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NSW Statewide Burn Injury Service
A clinical guideOCTOBER 2020
Donor site management for burn patients
aci.health.nsw.gov.au
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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.
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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
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Summary
ThisdocumentwasdesignedtoaccompanytheBurn Patient ManagementguideandtheSkin Graft Management for Burn Patients.Itprovidesspecificdonorsitemanagementadviceanddirection.Allofthesedocumentsweredesignedtocomplementrelevantclinicalknowledgeandthecareandmanagementtechniquesrequiredforeffectivepatientmanagement.Cliniciansworkingoutsideaspecialistburnunitareencouragedtoliaisecloselywiththeircolleagueswithinthespecialistunitsforadviceandsupportinburnpatientmanagement,includingfollow-upcarepost-discharge.
Thisdocumentwillbereviewedeveryfiveyears,ormorefrequentlyifindicated,andupdatedasrequiredwithcurrentinformationatthattime.
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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
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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
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Donor site dressings
Selectingthemostappropriatedressingforawoundcanbechallenginganddonorsitesarenoexception.Therearemanydifferentopinionsofwhichisthemostappropriatedressingforthesewounds.4Someincludefilm,alginate,hydrocolloidandimpregnatedgauze.Whensignsofinfectionarepresent,asilverdressingisoftenusefulforantimicrobialcoverage.
Donorsitedressingsaimtoenhancerapidhealing,maintainamoistwoundenvironmentandpreventadherencetothewoundbed.6,7Otherqualitiesconsideredtobeimportantincludeabsorbencyandeaseofremoval.8
Protectionofthewoundbedandsupporting re-epithelialisationisthemostimportantconsiderationinchoosinganappropriatewounddressing.Dressingsthatcanbeleftintactfor 7–10daysareoptimal.Antimicrobialsshouldnotbenecessaryifthewoundisappropriatelydressedastheyarecreatedinasterileenvironment.However,anyinfectionmustbecleansedanddressedappropriately.
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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.
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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.
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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.
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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.
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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
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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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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:
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SummaryDefinitionsDonor site dressingsHarvesting the donor skin in operating theatres (OT)Harvesting the donor skin in operating theatres (OT)Initial inspectionDressing removalReferences