-Kader, El-Gendy, & Ashmawy, 2013).
Post-discharge, the patient must visit weekly until all the wounds have reepithelialized and reasonable growth is seen in the patient’s intervention. After that once in a month or once in two months, the patient must visit until six months so that assessment of his restoration of functional abilities can be made and effective recommendations can be made to make him/her return to his/her pre-surgery work status. Restoration of functional capibilities is one of the major goals of post-operative care. (Kagan, Peck, Hickerson, Holmes, & Kraatz, 2009).
To manage the mental state of the patient post-operatively as they usually suffer from anxiety, pain and depression, assistance from multidisciplinary team is required.
Some of the common postoperative complications that the patient is likely to experience in split skin grafting is inadequate control of pain. The pain is very extreme and is the chief cause of substantial postoperative discomfort. Therefore, prior planning of pain control is essential. Another complication is ongoing bleeding which can be managed by replacing fluid loss with suitable support to clotting. In addition, keeping the patient’s body temperature above 37º C will also decrease postoperative bleeding. Pulmonary edema is another frequent complication of the skin grafting, which should be managed by careful evaluation of intraoperative fluid requirements. Delirium may also occur which should be reduced by administration of anxiolytics and analgesics. Sepsis may also occur which should be managed by maintaining strict aseptic guidelines while handling all the procedures.
Further issues with wound management may occur because of conduction of grafting on an inefficiently prepared or inappropriate bed. Problems like avascularity and infection may occur. Some early grafting issues are failure of take because of insufficient contact between graft bed, poor fixation, hematoma and graft lysis because of infection. Late grafting issues include contracture, extremely extended mesh graft, graft margins passing the anatomical segment & trophic ulceration, graft insensate and lastly, graft unable to serve as permanent cover because not enough thickness. The donor site complications largely include poor healing and infection.
Conclusion
The preoperative and postoperative care for the patients of split skin grafting can be complicated and should be planned individually. Various expertise is required such as dressing, wound management, pain control, knowledge competency, etc. Suitable postoperative as well as preoperative care for a patient is based on several factors such as the age and health status of the patient and the condition of the donor and recipient site. Burn-induced injuries in a patient although frequently need surgical management but presents a range of pathophysiologic challenges perioperative and postoperative care. Standard management protocols of the burn injury sustained patients require a detailed preoperative assessment and careful analysis of risk factors such as burn shock and resuscitation, challenging airway functioning, lung dysfunction which can increase the likelihood of morbidity and mortality for these patients. Appropriate and safe management can be done of burn patients by planning and providing care after completely understanding, acknowledging, and anticipating the typical preoperative, intraoperative, and postoperative protocols, probable complications of the skin grafting procedure.
References
Bittner, Shank, Woodson, & Martyn. (2015). Acute and Perioperative Care of the Burn-injured Patient. Anesthesiology, 122, 448-464.
El-Kader, El-Gendy, & Ashmawy. (2013). PHYSICAL THERAPY APPROACHES FOR WOUND CARE.
Ellis, D. (2017). What the Anesthesiologist Should Know before the Operative Procedure. Retrieved from Clinical Pain Advisor: https://www.clinicalpainadvisor.com/anesthesiology/skin-grafting-for-burns–procedures/article/581554/
Fanara, Manzon, Barbot, Desmettre, & Capellier. (2010). Recommendations for the intra-hospital transport of critically ill patients. Crit Car, 14.
Hernandez, Savetamal, Crombie, Cholewczynski, Atweh, Possenti, & Schulz. (2013). Use of continuous local anesthetic infusion in the management of postoperative split-thickness skin graft donor site pain. J Burn Care Res, 34, 257–62.
Kagan, Peck, Hickerson, Holmes, & Kraatz. (2009). Surgical Management of the Burn Wound and Use of Skin Substitutes. American Burn Association.
Simman, R. (2009). Wound Closure and the Reconstructive Ladder in Plastic Surgery. J Am Col Certif Wound Spec, 1(1), 6-11.
Woodson, Sherwood, Kinsky, Morvant, & Talon. (2012). Anesthesia for burned patients. In Total Burn Care (4 ed., pp. 174-98). Edinburgh: Elsevier.Question:
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