donor site management for burn patients - agency for clinical … · 2020. 10. 19. · patient...

NSW Statewide Burn Injury Service

A clinical guideOCTOBER 2020

Donor site management for burn patients

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. Donor site management for burns patients – A clinical guide

SHPN (ACI) 200183 ISBN 978‑1‑76081‑389‑5.

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

Trim: ACI/D20/1314

© 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.auhttps://www.aci.health.nsw.gov.au

Summary 1

Definitions 2

Donorsitedressings 4

Harvestingthedonorskininoperatingtheatres 6

Dressingprocedure 7

Initialinspection 8

Dressingremoval 9

References 9

Acknowledgements 10

Contents

Donor site management for burn patients October 2020

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

Summary

ThisdocumentwasdesignedtoaccompanytheBurn Patient ManagementguideandtheSkin Graft Management for Burn Patients.Itprovidesspecificdonorsitemanagementadviceanddirection.Allofthesedocumentsweredesignedtocomplementrelevantclinicalknowledgeandthecareandmanagementtechniquesrequiredforeffectivepatientmanagement.Cliniciansworkingoutsideaspecialistburnunitareencouragedtoliaisecloselywiththeircolleagueswithinthespecialistunitsforadviceandsupportinburnpatientmanagement,includingfollow-upcarepost-discharge.

Thisdocumentwillbereviewedeveryfiveyears,ormorefrequentlyifindicated,andupdatedasrequiredwithcurrentinformationatthattime.


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

Donor siteAdonorsiteistheareawheretissueisharvestedtoprovidecovertoreplaceadefectsomewhereelseonthebody.Thiscanbeusedforcoverageofareasofburnorotherlosssuchastrauma,skintearorlesionremoval.Donorsitescanbesplitthicknessorfullthickness.Theareathattheskinhasbeentakenfrom,thedonorsite,becomesanewareaofskinlossinadditiontoanyotherskinlossareas.1Thisdonorsiteintroducesanewwound,whichcanalsoincludeissuessuchaspain,bleeding,infection,difficultyhealingandscarproduction.2-4

Split thickness donorSplitthicknessiswhereepidermalandpapillarydermaltissueisharvested.Thisisthemostcommonlyusedmethodforburnsduetotheabilityofthedonorsitetohealquicklywithminimalscarring.5

Full thickness donorFullthicknessiswhereepidermalandthefulldermaltissueisharvested.Thisisusedlessoftenthanthesplitthicknessdonorasitrequiresasecondarysplitthicknessgraftorprimaryclosureofthedonorsitetoheal.Generally,onlysmallareasoffullthicknessskinareused.

Definitions

Epidermal

Burn depthSkin layer

Epidermis Split thickness

Dermis

Subcutaneous tissue

Muscle

Mid dermal

Deep dermal

Full thickness

Superficial dermalFullthickness

Donor site depths

Figure 1: Cross section of skin showing donor depths



Common donor sitesCommonsplitthicknessdonorsiteareasincludethethighs,upperarm,buttocksandscalp(Figure2),astheseareasarenotreadilyvisibleandcanprovidelargestripsofdonorskin.6,7Forfullthicknessdonorgrafts,skinareassuchasfrombehindtheearorthegroinareused(Figure3).Howeverdonorsitescanbe

takenfromanareaofthebodyclosestincolourmatchforthegraftsite.6,7Ifavailabledonorskinislimited,almostanyareaonthebodycanbeusedasadonorsite.

Figure 2: Common split thickness sites for skin harvesting

Figure 3: Common full thickness sites for skin harvesting



Donor site dressings

Selectingthemostappropriatedressingforawoundcanbechallenginganddonorsitesarenoexception.Therearemanydifferentopinionsofwhichisthemostappropriatedressingforthesewounds.4Someincludefilm,alginate,hydrocolloidandimpregnatedgauze.Whensignsofinfectionarepresent,asilverdressingisoftenusefulforantimicrobialcoverage.

Donorsitedressingsaimtoenhancerapidhealing,maintainamoistwoundenvironmentandpreventadherencetothewoundbed.6,7Otherqualitiesconsideredtobeimportantincludeabsorbencyandeaseofremoval.8

Protectionofthewoundbedandsupporting re-epithelialisationisthemostimportantconsiderationinchoosinganappropriatewounddressing.Dressingsthatcanbeleftintactfor 7–10daysareoptimal.Antimicrobialsshouldnotbenecessaryifthewoundisappropriatelydressedastheyarecreatedinasterileenvironment.However,anyinfectionmustbecleansedanddressedappropriately.



Aim• Toharvestappropriateskintocoveradeficit.

• Tomaintainanaseptictechniqueatalltimes.

ProcedureTherequiredskinisremovedeitherwithabladeoranelectronicsurgicalcuttingtoolcalledadermatome.6,7Thedermatomehasmultipledepthsettingsandcantakeaverythinshavingofskin.

Harvesting the donor skin in operating theatres

Figure 4: Area prepared for donor site

Theselectedareaispreparedusinganappropriatesolution(e.g.povidone-iodine)andsteriledrapes.

Figure 5: Taking donor skin with dermatome

Theskinisstretchedtoallowevenpressureonallareasofskinharvested,thusprovidinganevenpieceofdonorskin.

Figure 6: Freshly harvested donor site

Oncetheskinisharvested,thedonorsiteisleftasableedingwoundbed.



Aim• Toallowthedonortissuetohealthroughthe

body’sownprocessofre-epithelialisation.

• Toapplythemostappropriatedressingusingcorrecttechnique.

• Toapplyadressinginatimelymannertoavoidhypothermia,excesspainortrauma.

• Tomaintainanaseptictechniqueatalltimes.

Procedure• Afterthedonorskinhasbeentaken,thebleeding

woundiscoveredwithadrenalinesoakstopromotecoagulation.9

• Whenhaemostasishasbeenachievedandthebleedinghasstopped,anappropriatedressingsuchasanocclusivefilmdressingoracalciumalginateisappliedtothedonorsite.Filmdressingsallowmoistwoundhealingandtheocclusivenatureallowsthewoundtobeundisturbedduringhealing.10Calciumalginatedressingproductscanpromotecoagulationofbloodfromthedonorsite.Theycanalsopromotemoistwoundhealingandreducepain.6Alternatively,donorsitescanbedressedwithsiliconedressingswhichareofteneasiertoremove.Hydrofibresandhydrocolloidscanprovideamoistwoundhealingenvironment.Singlelayerimpregnatedgauzeordrygauzearenotrecommendedasremovaloftenleadstowoundbedtrauma.

• Applytheprimarydressingdirectlytothedonorsitewound.Theprimarydressingshouldhavea2–5cmoverlapandborder.Itisimportanttocoverthewholearea,onandslightlyaroundthewoundsitetoallowformovement.

• Asuitableabsorbentsecondarydressingshouldthenbeapplied.

• Secondarydressingsmustnotcomeincontactwiththedonorsiteastheymayadhereandcausetraumaonremoval.

• Afixationdressing,suchasanadhesivetape,isthenusedtosecurethedressinginplaceandpreventslippage.Crepebandagesmaybeusedbutmustbewellsecuredtoavoidslippage,particularlyoftheprimarydressing.

Dressing procedure

ImportantCare must be taken not to tightly wrap primary dressings circumferentially around the wound.



Aim• Observedonorsiteprogressat24–48hours

post-surgery.

• Provideeffectivedonorsitemanagementandproblemsolving.

Procedure• Evaluatepainandprovideanalgesiaifrequired.

• Assessthedonorsitewounddressing.Ifexudatemoderatetolarge,removeouterdressing.

• Iftheprimarydressingisdryandclean,leaveintact.

• Ensuredressingiskeptcleananddry(i.e.coverwithaplasticbagduringshowering).

• Lookforcomplicationssuchas:

– bloodorexudatevisibleonsecondaryorexternaldressing(Figure7)

– dressingslippage(Figure8) – malodour – signsofscratchingduetoitch – excessivepain,moistureorswelling.

Initial inspection

Figure 7: Blood soaked dressing

Figure 8: Dressing slippage

Managing complications• Ifanyofthepreviouslymentionedcomplications

arenoted,thedressingshouldberemovedandtheareacleanedthoroughlywithanappropriatesolutionsuchas0.9%sodiumchloride.Swabwoundforcultureifclinicallyindicatinginfection.

• Ifodourandoffensiveexudateispresent,applyappropriateantimicrobialdressing(e.g.silverdressing).Ensureanoverlapandborderof2–5cm.

• Applyasecondaryretentivedressing.Leaveintactfortwotofourdays.

• Ifindicationofscratchingispresent,thepatientshouldbeencouragedtouseantihistaminesandothernon-pharmacologicalmethodssuchasicepacksoramassager.

• Ifthewoundiscleanandbleedinghasbeencontrolled,re-dresswithappropriatedressing,suchasasiliconedressingandretentivesecondarydressing(e.g.absorbentpadandtape).Leavethedressingintactforsevendays.



Aim• Observedonorsitewoundprogress.

• Provideappropriatemanagementforlevelofhealing.

Taking donor site dressing down at day 8 to 10 post-harvesting• Assesspainandprovideanalgesiaasappropriate,

givingtimeforittotakeeffect.

• Donorsitesshouldbefullytakendownandassessedwithinthe8–10daytimeframe, unlessotherwiseadvisedbyanappropriatespecialistclinician.

Donor healedSkinhasre-epithelialisedwithnomoistareas, (Figure9).

• Leaveexposed,ifappropriatetodoso,toallowmoisturiserapplication.

• Applywater-basedmoisturiserfourtofivetimesaday(e.g.sorbolene,vitaminEoroatmeal-basedmoisturiser).

• Educatethepatientondonorsitecare,includingtheneedtocontinuemoisturisingandensureshearandfrictionisprevented.

• Ensurethepatientisawareofappropriatesuncare.

Dressing removal

Figure 9: Healed donor site Figure 10: Donor site with fresh bleeding

Donor not healedSkinhasnotre-epithelialised,withrawandmoistareaspresent(Figure10).

• Assessanddocumenttheappearanceofthe woundbed.

• Ifthedonorsiteisrawbuttherearenosignsofwoundinfection,applyanappropriatedressing(e.g.silicone)andleaveintactforthreetofivedays.

• Ifthewoundhasobvioussignsofinfectionandhealinghasnotprogressedoverthelast10days,takeawoundswabforculture.Discusswithanappropriatespecialistcliniciantodeterminethebestdressingoptionsanddocumentthecourseofactionintheintegratednotes.

• Continuetoreassessasrequiredandleavethedressingintactfortheprescribedperiodoftime.

• Anappropriatespecialistclinicianmustbenotifiedifthedonorsiteremainsunhealedafterafurthersevendays.Theywilldirectanappropriatecourseofaction.



1. PripotnevS,PappA.Splitthicknessskingraftmeshingratioindicationsandcommonpractices.Burns.2017;43(8):1775-81.

2. ChowdhrySA.Useofoxidizedregeneratedcellulose(ORC)/collagen/silver-ORCdressingstohelpmanageskingraftdonorsitewounds.JPRASOpen.2019;22:33-40.

3. RotatoriRM,StarrB,PeakeM,FowlerL,JamesL,NelsonJ,etal.PrevalenceandRiskFactorsforHypertrophicScarringofSplitThicknessAutograftDonorSitesinaPediatricBurnPopulation.Burns.2019;45(5):1066-74.

4. IliescuNeleaM,PaekL,DaoL,RouchetN,EfanovJI,EdouardC,etal.In-situcharacterizationofthebacterialbiofilmassociatedwithXeroformandKaltostatdressingsandevaluationoftheireffectivenessonthinskinengraftmentdonorsitesinburnpatients.Burns.2019;45(5):1122-30.

5. BurnettLN,CarrE,TappD,RaffinBouchalS,HorchJD,BiernaskieJ,etal.Patientexperienceslivingwithsplitthicknessskingrafts.Burns.2014;40(6):1097-105.

6. HerndonD,editor.TotalBurnCare(5thEdition).5thed.London:Saunders;2018.

7. IsmailAlyME,DannounM,JimenezCJ,SheridanRL,LeeJO.OperativeWoundManagement.In:HerndonD,editor.TotalBurnCare(5thEd).London:Saunders;2018.p.114-30e2.

8. DingX,ShiL,LiuC,SunB.ArandomizedcomparisonstudyofAquacelAgandAlginateSilverasskingraftdonorsitedressings.Burns.2013;39(8):1547-50.

9. HoCWG,KokYO,ChongSJ.Photographicevaluationofdifferentadrenaline-containingtumescentsolutionsonskingraftdonorsitebleeding:Aprospectiverandomisedtrial.Burns.2018;44(8):2018-25.

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

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.



Our vision is to create the future of healthcare, and healthier futures for the people of NSW.

The Agency for Clinical Innovation (ACI) is the lead agency for innovation in clinical care.

We bring consumers, clinicians and healthcare managers together to support the design, assessment and implementation of clinical innovations across the NSW public health system to change the way that care is delivered.

The ACI’s clinical networks, institutes and taskforces are chaired by senior clinicians and consumers who have a keen interest and track record in innovative clinical care.

We also work closely with the Ministry of Health and the four other pillars of NSW Health to pilot, scale and spread solutions to healthcare system‑wide challenges. We seek to improve the care and outcomes for patients by re‑designing and transforming the NSW public health system.

Our innovations are:

• person‑centred

• clinically‑led

• evidence‑based

• value‑driven.

www.aci.health.nsw.gov.au

SummaryDefinitionsDonor site dressingsHarvesting the donor skin in operating theatres (OT)Harvesting the donor skin in operating theatres (OT)Initial inspectionDressing removalReferences

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